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THE JOURNAL

MENTAL SCIENCE.

EDITORS>

Henry Rayner, H.D. A. R. Urquhart, H.D.

Conolly Norman, F.R.C.P.I.

ASSISTANT EDITORS:

J. Chambers, H.D. J. R. Lord, H.B.

VOL. XLVIII.

LONDON:

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCIl.

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“ In adopting our title of the Journal of Mental Science, published by authority
of the Medico-Psychological Association, we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the term
mental physiology or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro¬
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid; for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we
admit that metaphysics maybe called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to-a certain extent, attains immediate practical results of the greatest utility
to the Welfare of mankind ; we therefore maintain that our Journal is not inaptly
called the Journal of Mental Science, although the science may only attempt to
deal with sociological and medical inquiries, relating either to the preservation 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 meta¬
physical knowledge as may be available to our purposes, as the mechanician 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 cultivate; 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 cap¬
tain of a ship would be none the worse for being well acquainted 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.”— Sir J. C. Bucknill,
M.D., F.R.S.

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THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS, 1901-2.

president.— OSCAR T. WOODS, M.D.
president elect.— J. WTGLE8WOBTH, M.D.
ex-president. —FLETCHER BEACH, M.B.
treasurer.— H. HAYES NEWINGTON, F.R.C.P.Ed.

fHENRY RAYNER. M.D.
editors op journal. -[ A. R. URQUHART, M.D.

(CONOLLY NORMAN, F.R.C.P.I.

assistant editors. 5 JAMES CHAMBERS, M.D.

(Not Members of Council.) / JOHN R. LORD, M.B.

(ERNEST W. WHITE. M.D.
auditoh*.| james m m001)T> m.R.C.S.

divisional secretary for south-eastern division.— A. N. BOYCOTT, M.D.
DIVISIONAL SECRETARY POR SOUTH-WR8TERN DIVI8ION.— P. W. MACDONALD, M.D.
DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION.

C. K. HITCHCOCK, M.D.

DIVISIONAL SECRETARY FOR SCOTLAND.— LEWIS C. BRUCE, M.B.
DIVISIONAL SECRETARY POR IRELAND.— A. D. O’C. FINEGAN, L.R.C.P.I.
GENERAL SECRETARY. —ROBERT JONES, M.D., B.S., F.R.C.S.

•secretary op educational committbe.— C. A. MERCIER, M.B. (appointed by
Educational Committee, but with seat on Council).

registrar. —H. A. BENHAM, M.D.

MEMBERS OP COUNCIL.

H. T. 8. AVELINE, M.R.C.8
D. M. CASSIDY, M.D.

W. R. DAW80N. M.D.

G. 8TANLEY ELLIOT,
M.R.C.P.

D. HOTCHKIS, M.D.
PERCY SMITH, M.D.

H. BOND, M.D.

G. HAVELOCK, M.D.

P. HEARDER, M.D.

H. GARDINER HILL,

M.R.C.S.

ALFRED MILLER, M.B.

L. A. WEATHERLY, M.D.

T. S. ADAIR. M.B.

THEO. B. HYSLOP, M.D.

H. A. KIDD, M.R.C.8.

1900. | R. L. RUTHERFORD, M.D.

J. BEVERIDGE SPENCE, M.D.
A. R. TURNBULL, M.B.

[The above form the Council.]

1900.

l&i.

KXAXIHBBS.

| THEO. B. HYSLOP. M.D.
enolakd jj WH1TCOMBE, M.R.C.S.

_(«. M. BOBEBTSON. M.B.

80 OTLAKD j LEWIg p BR U CE , J£.B.

NOLAN. L.B.C.P.I.

isblamd | CO n OLL Y nobman, f.b.c.p.i.

Examiners for the Nursing Certificate of the Association :

R. PERCY SMITH, M.D.; J. B. SPENCE, M.D.; (VACANT).

PARLIAMENTARY

FLETCHER BEACH

(Secretary).

H. BENHAM.

G. F. BLANDFORD.

DAVID BOWER.

D. M. CASSIDY.

T. 8. CLOUSTON.

A. D. O’C. FINEGAN.

H. GARDINER HILL.

C. K. HITCHCOCK.

J. CARLYLE JOHNSTONE.

ROBERT JONE8.

H. ROOKE LEY.

J. G McDOWALL.

C. MERCIER.

COMMITTEE.

H. HAYES NEWINGTON

(Chairman),
CONOLLY NORMAN.

EVAN POWELL.

H. RAYNER.

G. H. SAVAGE.

R. PERCY SMITH.

J. B. SPENCE.

A. H. STOCKER.

D. G. THOMPSON.

E. B. WHITCOMBE.

ERNEST W. WHITE.

J. WIGLE8W ORTH. 'J
OSCAR WOODS.

D. YELLOWLEES.

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EDUCATIONAL COMMITTEE.

T. 8. ADAIR.

FLETCHER BEACH.

H. A. BENHAM.

(i. J. BLANDFORD.

A. CAMPBELL CLARK.

T. 8. CLOD8TON.

A. D. O’C. PINEGAN.

W. GRAHAM.

J. G. HAVELOCK.

T. B. HT8LOP.

J. CARLYLE JOHNSTONE.
W. 8. KAY.

P. W. MACDONALD.

T. W. McDOWALL.

J. MALONEY.

W. F. MENZIES.

C. MERCIER (Secretary'),
W. F. MICKLE.

G. W. MOULD.

H. HAYES NEWINGTON.

CONOLLY NORMAN.

H. KAYNER.

W. REID.

C. ROGERS.

J. RORIE.

G. H. SAVAGE.

T. CLAYE SHAW.

R. PERCY SMITH (Chairman).

J. B. SPENCE.

A. R. TURNBULL.

L. A. WEATHERLY.

E. B. WHITCOMBE.

ERNEST W. WHITE.

J. R. WHITWELL.

J. WIGLE8WORTH.

J. KENNEDY WILL.

OSCAR WOOD8.

D. YKLLOWLEES, and
PRESIDENT (OSCAR T. WOODS).

LIST OF CHAIRMEN.

1841. Dr. Blake, Nottingham.

1842. Dr. de Vitr6, Lancaster.

1843. Dr. Conolly, Han well.

1844. Dr. Thurnam, York Retreat.

1847. Dr. Win tie, Wurneford House, Oxford.

1861. Dr. Conolly, Hanwell.

1852. Dr. Wintle, Wameford House.

LIST OF PRESIDENTS.

1854. A. J. Sutherland, M.D., St. Luke’s Hospital, London.

1855. J. Thurnam, M.D., Wilts County Asylum.

1856. J. Hitchmau, M.D., Derby County Asylum.

1857. Forbes Winslow’, M.D., Sussex House, Hammersmith.

1858. John Conolly, M.D., County Asylum, Hanw*ell.

1859. Sir Charles Hastings, D.C.L.

1860. J. C. Bncknill, M.D., Devon County Asylum.

1861. Joseph Lalor, M.D., Richmond Asylum, Dublin.

1862. John Kirkman, M.D., Suffolk Couuty Asylum.

1863. David Skae, M.D., Royal Edinburgh Asylum.

1864. Henry Munro, M.D., Brook House, Clapton.

1865. Wm. Wood, M.D., Kensington House.

1866. W. A. F. Browne, M.D., Commissioner in Lunacy for Scotland.

1867. C. A. Lockhart Robertson, M.D., Haywards Heath Asylum.

1868. W. H. O. Sankey, M.D., Sandy well Park, Cheltenham.

1869. T. Lay cock, M.D., Edinburgh.

1870. Robert Boyd, M.D., County Asylum, Wells.

1871. Henry Maudsley, M.D., The Lawn, Hanwell.

1872. Sir James Coxe, M.D., Commissioner in Lunacy for Scotland.

1873. Harrington Tuke, M.D., Manor House, Chiswick.

1874. T. L. Rogers, M.D., County Asylum, Rainhill.

1875. J. F. Duncan, M.D., Dublin.

1876. W. H. Parser, M.D., Warwick County Asylum.

1877. G. Fielding Blandford, M.D., London.

1878. Sir J. Crichton-Browne, M.D., Lord Chancellor's Visitor.

1879. J. A. Lush, M.D., Fisherton House, Salisbury.

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Ill

1880. Q. W. Mould, M.R.C.S., Royal Asvlum, Cheadle.

1881. D. Hack Take, M.D., London.

1882. Sir W. T. Oairdner, M.D., Glasgow.

1883. W. Orange, M.D., State Criminal Lunatic Asylum, Broadmoor.

1881. Henry Rayner, M.D., County Asylum, Han well.

1885. J. A. Eames, M.D., District Asylum, Cork.

1886. Geo. H. Savage, M.D., Bethlem Royal Hospital.

1887. Fred. Needham, M.D., Barnwood House, Gloucester.

1888. T. S. Clouston, M.D., Royal Edinburgh Asylum.

1889. H. Hayes Newington, M.R.C.P., Ticehuret, Sussex.

1890. David Tellowlees, M.D., Gartnavel Asylum, Glasgow.

1891. E. B. Whitcombe, M.R.C.S., City Asylum, Birmingham.

1892. Robert Baker, M.D., The Retreat, York.

1893. J. Murray Lindsay, M.D., County Asylum, Derby.

1894. Conolly Norman, F.R.C.P.I., Richmond Asylum, Dublin.

1895. David Nicolson, M.D., C.B., New Law Courts, Strand, W.C.

1896. William Julius Mickle, M.D., Grove Hall Asylum, Bow.

1897. Thomas W. McDowall, M.D., Morpeth, Northumberland.

1898. A. R. Urquhart, M.D., James Murray's Royal Asylum, Perth

1899. J. B. Spence, M.D., Burntwood Asylum, nr. Lichfield, Staffordshire.

1900. Fletcher Beach, M.B., 79, Wimpole Street, W.

HONORARY MEMBERS.

1896. Allbutt, T. Clifford, M.D., F.R.C.P., Regius Professor of Physic, Univ..
Camb., St. Radegund’s, Cambridge.

1881. Benedikt, Prof. M., Franciskaner Platz 5, Vienna.

1900. Blumer, G. Alder, Utica Hospital for the Insane, Providence, U.S.A.
( Ord . Mem., 1890.)

1900. Bresler, Johannes, M.D„ Freiburg in Silesia, Germany. (Corr. Mem.,
1896.)

1881. Brosius, Dr., Bendorf-Sayn, near Coblenz, Germany.

1876. Browne, Sir J. Crichton-, M.D.Edin., F.R.S., Lord Chancellor's Visitor,
New Law Courts, Strand, W.C. (President, 1878.)

1887. Chapin, John B., M.D., Pennsylvania Hospital for the Insane, Phila¬
delphia, U.S.A.

1872 fC oortena y» E- Maziere, A.B., M.B., C.M.T.C.D., M.D., Inspector of
*« Lunatics in Ireland, Lunacy Office, Dublin Castle. (Secretory for
IW1 - 1 Ireland, 1876-87.)

1879. Echeverria, M. G., M.D.

1865. Falret, Jules, M.D., 114, Rue de Bac, Peris.

1892. FM, Dr. Charles, 37, Boulevard St. Michel, Paris.

1895. Ferrier, David, M.D., 34, Cavendish Square, London.

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Commissioner in Lunacy, 19,
Strathearn Road, Edinburgh.

.ggg , Gairdner, Sir William T., E.C.B., M.D.Edin., F.R.S., formerly Professor
1888* f °* Medicine in the University of Glasgow, Physician to H.M. the King
J in Scotland, 32, George Square, Edinburgh. (President, 1882.)

1896. Hine, George T., F.R.I.B.A., 35, Parliament Street, London, S.W.

1881. Hughes, C. H., M.D., St. Louis, Missouri, United States.

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Honorary and Corresponding Members .

1881. Krafft-Ebing, R. V., M.D., Vienna.

1866. Laehr, H., M.D., Schweizer Hof, bei Berlin, Editor of the Zeiteckrifl fur
Peychiatrie.

1887. Lentz, Dr., Asile d’Alidn£s, Tonrtiai, Belgique.

1898. MacDonald, A. E., M.D., Manhattan Asylum, Hew York, U.S.A.

1898. Magnsn, V., M.D., Asile de Ste. Anne, Paris.

1871.1 Manning, Frederick Horton, M.D.St. And., M.R.C.S. Eng., Inspector of
1884. J Asylums, 147, Macquarie Street Horth, Sydney, Hew South Wales.
1866. \ Mitchell, Sir Arthur, M.D.Aberd., LL.D., K.C.B., late Commissioner in
1871. J Lunacy for Scotland; 84, Drummond Place, Edinburgh.

1897. Morel, M. Jules, M.D., States Lunatic Asylum, Mons, Belgium.

1880. Motet, M m 161, Rue de Charonne, Paris.

1889. Heedham, Frederick, M.D.St And., M.R.C.P.Edin., M.R.C.S.Eng.,
Commissioner in Lunacy, 19, Campden Hill Square, Kensington,
W. (PBB8n>xvT, 1887.)

1891. (yFarrell, Sir G. P., M.D., M.Ch.Univ. Dubl., Inspector of Lunatics in
Ireland, 19, Fitzwilliam Square, Dublin.

1881. Peeters, M., M.D., Gheel, Belgium.

1878. Pitman, Sir Henry A., M.D.Cantab., F.R.C.P.Lond., Registrar of the
Royal College of Physicians, Enfield, Middlesex.

1900. Ritti, Ant., Maison Hationale de Charenton, St. Maurice, Paris. ( Corr .

Mem., 1890.)

1886. Roussel, M. Thlophile, M.D., Sdnateur, Paris.

1887. Schfile, Heinrich, M.D., lllenau, Baden, Germany.

1880. Sibbald, Sir John, M.D.Edin., F.R.C.P.Edin., M.R.C.S.Eng., Commis¬

sioner in Lunacy for Scotland; 18, Great King Street, Edinburgh.
(Editor of Journal, 1871-2.)

1888. Stearns, H. P., M.D., The Retreat, Hartford, Conn., TJ.S.A.

1881. Tamburiui, A., M.D., Reggio-Emilia, Italy.

1901. Toulouse, Dr. Edouard, Editor of the Revue de Peychiatrie, Asile de

Villejuif, Seine, France.

1881. Virchow, Prof. R., University, Berlin.

CORRESPONDING MEMBERS.

1896. Bianchi, Prof. Leonardo, Manicomio Provinciale di Hapoli.

1897. Buschan, Dr. G., Stettin, Germany.

1896. Cowan, F. M., M.D., 107, Perponcher Straat, The Hague, Holland.

1880. Komfeld, Dr. Hermann, Gleiwitz, Silesia, Germany.

1889. Kowalowsky, Professor Paul, Kharkoff, Russia.

1896. Lindell, Emil Wilhelm, M.D., Sweden.

1901. Manheimer-Gommfes, Dr., 32, Rue de 1’Arcade, Paris.

1897. Hicke, Dr. P., Hubertusberg Asylum, Leipzig.

1886. Parant, M. Victor, M.D., Toulouse.

1890. R6gis, Dr. E., 54, Rue Huguerie, Bordeaux.

1898. Semelaigne, Dr. Rln6, Secretaire des Stances de la Soci6t4 Mldico-

Psychologique de Paris, 16, Avenue de Madrid, Heuilly,Seine, France.

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MEMBERS OF THE ASSOCIATION.

Alphabetical Lift of Members of the Association, with the year in which they
joined. The Asterisk means Members who joined between 1841 and 1866.

1900. Abbott, Arthur J., M.D., B.Ch., B.A.O., T.C.Dublin, Hants County
Asylum, Fareham.

1900. Abbott, Henry Kingswell, M.B., B.Ch., M.D.Dublin, D.P.H.Ireland.

Hants County Asylum, Fareham.

1891. Adair, Thomas Stewart, M.B., C.M.Edin., Assistant Medical Officer

and Pathologist, Wadsley Asylum, near Sheffield.

1874. Adam, James, M.D.St. And., West Mailing, Kent.

1868. Adams, Josiah 0., M.D.Durh., F.R.C.S.Eng., Brooke House, Upper

Clapton, London.

1880. Agar, S. H., L.R.C.P.I., Glendossil, Henley-in-Arden.

1886. Agar, S. Hollingsworth, juu., B.A.Cantab., M.R.C.S., Glendossil, Henley -

in-Arden.

' 1901. Ahem, John M., L.R.C.P.&S.I., Assistant Medical Officer, Wameford
Asylum, Oxford.

1869. Aldridge, Chas., M.D.Aber., L.R.C.P., Plympton House, Plympton,

Devon.

1899. Alexander, Hugh de Maine, M.D., District Asylum, Murthly, Perth, N.B.

1890. Alexander, Robert Reid, M.D.Aber., Medical Superintendent, Han well

Lunatic Asylum.

1899. Allen, John Gower, L.R.C.P.&S.l., Part Proprietor, The Retreat,
Armagh.

1882. Alliott, A. J., M.D., Rosendal, Sevenoaks.

1899. Allmann, Dorah Elizabeth, M.B., B.Ch., B.A.O.R.U.I., Assistant Medical

Officer, District Asylum, Armagh.

1901. Ambler, John Richardson, M.R.C.S., L.R.C.P.Lond., Senior Assistant

Medical Officer, County Asylum, Chester.

1885. Amsden, G., M.B., Medical Supt., County Asylum, Brentwood, Essex.
1901. Anderson, James, M.B., C.M., Assistant Medical Officer, County Asylum,
Winterton, Ferryhill, Durham.

1900. Anderson, John Charles, M.D.Durh., Darenth Asylum, Dartford, Kent.
1896. Anderson, John Sewell, M.R.C.S., L.R.C.P., Assistant Medical Officer,

Hull City Asylum, Willerby, near Hull.

1901. Anderson, W. C., M.B., C.M., Fife and Kinross District Asylum,

Cupar, Fife.

1894. Andriezen, W. Lloyd, M.D.Lond., 7, Apsley Terrace, Acton, W.

1894. Angus, Charles, M.B., C.M., Royal Infirmary, Aberdeen.

1887. Aplin, A., M.R.C.S.E. and L.R.C.P.Lond., Medical Superintendent,

County Asylum, Sneinton, Nottingham.

1898. Astbury, Thomas, M.R.C.S., L.R.C.P., Market Bosworth, near Nuneaton.

1892. Atherstone, Walter H., M.D., Surgeon-Superintendent, Port Alfred

Asylum, South Africa.

1891. Aveline, Henry T. S., M.R.C.S., L.R.C.P., M.P.C., Medical Superin¬

tendent, County Asylum, Cotford, near Taunton, Somerset.

1894. Baily, Percy J., M.B.Edin., Senior Assistant Medical Officer, London
County Asylum, Hanwell, W.

1878. Baker, H. Morton, M.B.Edin., Assistant Medical Officer, Leicester Borough
Asylum, Humberstone, Leicester.

1888. Baker, John, M.B., 8, Lyndhurst Square, Peckham, S.E.

1876. Baker, Robert, M.D.Edin., Visiting Physician, The Retreat, York, 41,
The Mount, York. (President, 1892.)

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vi Members of the Association .

1900. Barnes, Joseph Sandert, M.R.C.S.Eng., L.R.C.P.Lond., 3, Lyndharst

Square, Peck ham, S.E.

1901. Barnett, Horatio, M.B., B.C.Cantab., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Stretton House, Church Stretton, Salop.

1895. Barraclough, Herbert, M.B., The Asylum, Parirua, nr. Wellington, New

Zealand.

1878. Barton, James Edward, L.R.C.P.Edin., L.M., M.R.C.S., Medical Superin¬

tendent, Surrey Count}’ Lunatic Asylum, Brookwood, Woking.

1901. Barwell, Francis B., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Darenth Asylum, Hartford, Kent.

1901. Baskin, J. Longheed, L.K.C.P.&S.Edio., L.F.P.S.Glas., Assistant
Medical Officer, County Asylum, Exminster, Devon.

1864. Bayley, J., M.R.C.S., Medical Superintendent, St. Andrew's Hospital,
Northampton.

1893. Bayley, Joseph Herbert, M.B., C.M.Edin., Assistant Medical Officer,

St. Andrew's Hospital, Northampton.

1874. Beach, Fletcher, M.B., F.R.C.P.Lond., formerly Medical Superintendent,
Darenth Asylum, Hartford; Winchester House, Kingston Hill,
Surrey, and 79, Wimpole Street, W. ( General Secretary , 1889—
1896. President, 1900—1901.)

1892. Beadles, Cecil F., M.R.C.S., L.R.C.P., Assistant Medical Officer, Colney
Hatch Asylum.

1896. Beamish, George, L.R.C.S.I., L.R.C.P.E., L.M., Medical Officer's House,

H.M. Prison, Wandsworth, London, S.W.

1881. Benham, H. A., M.D., Medical Superintendent, City and County Asylum,
Stapleton, near Bristol. (Registrar.)

1899. Beresford, Edwyn H., M.R.C.S. & M.R.C.P.Lond., Darenth Asylum,
Dartford, Kent.

1894. Bernard, Walter, F.R.C.P.I., M.R.C.S.Eng., 14, Queen Street,

Londonderry.

1894. Blachford, James Vincent, M.B., B.S.Durham, Assistant Medical Officer,

Bristol Asylum, Fishponds, near Bristol.

1899. Blackwood, Catherine Mabel, L.R.C.P.&S., L.F.P.&S.Glasg., Wadsley

Asylum, near Sheffield.

1898. Blair, David, M.A., M.B., C.M., County Asylum, Lancaster.

1883. Blair, Robert, M.D., Medical Superintendent, Woodilee Asylum, Lenzie,
near Glasgow.

1901. Blake, Thomas Frederick Hillyer, L.R.C.P.&S.Edin., Assistant Medical
Officer, District Asylum, Inverness, N.B.

1879. Blanchard, E. S., M.D., Medical Superintendent, Hospital for Insane,

Charlotte Town, Prince Edward's Island.

1857. Blandford, George Fielding, M.D.Oxon., F.R.C.P.Lond., 48, Wimpole
Street, W. (President, 1877.)

1897. Blandford, Joseph John Guthrie, B.A., D.P.H.Camb., M.R.C.S.Eng.,

L.R.C.P.Lond., Assistant Medical Officer, County Asylum, Whit-
tingham, Preston, Lancs.

1888. Blaxland, Herbert, M.R.C.S., Medical Superintendent, Callan Park
Asylum, New South Wales.

1895. Bodington, George Fowler, M.D.Durh., F.R.C.S.Eng., M.R.C.P.Lond.,

Hdtel Duna, Paris, France.

1897. Bois, Charles A., L.R.C.S., L.R.C.P.Edin., Waverley Lodge, St. Saviours
Road, Jersey.

1900. Bolton, Joseph Shaw, M.D., B.S., B.Sc.Lond., Claybury Hall, Woodford

Bridge, Essex.

1892. Bond, Charles Hubert, D.Sc., M.D., Ch.M.Edin., Senior Assistant Medical

Officer, London County Asylum, The Heath, Bexley, Kent.

18-77. Bower, David, M.D.Aber., Springfield House, Bedford.

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A., Medical Superintendent,
County Asylum, Devizes, Wilts.

1893. Bowes, William Henry, M.D.Lond., Assistant Medical Officer, Plymouth

Borough Asylum, Ivy bridge, Devon.

Digitized by v^,ooQLe

Members of the Association. vii

1900. Bowles, Alfred, M.R.C.S., L.B.C.P., 10, South Cliff, Eastbourne.

1896. Boycott, A. N., M.D.Lond., M.R.C.S.Eng., L.R.C.P.Lond., Medical
Superintendent, Herts County Asylum, Hill End, St. Albans, Herts.

1898. Boyle, A. Helen A., M.D., 3, Palmeira Terrace, Hove, Brighton.

1883. Boys, A. H., L.R.C.P.Edin., Chequer Lawn, St. Albans.

1891. Braine-Hartnell, George, L.R.C.P.Lond., M.R.C.S.Eng., Medical Super¬

intendent, County and City Asylum, Powick, Worcester.

1893. Bramwell, John Milne, M.B., C.M.Edin., 2, Henrietta Street, Cavendish
Square, London, W.

1881. Brayn, R., L.R.C.P.Lond., Medical Superintendent, Broadmoor Asylum,
Crowthorne, Berks.

1895. Briscoe, John Frederick, M.R.C.S.Eng., Resident Medical Superintendent,

Westbrooke House Asylum, Alton, Hants.

1892. Bristowe, Hubert Carpenter, M.D.Lond., Wrington, R.S.O., Somerset.

1864. Brodie, David, M.D.St. And., L.R.C.S.Edin., 68, Hamilton Road,

London, N.

1891. Bruce, John, M.B., C.M.Edin., M.P.C., Lauriston Town Hall Square,

Grimsby.

1893. Bruce, Lewis C., M.B.Edin., Druid Park, Murtbly, N.B.

• Brushfield, Thomas N., M.D.St. And., Budleigh Sal ter ton, Devon.

1896. Bubb, William, M.R.C.S., L.R.C.P.Lond., Second Assistant Medical

Officer, Worcester County Asylum, Powick, near Worcester.

1892. Bullen, Frederick St. John, M.R.C.S.Eng., 12, Pembroke Road, Clifton,

Bristol.

1869. Burman, Wilkie J., M.D.Edin., Ramsbury, Hungerford, Berks.

1891. Caldecott, Charles, M.B., B.S.Lond., M.R.C.S., Medical Superintendent,
Earlswood Asylum, Redhill, Surrey.

1889. Callcott, J. T., M.D., Medical Superintendent, Borough Asylum, New-
castle-on-Tyne.

1874. Cameron, John, M.D.Edin., Medical Superintendent, Argyll and Bute
Asylum, Lochgilphead.

1894. Campbell, Alfred Walter, M.D.Edin., Pathologist, County Asylum,

Rainhill, near Prescot, Lancashire.

1880.. Campbell, P. E.. M.B., C.M., Senior Assistant Medical Officer, District
Asylum, Caterham.

1897. Campbell, Robert Brown, M.B., C.M.Edin., Assistant Medical Officer,

Royal Asylum, Montrose, N.B.

1897. Cappe, Herbert Nelson, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Surrey County Asylum, Brookwood.

1891. Carswell, John, L.R.C.P.Edin., L. F.P.S.Glasg., Certifying Medical Officer,
Barony Parish, 5, Royal Crescent, Glasgow.

1896. Cashman, James, M.B., B.Cb., B.A.O.Royal Univ. Irel., Assistant Medical
Officer, Cork District Asylum.

1874. Cassidy, D. M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Public Health)
Edin., F.R.C.S.Edin., Medical Superintendent, County Asylum,
Lancaster.

1899. Chaldecott, John Henry, L.R.C.P.Lond., F.F.P.S.Glasg., 2, Lancaster

Road, Hampstead, N.W.

1888. Chambers, James, M.D., M.P.C., The Priory, Roehampton.

1865. Chapman, Thomas Algernon, M.D.Glns., L.R.C.S.Edin., Betula, Reigate.
1880. Christie, J. W. Stirling, M.D., Medical Superintendent, County Asylum,

Stafford.

Digitized by v^,ooQLe

viii Members of the Association.

1878. Clapham, Win. Crochley 8.. M.D., M.R.C.P., The Gablet, Mayfield,

Sussex.

1879. Clarke, Henry, L.R.C.P.Lond., H.M. Prison, Wakefield.

1901. Cleland, William Lennox, M.B., B.Ch.Edin., Park Side, South Australia*
1862. Clouston, T. S., M.D.Edin., F.R.C.P.Edin., F.R.S.E., Physician Super¬
intendent, Royal Asylum, Moruingside, Edinburgh. ( Editor of
Journal , 1873—1881.) (President, 1888.)

1879. Cobbold, C. S. W., M.D., The Elms, Batbeaston, Bath.

1900. Coffey, Patrick, L.R.C.P.&S.I., District Asylum Limerick, Ireland.

1892. Cole, Robert Henry, M.D.Lond., M.R.C.P.Loud., 48, Upper Berkeley

Street, W.

1900. Cole, Sydney John, B.A., M.B., B.Ch.Oxon., Colney Hatch Asylum,
London, N.

1896. Coles, Richard Ambrose, Barliam, near Canterbury.

1888. Cones, John A., M.R.C.S., Burgess Hill, Sussex.

1895. Conry, John, M.D.Aber., Fort Beaiufort Asylum, South Africa.

1900. Cook, John Benson, L.R.C.P.&S.Ed., Medical Officer H.M. Prison, Borstal,

Rochester.

1878. Cooke, Edward Marriott. M.D., M.R.C.S.Eng., Commissioner in Lunacy,
69, Onslow Square, S.W.

1899. Cooke, J. A., Medical Officer and Co-Licensee, Tue Brook Villa, near
Liverpool.

1901. Cooper, K. D., M.R.C.S.Eng., Assistant Medical Officer, The Lawn,

Lincoln.

1891. Corner, Harry, M.B.Lond., M.R.C.S., L.R.C.P., M.P.C., Brooke House,

Southgate, N.

1897. Cotton, William, M.A., M.D.Edin., D.P.H.Cantab., 231, Gloucester Road,

Bishopston, Bristol.

1893. Coweu, Thomas Phillips, M.B., B.S.Lond., Assistant Medical Officer,

County Asylum, Prestwich, Manchester.

1899. Cowper, Alfred, M.A., M.B., C.M.Edin., Valkenburg Asylum, Mowbray,
Cape Town.

1884. Cox, L. F., M.R.C.S., Medical Superintendent, County Asylum, Denbigh.

1878. Craddock, F. H., B.A.Oxon., M.R.C.S.Eng., L.S.A., Medical Superin¬
tendent, County Asylum, Gloucester.

1892. Craddock, Samuel, M.R.C.S.Eng., South Hill House, South Lyncombe,

Bath.

1893. Craig, Maurice, M.A., M.B., B.C.Cantab., M.R.C.P.Lond., Assistant

Medical Officer, Bethlem Royal Hospital, Southwark.

1897. Cribb, Harry Gifford, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical

Officer, Loudon County Asylum, Canehill, Surrey.

1898. Crookshank, F. G., M.D.Lond., M.R.C.S., L.R.C.P., 82, White Hart

Lane, Barnes, S.W.

1894. Cullinan, Henry M., L.R.C.P.I., L.R.C.S.I., Second Assistant Medical

Officer, Richmond District Asylum, Dublin.

1869. Daniel, W. C., M.D.Heidelb., M.R.C.S.Eng., Epsom, Surrey.

1899. Daunt, Elliot, M.R.C.S., L.R.C.P., D.P.H., Rosendal, Sevenoaks, Kent.

1896. Davidson, Andrew, M.B., C.M.Aber., Assistant Medical Officer, County

Asylum, Dorchester.

1868. Davidson, John H., M.D.Edin., Delamere House, Liverpool Road,
Chester.

Digitized by v^,ooQLe

Members of the Association . ix

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,

County Asylum, Exminster, Devon.

1894. Dawson, William R.,M.D., B.Ch.Dubl., F.R.C.P.I., Medical Superinten¬

dent, Farnhatn House Asylum, Finglas, Dublin.

1869. Deas. Peter Maury, M.B. and M.S.Lond., Medical Superintendent,
Wonford House, Exeter.

1900. Despard, Rosins C., M.D.Lond., Holloway Sanatorium, Virginia Water,

Surrey.

1901. De Steiger, Adfele, M.B.Lond., County Asylum, Brentwood, Essex.

1876. Dickson, F. K., F.R.C.P.Edin., Wye House Lunatic Asylum, Buxton

Derbyshire.

1879. Dodds, William J., M.D., D.Sc.Edin., Valkenburg, Mowbray, near Cape
Town, South Africa.

1886. Donaldson, Robert Lockhart, B.A., M.D., B.Ch.Univ. of Dubl., M.P.C.,
Senior Medical Officer, District Asylum, Monaghan.

1889. Donaldson, William Ireland, B.A., M.B., B.Ch.Univ. of Dubl., Assist¬

ant Medical Officer, London County Asylum, Canehill, Purley,
Surrey.

1892. Donelan, J. O’C., L.R.C.P.I., L.R.C.S.I., M.P.C., First Assistant Medical

Officer, Portland House, Donabate, co. Dublin.

1899. Donelan, Thomas O’Conor, L.R.C.P. & L.R.C.S.lreland, Mens ton Asylum*
near Leeds.

1898. Donnellan, Robert Vincent, L.R.C.P., L.R.C.S.Ed., Inisfail, 2, Lewisham

Park, S.E.

1891. Douglas, Archibald Robertson, L.R.C.S., L.R.C.P.Edin., Royal Albert
Asylum, Lancaster.

1890. Douglas, William, M.D.Queen’u Uuiv. Irel., M.R.C.S.Eng., Brandfold,

Goudhurst.

1897. Dove, Emily Louisa, M.B.Lond.

1884. Drapes, Thomas, M.B., Medical Superintendent, District Asylum, Ennis-
corthy, Ireland.

1899. Dudley, Francis, L.R.C.P.&S.I., Senior Assistant Medical Officer,

County Asylum, Bodmin, Cornwall.

1899. Eades, Albert J., County Asylum, Rainhill, nr. Liverpool.

1874. Eager, Reginald, M.D.Lond., M.R.C.S.Eng., North woods, near Bristol.
1873. Eager, Wilson, L.R.C.P.Lond., M.R.C.S.Eng., Northwoods, Wiuter-
bourne, Bristol.

1881. Earle, Leslie, M.D.Edin., 108, Gloucester Terrace, Hyde Park, W.

1891. Earls, James Henry, M.D., M.Ch., Ac., 71, Brighton Square, Dublin.

1895. Kasterbroolc, Charles C., M.A., M.D., M.R.C.P.Ed., Assistant Medical

Officer, Craig House, Morniugside Drive, Edinburgh.

1895. Edgerly, Samuel, M.B., C.M.Edin., Assistant Medical Officer, West Riding
Asylum, Menston, nr. Leeds.

1900. Edridge-Green, F. W., M.D., F.R.C.S., Hendon Grove, Hendon, N.W.

1897. Edwards, Francis Henry, M.D.Brux., L.R.C.P.Lond., M.R.C.S.Eug.,

Assistant Medical Officer, Camberwell House, S.E.

1901. Elgee, Samuel Charles, L.R.C.P., L.R.C.S.Ire., Assistant Medical Officer,

Horton Manor Asylum, Epsom, Surrey.

1889. Elkins, Frank Ashley, M.D., Medical Superintendent, Metropolitan
Asylnm, Leavesden.

1898. Ellerton, H. B., M.R.C.S., L.R.C.P., County Asylum, Nottingham.

Digitized by tjOOQle

x Members of the Association .

1873. Elliot, Q. Stanley, M.R.C.P.Edin., F.R.C.S.Edin., Medical Superintendent,
Cater ham, Surrey.

1900. Ellis, Henry Reginald, M.R.C.S., L.R.C.P.Lond.

1890. Ellis, William Gilmore, M.D.firuz., Superintendent, Government Asylum,

Singapore.

1899. Ellison, Eras. C., M.B., B.Ch., T.C.D., Assistant Medical Officer, District
Asylum, Castlebar.

1901. Elsworth, T. G., M.B., C.M.Edin., Assistant Medical Officer aud Patholo¬

gist, County Asylum, Winterton, Ferry hill, Durham.

1901. Erskine, Wm. J. A., M.D., C.M., Senior Assistant Medical Officer, City
Asylum, Nottingham.

1895. Enrich, Frederick William, M.D., C.M.Edin., 7, Liudum Terrace, Brad*
ford, Yorks.

1894. Eustace, Henry Marcus, M.B., B.Ch., B.A.Univ. Dublin, Assistant Physi¬
cian, Hampstead and Highfield Private Asylum, Glasnevin, Dublin.
1901. Evans, James Wm., M.R.C.S., L.S.A.. Lieut.-Col. Indian Medical Service
(retired). The Grange, Hogbourne, Didcot.

1897. Everett, William, M.D., Assistant Medical Officer, County Asylum, Chart-
ham Downs, Kent.

1891. Ewan, John Alfred, M.A., M.B., C.M.Edin., M.P.C., Medical Superin¬

tendent, Kesteven aud Grantham District Asylum.

1884. Ewart, C. T., M.B., C.M.Aberd., Claybury Asylum, Woodford Bridge,
Essex.

1894. Farquliarson, William F., M.D.Edin., Medical Superintendent, Counties
Asylum, Garlands, Carlisle.

1901. Fee, Wm. George, L.R.C.P. and L.R.C.S.Edin., Assistant Medical Officer,
Brooke House, Upper Clapton, N.E.

1897. Fielding, James, M.D., Victoria Univ., Canada, M.R.C.S.Eng., L.R.C.P.

Edin., Medical Superintendent, Bethel Hospital, Norwich.

1878. Finch, John E. M., M.D., Medical Superintendent, Borough Asyluifi,
Leicester.

1889. Finch, Richard T., B.A., M.B.Cantab., Resident Medical Officer, Fisherton
House Asylum, Salisbury.

1867. Finch, W. Corbin, M.R.C.S.Eng., Fisherton House, Salisbury.

1901. Findlay, John, M.B., Ch.B.Aber., Assistant Medical Officer, County
Asylum, Dorchester, Dorset.

1882. Finegan, A. D. O’Connell, L.R.C.P.I., Medical Superintendent, District
Asylum, Mullingar. (Hon. Secretary for Ireland.)

1889. Finlay, Dr., County Asylum, Bridgend, Glamorgan.

1898. Finn, P. Taafle, L.R.C.P., L.R.C.S.Ed., County Asylum, Newport, Isle of

Wight.

1891. Finny, W. E. St. Lawrence, M.B.Univ. Irel., Kenlis, Queen’s Road,
Kingston Hill, Surrey.

1894. Fitzgerald, Charles E., M.D., F.R.C.S.I., Surgeon-Oculist to the Queen in
Ireland, 27, Upper Merrion Street, Dublin.

1888. Fitzgerald, G. C., M.B., B.C.Cantab., M.P.C., Medical Superintendent,
Kent County Asylum, Chartham, nr. Canterbury.

1899. Fitzgerald, James J., M.B., B.Ch., B.A.O.R.U.I., Assistant Medical Officer,

District Asylum, Carlow.

1901. Fitzgerald, John J., M.D.Brux., L.R.C.P.AS.Edin., Assistant Medical
Officer, District Asylum, Cork.

1900. Fleck, David, M.B., Ch.B., B.A.O.Ireland, Caterham Asylum, Surrey.
1899. Flemmings, A. L., M.R.C.S.Eng., L.R.C.P.Lond., City and County

Asylum, Fishponds, Bristol.

1872. Fletcher, Robert Vicars, Esq., F.R.C.S.I., L.R.C.P.I., L.R.C.P.

Edin., Medical Supt., District Asylum, Ballinasloe, Ireland.

Digitized by v^,ooQLe

Members of the Association. xi

1804. Fleury, Eleonora Lilian, M.D., B.Ch., R.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

1899. Forsyth, Charles E. P., M.B., Ch.B., Eastern Hospital, The Grove,
Homerton, N.E.

1880. Fox, Bonville Bradley, M.A.Oxon., M.D., M.R.C.S., Brislington House,

Bristol.

1861. Fox, Charles H., M.D.St. And., M.R.C.S.Eng., 35, Heriot Row,
Edinburgh.

1896. France, Eric, M.B., B.S.Durh., Assistant Medical Officer, Claybury
Asylum, Woodford Bridge, Essex.

1881. Fraser, Donald, M.D., 3, Orr Square, Paisley.

1901. French, Louis Alexander, M.R.C.S., L.R.C.P., Betlilem Royal Hospital,
Lambeth, S.E.

1899. Frend, Eustace C.. M.R.C.S., L.R.C.P., Belmont, Hawke Road, Upper
Norwood, S.E.

1893. Garth, H. C., M.B., C.M.Edin., 4, Harrington Street, Calcutta, India.
1867. Gasquet, J. R., M.B.Lond., St. George’s Retreat, Burgess Hill, and 1,
College Gate, Brighton.

1890. Gaudin, Francis Neel, M.R.C.S., L.S.A., M.P.C., Medical Superintendent,
The Grove, Jersey.

1885. Gay ton, F. C., M.D., Brook wood Asylum, Surrey.

1896. Geddes, John W., M.B., C.M.Edin., Assistant Medical Officer, Durham

County Asylum, Wiuterton, Ferryhill, Durham.

1892. Gemmel, James Francis, M.B.Glosg., Assistant Medical Officer, County
Asylum, Lancaster.

1889. Gibbon, William, L.R.C.P.I., L.F.P.S.Glasg., Senior Assistant Medical
Officer, Joint Counties Asylum, Carmarthen.

1899. GilAllan, Samuel James, M.A., M.B.Edin., London County Asylum, Cane-
hill, Purley, Surrey.

1898. Gill, Frank A., M.D., C.M.Aber., Deputy Medical Officer, H.M. Prison,

Liverpool.

1889. Gill, Stanley, B.A., M.D., M.R.C.P.Lond., Shaftesbury House, Formby,
Lancashire.

1897. Gilmour, John Rutherford, M.B., C.M.Edin., Assistant Physician,

Crichton Royal Institution, Dumfries.

1901. Glasgow, John George, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Borough Asylum, Portsmouth.

1878. Glendinning, James, M.D.Glasg., L.R.C.S.Edin., L.M., Medical Super¬
intendent, Joint Counties Asylum, Abergavenny.

1898. Goldie-Scot, Thomas, M.B., C.M.Edin., M.R.C.S., L.R.C.P., Junior

Assistant Physician, Royal Asylum, Gartnavel, Glasgow.

1899. Goldschmidt, Oscar Bernard, M.B., Ck.B.Vict., 8, Park Place, St.

James’s, S.W.

1897. Good, Thomas Saxty, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, County Asylum, Littlemore, Oxford.

1889. Goodall, Edwin, M.D., M.S.Lond., M.P.C., Medical Superintendent,
Joint Counties Asylum, Carmarthen.

1899. GoodlifFe, John Henry, Morton Hall, near Sheffield.

1899. Gordon, J. Leslie, M.B., Ch.B., County Asylum, Devizes, Wilts.

• Gordon, W. S., M.B., District Asylum, Mullingar.

1901. Gostwyck, C. H. Q., M.B., Ch.B., Medical Officer, Kent Lunatic Asylum,
Chartham Downs, nr. Canterbury.

1899. Graham, R. A. L., B.A., M.B., B.Ch., R.U.I., Assistant Medical Officer,
District Asylum, Belfast.

Digitized by v^,ooQLe

xii Members of the Association.

1894. Graham, Samuel, L.R.C.P.Lond., Assistant Medical Officer, District
Asylum, Antrim.

1888. Graham, T., M.D.Glasg., 8, Garth land Place, Paisley.

1887. Graham, W., M.D. (R.U.I.), Medical Superintendent, District Lunatic
Asylum, Belfast.

1890. Gramshaw, Farbrace Sidney, M.D., L.R.C.P.Irel., L.R.C.S.Edin., L.M.,

L.A.H.Dubl., The Villa, Stillington, Yorkshire.

1897. Grant-Wilson, Charles Westbrook, L.R.C.P.Lond., M.R.C.S.Eng.,
St. Winnows, Bromley, Kent.

1886. Greenlees, T. Duncan, M.B., Medical Superintendent to the Grahams-
town Asylum, Cape of Good Hope.

1900. Gregor, £. W., M.R.C.S., L.R.C.P., Peckham House, Peckham, S.E.
1896. Greene, Thomas Adam, Assistant Medical Officer, District Asylum, Ennis,

Ireland.

1894. Griffin, Edward W., M.D., M.Ch., R.W.I., Assistant Medical Officer, The
Asylum, Killarney.

1896. Griffiths, George Batlio G., M.R.C.S., L.R.C.P.Lond., Assistant Surgeon,

H.M. Convict Prison, Parkhurst, Isle of Wight.

1901. Grills, Galbraith Hamilton, M.B., B.Ch., Assistant Medical Officer,

County Asylum, Chester.

1900. Grove, Ernest George, M.R.C.S., L.R.C.P., York Lunatic Hospital,

Bootham, York.

1894. Gwynn, Charles Henry, M.D.Edin., co-Licensee, St. Mary's House,
Whitchurch, Salop.

1879. Gwynn, S. T., M.D., St. Mary's House, Whitchurch, Salop.

1894. Halstead, Harold Cecil, M.D.Durh., Assistant Medical Officer, Peckham

House, Peckham.

1896* Han bury, William Reader, M.R.C.S., L.R.C.P., County Asylum, Brent¬
wood, Essex.

1901. Hannay, Mary Baird, M.B., C.M., Gartloch Asylum, Gartcosh, Glasgow,

N.B.

1901. Harding, William, M.D., M.R.C.P.Loud., Medical Superintendent,
Northampton County Asylum, Berry Wood, Northampton.

1899. Harmer, W. A., L.S.A., Resident Superintendent and Licensee, Redlauds

Private Asylum, Tonbridge, Kent.

1895. Harper, Thomas Edward, L.R.C.P.Lond., M.R.C.S.Eng., Assistant

Medical Officer, St. Ann's Heath, Virginia Water.

1897. Harris, William, M.D.St. And., F.R.C.S.Edin., M.R.C.P.Edin., Medical

Superintendent, City Asylum, Hellesdon, Norwich.

1898. Harris-Liston, L., M.D., M.R.C.S., L.R.C.P.Lond., L.S.A., City Asylum,

Digbys, Exeter.

1886. Harvey, Crosbie Bagenal, L.A.H., Assistant Medical Officer, District
Asylum, Clonmel.

1892. Haslett, William John, M.R.C.S., L.R.C.P., Resident Medical Superin¬
tendent, Halliford House, Sunbury-on-Thames.

1891. Havelock, John G., M.B., C.M.Edin., Physician Superintendent, Montrose

Royal Asylum.

1890. Hay, Frank, M.B., C.M., Physician Superintendent, Ashburn Hall Asylum,
Dunedin, New Zealand.

1900. Haynes, Horace E., M.R.C.S., L.S.A., Bishops tow House, Bedford.

1895. Hoarder, Frederic P., M.D., C.M., Assistant Medical Officer, West

Riding Asylum, Waketield.

1885. Henley, E. W., L.R.C.P., Barn wood House, Gloucester.

1899. Herbert, W. W., M.D., C.M.Edin., North Wales Counties Asylum,

Denbigh, North Wales.

Digitized by tjOOQle

Members of the Association . xiii

1877. Hetberington, Charles, M.B., Medical Superintendent, District Asylum,
Londonderry, Ireland.

1877. Hewaon, R. W. v L.R.C.P.Edin., Medical Superintendent, Cotton Hill,

Stafford.

1891. Heygate, William Harris, M.R.C.S.Eng., L.S.A., Cranmere, Cosharo,
Hants.

1888. Hill, Dr. H. Gardiner, Medical Superintendent, Middlesex County Asylum,
Tooting.

1900. Hill, J. R.,M.R.C.S., L.R.C.P., Fenstanton, Christchurch Road, Streatham
Hill, S.W.

1857. Hills, William Charles, M.D.Aber., M.R.C.S.Eng., The Chantry,
Norwich.

1871. Hingston, J. Tregelles, M.R.C.S.Eng., Medical Superintendent, North
Riding Asylum, Clifton, Yorks.

1881. Hitchcock, Charles Knight, M.D., Bootham Asylum, York.

1900. Holl&nder, Bernard, M.D., M.R.C.S.. L.R.C.P., 62, Queen Anne Street,
London, W.

1898. Holmes, James, M.D.Edin., Overdale Asylum, Whitefield, Lancashire.

1896. Horton, James Henry, M.R.C.S.Eng., L.R.C.P.Lond., c/o Messrs. Watson,
8, Hornby Road, Bombay.

1894. Hotchkis, R. D., M.D., C.M., M.P.C., Assistant Physician, Royal Asylum>
Glasgow.

1900. Hughes, Percy T., M.B., Ch.M.Edin., London County Asylum, Bexley,
Kent.

1900. Hughes, George Osborne, M.D.Virginia, M.R.C.S., L.R.C.P., 16, Harvey
Road, Hornsey, London, N.

1867. Humphry, J., M.R.C.S.Eng , Medical Superintendent, County Asylum,
Stone, near Aylesbury, Bucks.

1896. Hungerford, Geoffrey, L.R.C.P., L.R.C.S., Wonford House Hospital,

Exeter.

1897. Hunter, David, M.A., M.B., B.C.Cantab., West Ham Borough Asylum,

Goodmayes, Ilford, Essex.

1882. Hyslop, James, M.D., Pietermaritzburg Asylum, Natal, South Africa.
1888. Hyslop, Theo. B., M.D., C.M.Edin., M.R.C.P.E., M.P.C., Bethlem

Royal Hospital, S.E.

1871. Ireland, W. W., M.D.Edin., 1, Victoria Terrace, Musselburgh, N.B.

1896. Isacke, Matthew W. S., M.R.C.S.Eng., L.R.C.P.Lond., North Foreland

Lodge, Broadstairs.

1866. Jackson, J. Hughlings, M.D.St. And., F.R.C.P.Lond., F.R.S., Physician
to the Hospital for Epilepsy and Paralysis, Ac., 3, Manchester
Square, London, W.

1893. Johnston, Gerald Herbert, L.R.C.S. and L.R.C.P.Edin., Ticehurst House,
Sussex.

1878. Johnstone, J. Carlyle, M.D., C.M., Medical Superintendent, Roxburgh

District Asylum, Melrose.

1880. Jones, D. Johnson, M.D.Edin., Medical Superintendent, Banstead Asylum,
Surrey.

1866. Jones, Bvan, M.R.C.S.Eng., Ty-mawr, Aberdare, Glamorganshire.

1882. Jones, Robert, M.D.Lond., B.S., F.R.C.8., Medical Superintendent,
London County Asylum, Claybury, Woodford, Essex. (Gen.
Secretary from 1897.)

1897. Jones. Samuel Lloyd, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical

Officer, London County Asylum, Colney Hatch. N.

1898. Jones, W. Ernest, M.R.C.S.Eng., L.R.C.P.Lond., Berry Wood Asylum,

Northampton.

1897. Jones, William Edward, Assistant Medical Officer, Earlswood Asylum,
Redhill.

Digitized by v^,ooQLe

xiv Members of the Association .

1900. Kay, Alfred Reginald, M.R.C.S.Eng., L.R.C.P.Lond., Middlesex County
Asylum, Tooting, S.W.

1879. Kay, Walter S., M.D., Medical Superintendent, South Yorkshire Asylum,
Wadsley, near Sheffield.

1886. Keay, John, M.B., Medical Superintendent, District Asylum, Inverness.

1899. Keegan, Lawrence Edward, M.D., Medical Superintendent, Lunatic
Asylum, St. John’s, Newfoundland.

1898. Kemp, Norah, M.B., C.M.Glas., The Retreat, York.

1899. Kennedy, Hugh T. J., L.R.C.P.&S.I., L.M., Assistant Medical Officer,

District Asylum, Enniscorthy.

1897. Kerr, Hugh, M.A., M.D.Glasg., Assistant Medical Officer, Bucks County

Asylum, Stone, Aylesbury, Bucks.

1898. Kershaw, Herbert Warren, M.R.C.S.Eng., L.R.C.P.Lond., Dinsdale Park,

near Darlington.

1897. Kesteven, William Henry, M.R.C.S.Eng., L.S.A.Lond,, 118, Stamford
Street, S.E.

1897. Kidd, Harold Andrew, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, West Sussex Asylum, Chichester.

1897. Kingdon, Wilfred Robert, M.B., B.S.Durh., 65, Haverstock Hill,

London, N.W.

1899. Kirwan, J. St. L., M.B., Ch.B., T.C.D., District Asylum, Ballinasloe,

Ireland.

1898. Labey, Julius, M.R.C.S., The Myrtles, St. Saviour’s, Jersey.

1900. Laing, Charles Frederick, M.B., C.M.Glasg., County Asylum, Wells,

Somerset.

1900. Lambert, Ernest Charles, M.R.C.S.Eng., L.R.C.P.Lond., London County
Asylum, Hanwell, W.

1896. Langdon-Down, Reginald L., M.B., B.C.Cantab., M.R.C.P.Lond.,
Normansfteld, Hampton Wick.

1898. Lavers, Norman, M.R.C.S., 33, Peckham Road, London, S.E.

1899. Law, Charles D., L.R.C.P.&S.Edin., L.F.P.G.S., Derby Borough Asylum,

Rowditch, Derby.

1892. Lawless, Dr. George Robert, A.M.O., District Asylum, Armagh.

1870. Lawrence, A., M.D., County Asylum, Chester.

1883. Layton, Henry A., L.R.C.P.Edin., Cornwall County Asylum, Bodmin.

1899. Leeper, R. R., F.R.C.S.I., Medical Superintendent, St. Patrick’s
Hospital, Dublin.

1883. Legge, R. J., M.D., Medical Superintendent, County Asylum, Derby.

1894. Lentagne, John, B.A., F.R.C.S.I., Medical Visitor of Lunatics to the
Court of Chancery, 5, Upper Merrion Street, Dublin.

1899. Lewis, H. Wolseley, M.R.C.S.Eng., L.R.C.P.Lond., Banstead Asylum,
Sutton, Surrey.

1879. Lewis, William Bevan, West Riding Asylum, Wakefield.

1863. Ley, H. Rooke, M.R.C.S.Eng., Medical Superintendent, County Asylum,
Prestwich, near Manchester.

1899. Ligertwood, Walter H., L.R.C.P., Wells Asylum, Somerset.

1900. Lindsay, David Lauder, L.R.C.P.&S.Edin.

1859. Lindsay, James Murray, M.D.St. And., F.R.C.S. and F.R.C.PJ2din,
26, Combe Park, Bath. (Pbbsidbvt, 1893.)

Digitized by v^,ooQLe

Members of the Association .

1888. Lisle, S. Ernest de, L.R.C.P.I., Three Counties Asylum, Stotfold, Baldock.

1899. Longworth, Stephen G., L.R.C.P. and S.I., County Asylum, Melton,
Suffolk.

1898. Lord, John R., M.B., C.M., Heath Asylum, Bexley, Kent.

1872. Lyle, Thomas, M.D.Glasg., 34, Jesmond Road, Newcastle-on-Tyne.

1899. Macartney, W. H. C., L.R.C.P.&S.I., The Grange, East Finchley,

London,N.

1880. MacBryan, Henry C., Kingsdown House, Box, Wilts.

1901. Macdonald, J. H., M.B., Ch.B.Glasg., Govan District Asylum, Hawk-
head, Paisley, N.B.

1884. Macdonald, P. W., M.D., C.M., Medical Superintendent, County Asylum,
near Dorchester, Dorset. (Hon. Sec . S.W. Division.)

1898. Macevoy, Henry John, M.D., B.Sc.Lond., M.P.C., 41, Buckley Road,

Brondesbury, London, N.W.

1895. Macfarlane, Neil M., M.D.Aber., Medical Superintendent, Government

Hospital, Thlotse Heights, Leribe, Basutoland, South Africa
1888. Macfarlane, W. H., M.B. and Cli.B.Univ. of Melbourne, Medical Super¬
intendent, Hospital for the Insane, New Norfolk, Tasmania.

1891. Mackenzie, Henry J., M.B., C.M.Edin., M.P.C., Assistant Medical Officer,
The Retreat, York.

1886. Mackenzie, J. Camming, M.B., C.M., M.P.C., late Medical Superin¬
tendent, District Asylum, Inverness; care of Mr. Mackenzie, Enzie
Station, Buckie, N.B.

1899. Mackeown, W. John, A.B., M.B., B.A., O.R.U.I., A.M.O., County Asylum,

Fareham, Hants.

* Mackintosh, Donald, M.D.Durh. and Glasg., L.F.P.S.Glasg., 10, Lancaster
Road, Belsize Park, N.W.

1878. Macleod, M. D., M.B., Medical Superintendent, East Riding Asylum,
Beverley, Yorks.

1901. Macleod, Neil, M.D., C.M.Edin., H.B.M. Consular Surgeon and Surgeon
General, The Hospital, Shanghai, China.

1899. MacLulich, Peers, M.B., B.C., B.A.Dubl., Joint Counties Asylum,
Carmarthen, S. Wales.

1899. Macmillan, Niel Harrismith, M.B.Edin., M.R.C.S.Eng., Claybury Asylum,

Woodford Bridge, Essex.

1898. Macnaughton, George W. F., M.D., Warwick Lodge, 436, Fulham Road,
London, S.W.

1882. Macphail, Dr. S. Rutherford, Derby Borough Asylum, Rowditch,
Derby.

1896. Macpherson, Dr. Charles, Deputy Commissioner in Lunacy, 51, Queen

Street, Edinburgh.

1886. Macpherson, John, M.B., M.P.C., 8, Darnaway Street, Edinburgh.

1901. MacRae, Duncan M., M.B., C.M., County Asylum, Devizes, Wilts.

1895. Madge, Arthur E., M.R.C.S.Eng., L.R.C.P.Lond.

1896. Magnire, Charles Evan, M.B., C.M., District Medical Officer, Old

Calabar, Southern Nigeria, W. C. Africa.

1896. Mallanah, S., M.B.Edin., Medical School, Hyderabad, Deccan, India.

1865. Manning, Harry, B.A.Lond., M.R.C.S., Laverstock House, Salisbury.

1900. Manning, Herbert C., M.R.C.S., L.R.C.P., County Asylum, Cotford, near

Taunton.

1896. Marr, Hamilton C., M.D.Glasg. Univ., Medical Superintendent*
Woodilee Asylum, Lenzie.

Digitized by v^,ooQLe

xvi Members of the Association.

1897. Marshall, John, M.B., C.M.Glasg., Assistant Medical Officer, County
Asylum, Bridgend, Glamorgan.

1896. Martin, James Clarke, L.R.C.S.I., L.M., L.R.C.P., Assistant Medical

Officer, District Asylum, Donegal.

1897. Mathieson, George, M.B., C.M.Glasg., Fir Vale, Sheffield.

1888. McAlister, William, M.B., C.M., The Elms, Kilmarnock, N.B.

1900. McClintock, John, L.R.C.P. & L.R.C.S.Edin., Resident Medical Super¬
intendent, Grove House, Church Stretton, Salop.

1900. McConaghey, J. C., M.B., C.M.Edin., Park side Asylum, Macclesfield,

Cheshire.

1886. McCreery, James Vernon, L.R.C.S.I., Medical Superintendent, Hospital

for Insane, New, Victoria.

1897. McCutchan, William Arthur, L.R.C.P.S.Edin., Assistant Medical Officer,

County and City Asylum, Hereford.

1876. McDowall, John Greig, M.B.Edin., Medical Superintendent, West

Riding Asylum, Menston, near Leeds.

1870. McDowall, T. W., M.D.Edin., L.R.C.S.E., Medical Superintendent,

Northumberland Couuty Asylum, Morpeth. (President, 1897.)
1899. McKelvey, Alexander Niel, L.&M.P.C.P.&S.I., District Asylum, Omagh,
co. Tyrone, Ireland.

1882. McNaughton, John, M.D., Medical Superintendent, Criminal Lunatic
Asylum, Perth.

1901. McRae, G. Douglas, M.B., C.M.Edin., Assistant Physician, Royal

Asylum, Morningside, Edinburgh.

1894. McWilliam, Alexander, M.B., C.M.Aber., Medical Superintendent,
Heigham Hall, Norwich.

1890. Menzies, W. F., M.D., B.Sc.Edin., Medical Superintendent, Stafford

County Asylum, Cheddleton, near Leek.

1891. Mercier, Charles A., M.B.Lond., F.R.C.S.Eng., Lecturer ou Insanity,

Westminster Hospital; Flower House, Catford, S.E.

1877. Merson, John, M.D.Aber., Medical Superintendent, Borough Asylum,

Hull.

1871. Mickle, William Julius, M.D., F.R.C.P.Lond., Medical Superintendent,

Grove Hall Asylum, Bow, London. (President, 1896.)

1867. Mickley, George, M.A., M.B.Cant&b., Fresh well House, Saffron Walden,
Essex.

1898. Middlemass, James, M.D., F.R.C.P., C.M., B.Sc.Edin., Borough Asylum,

Ryhope, Sunderland.

1898. Middleinist, George Edwyn, M.B., Moretonhampstead, Devon.

1888. Miles, George E., M.R.C.P., Ac., Medical Superintendent, Hospital for
the Insane, Rydaliuere, New South Wales.

1887. Miller, Alfred, M.B. and B.C.Dubl., Medical Superintendent, Hatton

Asylum, Warwick.

1893. Mills, John, M.B., B.Ch., and Diploma in Mental Diseases, Royal
University of Ireland, Assistant Medical Officer, District Asylum,
Ballinasloe.

1881. Mitchell, R. B., M.D., Medical Supt., Midlothian District Asylum.

1885. Molony, John, F.R.C.P.I., St. Edmuudsbury, Lucan, co. Dublin, Ireland.
1897. Montgomery, Sydney Hamilton Rowan, M.B., B.Ch., B.A.O., Royal
University, Ireland, Assistant Medical Officer, Borough Asylum,
Nottingham.

1878. Moody, James M., M.R.C.S.Eng., L.R.C.P.AL.M.Edin., Medical Super¬

intendent, County Asylum, Cane Hill, Surrey.

1885. Moore, E. E., M.B.Dubl., M.P.C., Medical Superintendent, District
Asylum, Letterkenny, Ireland.

1899. Moore, Wm. D., M.D., M.Ch., Medical Superintendent, Holloway

Sanatorium, Virginia Water, Surrey.

Digitized by v^,ooQLe

Members of the Association .

XVli

1892. Morrison, Cuthbert 8., L.R.C.P. and L.R.C.S.Edin., Medical Super*

intendent, County and City Asylum, Burghill, Hereford.

1896. Morton, W. B., M.B., Assistant Medical Officer, Brislington House,
Bristol.

1896. Mott, F. W., M.D., B.Sc., B.S., F.R.C.P.Loud., F.R.S., 25, Nottingham
Place, W.; Pathologist, London County Asylums; Assistant
Physician, Charing Cross Hospital.

1896. Mould, Q. E., M.R.C.S., L.R.C.P.Lond., The Grange, Rotherham, Yorks.
1862. Mould, George W., M.R.C.S.Eng., Medical Superintendent, Royal

Lunatic Hospital, Cheadle, Manchester. (President, 1880.)

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical

Officer, Royal Lunatic Hospital, Cheadle, Manchester.

1897. Mumby, Bonner Harris, M.D.Aber., D.P.H.Cautab., Medical Superin¬
tendent, Borough Asylum, Portsmouth.

1901. Munn, Patrick James, M.B., C.M.Edin., Assistant Medical Officer,
Three Counties Asylum, nr. Hitchin, Herts.

1893. Murdoch, James William Aitken, M.B., C.M.Glasg., Medical Superin¬

tendent, Berks County Asylum, Wallingford.

1900. Murphy, Jerome J., M.R.C.S., L.R.C.P.Lond., Banstead Asylum,

Sutton, Surrey.

1878. Murray, Henry G., L.R.C.P.Irel., L.M., L.R.C.S.I., Assistant Medical
Officer, Prestwich Asylum, Manchester.

1891. Musgrove, C. D., M.D.Edin., 8, Herbert Terrace, Penarth, S. Wales.

1880. Neil, James, M.D., M.P.C., Assistant Medical Officer, Warneford Asylum,

Oxford.

1875. Newington, Alexander, M.B.Camb., M.R.C.S.Eng., Woodlands, Tice-
hurst.

1873. Newington, H. Hayes. F.R.C.P.Edin., M.R.C.S.Eng., Ticehurst, Sussex.
(President, 1889.) ( Treasurer .)

1893. Newingtou, John, M.B.Edin., Zoffany House, Bushey Hall Road, Bushey,
Herts.

1881. Newth, A. H., M.D., Ardlin House, Haywards Heath, Sussex.

1869. Nieoleon, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
Balgownie, Edgeborough Road, Guildford. (President, 1895.)
1899. Nixon, J. C., M.B., West Riding Asylum, Menston, nr. Leeds.

1893. Nobbs, Atheist,me, M.B., C.M.Edin., 339, Queen's Road, Battersea Park,
S.W.

1888. Nolan, Michael J., L.R.C.P.I., M.P.C., Medical Superintendent, District
Asylum, Downpatrick.

1892. Noott, Reginald Harry, M.B., C.M.Edin., Senior As-istant Medical

Officer, Broadmoor Criminal Lunatic Asylum, Crowthorne,
Wokingham.

1880. Norman, Conolly, F.R.C.P.I., Medical Superintendent, Richmond District

Asylum, Dublin, Ireland. {Hon. Secretary for Ireland, 1887—1894.)
(President, 1895.) {Editor of Jowmal.)

1885. Oakshott, J. A., M.D., Medical Superintendent, District Asylum, Water¬

ford, Ireland.

1901. Ogilvy, David, B.A., B.Cb., M.D., L.M.Dub., Assistant Medical

Officer, Banstead Asylum, Sutton, Surrey.

1892. O’Mara, Dr., District Asylum, Ennis, Ireland.

1881. O’Meara, T. P., M.B., Medical Superintendent, District Asylum, Carlow,

Ireland.

1886. O’Neill, E. D., L.R.C.P.I., Medical Superintendent, The Asylum,

Limerick.

1868. Orange, William, M.D.Heidelb., F.R.C.P.Lond., C.B., Oakhurst,
Godaiming, Surrey. (President, 1883.)

1899. Osborne, Cecil A. P., F.R.C.S.Edin., L.R.C.P.Edin., The Grove, Old
Catton, Norwich.

Digitized by tjOOQle

xviii Members of the Association.

1890. Oswald, Landel R., M.H., M.P.C., Physician Superintendent, Royal

Asylum, Gartnavel, Glasgow.

1899. Owen, Corbet W., M.B., C.M.Edin., Counties Asylum, Denbigh, North
Wales.

1898. Parker, William Arnot, M.B., C.M., Gartloch Asylum, Gartcosh, N.B.

1899. Parsons, L. D., B.A., M.B., Ch.B., New Provinciau Asylum, Nassau,

Bahamas.

1898. Pasmore, Edwin Stephen, M.D.Lond., M.R.C.P.Lond., London County

Asylum, Baustead, Sutton, Surrey.

1901. Passmore, Wm. Edwin, L.S.A.Lond., 2, Sylvan Villas, Woodford Green,
Essex.

1899. Paton, Robert N., L.R.C.P., L.R.C.S.Edin., Medical Officer, H.M. Prison,

Wormwood Scrubb«, London, W.

1899. Patrick, John, M.B., Ch.B., District Asylum, Belfast.

1892. Patterson, Arthur Edward, M.B., C.M.Aber., Senior Assistant Medical
Officer, City of London Asylum, Dartford.

1889. Peacock, H. G., L.R.C.P.Edin., M.R.C.S. and L.S.A.Lond., The Home¬
stead, Monckton Combe, near Bath, and Ash wood House, Kings-
winford, Dudley.

1899. Pearce, G. Heneage, M.R.C.S., Borough Asylum, Humberstone, Leicester.
1878. Pedler, George H., L.R.C.P.Lond., M.R.C.S.Eng., 6, Trevor Terrace,
Knightsbridge, S.W.

1899. Penfold, William James, M.B., C.M.Edin., 99, Frank Street, Ben well,

Newcastle-on-Tyne.

1898. Perceval, Frank, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superintendent,
County Asylum, Prestwicb, Manchester, Lancashire.

1878. Philipps, Sutherland Rees, M.D.. C.M. Queen’s Univ. Irel., F.R.G.S.,
2, Berkeley Place, Cheltenham.

1875. Philipson, Sir George Hare, M.D. and M.A.Cantab., F.R.C.P.Lond., 7,

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 House, Kingswinford, near

Dudley, Stafford.

1898. Piper, Francis Parris, M.B.Lond., M.R.C.S., L.R.C.P., London County

Asylum, Bexley, Kent.

1896. Planck, Charles, M.R.C.S.Eng., L.R.C.P.Lond., M.A.Camb., Assistant
Medical Officer, East Sussex County Asylum, Haywards Heath.

1877. Plaxton, Joseph William, M.R.C.S., L.S.A.Eng., Lunatic Asylum,
Kingston, Jamaica.

1889. Pope, George Stevens, L.R.C.P. and L.R.C.S.Edin., L.F.P. and S.Glasg.,

Medical Superintendent, Middlesbrough Asylum, Cleveland, Yorks.
1901. Potts, George, L.R.C.P., and L.R.C.S. Edin., 17, Bernard Street, Russell
Square, W.C.

1900. Powell, A. B. S., L.R.C.P. and S.Edin., Grahamston Asylum, Cape of

Good Hope.

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., Merriebank, Moss Lane, Ain tree,
Liverpool.

1875. Pringle, H. T., M.D.Glasg., Medical Superintendent, County Asylum,
Bridgend, Glamorgan.

1901. Pugh, Robert, M.B., Ch.B., Clay bury Asylum, Woodford Bridge, Essex.

1899. Rainsford, F. E., B.A., M.B., T.C.D., Resident Physician, Stewart Insti¬

tute, Palmerston, co. Dublin.

1894. Rambaut, Daniel F., M.D.Univ. Dubl., Third Assistant Medical Officer
and Pathologist, Richmond District Asylum, Dublin.

Digitized by v^,ooQLe

XIX

Member* of the Association .

1889. Raw, Nathan, M.D., M.P.C., Mill Road Infirmary, Liverpool.

1893. Rawes, William, M.B.Darh., F.R.C.S.Eng., Medical Superintendent, St.
Luke’s Hospital, Old Street, London, E.C.

1870. Rayner, Henry, M.D.Aberd.,M.R.C.P.fidin., 16,Qneen Anne Street, London,

W., and Upper Terrace House, Hampstead, London, N.W. (Presi¬
dent, 1884.) {Late General Secretary,) (Editor of Journal,)

1899. Redington, John, L.R.C.P., L.R.C.S.I., A.M.O., Richmond Asylnm,
Dublin.

1887. Reid, William, M.D., Physician Superintendent, Royal Asylum, Aberdeeu.

1891. Renton, Robert, M.B., C.M.Edin., M.P.C., Courtburn, Coldingham,
Berwickshire.

1886. Rerington, George, M.D, and Stewart Scholar Univ. Dubl., M.P.C.,

Medical Superintendent, Central Criminal As\lum, Dundrum,
Ireland.

1897. Richard, William J., M.A., M.B., C.M.Glasg., Medical Officer, Govan
Parochial Asylum, Merry flats, Govan.

1899. Richards, John, M.B., C.M.Edin., Leicestershire and Rutland Asylum,
Leicester.

1889. Richards, Joseph Peeke, M.R.C.S., L.S.A., 6, Freeland Road, Ealing, W.
1899. Richardson, A. Y., M.B., B.S., County Asylum, Melton, Suffolk.

1899. Rice, David, L.R.C.P., Cheddleton Asylum, nr. Leek, Staffs.

1893. Rivers, William H. Rivers, M.D.Lond., St. John’s College, Cambridge
University.

1871. Robertson, Alexander, M.D.Ediu., 1 J, Wood side Crescent, Glasgow.

1887. Robertson, G. M., M.B., C.M., M.P.C., Medical Superintendent, District

Asylum, Larbert. Stirling.

1895. Robertson, William Ford, M.B., C.M., 7, Hill Square, Edinburgh.

1900. Robinson, Harry A., M.B., Cb.B.Vict., County Asylum, Rainhill, near

Liverpool.

1876. Rogers, Edward Coulton, M.R.C.S.Eng., L.S.A., County Asylum, Ful-

bourn, Cambridge.

1869. Rogers, Thomas Lawes, M.D.St. And., M.R.C.P.Lond., M.R.C.S.Eng.,
Eastbank, Court Road, Elthaui, Kent. (President, 1874.)

1895. Rolleston, Lancelot W., M.B., B.S.Durh., Senior Assistant Medical
Officer, Middlesex County Asylum, Tooting, S.W.

1879. Ronaldson, J. B., L.R.C.P.Edin., Medical Officer, District Asylum, Had¬
dington.

1879. Roots, William H., M.R.C.S., Can bury House, Kingston-on-Thames.

1899. Rorie. George Arthur, M.B., C.M., Senior Assistant Medical Officer,
Dorset County Asylum, Dorchester.

1860. Rorie, James, M.D.Edin., L.R.C.S.Edin., Medical Superintendent, Royal
Asylum, Dundee. {Late Hon. Secretary for Scotland.)

1888. Ross, Chisholm, M.B.Edin., M.D.Sydney, Hospital for the Insane, Ken-

more, New South Wales.

1899. Rotherham, Arthur, M.B., B.C.Cantab., Horton Manor Asylum, near
Epsom, Surrey.

1884. Rowe, E. L., L.R.C.P.Edin., Medical Superintendent, Borough Asylum,
Ipswich.

1883. Rowland, E. D., M.D., C.M.Edin., The Public Hospital, New Amsterdam,
British Guiana.

1877. Russell, A.^*., M.B.Edin., The Lawn, Lincoln.

1866. Rutherford, Jameh, M.D.Edin., F.R.C.P.Edin., F.F.P.S.Glasgow, Physician
Superintendent, Crichton Royal Institution, Dumfries. {Hon. Secre¬
tary for Scotland , 1876-86.)

Digitized by v^,ooQLe

xx Members of the Association.

1890. Rutherford, James M., M.B., C.M.Edin., Assistant Physician, Royal

Edinburgh Asylum, Morningside.

1896. Rutherford, Robert Leonard, M.D., Medical Superintendent, Digby’s
Asylum, Exeter.

1892. Ruttledge, Victor, M.B., District Asylum, Londonderry, Ireland.

1894. Sankey, Edward U. O., M.A., M.B., B.C.Cantab., Resident Medical

Licensee, Boreatton Park Licensed House, Buschurch, Salop.

* Sankey, R. Heurtley H., M.R.C.S.Eng., Medical Superintendent, Oxford
County Asylum, Littlemore, Oxford.

1878. Savage, Q. H., M.D.Lond., 8, Henrietta Street, Cavendish Square, W.

(Late Editor of Journal.) (President, 1886.)

1862. Schofield, Frank, M.D.St. And., M.R.C.S., Windermere, Spa Road, Wey¬
mouth.

1899. Scott, Charles R., M.B., C.M.Edin., 47, Dalrymple Loan, Musselburgh,

N.B.

1896. Scott, James, M.B., C.M.Edin., Medical Officer, H.M. Prisons, Holloway
and Newgate; 8, Parkhurst Road, Holloway, London, N.

1889. Scowcroft, Walter, M.R.C.S., Senior Assistant Medical Officer, Royal
Lunatic Hospital, Cheadle, near Manchester.

1880. Seccombe, George, L.R.C.P.L., The Colonial Lunatic Asylum, Port of
Spain, Trinidad, West Indies.

1879. Seed, William, M.B., C.M.Edin., The Poplars, 110, Waterloo Road,

Ashton-on-Ribble, Preston.

1889. Sells, Charles John, L.R.C.P., M.R.C.S., L.S.A., White Hall, Guildford.
1882. Seward, W. J., M.B.Lond., M.R.C.S., Medical Superintendent, Colney
Hatch Asylum, London, N.

1901. Shaw, B. Henry, M.B., B.Ch., B.A.O., R.M.I., Assistant Medical Officer,
County Asylum, Stafford.

1891. Shaw, Harold B., B.A., M.B., B.B., D.P.H.Camb., Medical Superin¬

tendent, Isle of Wight County Asylum, Whitecroft, Newport, Isle
of Wight.

1880. Shaw, James, M.D., 310, Kensington, Liverpool.

Shaw, T. Claye, M.D.Lond., F.R.C.P.Lond., 30, Harley Street, London,
W.

1882. • Sheldon, T. S., M.B., Medical Superintendent, Cheshire County Asylum,
Pkrkside, Macclesfield.

1900. Shera, K. P., L.R.C.P.I., Kent County Asylum, Chartham, near Canter¬

bury.

1898. Sherrard, David John, B.A., M.B., M.Ch.Dubl., The Laurels, Hailsham,

Sussex.

1900. Shoyer, A. F., M.B., B.C., B.A.Cantab., City Asylum, Birmingham.

1877. Shuttle worth, G. E., M.D.Heidelb., M.R.C.S. and L.S.A.Eug., B.A.Lond.,

late Medical Superintendent, Royal Albert Asylum, Lancaster;
Ancaster House, Richmond Hill, Surrey.

1899. Sibley, Reginald Oliver, M.B.Lond., M.R.C.S., L.R.C.P., Assistant

Medical Officer, London County Asylum, Cane hill, Purley, Surrey.

1901. Simpson, Alexander, M.A., M.D.Aber., Medical Superintendent, County

Asylum, Winwick, Newton-le-Willows, Lancashire.

1895. Simpson, Francis Odell, M.R.C.S., L.R.C.P., Senior Assistant Medical

Officer, County Asylum, Rainhill, near Liverpool.

1889. Simpson, Samuel, M.B. and B.Ch.Dubl., M.P.C.

1888. Sinclair, Eric, M.D., Medical Superintendent, Gladesville Asylum, New
South Wales. %

1891. Skeen, James Humphrey, M.B., C.M.Aber., Medical Superintendent,
Glasgow District Asylum, Bothwell.

1898. Skeen, William St. John, M.B., C.M., County Asylum, Winterton, Ferry-
hill, Durham.

Digitized by

Google

XXI

Membere of the Association.

1900. Skinner, Ernest W., M.D., C.M.Edin., Bank House, Bye, Sussex.

1901. Slater, 6. N. O., M.D., Assistant Medical Officer, Essex County Asylum,

Brentwood.

1897. Smalley, Herbert, M.D.Durh., L.R.C.P., M.R.C.S., Prison Commission,

Home Office, Whitehall, S.W., and 62, York Mansions, Battersea
Park, London.

1899. Smith, J. Q., M.D., Herts County Asylum, Hill End, St. Albans, Herts.

1885. Smith, R. Percy, M.D., B.S., F.R.C.P., M.P.C., 86, Queen Anne Street,
Cavendish Square, W. (General Secretary, 1896-7.)

1858. Smith, Robert, M.D.Aber., L.R.C.S.Edin., Middeltou Hall, Middelton
St. George, Durham.

1884. Smith, W. Beattie, F.R.C.S.Edin., L.R.C.P.Lond., Medical Superin¬

tendent, Hospital for the Insaue, Kew, Melbourne, Victoria.

1901. Smyth, R. B., M.D., Ch.B., Senior Assistant Medical Officer, County
Asylum, Gloucester.

1899. Smyth, Walter, M.B., B.Ch., R.U.I., Assistant Medical Officer, County
Asylum, Antrim.

1881. Snell, George, M.D.Aber., M.R.C.S.Eng., 38, Caledonia Place, Clifton,
Bristol.

1885. Sontar, J. G., Barn wood House, Gloucester.

1883. Spence, J. B., M.D., M.C., The Asylum, Colombo, Ceylon.

1875. Spence, J. Beveridge, M.D., M.C.Queeu's Uuiv., Medical Superintendent,
Burntwood Asylum, near Lichfield. (President, 1899—1900,
formerly Registrar.)

1899. Spicer, A. H., M.B., B.S.Lond., Petworth, Sussex.

1898. Sproat, James Hngh, M.B.Lond., M.R.C.S., L.R.C.P., Somerset and Bath

Asylum, Wells.

1891. Stansfield, T. E. K., M.B., C.M.Ediu., The Heath Asylum Bexley, Kent.

1901. Starkey, William, M.B., B.Cli., B.A.O.Roy. Univ. Irel., Assistant Medical
Officer, Lancashire County Asylum, Prestwich, near Manchester.

1898. Steen, Robert H., M.D.Lond., Went Sussex Asylum, near Chichester.

1899. Stevens, Reginald C. J., M.B., B.S.Durh., County Asylum, Exminster,

Devon.

1868. Stewart, James, B.A.Queen’s Univ.Irel., F.R.C.P.Edin., L.R.C.S.Irel.,
late Assistant Medical Officer, Kent County Asylum, Maidstone;
Dunmurry, Sneyd Park, near Clifton, Gloucestershire.

1884. Stewart, Robert S., M.D., C.M., Assistant Medical Officer, Angelton

Bridgend, Glamorgan.

1887. Stewart, Rothsay C., M.R.C.S., Medical Superintendent, County Asylum,
Leicester.

1862. Stilwell, Henry, M.D.Ediu., M.R.C.S.Eng., Moorcroft House, Hillingdon,
Middlesex.

1899. Stilwell, Reginald J., M.R.C.S., L.R.C.P., Moorcroft House, Hillingdon,

Middlesex.

1864. Stocker, Alonzo Henry, M.D.St. And., M.R.C.P.Lond., M.R.C.S.Eng.,
Medical Superintendent, Peck ham House Asylum, Peckham.

1897. Stoddart, William Henry Butter, M.D., B.S.Lond., M.R.C.S.Eng.,
M.R.C.P.Loud., Bethlem Royal Hospital, London, S.E.

1900. Stracey, Bernard, M.B., Ch.B.Ediu., Crichton Royal Institution, Dum¬

fries, N.B.

1868. Strange, Arthur, M.D.Edin., Medical Superintendent, Salop and Mont¬
gomery Asylum, Bicton, near Shrewsbury.

1899. Strongman, Lucia F., L.R.C.P.&S.I., L.M., District Asylum, Cork.

1896. Straton, Charles Robert, F.R.C.S.Edin., Medical Visitor, Fisherton
House and Laverstock House, West Lodge, Wilton, Wilts.

Digitized by v^,ooQLe

xxii Members of the Association.

1885. Street, C. T., M.R.C.S., L.R.C.P., Haydock Lodge, Ashton, Newton-le-

Willows, Lancashire.

1900. Staart, Esther Molyneux, M.B., C.M.Edin., County Asylum, Morpeth,
North nmberlaud.

1900. Stuart, P. J., M.R.C.S., L.R.C.P., Berrywood Asylum, Northampton.

1897. Stuart, Robert, M.R.C.S., L.R.C.P.Lond., 20, New El vet, Durham.

1900. Sturrock, James Paiu, M.A., M.B., C.M.Edin., Midlothian and Peebles

Asylum, Rosslyniee, N.B.

1886. Suffern, A. C., M.D., Medical Superintendent, Ruherry Hill Asylum,

near Bromsgrove, Worcestershire.

1894. Sullivan, W. C., M.D.R.U.I., H.M. Prison, Pentonville, London, N.

1898. Sutcliffe, John, M.R.C.S., L.U.C.P., Royal Asylum, Cheadle, near Man¬

chester.

1895. Sutherland, John Francis, M.D.Edin., Deputy Commissioner in Lunacy,

19, Mayfield Road, Edinburgh.

1877. Swanson, George J., M.D.Edin., The Pleasaunce, Heworth Moor, York.

1901. Sykes, Arthur, M.R.C.S., L.R.C.P., Assistant Medical Officer, City

Asylum, Hellesdon, nr. Norwich.

1897. Tait, James Sinclair, M.D., L.R.C.P.Lond., F.R.C.S.Edin., L.R.C.P.

Ediu., D.P.H.Edin., R.C.P.S.Edin., F.P.S.Glasg., Medical Superin¬
tendent, Hospital for Insane, St. John's, Newfoundland.

1857. Tate, William Barney, M.D.Aber., M.R.C.P.Lond., M.R.C.S.Eng.,
Medical Superintendent of the Lunatic Hospital, The Coppice,
Nottingham.

1897. Taylor, Frederic Ryott Percival, M.D., B.S.Lond., M.R.C.S.Eng.,

L.R.C.P.Lond., Darenth Asylum, Dartford, Kent.

1890. Telford-Smith, Telford, M.A., M.D., Wimborne, Dorset.

1899. Thom, J. Maxtone, M.B., C.M., D.P.H., Surgeon, H.M. General Prison,

Barlinuie, near Glasgow.

1888. Thomas, E. G., Park House, Caterham, Surrey.

1880. Thomson, D. G., M.D., C.M., Medical Superintendent, County Asylum.

Thorpe, Norfolk.

1901. Tiglie, John, M.B., B.Ch., B.A.O.Irel., North Riding Asylum, Clifton,
Yorks.

1900. Tinker, William, L.R.C.P., Holloway Sanatorium, Virginia Water,

Surrey.

1898. Todd, Percy Everald, M.B., Medical Superintendent, Pretoria Asylum,

Transvaal, South Africa.

1901. Torney, George Parsons, A.B.Dubl., L.RC.P., L.R.C.S.I., L.M.,

Medical Superintendent, County Asylum, Lincoln.

1896. Towusend, Arthur A. P., M.R.C.S.Eng., L.R.C.P.Lond., Assistant

Medical Officer, Hospital for Insane, Barnwood House, Gloucester.

1881. Tuke, Charles Molesworth, M.R.C.S.E., Chiswick House, Chiswick.

1888. Tuke, John Batty, jun., M.B., C.M., M.R.C.P.E., Resident Physician,

Saughton Hull, Edinburgh.

1885. Tuke, T. Seymour, M.B., B.Ch.Oxford, M.R.C.S.E., Chiswick House,
Chiswick, W.

1877. Turnbull, Adam Robert, M.B., C.M.Edin., Medical Superintendent, Fife

and Kinross District Asylum, Cupar. (J Ton. Secretary for Scotland.)

1889. Turner, Alfred, M.D. and C.M., Plympton House, Plympton. S. Devon.

1890. Turner, John, M.B., C.M.Aberd., Senior Assistant Medical Officer, Essex

County Asylum, Brentwood.

1878. Urquhart, Alex. Reid, M.D., F.R.C.P.E., Physician Superintendent,

James Murray’s Royal Asylum, Perth. ( Editor of Journal.) {Hon.
Secretary for Scotland , 1886-94.) (President, 1898.)

Digitized by C.ooQle

Members of the Association. xxiii

1900. Veitch, J. Ogilvie, M.B., C.M.Edin., County Asylum, Powick, Worcester.

1894. Vincent, William James. M.B.Durh., Assistant Medical Officer, Wadsley

Asylum, near Sheffield.

1884. Walker, E. B. C., M.B., C.M.Edin., Assistant Medical Officer, County
Asylum, Haywards Heath.

1896. Walker, William F. t L.R.C.S. and L.M.Edin., L.S.A.Loml., co-proprietor

and licensee. Home for Inebriates, Street Court, Kingsland, R.S.O.,
Herefordshire.

1898. Wall, Charles Percivale Bligh, M.B., Ch.B.Edin., Butterworth, Transkei,
Cape Colony.

1877. Wallace, James, M.D., Visiting Medical Officer, 16, Union Street,
Greenock.

1900. Walters, John Basil, M.R.C.S.Eng., L.R.C.P.Lond., Crinnis, Par
Station, Cornwall.

1889. Warnock, John, M.D., C.M., B.Sc., Abassia, Egypt.

1895. Waterston, Jane Elizabeth, M.D.Bru., L.R.C.P.I., L.R.C.S.Edin.,

53, Grave Street, Cape Town, South Africa.

1891 Watson, George A., M.B., C.M.Edin., M.P.C., 29, Abbot's Park Road,
Leyton, Essex.

1900. Watson, W. Muir Crawford, M.D., C.M.Edin., Beechville, Ripon Road,

Harrogate.

1898. Watson, William R. K., M.A., M.B., C.M., H.M. Prison, Holloway,
London, N.

1885 Watson, William Riddell. L.R.C.S. aud L.R.C.P.Edin., Govan District
Asylum, Hawkhead, Paisley.

1880. Weatherly, Lionel A., M.D., Bailbrook House, Bath.

1897. Welsh, Gilbert Aitken, M.B., C.M.Edin., The Crescent, Garliestown, N.B.
1880. West, George Francis, L.R.C.P.Edin., Medical Superintendent, District

Asylum, Kilkenny, Ireland.

1872. Whitcombe, Edmund Banks, M.R.C.S., Medical Superintendent, Winson
Green Asylum, Birmingham. (President, 1891.)

1884. White, Ernest William, M.B.Lond., M.R.C.P.Lond., Resident Physician
and Superintendent, City of London Asylum, nr. Dartford, Kent.
(Hon. See. South Eastern Division , 1897—1900.)

1901. White, William, M.B., B.Ch., B.A.O., R.U.I., Assistant Medical Officer,

District Asylum, Waterford, Ireland.

1889. Whitwell, James Richard, M.D. and C.M., Medical Superintendent,

Suffolk County Asylum, Melton Woodbridge.

1883. Wigleswortli, J., M.D.Lond., Rainbill Asylum, Lancashire.

1895. Wilcox, Arthur William, M.B., C.M.Edin., Second Assistant Medical

Officer, County Asylum, Hatton, Warwick.

1900. Wilkinson, H. B., M.R.C.S., L.R.C.P., Assistant Medical Officer,

Plymouth Borough Asylum, Blackadon, Ivybridge, South Devon.
1887. Will, John Kennedy, M.B., C.M., M.P.C., Bethnal House, Cambridge
Road, N.E.

1901. Wilson, Albert, M.D.Edin., Minto House, South Woodford, Essex.

1890. Wilson, George R., M.B., C.M., M.P.C., Medical Superintendent, Linden

Lodge, Loanheak.

1900. Wilson, James Patterson, M.B., Ch.B.Glasg., c/o Mr. McPhee, 43, Cale¬
donian Road, London, N.

1896. Wilson, Robert, M.B., C.M.Glasg., Nailswortb, Gloucestershire.

1897. Winder, W. H., M.R.C.S., L.R.C P.Lond., D.P.H.Cantab., Deputy

Medical Officer, H.M. Convict Prison, Aylesbury.

1875. Winslow, Henry Forbes, M.D.Lond., M.R.C.P.Lond., 14, York Place,
Port man Square, Londou.

Digitized by v^,ooQLe

xxiv Members of the Association.

1897. Wiseman, David William, M.R.C.S.Eng., L.R.C.P.Lond., 300, Commercial
Road, Portsmouth.

1894. Wood, Guy Mills, M.B.Durli., 6, Woburn Square, London, W.C.

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.

1885. Woods, J. F., M.R.C.S., Medical Superintendent, Hoxton House, N.

1873. Woods, Oscar T., M.B., M.D.Dubl., L.R.C.S.I., Medical Superintendent,
District Asylum, Cork. (Hon. Secretary for Ireland , 1897.)

1900. Worth. Reginald, M.R.C.S., L.R.C.P., Middlesex County Asylum,
Wandsworth, S.W.

1877. Worthington, Thomas Blair, M.A., M.B., and M.C.Trin. Coll., Dubl.,
Medical Supt., County Asylum, Knowle, Fareliaui, Hants.

1899. Wrangham, John Marris, B A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P.,
Wadsley Asylum, Sheffield.

1898. Yeates, Thomas, M.B., C.M., Borough Asylum, Ryhope, Sunderland.
1862. Yellowlees, David, M.D.Edin., F.F.P.S.Olasg., LL.D., 6, Albert Gate,
Dowan Hill, Glasgow. (President, 1890.)

Ordinary Members
Honorary Members
Corresponding Members

580

Total . 628

Members are particularly requested to send changes of address , Sfc. % to Dr.

Robert Jones , the Honorary Secretary , 11, Chandos Street , Cavendish
Square , London , W. t and in duplicate to the Printers of the Journal ,
Messrs. Adlard and Son , 22 J Bartholomew Close, London , E.C.

Digitized by v^,ooQLe

XXV

List of those who hare passed the Examination for the Certificate of Efficiency
in Psychological Medicine, entitling them to append M.P.C. (Med. Psych.
Certif.) to their names.

Adamson, Robert O.

Adkins, Percy, R.

Ainley, Fred Shaw.

Ainslie, William.

Alexander, Edward H.
Anderson, A. W.

Anderson, Brace Arnold.
Anderson, John.

Andrieson, W.

Armour, E. F.

Attegalle, J. W. S.

Aveline, H. T. S.

Ballantyne, Harold S.

Barbour, William.

Barker, Alfred James Glanville.
Bashford, Ernest Francis.

Begg, William.

Belben, F.

Bird, James Brown.

Blachford, J. Vincent.

Black, Robert S.

Black, Victor.

Blackwood, John.

Blandford, Henry E.

7 Bond, C. Hubert.

Bond, R. St. G. S.

Bowlan, Marcus M.

Boyd, James Paton.

Bristowe, Hubert Carpenter.
Brodie, Robert C.

Brough, C.

Bruce, John.

Bruce, Lewis C.

Brush, S. C.

Bulloch, William.

Calvert. William Dobree.
Cameron, James.

Campbell, Alex Keith.

Campbell. Alfred W.

Campbell, Peter.

Carmichael, W. J.

Carrutbers, Samuel W.

Carter, Arthur W.

Chambers, James.

Chapman, H. C.

Christie, William.

Clarke, Robert H.

Clayton, Frank Herbert A.
Clinch, Thomas Aldous.

Coles, Richard A.

Collie, Frank Lang.

Collier, Joseph Henry.

Coo oily, Richard M.

Conry, John.

Cook, William Stewart.

Cooper, Alfred J. S.

Cope, George Patrick.
Corner, Harry.

Cotton, William.

Cooper, Sinclair.

Cowan, John J.

Cowie, C. G.

Cowie, George.

Cowper, John.

Cox, Walter H.

8 Craig, M.

Cram, John.

Cross, Edward John.
Cruickshank, George.
Cullen, George M.
Dalgetty, Arthur B.
Davidson, Andrew.
Davidson, William.

6 Dawson, W. R.

De Silva, W. H.

Distin, Howard.

Donald, Wm. D. D.
Donaldson, R. L. S.
Donellan, James O'Conor.
Douglas, A. R.

Downey, Augustine.
Drummond, Russell J.
Eames, Henry Martyu.
Earls, Jame^ H.

East, W. Norwood.
Easterbrook, Charles C.
Eden, Richard A. S.
Edgerley, S.

Edwards, Alex. H.

Elkins, Frank A.

Ellis, Clarence J.

English, Edgar.

Eustace, J. N.

Eustace, Henry Marcus.
Evans, P. C.

Ewan, John A.

Ezard, Ed. W.

Falconer, James F.
Farquharson, Wm. Fredk.
Fennings, A. A.

Ferguson, Robert.

Findlay, G. Landsborough.
Fitzgerald, Gerald.

Fleck, David.

Fox, F. G. T.

Fraser, Donald Allan.
Fraser, Thomas.

Frederick, Herbert John.
Oaudin, Francis Neel.
Gawn, Ernest K.

Gemmell, William.

Genney, Fred. S.

Digitized by v^,ooQLe

XXVI

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilmour, John R.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Uoodall, Edwin.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Wemyss.

Grant, Lacklan.

Gray, Alex. C. E.

Griffiths, Edward H.

Hall, Harry Baker.

Hals ted. H. C.

Haslam, W. A.

Haslett, William John Handfield.
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hennan, George.

Hewat, Matthew L.

Hicks, John A., jun.

Hitchings, Robert.

Holmes, William.

Horton, James Henry.

Hotchkis, R. D.

Howden, Robert.

Hnghes, Robert.

Hutchinson, P. J.

2 Hyslop, Thos. B.

Ingram, Peter R.

Jagannadhan, Annie W.

Johnston, John M.

Kelly, Francis.

Kelso, Alexander.

Kelson, W. H.

Ker, Claude B.

Kerr, Alexander L.

Keyt, Frederick.

King, David Barty.

King, Frederick Trnby.

Laing, C. A. Barclay.

Laing, J. H. W.

Law, Thomas Bryden.

Deeper, Richard R.

Leslie, R. Murray.

Liveeay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Low, Alexander.

McAUum, Stewart.

Macdonald, David.

Macdonald, G. B. Douglas.
Macdonald, John.

Macevoy, Henry John.

McGregor, George.

Maclnnes, Ian Lamont.
Mackenzie, Henry J.

Mackenzie, John Cutnming.

Mackenzie, William H.
Mackenzie, William L.

Mackie, George.

McLean, H. J.

Macmillan, John.

6 Macnanghton, Geo. W. F.
Macneice, J. G.

Macpherson, John.

Macvean, Donald A.

Mallannah, Sreenagula.

Marr, Hamilton C.

Marsh, Ernest L.

Martin, A. A.

Martin, A. J.

Martin, Wm. Lewis.

Masson, James.

Meikle, T. Gordon.

Melville, Henry B.

Middlemass, James.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Monteith, James.

Moore, Edward Erskine.

1 Mortimer, John Desmond Ernest.
Murison, Cecil C.

Myers, J. W.

Nair, Charles R.

Nairn, Robert.

Neil, James.

Nixon, John Clarke.

Nolan, Michael James.

Norton, Everitt E.

Orr, David.

Orr, James.

Orr, J. Fraser.

Oswald, Laudel R.

Paget, A. J. M.

Parker, William A.

Parry, Charles P.

Patterson, Arthur Edward.
Patton, Walter S.

Paul, William Moncrief.

Pearce, Walter.

Penfold, William James.

Philip, James Farquhar.

Philip, William MarshalL
Pieris, William C.

Pilkington, Frederick W.
Pitcairn, John James.

Porter, Charles.

Price, Arthur.

Pring, Horace Reginald.

Rainy, Harry, M.A.

Ralph, Richard M.

Rannie, James.

4 Raw, Nathan.

Reid, Matthew A.

Ren tou, Robert.

Rice, P. J.

Rigden, Alan.

Ritchie, Thomas Morton.

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XXVII

Rivers, W. H. R.

8 Robertson, G. M.

Robson, Francis Wm. Hope.
Boris, George A.

Rose, Andrew.

Rowand, Andrew.

Rudall, James Ferdinand.

Rust, James.

Rast, Montague.

Rutherford, J. M.

Scott, George Brebner.

Scott, J. Walter.

Scott, William T.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skae, F. M. T.

Skeen, George.

Skeen, James H.

Slater, William Arnison.

Smith, Percy.

Smyth, William Johnson.
Snowball, Thomas.

Soutar, James G.

Sproat, J. H.

Stanley, John Douglas.

Staveley, William Henry Charles.
Steel, John.

Stephen, George.

Stewart, William Day.

S tod dart, John.

9 Stoddart, William Hy. B.
Strangman, Lucia.

Strong, D. R. T.

Stuart, William James.
Symes, G. D.

Thompson, George Matthew.
Thomson, Eric.

Thomson, George Felix.
Thorpe, Arnold E.

Trotter, Robert Samuel.
Turner, W. A.

Umney, W. F.

Walker, James.

Warde, Wilfred B.
Waterston, Jane Elisabeth.
Watson, George A.

Welsh, David A.

West, J. T.

Whitwell, Robert R. H.
Wickham, Gilbert Henry.
Will, John Kennedy.
Williams, D. J.

Williamson, A. Maxwell.

4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, David James.
Wright, Alexander, W. 0.
Yeates, Thomas.

Yeoman, John B.

Young, D. P.

Younger, Henry J.

Zimmer, Carl Raymond.

1 To whom the Gaskell Prize (1887) was awarded.

2 To whom the Gaskell Prize (1889) was awarded.

3 To whom the Gaskell Prize (1890) was awarded.

4 To whom the Gaskell Prize (1892) was awarded.
6 To whom the Gaskell Prize (1895) was awarded.

6 To whom the Gaskell Prize (1896) was awarded.

7 To whom the Gaskell Prize (1897) was awarded.

8 To whom the Gaskell Prize (1900) was awarded.

9 To whom the Gaskell Prize (1901) was awarded.

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THE

JOURNAL OF MENTAL SCIENCE

[<Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland 1 ]

No. 200 [ nb n w 0 X 9 ] JANUARY, 1902. Vol. XLVIII.

Part I.—Original Articles.

Some Cases of Pellagrous Insanity. By John Warnock,
M.D., Director of the Cairo Asylum, Egypt.

The existence of pellagra in Egypt has been pointed out
within recent years by Dr. F. M. Sand with, and for a descrip¬
tion of the disease as it occurs in hospital practice reference
may be made to his articles^ 1 )

As a cause of insanity in Egypt, pellagra seems to have
attracted little notice until Dr. Sandwith drew my attention to
its existence in this asylum in 1895. Since then the number
of cases admitted annually has been as follows :

Year.

Number of cases of Pellagra admitted.

Male.

Female.

Total.

1896 . .

1897. .

1898. .

1899 . .

1900 . .

Total .

141

Most cases came from the Delta, few from Upper Egypt.
The country districts produce practically all the cases, in con¬
trast to the towns , which, free from pellagra, send almost all the
general paralytics and hasheesh cases that arrive here.

XLVIII. 1

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2 SOME CASES OF PELLAGROUS INSANITY, [Jan.,

The usual symptoms as observed here are those of melan¬
cholia, which soon passes into dementia; later on great
emaciation and anaemia with paresis of the lower limbs,
intermittent diarrhoea, and a prolonged state of prostration
precede the fatal termination.

Pellagra is never uncomplicated in the stage seen here.
Every patient suffers from parasitic diseases. Favus, often pro¬
ducing complete baldness, is frequently present. The anchy-
lostomum worms are always present, and the resulting extreme
anaemia accounts partly for the great prostration of these cases.
Other intestinal worms often occur. Bilharziosis of the rectum
or bladder affects many cases and further aids the development
of the anaemia and exhaustion. In fact it is a matter for
astonishment that an individual preyed on by so many kinds
of parasites is able to survive so long. Many of these patients
have a dried-up wizened look, suggesting that of a mummy.

All cases admitted here arrive late in the course of the
disease, the mental symptoms not having been sufficiently
alarming in the early stages to necessitate removal to the
asylum. The characteristic skin lesion of pellagra has therefore
often disappeared before the patient is brought here (“ pellagra
sine pellagra ”), but its former existence can be inferred from
the state of the skin left bare after the exfoliation df the rash.
The dark flaky rash of pellagra leaves the diseased skin paler
than that of the surrounding parts, with a darker areola along
the line where the diseased meets the healthy skin. This
paleness does not always persist, but gradually the skin assumes
a brownish shrivelled appearance and its texture becomes
thinner, especially around the neck.

The situations where the signs of old pellagrous rashes are
most often found are the dorsal surfaces of the hands and feet,
the forearms and legs, the neck and the front of the upper
portion of the thorax ; all these parts are exposed to the sun
when the patients work in the fields. Dark indurated patches
are also found over the great trochanters and on the elbows
and knees, which persist often when the rest of the rash has
disappeared.

A number of patients who were admitted without noticeable
skin lesion have developed the characteristic rash of pellagra
while in hospital during the spring. The rash appears annually,
chiefly at this season, and after some months gradually de-

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1902.] BY JOHN WARNOCK, M.D. 3

squamates and disappears, only to return in the next spring¬
time.

Some sufferers complain of burning and itching in the
affected skin, and there seems to be a connection between this
discomfort and the frequent delusions of being burned, of
sorcery, and of persecution.

Tenderness on pressure at the sides of the dorsal vertebrae,
near the scapulae, was obtainable in many cases, but the mental
condition often prevented the investigation of this symptom. I
noticed scars of cauterisation over the spinal column, probably
done to cure back pain, in ten out of forty-five consecutive
caLses.

The patellar reflexes are usually much increased in force,
though in five out of forty-five cases they were noted to be
absent. A paretic gait is observed in advanced cases ; the
patient walks with the legs well apart, the shoulders raised
and bent forwards, and after a few short feeble steps
he falls over. Many cases are unable to stand up, or even to
raise themselves up in bed. This loss of power is sometimes
accompanied by tremors of the limbs. Ankle-clonus can be
obtained in some advanced cases. Wrist-drop developed
suddenly in one case, and epileptic convulsions in another. I
may mention that epilepsy is a common disease in Egypt, and,
as in other countries, is associated with insanity ; no doubt
epileptic patients acquire pellagra occasionally, and the con¬
vulsions observed in the course of pellagra may not be a
symptom of this disease. A general atrophy of all the
muscles of the body occurs as part of the general emaciation
and malnutrition. Loss of control of the rectum and bladder
is common.

The alimentary system is profoundly affected. Intermittent
and uncontrollable diarrhoea occurs almost invariably. The
pale anaemic tongue hats often a peculiar appearance, being
smooth and “ slimy looking ” at the tip and sides, as though
stripped of its epithelium. This “ bald tongue,” as Sandwith
calls it, was noticed in about three fourths of the cases, but its
presence varies with the state of the patient's nutrition. Spongy
gums, easily bleeding on pressure, and scorbutic cachexia were
several times noted. A swelling of the parotid glands occurred
in a few cases.

Mentally .—Usually the mental condition on admission is

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SOME CASES OF PELLAGROUS INSANITY, [Jan.,

one of melancholia. There is great depression, with feelings of
illness and discomfort, and a childish, unreasoning discontent
with everything. Resistiveness, refusal of food, and suicidal
tendencies are common. Unpleasant delusions as to possession
by devils, persecution, poisoning, sorcery, or of impending violent
death of self or relatives often occur. Hallucinations of taste
and smell are more frequent than those of the other senses.
The melancholia does not last long without showing signs of
oncoming dementia. Besides apathy, one notices some con¬
fusion and incoherence, loss of memory and slowness in com¬
prehension, and gradually the patient becomes demented, so
that in the later stages there are few signs of melancholia
remaining; the patient smiles vacantly and appears to have
lost interest in everything, and cannot give any account of
himself. His remarks become limited to requests for more
food and cigarettes.

It seems to me that the form of insanity occurring with
pellagra is one peculiar to it, and is not simply the mental
expression of the incidental cerebral malnutrition and anaemia.
For we admit numbers of emaciated patients suffering from
the terrible anaemia of anchylostomiasis who do not present
symptoms of such grave melancholia as occurs in pellagra ; in
fact, the majority of them are maniacal, and, indeed, so excited
that the treatment of their parasitic malady has to await their
becoming more tranquil.

The frequent early occurrence in pellagra of symptoms of
dementia, with loss of memory and childishness, points to
organic brain disease, and reminds one of the mental condition
of patients suffering from organic dementia due to gross brain
lesions, and of the later stages of general paralysis. Indeed,
the last stage of a general paralytic of the melancholic type
and that of a pellagrous patient have many resemblances to
one another.

The melancholia of pellagra is so much in contrast to the
maniacal forms of insanity prevailing among the Arabs, that
whenever an Arab fellah is melancholic the suspicion is raised
that he may have pellagra, and search is made for signs of that
disease. Among the Copts, on the other hand, who are
descended from the ancient inhabitants of Egypt and profess a
form of Christianity, melancholia is not uncommon even apart
from pellagra. I may note in passing that the Copts suffer more

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1902.]

BY JOHN WARNOCK, M.D.

frequently from insanity than the Arabs, and that in them
hereditary influence is often apparent. Also the Copts use
alcohol as well as hasheesh, while the Arabs mostly indulge
in the latter stimulant.

One type of pellagrous insanity, though not common, deserves
special mention. In lieu of melancholic ideas, the patient
develops expanded notions of himself. He has an exaggerated
feeling of bien-itre y mental and physical; although emaciated
and unable to stand he declares he is in good health, very
strong and rich, etc. The differential diagnosis of cases of this
type from general paralysis is not always easy. At first sight
one would expect the skin lesions of pellagra to be sufficiently
distinctive; however, in some cases the rash has disappeared,
and the patient having been confined to his house for some
years from debility only exhibits a dirty-coloured skin. Unfor¬
tunately the pupillary reactions are often unobservable owing
to old eye disease resulting in corneal opacities, iritic adhe¬
sions, etc. Even when the eyes are healthy, the observation of
the pupillary reactions of an insane Arab patient in whom the iris
is almost black is not easy. So far as my experience yet extends,
the speech does not seem affected in pellagra, beyond being
hollow and nasal in tone in a few cases, and, provided the
patient can be induced to speak freely, the diagnosis may thus
be effected. I append notes of two cases of pellagrous insanity
of this uncommon type (Cases I and II).

Cases III and IV are in advanced stages of the disease.

Case V was formerly an inmate here in good bodily health,
but maniacal and without pellagrous symptoms.

Case VI presented the usual melancholic symptoms.

Case I. — A. R. A—, admitted July ist, 1901 ; Arab, fellah, from
Gharbieh Province, aet. about 45. His medical certificate states that he
is delirious, talks nonsense, is destructive, and is dirty in habits.

On admission his weight is 46 kilogrammes. He is emaciated
and anaemic; all musculature atrophied. He has a typical pellagrous
black rash on the back of the neck, on the legs, forearms, dorsal surfaces
of hands and feet. The black scales are peeling off. There are no
signs of syphilis.

Pupils .—Examination impossible owing to opacities of comeae.

Gait. —Paretic. He staggers and falls after a few moments; while
standing kept his feet widely separated.

Patellar reflexes exaggerated in both sides.

Ankle-clonus well marked in both legs.

Tongue pale flabby, fairly steady.

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SOME CASES OF PELLAGROUS INSANITY, [Jan.
Speech slow, but no actual articulatory defect.

He is bald from old favus of scalp. There are cautery marks along
his spinal column, and he complains of tenderness on pressure over the
dorsal vertebrae. He is dirty in habits.

Mentally .—He has expanded and quite unfounded ideas of his
strength and abilities. He smiles, saying that he is happy and is as
strong as ten men, is the “ Lion of lions,” etc. He is childish and
can’t explain his statements; he is passive, prostrate, and demented;
his memory is much impaired.

Note of autopsy of Case /, who died on September 25 M, 1901. P.M.
twelve hours after death ; temperature 95 0 Pa hr.

The calvarium was very thin and transparent, especially in the tem¬
poral and parietal regions.

The brain y with membranes, weighed 1300 grammes. Dura mater
thickened; on its under surface, over the superior and lateral surfaces of
the left hemisphere, there was a layer of brownish-red semi-transparent
membrane, adherent to the dura mater, but peeling easily; numerous
rusty stains on under surface of dura mater (pachymeningitis
haemorrhagica). The pia mater and arachnoid were generally healthy,
but there was some milky opacity over the fourth ventricle. These
membranes stripped easily from the convolutions and left no erosions.
Vessels at base healthy. The brain was generally soft and flabby, and
collapsed on the table. On section no obvious changes were observed
beyond anaemia, excess of fluid, and marked dilatation of lateral
ventricles. (Spinal cord preserved for microscopical examination.)

Heart weighed 2 50 grammes ; coronary arteries convoluted and white ;
endocardium shrivelled and pale; valves and aortic arch healthy; no
atheroma; heart muscle flabby, and faded brown in colour; large ante¬
mortem clot; condition of brown atrophy .

Kidneys. —Capsules of both were difficult to remove; on removal,
kidney surfaces were fairly smooth ; long, depressed, linear scars traversed
both kidneys. Left weighed 150 grammes; pyramids congested and dark
in colour, large dilated veins; cortex not atrophied, but yellowish.
Right , in section, was of dark purple colour ; congested ; weighed 140
Grammes; pelvis dilated.

Intestines generally atrophied, and almost transparent, contained
anchylostoma.

Spleen weighed 340 grammes; soft, friable, congested.

Liver 1220 grammes ; dark purple in colour.

Lungs both congested and cedematous. A patch of gangrene
existed at base of right lung.

Case II. —S. K—, admitted July 27th, 1901; Arab, fellah, from
Gharbieh Province, set. about 45. His medical certificate states that he
is excited, dirty in habits, and suffers from pellagra.

On admission patient was found to be emaciated and anaemic
from anchylostomiasis. The skin of the neck, especially behind, is
the seat of marked changes; flakes of hardened epithelium, black as
though caked with soot, still adhere in some places ; in others, pale

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1902.

Case II.

To illustrate Dr. Warnock’s paper.

Hair and Danirhunn, Ltd.

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1902 .]

BY JOHN WARNOCK, M.D.

skin is left bare by the exfoliation. A yoke of diseased skin is easily
discernible around the neck. Over the upper portion of the chest, on
the extensor surfaces of the forearms, wrists and hands, legs and feet,
a similar, though somewhat paler, indurated layer of diseased epithelium
exists. The patient says that he has had eruptions for seven years (see
photograph).

Patellar reflexes .—Very strong reactions.

Pupils . —Both clouded.

Gait . —He makes a feeble attempt to walk, but has little power in
his lower limbs, and soon falls.

Tongue. —Pale, clean, steady.

Speech clear, no stammer.

There is no pain in back or cautery marks. He is clean in habits
here.

Mentally .—He says he is very well and strong, “ stronger than the
world,” then says he is weak ; he says he is happy; he is incoherent;
his memory is much impaired; he cannot relate his recent history;
he is passive, contented, and unconcerned; he is demented, asks for
food at all hours, and doesn’t know where he is.

Case III.—M. I—, admitted July 2nd, 1901,from Sharkiyeh Province;
Arab, fellah, aet. 35. Duration of insanity, two years (?). His
certificate states that his neighbours complain of his excitement, and
that he is irrational and resistive.

On admission he objected to examination, and refused to give
any information about himself. There are patches of black indurated
skin over his elbows, buttocks, great trochanters, and knees. He is
extremely emaciated, and has a dried-up appearance.

Gait .— He walks feebly, with bent back ; he has tremors in his
limbs.

Pupils equal; reactions cannot be observed on account of
patient’s violence.

Tongue smooth, denuded, and characteristic of pellagra.

Speech clear, but his voice is hollow and nasal in tone.

Patellar reflexes. —Slight reaction on right side, none on left. The
existence of back pain cannot be investigated, but he has cautery scars
along the spine. His habits are dirty. There are no signs of favus or
syphilis.

Mentally he is very demented, and appears unable to comprehend
simple questions; he is irritable and restless; he gropes about the
floor, and snaps at me, and makes feeble attempts to strike the
attendants; he mutters incoherently; he seems to be suspicious of
every one ; he strips himself naked.

Case IV.—F. S. F—, admitted June 18th, 1901, from Sharkiyeh
Province ; Arab, fellah, aet about 40 ; his brother is insane. Duration
of existing attack, three months (?). His certificate states that he is
unfit to be at liberty, that he talks incoherently and is resistive.

On admission he was emaciated and anaemic, weighing 43 kilo¬
grammes. There is a well-marked pellagrous rash on the elbows and
arms ; it is exfoliating, leaving pale skin evident.

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8 SOME CASES OF PELLAGROUS INSANITY. [Jan.

Gait . —He couldn’t stand on admission; to-day (August ist) he can
walk feebly.

Speech . —Nasal and monotonous voice.

Tongue raw, denuded at tip and edges.

Pupils react to light satisfactorily.

Patellar reflexes both exaggerated. He has back pain and cautery
scars on spine. His habits are dirty. No signs of favus or syphilis.

Mentally .—His memory is impaired as to recent events. He sleeps
much and is always hungry. He has a vacant expression of face; he
doesn’t know where he is; he is demented; he talks to himself, but
cannot converse intelligibly; he seems to be uncomfortable; continu¬
ally asks for food.

Case V.—K. I—, re-admitted July 17th, 1901, from Gharbieh Pro¬
vince ; Arab, prostitute, aet. about 30. Her certificate states that she is
noisy, weeping and laughing, frowning and making grimaces. She has
pellagra.

On admission she was emaciated and anaemic. A well-marked
dark pellagrous rash exists on her neck and chest, and on the extensor
surfaces of her arms (see photograph).

Gait normal.

Tongue coated. She suffers from diarrhoea.

Pupils sensitive to light.

Speech clear. She has tenderness on pressure over the dorsal
vertebrae.

Patellar reflexes are diminished. Her habits are dirty.

Mentally. —Patient is depressed and in a state of fear; she rushes
suddenly away from me and moans and weeps. She is restless and
resistive.

In 1895 patient was an inmate of the asylum for seven months,
suffering from mania from which she recovered.

In 1898 she was again admitted, suffering from mania, attributed to
hasheesh. She was also suffering from secondary syphilis. She
completely recovered after ten months’ treatment. On neither of these
occasions were there any signs of pellagra.

Case VI.—A. N. A—, admitted June 20th, 1896, from Sharkiyeh
Province; Arab, fellah, aet. about 20.

On admission he was emaciated and had a dwarfed, shrivelled
appearance. Weight 33 kilogrammes. Anaemic and cachectic. Skin
of a yellowish tint generally. Had pellagrous rash, and cautery marks
along spine.

Mentally .—He was talkative, emotional, and deluded. He kept
repeating the statement that he had drunk poison and would be killed.
He was melancholic and frantically afraid of poison.

June ist, 1898.—Since admission he has steadily become worse
mentally, and is now a restless, urgent melancholiac, distressing his
neighbours by his cries, catching hold of visitors and imploring protec¬
tion from his poisoning enemies. He often refuses food and exhibits
his abdomen, declaring it to be full of poison. He becomes destructive
and reckless when his entreaties are disregarded. He is usually sleep-

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JOURNAL OF MENTAL SCIENCE, JANUARY, 190*2.

Cask V.

To illustrate Dr. Warnock’s paper.

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1902.] NOTE ON THE PREFRONTAL LOBES.

less, declaring that when he sleeps his enemies fill him with poison \ he
says that salt drinking-water has made his legs swell. He points to the
ward medicine bottles, declaring they are for the purpose of poisoning
him. He steals food when unobserved; he thinks that the tell-tale
clock shakes him at night. He had an attack of stomatitis last year,
and became very exhausted, refusing food and medicines, and suffering
from retention of urine. He often suffers from diarrhoea; he has back
pain between the scapulae; his tongue is raw-looking. His face, hands,
and shins are black in patches; his patellar reflexes are much exaggerated.
No abdominal skin reflexes exist Cremasteric reflex is weak. He has
advanced favus of scalp.

He died in January, 1899.

(*) Sandwith, F. M., “ Pellagra in Egypt,” Journal of Tropical Medicine,
Oct., 1898 , and Brit. Journal of Dermatology , No. 121 , vol. x, 1898 . 11 Three
Fatal Cases of Pellagra, with Examination of the Spinal Cords,” Journal of
Pathology and Bacteriology , November, 1901 . Article on “Pellagra” in Encyclo¬
paedia Medico, 1901 .

Note on the Prefrontal Lobes and the Localisation of
Mental Functions . By P. W. MacDonald, M.D.,

Medical Superintendent, Dorset County Asylum^ 1 )

ABOUT the time that this very interesting specimen came
under notice, the members of the Medico-Psychological
Association were being treated to an able exposition of the
present-day views on the burning question of the localisation
of mental functions. The intention of this short contribution
is very humble, my main object being to explain the specimen,
and while doing so to offer a few general observations on any
bearing it may be thought to possess regarding the localisation
of intellect.

Before dealing with the specimen, I think I ought to say a
few words respecting the subject from which it was obtained.
The patient had been in the Dorchester Asylum for over
twenty-five years, and at the time of his death was almost 60
years of age. He was a congenital imbecile, with a fairly well-
formed head, a short stumpy body and limbs, and was from
birth afflicted with primary spastic paraplegia. He could not
read or write, but he could mutter words and appeared to know
after a fashion what was going on, whether in a room or out
of doors. By the aid of his mutterings and signs he was able

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10 NOTE ON THE PREFRONTAL LOBES, [Jan.,

to make himself fairly well understood, /. g . if he had a pain
he would shake his head violently, muttering unintelligible
jargon, and place his hand over the spot. I do not think he
was possessed of reasoning power, or of any of the higher or
finer intellectual faculties, but he was unquestionably the
possessor of a certain amount of intelligence as shown by his
childish precociousness. After a lingering illness he died from
chronic pulmonary disease.

Let us now turn to the specimen. From its defective and
irregular development this brain is of unusual and exceptional
interest, not only to the anatomist but equally to the physio¬
logist and medico-psychologist. Professor Reid, of Aberdeen
University, has been kind enough to examine the brain, and I
cannot do better than quote you his words. He says : “ The
specimen shows absence of the superior longitudinal fissure in
the region of the frontal and the anterior part of parietal
regions, so that here the lobes of opposite sides are quite
continuous with each other, the convolutions passing across
without interruption. There is also a marked want of develop¬
ment of the frontal lobes. Without a dissection little further
can be noted, but there seems to be a want of development of
the body of the corpus callosum. ,, (See Figs, i and 2.)

The marked deficiency and errors in development make the
specimen of great value to any pathological museum. Here I
would remind you that the patient’s head was fairly well
shaped ; by this I mean there was not a flattened or receding
forehead, as might have been expected with such a brain.
Nature seemed to provide against this by an enormously
thickened frontal bone, which in places was over half an
inch in thickness. As this specimen will probably form the
basis of a communication from the anatomist’s point of view, I
will not further trespass on his preserves.

Meeting with a brain of this description in a case of
congenital imbecility obviously leads up to the question, what,
if any, connection was there between the state of the intel¬
lectual faculties in this case and the arrested development of
the prefrontal lobes ?

At the present time two theories are held regarding the
localisation of mind, or, to put it more concretely, the intel¬
lectual faculties. In the April number of the Journal of
Mental Science for the present year Dr. Hollander contributes

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1002

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To illustrate Dr. Macdonald’s paper.

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1902 .]

BY P. W. MACDONALD, M.D.

I I

a carefully prepared paper, since given to the reading scientific
world in book form, in which he advocates and supports the
more generally accepted view of this vexed question. He
says : “ It has been a universal belief at all times that the
frontal lobes, or, more correctly speaking, the prefrontal lobes,
are concerned with the highest intellectual operations.” It is
not the object of this note to enter the field of speculative
theories, therefore I do not intend to trouble you with extracts
from the writings of leading and distinguished men who do
still accept the prefrontal theory. The later theory main¬
tains that the occipital lobes are the seat of the intellectual
faculties, and in the Handbook of Physiology for 1900 it is
asserted “ that experimental physiology lends no support to the
view that the frontal brain is the seat of the intellectual
faculties.” The April number of the Journal of Mental Science
for 1898 contains a paper by Dr. Crochley Clapham, on the
“ Comparative Intellectual Value of the Anterior and Posterior
Lobes,” in which he strongly and absolutely supports the
occipital theory of the seat of intelligence, closing his paper
with these words: u I think the evidence scales heavily in
favour of the superior intellectual value of the posterior lobes.”

These opposing views are supported by voluminous quota¬
tions and extracts from the writings of able thinkers ; nay
more, statistics are tabulated, experimental researches rehearsed,
and a position claimed, which savours rather of philosophical
speculation than the humble truth of sound reasoning deduced
from facts. Wishing, therefore, to abide by facts rather than
opinions, I have made a careful study of the post-mortem
records of the idiots and imbeciles who died in the Dorchester
Asylum between the years 1883 and 1901, and with the
following results:—Out of a total of forty, in twenty-five
instances the brain was of fair size with no marked deficiency,
but much irregularity in the convolutions ; twelve showed
marked irregularity with arrested development in the pre¬
frontal lobes ; in two cases the occipital lobes were small and
defective, and in one instance both prefrontal and occipital
lobes showed defective development and irregularity.

These facts are curiously in agreement with the opinion of a
distinguished pathologist, Professor Hamilton, who records a
case in his Text-book on Pathology wholly in support of the
prefrontal theory. Without venturing on any definite ex-

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12 NOTE ON THE PREFRONTAL LOBES. [Jan.,

pression of opinion, it may be that the rigid localisation of
mental functions is not so clearly established as either school
of thought would have us believe. In one of the dis¬
cussions following the papers already mentioned, it was stated
that in all probability the cortex of the brain, with its
magnificent cells and their multiplicity of ramifications, was
largely concerned in the process of mental functions. Yet
notwithstanding the intimacy, sympathy, unionism, and col¬
laboration between the various sections of the grey cortex of
the brain, there would still seem to be a consensus of opinion
in favour of the theory that the finer reasoning processes of
mental action are localised in the prefrontal region. Take
the subject whose brain has been the starting-point of these
observations. It could not be said that this man was absolutely
without intelligence, it could not be said that he was dead to
everything going on around him ; but throughout his life it
was manifest that the higher intellectual operations of reason¬
ing, judgment, memory, reflection, etc., were wanting. May it
not, then, reasonably be assumed that these defects followed and
resulted from the arrested development of the prefrontal
lobes ? There is one further argument strongly opposed to the
occipital theory. We are all familiar with the fatuity of mind
and intellectual dementia so commonly met with in general
paralytics, and so characteristically described by Dr. Yellowlees
as brain death—the morbid evidences of which are mostly met
with in the mid and fore brain.

I do not wish to put forward these facts as proof for or
against either theory, but, speaking generally, I think they
establish a sound link in the evidence which has helped to
build up the universal belief that the prefrontal lobes are
concerned with the highest intellectual operations. Individual
and scattered fragments are apt to be lost in the conflict
of opinions, but a combination of action and a sifting of
truthful facts in the common sphere of work will go far to
unravel the tangled skein of scientific thought which at the
present time hovers around the localisation of the higher
intellectual faculties. Is it too much to ask and expect a
mighty contribution in this and other fields of scientific
reckoning from amongst the hidden wealth of our asylum
laboratories ? No ; I do not think so. Every individual
worker should go steadily onwards, and if his efforts are not

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FEMALE CRIMINAL LUNATICS.

rewarded as he and others might wish, and think they should
be, he will at any rate receive that reward which even time
does not efface, the indebtedness of science and the gratitude
of fellow-workers.

(*) Read at the Autumn Meeting of the South-Western Division, Bath, October
22 nd, 1901 .

Female Criminal Lunatics : a Sketch . By John Baker,

M.D., Deputy Superintendent, State Asylum, Broadmoor.

In the communication which I have the honour to submit
to the members of the South-Western Division to-day, I
intend to bring forward some facts and some figures, not
hitherto recorded, relating to the female patients now and
formerly resident at this asylum.

In passing, I may remark that the term criminal lunatic
embraces two classes of individuals entirely distinct from one
another. First, there are those persons who have been found
guilty of certain crimes or misdemeanours, but have been
acquitted on the plea that they were insane at the time such
acts were committed—persons, therefore, strictly speaking,
free from the taint of crime, having been held to be irre¬
sponsible for the acts in question by virtue of their affliction,
with certain cerebral diseases or disorders damaging to their
power of self-control, or, in legal phraseology, to their judg¬
ment between right and wrong. The law provides that such
persons shall be taken care of, not with a view to the punish¬
ment of the individual, but for the purpose of ensuring the
safety of the public at large. These are the criminal lunatics
properly so called.

The other class consists of convicts and felons who, during
their sentence of penal servitude or imprisonment, display
symptoms of mental derangement, and are transferred to
Broadmoor on certificate. In contradistinction to the former
they are termed lunatic criminals.

In the early days of the asylum the proportion of the two
classes amongst the female inmates was about equal, but from
various causes, such as the diminution in the number of female

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FEMALE CRIMINAL LUNATICS,

[Jan.,

convicts, the gradual absorption of wandering lunatics into
asylums, and the readier recognition of mental disease, the
number of female lunatic criminals has very sensibly
diminished, and they now form but a small class—a class,
however, very much in evidence, owing to their capacity for
taxing the resources of the institution, and creating turmoil
and disturbance in the wards. Since the opening of the
asylum in 1864, this class has constituted about one third of
the female admissions. Most of them were convicted of
larceny ; arson, housebreaking, robbery, and false pretences
were amongst the other offences. Fifty-five per cent, of these
women were under thirty years of age, 45 per cent, had
reached middle life,—indeed, the proportion who became insane
at the climacteric is striking ; 5 per cent, were old women. In
nearly one fourth of the younger females congenital defect was
noted, in 18 per cent, a history of previous attack was ascer¬
tained, a limited number suffered from epilepsy and general
paralysis.

The type of insanity most commonly observed amongst
these lunatic criminals is delusional mania. As a rule they
are demonstrative and noisy, obscene in language, degraded in
behaviour, and subject to outbursts of paroxysmal violence.
The maniacal affection is often associated with delusions of
suspicion and persecution, and with aural and visual hallucina¬
tions ; perversion of the senses of smell and taste is sometimes
also met with. Very frequently these insane manifestations
have a sexual bearing, and it is noteworthy that the ranks of
this class of lunatic are mainly recruited from women of loose
character and irregular life.

In their quieter moments they seek one another and herd
together just like epileptics ; but jealousy soon springs up, they
denounce one another, conspire one against the other, friend¬
ship is hardly born before it dies, and is transformed into
enmity. They are indolent and idle by nature, but can
sometimes be induced to work. They then form great pro¬
jects and good resolutions, are full of energy and activity,
become very fussy and desirous of showing everyone how
industrious they can be, but the effort is sustained for a
brief period of time only, and they sink again into the ways of
indolence. Whilst offences of acquisitiveness are most prevalent
amongst lunatic criminals, crimes of violence predominate

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BY JOHN BAKER, M.D.

amongst criminal lunatics. They include murder, manslaughter,
and attempted murder, together with a few cases of suicidal
attempts and assault. I do not propose to discuss the cases of
homicide outside the class of child-murder, because they are
comparatively few in number ; suffice to say that in thirteen
instances the victim was a relative, and in five cases a fellow-
patient in another asylum. One woman was made a criminal
lunatic for the manslaughter of an attendant. This brings us
to the consideration of the cases which form the bulk of the
female population of Broadmoor, viz. the infanticides. This
class of crime perpetrated by insane women has not attracted
the attention it deserves; the literature on the subject is scanty
in the extreme ; such cases do not lead to sensational trials,
and the interest aroused is, for the most part, purely local. The
facts surrounding the commission of the deed are simple, there
is rarely any attempt at concealment, except in the case of
single women who endeavour to hide their shame; indeed,
amongst married women, the culprit is usually the first to draw
attention to the tragedy. Further, the lawyers are more than
ready to accept a plea of insanity, pity inspires both judge and
jury, and the opinion of the expert is not often required in
evidence.

It is a sad fact to record, but the registers of Broadmoor
show that 253 women slaughtered their children. In 24
instances the lives of 2 children were involved, and in 8
cases 3 children were sacrificed by the mother at one fell
swoop. In addition, maternal violence was responsible for
attempts on the lives of 33 infants. The difference between
the number of murders accomplished and the number at¬
tempted is remarkable, and indicates that great deliberation is
exercised in the perpetration of this class of crime.

In reviewing the subject from a psychological standpoint I
have included the attempted murders, because it was only an
accident that a fatal result did not ensue, and I therefore
propose to consider these 286 cases of infanticide, completed
and attempted, in their relation to the mental disorders
associated with gestation and the climacteric.

It is not my intention to dwell on the symptoms of those
disorders, our business is with the medico-legal aspect of the
question. The text-books say that the child may be in danger,
but how, or why, or at what period, is not definitely stated.

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FEMALE CRIMINAL LUNATICS,

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It is affirmed that homicidal and suicidal propensities are
present, separately or combined, in at least one third of the
cases of puerperal insanity, but that, as a rule, they are neither
vicious, nor deliberate, nor well-directed. Vicious, no; but
deliberate and well-directed, yes, especially after the first week.
It may seem paradoxical, but it is not vice that leads to the
death of the infant, rather is it morbid and mistaken maternal
solicitude ; rarely do they deny the act, but excuse themselves
on the plea that the child is happy in Heaven. The mental
disorders connected with gestation are conveniently divided
into three groups, each having its special characteristics, viz.
the insanity of pregnancy, puerperal insanity, and the insanity
of lactation. The insanity of pregnancy is the rarest form,
puerperal insanity the most common. From a medico-legal
point of view the same holds good with regard to the insanity
of pregnancy, but not with respect to the other two forms, for I
find, from a study of the Broadmoor cases, that infanticide
occurs much more frequently in connection with the insanity of
lactation than it does in association with puerperal insanity.
This may appear surprising, for the term puerperal mania is
invariably employed in connection with such cases. The term
has become established by use and wont, but is really a mis¬
nomer, and puerperal melancholia would be much more accurate.
In true puerperal insanity the maniacal form is apt to come on
at a period much nearer delivery than the melancholic type ;
thus Batty Tuke found that all his cases of mania appeared
within sixteen days of parturition. In such a condition of
affairs those in attendance would naturally remove the child and
guard against the contingency of danger. At this early period
violence is usually directed towards the husband ; the child
may be attacked, but it does not seem to happen often, for out
of sixty-four cases of infanticide occurring during the puerperal
period, i. e. within two months of parturition, only sixteen took
place during the first three weeks. In this computation the
murder of newly-born children is excluded.

Infanticides occur in the following proportion (Broadmoor
cases):

In the insanity of pregnancy . . 5 per cent.

In puerperal insanity . . *35 per cent.

In the insanity of lactation . . 60 per cent.

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BY JOHN BAKER, M.D.

1 7

Insanity of Pregnancy .

We are still far from possessing an adequate comprehension
of the psychology of pregnancy. We are aware that it is
often accompanied by intense mental depression, which some¬
times deepens into true melancholia. The Broadmoor cases
eleven in number, were of this type. In all but two cases the
insanity was developed and the infanticide committed during
the later months of pregnancy. Ten of these women were
delivered in the asylum (two recently), and one gave birth to a
child in prison just prior to admission. The age of the patient
is supposed to have some influence on the development of
the insanity of pregnancy, the proportion of ca$es between
thirty and forty years of age being stated to be much larger
than in younger women. This is not confirmed by the Broad¬
moor cases, for seven were between twenty and thirty years of
age, three between thirty and forty, and one, a widow, was
forty-one ; she had an illegitimate child. Eight were married
and two single. Six were primipara, five multipart. Hereditary
influence was ascertained in four cases, two direct, and two
collateral. In one instance a previous attack had occurred.
There was no history of drink. Domestic trouble, desertion of
husband, and illegitimacy of child were recognised as con¬
current causes. Two recovered, five remain, two were trans¬
ferred to other asylums, and one died.

A disposition to steal is sometimes observed amongst preg¬
nant women. This propensity displayed itself in one of our
recent cases, and really had much to do with her subsequent
trouble. Without being in actual need or want, she stole a
shawl of no great value from a neighbour’s house. She was
detected and arrested for the theft. The stigma preyed
upon her mind, she became very melancholic, poisoned her
youngest child, and attempted to poison herself. From
the time of her admission until the child was bom she
maintained a quiet and reserved attitude, varied occasionally
by waves of emotional disturbance, when she took a
desponding view of her condition and looked forward to the
result of her labour with gloomy apprehension. Such oscillat¬
ing exhibitions of dejection are not infrequently associated with
the insanity of pregnancy, but in her case the depression was

XLVIIL 2

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FEMALE CRIMINAL LUNATICS,

[Jan.,

intensified by the fact that she had taken poison, and in a
piteous way she appealed to know whether her suicidal
attempt was likely to have a prejudicial effect on her unborn
child. Her fears on this score were ultimately removed, for
she was delivered at full time of a remarkably healthy male
infant. All went well until a fortnight after delivery, when
one morning she was reported to be rather restive and queru¬
lous. She happened to look up as I entered the room. I was
struck by that look—1 do not think I ever saw it before ; it
conveyed dread and apprehension, and something undefinable.
It approached the look of a hunted animal. I immediately
removed her from the vicinity of the child, although they had
never been permitted to be alone together, nor had she been
allowed to nurse it. There were no physical symptoms to
account for the restlessness. She explained that she was
fretting because she was aware that the child would soon
have to be removed to the care of its grandmother, and she
was afraid of becoming too much attached to it, which would
make the separation all the harder. That was no doubt true,
but the look in her eyes expressed a good deal more, and I
believe that the child was in danger had she got a suitable
opportunity to injure it. She seemed relieved when removed
to the infirmary ward, and the symptoms passed away in a few
days. She bore the departure of the child with equanimity,
and is now progressing favourably. This episode serves to
introduce the subject of puerperal insanity, which may be
defined as that form of mental disorder which comes on within
a limited period after delivery, and which is probably inti¬
mately connected with that process. Authorities are not
agreed as to where the influence of the puerperal state ends
and that of lactation begins. Clouston gives six weeks as the
technical limit for puerperal insanity, Batty Tuke fixes it at a
month, but allows two months for debatable cases; Campbell
Clark proposes that a post-puerperal period of two to three
months should be allowed in mixed and uncertain cases. In
dealing with the Broadmoor cases, I have regarded, as puerperal,
those in which the crime of infanticide took place within two
months of parturition, and as lactational, those in which the
child-murder occurred later. But, in truth, the distinction is
an arbitrary one, for in many cases the mental causes are
insidiously at work for weeks and months of pregnancy, and

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BY JOHN BAKER, M.D.

1902 .]

continue for weeks and months afterwards, finally culminating
in a tragedy during the lactational period.

In connection with puerperal insanity we have first to con¬
sider the murder of newly-born children. In all, I find twenty
instances of this form of homicide, and in no less than sixteen
cases the mother was single. What usually happens is this :
The girl has concealed or strenuously denied the fact of
pregnancy, she has made no preparation for the birth, ex¬
cept that sometimes a knife or pair of scissors is kept at
hand for the purpose of severing the cord. Labour comes
on, the child is bom, and begins to cry. This contingency has
been overlooked, and in desperation lest its wail be heard, she
cuts its throat, stabs, or otherwise mutilates it. In some cases
this is followed by an attempt to conceal the body. It may
be called transient frenzy ; no doubt it is, but the mother is
generally capable of afterwards detailing all the circumstances.

If the child has had a separate existence the law calls it
murder, but in cases of this sort, judge, counsel, and jury, as a
rule, combine to prove the contrary, or to reduce the charge to
concealment of birth, or to bring in a verdict of insanity.
Occasionally sentence of death is passed, but is never carried
into effect. It seems to me that the Legislature might devise
some term short of constructive murder to define such cases,
so that the sentence might be apportioned according to the
degree of guilt and the measure of responsibility. The gravity
of the mental symptoms may be gauged from the fact that
twelve of the twenty Broadmoor cases were discharged after a
comparatively short detention. This is the highest recovery rate
of any class of homicidal insanity preceding or following
gestation.

One of the cases recently admitted is probably unique. She
is a married woman, a multipara, and the subject of epilepsy ;
she had previously been confined in an asylum. Left alone in
the house one day, labour suddenly came on, and almost
immediately she was delivered of a child whilst standing
holding on to a table. She severed the cord, took the child
in her arms, walked out of the house, and threw the infant into'^
a canal which flowed past the rear of her dwelling-place. She
returned to the house, and was shortly afterwards found in a
state of acute mania, with the placenta undelivered. She
recollects the birth of the child, the severance of the cord, the

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FEMALE CRIMINAL LUNATICS,

[Jan.,

act of drowning, and her return to the house ; then memory
fails her. It is more than probable that a fit occurred when
she regained her abode, followed by post-epileptic mania, and
that the homicidal act was one of those phenomena sometimes
associated with pre-epileptic conditions, for she had experienced
no trouble in connection with her previous confinements.
Amnesia is more frequently met with in the delirious mania
of the puerperal period proper. It may be that the woman,
especially if she belongs to the poorer classes, has been allowed
to get about too soon, or that some form of blood-poisoning
has set in. The milk ceases to flow, the lochia disappear, the
temperature rises, and mania occurs. During the continuance
of this state the child sometimes falls a victim to violence of
an extreme character. The child's head is dashed against the
bed-post, or a pair of scissors is driven into the brain, or
the throat is cut, or the head battered in with a poker ; the
more deliberate acts of drowning and poisoning are reserved
for the later stages, and are usually associated with melan¬
cholia. When the mother regains her mental balance after
the maniacal attack, she is invariably unable to recall the
circumstances, or can only give a confused and incoherent
account of the affair.

These are the cases which occur in the early days after par¬
turition, and, as explained before, they are comparatively few
in number. I have already stated that most of the infanticides
take place in the later stages of the puerperal period, and are
due to mental disorder of the melancholic type. They resemble
in their general bearings the homicidal cases of the lactational
variety, and may be fitly considered with that class. I find in
all sixty-four cases of child-murder occurring during the puer¬
peral period, u e % within two months of parturition. They are
exclusive of the twenty cases of infanticide of newly-born
children previously alluded to. In thirteen instances the child
deprived of life was not the youngest. The only explanation
I can give of this somewhat unusual occurrence is that either
the mother sacrificed her favourite child, or that, having killed
an elder one, she was interrupted in her gruesome work before
she could take the life of her latest-born.

The great majority of these women were multipart, forty-
eight were married, fourteen single, and two widows. One was
under 20 years of age, thirty-four between 20 and 30,

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1902 .]

BY JOHN BAKER, M.D.

twenty-seven between 30 and 40, and two over 50. Twenty
recovered and were discharged, thirty-two remain, and twelve
died.

The occurrence of child-murder is far more frequent in the
insanity of lactation than in the preceding insanities. Lactation
is an exhausting process, and, to quote Campbell Clark, “many
undertake nursing with an eager maternal desire who should
be strongly dissuaded or firmly obstructed in their attempts to
do so. These are frequently the women who break down.
Another group is that numerous set in the poorer walks of life
who seem to be pregnant or nursing mothers all the time, who
toil and moil all their married life through; while a third class
is of the over-lactation species, suckling to prevent conception,
which is ruinous for mother and child.” Is it to be wondered
at that many develop melancholia, and frequently become
actively suicidal ? for suicide completed, attempted, or contem¬
plated, almost invariably accompanies the infanticide. Their
act, although at first sight it looks like infanticide, followed by
suicide, is in reality, so to speak, only the completion of their
own self-inflicted death. To die alone and leave their children
is impossible for them, the children being almost an organic
portion of themselves. Maternity is a function which exists for
the protection of the weak, and a mother provides for her
children by every means in her power, such means including at
times the pathological phenomenon at present under considera¬
tion

in many cases the mother has a happy home and comfort¬
able surroundings, but weighed down by the strain of lactation,
and in addition, perhaps, by overwork and the anxiety of
nursing a sick child, or by grief, perchance, if it dies, depression
comes on, everything looks black and dismal, the idea takes
possession of her that want and poverty are in store for her
and her family. At first an obsession, it becomes a delusion;
the thought of suicide projects itself into her mind, she cannot
leave the child behind, it must be sacrificed first; the dreadful
thought is banished again and again only to recur with renewed
intensity, until it really seems to fascinate, and finally over¬
whelm her—the deed is done, and a ruined home is the result.
These tragedies are frequently preventable. Although the
patient is, as a rule, sanely conscious of many things and
usually coherent, it begins to dawn on the friends that thj! mind

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2 2 FEMALE CRIMINAL LUNATICS, [Jan.,

is gradually giving way, yet, owing to some perverse reasoning,
they defer placing her under asylum care and treatment, even
if the woman herself begs to be safeguarded.

As already stated, the murder of the child is often followed
by the self-destruction of the mother; some try, but fail to
succeed, others again are detected before they can carry out
their design. Many experience a feeling of relief immediately
after the infanticide, as if some tension were removed from their
over-wrought brain. The feeling of vertex headache, which is
one of the commonest symptoms, seems to be relieved, and
tends to postpone the suicidal act.

Some women after drowning their children have prepared
them for burial, and have laid them out in bed, sitting calmly
by and contemplating them with a quiet sort of satisfaction,
reasoning in their insane way that their offspring are happy in
Heaven ; but reaction soon comes, they begin to dimly realise
the gravity of the act, melancholic despair again seizes them,
their only wish is to die, and they cry aloud to be led to instant
execution. In others the crime is followed by a dazed feeling,
they confess to their offence in a mechanical manner, they shed
no tears, express no remorse, but stare vacantly in front of them.
The cerebral action seems for the time being to be nearly sus¬
pended, they are in a dream-state somewhat similar to that
seen in post-epileptic conditions. The advent of tears brings
relief, only to be followed by the same train of melancholic
symptoms.

Others, again, immediately run to tell their nearest neigh¬
bour of the crime, or give themselves up to the police; their
story is always the same—the child is free from trouble and
happy in Heaven.

It is remarkable how frequently, in these cases, religious
ideas colour the mental obsessions. Sometimes the child is
offered up as a sacrifice to appease an angry deity, whose dis¬
pleasure has been aroused by some trifling fault or omission,
magnified by the poor deluded creature into the unpardonable
sin. In one case the sacrificial altar was the child's bassinette,
under which the mother proceeded to kindle a fire ; her sub¬
sequent suttee-like act of self-immolation was only prevented
by an hallucinatory appearance of the Saviour, whose imaginary
voice was heard by the woman calling upon her to desist.

At other times the child is afflicted with some deformity ;

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BY JOHN BAKER, M.D.

talipes and cleft palate are mentioned in our cases. This is
put down to the agency of the devil, and the child is destroyed
as the offspring of the evil one.

The number of females classified under the insanity of
lactation is 115. They differ from the puerperal cases in that
more were older women. Fifty-two were between the ages of
20 and 30 ; fifty-three between 30 and 40 ; and ten between
40 and 45. The recovery rate, however, as in the former
insanities, was highest amongst the younger females. Multi¬
part were in the majority, forming 70 per cent, of the whole.
One hunded and two were married, ten single, and three were
widows.

In these homicidal cases associated with the mental
disorders accompanying gestation, there are various circum¬
stances which tend to retard or militate against the chances of
recovery. They may be enumerated as follows :

1. The age of the patient. As a rule the older the patient
on admission the less the chance of recovery.

2. The number of children. Where a woman has been
exhausted and debilitated by frequent pregnancies, the pro¬
gnosis is generally unfavourable.

3. The incidence of previous attacks. These attacks are,
for the most part, puerperal. They occurred in 24 per cent,
of the Broadmoor cases.

4. Hereditary predisposition, which was ascertained in 28
per cent.

5. The complication of epilepsy.

6. Where the child killed has been the illegitimate offspring
of a married woman or widow.

There were thirty-three cases admitted of females who had
killed their children under the influence of climacteric insanity.
They resemble in most particulars the cases hitherto described,
only amongst this class the children murdered were naturally
older. Drink, also, which was infrequently noted as a compli¬
cation in the insanities associated with gestation, played a con¬
spicuous part amongst a section of these cases. In two
instances of this form of insanity the circumstances associated
with the tragedy were so singular and peculiar in their charac¬
ter that they may be deemed worthy of record. Only one
involved the crime of child-murder, but in this case the father
was an accomplice in the act, which was followed by the

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attempted suicide of both parents. The couple were in
monetary difficulties, and poverty stared them in the face. The
combination of adverse circumstances and the climacteric had
unhinged the woman's mind, and it was agreed that they
should poison the child (aged eight years) and thereafter poison
themselves. The decision was carried out with fatal effects to
the boy, but the dose was insufficient to cause the death of the
parents. They were subsequently tried for murder, a verdict
of insanity was brought in, and both were sent to Broadmoor.
The man has since died, the woman survives. This case is
probably unique. In the next case the element of infanticide
did not enter. Similarly, however, a married couple of middle
age agreed to take poison. The husband did so and died
soon afterwards, the wife was prevented from following his
example by someone appearing on the scene. She was tried
for murder and acquitted on the ground of insanity, which was
due to climacteric origin.

These cases are, perhaps, not quite germane to my subject,
and reach beyond the limitations to which I had bound myself,
but I have narrated them as instances of attempted double
suicide, which is of extremely rare occurrence amongst married
couples. Only one such case has come under the observation
of Lombroso, but in this instance the double suicide was
completed.

In the remaining cases of infanticide not included under the
foregoing classification, pregnancy was not present, the age of
the child precluded puerperal or lactational insanity, the age of
the woman climacteric disorder. The causes of the insanity in
this class were principally domestic trouble and desertion
of husband amongst the married women ; congenital defect,
illegitimacy of child, and destitution amongst the unmarried.

In all these cases of homicide associated with the mental
disorders connected with gestation and the climacteric, the
form of insanity on admission has invariably been melancholic,
—simple, delusional, resistive, or stuporose. The maniacal
type has been comparatively rare. When recovery has taken
place the melancholia has given way after a period of shorter
or longer duration, or has been succeeded by an attack of
mania prior to the restoration of mental health. In cases of
non-recovery the melancholia either becomes chronic or is fol¬
lowed by attacks of recurrent mania,or chronic mania supervenes,

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1902 .]

BY JOHN BAKER, M.D.

passing into dementia. Even at their mental best many of
these mothers are haunted by the ever-present shadow of their
crime, which spreads around an almost universal tendency to
sadness.

On admission, many cases suffer from amenorrhoea. To
show the prevalence of this form of disordered menstruation, I
have taken the cases of patients admitted since June, 1900—
twelve in all. Two were women at the climacteric, and are
therefore deleted. Of the ten remaining, no less than six
suffered from amenorrhoea on admission, in one it still continues,
in two it lasted seven months, and in four from three to six
months. Whenever natural menstruation returns, an improve¬
ment is noticeable in the mental condition. In climacteric cases
on the other hand, menorrhagia is often found. One woman,
recently admitted, murdered two children after an exhausting
flooding of nine days’ duration.

In the course of these investigations I was enabled to elucidate
the curious and interesting pathological fact that the brain-
weights of homicidal female lunatics were below the normal
standard of sane women, and that the brain-weights of lunatic
criminals—the thieves and fire-raisers—were still more deficient
in this respect.

The average weight of the normal female brain as stated in
‘Quain’s Anatomy ’ is 44 ounces, or 1247 grammes, that of
the homicidal female lunatics who died in Broadmoor, 1190
grammes, and that of the female lunatic criminals, 1120
grammes, a deficiency of 57 and 127 grammes respectively.
To those interested in the subject the following table may be
of use in comparing the brain-weights of the different classes
at various ages:

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FEMALE CRIMINAL LUNATICS,

[Jan,

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The table requires little explanation. It will be seen at a glance that, with a few exceptions, there is a progressive decline as
regards maximum, minimum, and average brain-weights through the different classes at the various ages.

1902 .]

BY JOHN BAKER, M.D.

There are many important features, both clinical and patho¬
logical, which I have been unable to embody in a communica¬
tion of this scope. I am conscious of having but touched the
fringe of my subject, and I must leave to future effort the
further elucidation and explanation of a wide and intricate
medico-legal question.

Discussion

At the Autumn Meeting of the South-Western Division, Bath, October 22nd, 1901.

Dr. L. Weatherly said that the part of the paper which appealed to him was
that which referred to grades of criminal responsibility. That was a question upon
which they were all agreed—that there were grades of responsibility in all crimes,
and that the punishment should fit the amount of responsibility. It seemed to him
that in many cases, if these murders by females had been committed by men
instead of women, the murderers would have gone to the gallows. The sympathy
of judge and jury with a woman was well known, and he was perfectly satisfied that
many of the cases of females sent to Broadmoor as having been insane would not
have been so dealt with had the murderer been a man instead of a woman. In the
discussion which took place not long ago in their Association with regard to the
question of punishment, he was astounded that no gentleman who spoke at that
meeting—unfortunately, they were deprived of listening to many of their own
fraternity, because the discussion was taken up by men who did not belong to the
Association—correctly represented their views on the matter. He was surprised to
find that whereas they classified the punishment of crime under two headings—
that which acts as a deterrent and that which tends to the reformation of the
criminal—they more or less sneered at the psychological section of the profession
as trying to make out that people who committed crimes were more or less insane
and ought not to be punished. Every medical man who went into the witness-box to
try to prove that a person was not responsible by reason of mental disease, did not
enter the box to make out that he ought not to be punished, he simply said it ought
not to be of the same class as if he were perfectly responsible. He asked the judge
to incarcerate them somewhere, to take away their liberty—which was one of the
greatest punishments man or woman could have—and to send them to some place
where the disease could be properly treated, and the patient could get better. There¬
fore any person who went into the witness-box did not ask the judge not to punish
them, but to do what the law required, to give them a punishment to fit the crime,
firstly as a deterrent, and secondly as a reformatory measure.

Dr. Goodall thought that the percentage of 28 as being hereditary seemed low ;
be dared say fuller facts and a more careful inquiry, in which relatives were not
keen in aiding, might produce a larger percentage of heredity. He should like to
know whether or not it was common for the offspring of parents and grandparents
who had whilst insane committed criminal acts during the period of gestation, to
show the same tendency. The paper having a wide name, he might be pardoned
for asking whether anything was done in the way of examining these people
anthropologically so as to establish whether they were degenerates or not. He held
strong views on the union of asylums with prisons as was done in Belgium and
other countries.

Dr. Deas said the paper covered a very wide range of the subject dealt with.
He had had occasion to be called in in many cases, and the only class of case he
had a difficulty about was one Dr. Baker did not allude to. It was the case of a
single woman where there had been a little natural weak-mindedness and nothing
more, but where the element of malingering came into play. He remembered one
where a woman got off at the trial because there was evidence of a certain amount
of weak-mindedness, but he believed himself it was a case of decided and brutal
murder, and he was not sure that there was not an element of malingering. He did
not think Dr. Baker alluded to persons of the criminal type who commit murder from
the pure reason of getting rid of the bother of the child. He recalled a case in

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CRIME IN GENERAL PARALYSIS,

[Jan.,

which the girl had been in the workhouse, and she got her discharge, and took the
child away into a quiet place where, having stripped if, she threw the child into a
ditch of water. As in so many cases, she overlooked the fact that little things
may attract attention. She had gone in an omnibus to a small village in North
Devon, and had been noticed by the driver. When returning, she happened to
meet the man, who had got off his ’bus in a side lane; she had a bundle but no
baby, and giving him confused answers as to what had become of the child, her
arrest followed. She showed great deliberation and forethought, but she over¬
looked the possibility of being met by the man who drove the omnibus. That was
a case one would not say was due to insanity, although it had many of the ap¬
parent features connected with it, and he would like to ask Dr. Baker whether, at
Broadmoor, they might not have the means of checking cases which had been
passed as insane, and which afterwards at Broadmoor exhibited no trace of insanity.
Such cases did occur, and he was not sure fuller justice would not have been done
in the one he had mentioned, if she had met the full penalty of the law.

Dr. Baker, in reply, said with regard to Dr. Weatherly’s point about making
an analogy between men and women, he did not think one could do that in this
case because the fact of parturition came in. With regard to Dr. Goodall’s
remark about heredity, he had no doubt in a good many cases—in the greater
proportion—heredity was present, but they had no means of ascertaining unless
the relatives came to the asylum. The cases were tried, and the patients came to
them from prison, and they had only the prison records for information, and unless,
as he had said, the relatives came, they could not get information about their ante¬
cedents. With regard to the anthropometrical point, he had seen many of the
measurements, but he could not say they were of any great value from his
own experience, at all events so far as gauging the mental calibre. Of course in
prisons there was a great majority of the ordinary type seen, but there was a
residue of 2 or 3 per cent, which showed symptoms of congenital weak-mindedness,
and he dared say the measurements would be different in those cases. He knew
the case referred to by Dr. Deas, because she was a congenital imbecile, and his
opinion was that justice had been done.

Crime in General Paralysis . By W. C. Sullivan, M.D.,

Deputy Medical Officer, H.M. Prison, Pentonville.

The minute study of morbid organisation as a factor in the
genesis of crime which has been extensively pursued in recent
years has been for the most part concerned with conditions of
arrested or distorted cerebral development, with the different
forms and degrees of innate defect. Less attention has, on
the whole, been given to the other large class of neuropathic
criminals, those in whom the morbid aptitude for criminal acts
is connected with deterioration of brain, where the mental
defect is acquired.

It has appeared to me, therefore, that some relative freshness
of interest might be found in a discussion of these conditions
of acquired defect ; and this the more because of the excep¬
tional clearness with which their study illustrates certain
essential points in the relation of organisation to conduct.

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1902 .]

BY W. C. SULLIVAN, M.D.

One of these morbid states—perhaps the most important in
our special point of view—that, namely, due to chronic intoxi¬
cation by alcohol, I have discussed in some detail in papers
published in the Journal of Mental Science and elsewhere^ 1 )
The natural direction of our inquiry leads next to those condi¬
tions nearest allied to chronic alcoholism, chief among which
are general paralysis and senility. The present paper, then,
will deal with the former of these diseases, the term “ general
paralysis ” being taken for the purposes of the discussion at its
current value, as—to use Schiile’s phrase—a convenient
“ clinical collective name ” for a not very clearly delimited
group of cases with more or less distinct, but nowise pathogno¬
monic clinical and pathological characters.

Forms of crime in general paralysis .—The examination of
conduct in chronic alcoholism showed a remarkable frequency
of suicidal and homicidal impulse, and, in very much lesser
degree, a tendency to certain forms of sexual crime, especially
the defilement of children ; offences of acquisitiveness, on the
contrary, did not appear to be very importantly related to this
condition.

Crime dependent on the senile involution to a great extent
resembles alcoholic crime in all these points.

In general paralysis, on the other hand, the character of
conduct is entirely different. A rough illustration of the con¬
trast may be given in statistical form. During nine years.
(1888-96) among accused and convicted prisoners certified as
insane in the local prisons of England and Wales there were
274 cases (261 males and 13 females) in which the form of
mental disease was considered to be general paralysis.( 2 >
Amongst the other prisoners found insane during the same
period were 140 males aged sixty years and upwards. Com¬
paring the character of the delinquency in this senile group
with that in the group of male paralytics we get this result :

G.P.

(a) Crimes of violence—Homicide ... 4

Homicidal attempts . 5

Assaults . .21

Threats ... 8

( 5 ) Suicidal attempts.8

( c) Crimes of acquisitiveness 144

(d) Sexual offences.13

\e) Other offences.58

Senile.

5
8

6
24
30

261 140

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30 CRIME IN GENERAL PARALYSIS, [Jan.,

Thus, while in the senile insane grave homicidal acts (first
two groups of crimes of violence) and attempts to commit
suicide amount respectively to 9*2 per cent, and 17" i per cent,
of the total delinquency, in the paralytics the corresponding
figures are only 3*45 per cent, for homicidal acts, and 3*07 per
cent, for suicidal attempts ; and while impulses of acquisitive¬
ness account for 55*17 per cent, of paralytic crime, they appear
in only 21*76 per cent, of the senile cases.

It is, of course, needless to point out that these figures are
to be taken with large qualifications ; they are quoted here
merely to give a general view of the character of paralytic
crime before entering on the detailed discussion of its
varieties.

Crimes of acquisitiveness . — Offences of this class are
notoriously common in general paralysis, and they have been
so often described in this connection that a very summary
account of them will suffice here. Their most typical form is
petty larceny, but frauds, forgery, and embezzlement are also
frequent.

Generally the circumstances and execution of the offence
show a characteristic silliness. Exceptions to this rule, how¬
ever, are met with ; paralytics do sometimes commit robberies
and frauds with an appearance of adequate motive and pre¬
meditation. In an observation, for instance, published by
Maudsley,( 8 ) a general paralytic in the prodromal stage skil¬
fully robbed a number of railway passengers of their watches ;
he had provided himself for his expedition with a false beard
and a dagger. And other somewhat similar instances of pre¬
meditation are on record.

Such relatively intelligent acts are linked by cases interme¬
diate in complexity to the more simple expressions of acquisi¬
tiveness—the automatic theft and the rubbish-gathering of
advanced dementia (Mendel).

The most important point to be noted about this tendency
is that it occurs in exalted or at least optimistic paralytics, and
not in those with the melancholic form of the disease. Ritti,( 4 )
indeed, has seen some instances of theft by depressed para¬
lytics ; but such cases would appear to be quite exceptional.

This association of acts of acquisitiveness with exaltation
has led some observers (Burman) ( 5 ) to suppose that the acts
are caused by the delirious ideas. Clinically, however, it is very

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1902 .]

BY W. C. SULLIVAN, M.D.

rare to see cases which would conceivably admit of this inter¬
pretation. Very often, on the contrary, the impulse precedes
the delusions of exaltation by a long period of time—seven
years in one of Brierre de Boismont’s observations^ 6 ) And
acts of acquisitiveness are very common in the purely demential
form of the disease where such delusions never develop ; this
is the form of paralysis most frequently seen in prison
experience.

Corresponding with the purely impulsive character of his
conduct is the paralytic’s confused state of consciousness.
Sometimes he will deny all knowledge of his action, or if he
remembers it, he may profess amnesia of the motive. And
very often, when he does not explicitly plead amnesia, but on
the contrary endeavours to explain or excuse his conduct, his
explanation is really nothing more than his personal theory to
account for an action whose true motive entirely escapes him.
This ex post facto origin of the paralytic’s idea of his own motives
is most apparent in the later stages of the disease, when the
patient in the course of a few minutes’ interview may assign
three or four different and contradictory reasons for his action,
his explanations varying with his moods. The following
observation illustrates this point :

H. F— stole a piece of bacon from a stall outside a shop in a large
thoroughfare; he simply picked the bacon up, hid it under his coat,
and walked away ; the shopman stopped him, he replaced the bacon on
the stall, and waited till the police came and arrested him.

Prisoner is aet 55, painter by trade, married, has three children.
Marked lingual and facial tremor, blurred speech, exalted patellar
reflexes. No special ocular symptoms. No signs of alcoholism.
Very demented, e.g. blunders over the names and order of the months,
cannot calculate his earnings over more than two weeks, etc. Facile,
self-satisfied in mood; no obvious delusions; has had several congestive
seizures.

Asked why, being an honest man, he committed a theft, says he was
in drink and did not know what he was doing. Says later that he is
hard-working and devoted to his family, that he has not taken liquor
for years; becomes emotional on the subject of his children. Asked
now why he stole the bacon, says it was to take it home to his children
who had nothing to eat Questioned about his work, says he is an
excellent workman, gets good wages, has saved money, has £15 in the
bank ; beamingly optimistic. Asked now why he stole the bacon, says
he did it for a joke. Reminded of his other explanations, says he does
not know why he stole it, “ it must have been for a joke.”

Besides this impulsive origin, acts of acquisitiveness may

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[Jan.,

also be more indirectly connected with general paralysis.
Paralytics, for instance, who have blundered in their accounts or
lost money, may in a more lucid phase embezzle to make good
the deficit. This is a point of some practical importance in
relation to the question of legal responsibility, because it may
happen—and I have recently seen an instance of the sort—
that the fraud has the appearance of intelligent execution,
while the error it was designed to cover was stamped with the
character of dementia.

Paralytics are also very amenable, through their naivett to
criminal suggestions by others. Magnan ( 7 ) quotes the case of
a patient who was sent by his wife to steal in the Bon Marche ;
and Foville( 8 ) mentions two instances where paralytics were
used as tools to utter forgeries.

Suicide .— The frequency of suicidal tendency in general
paralysis is a question regarding which opinion appears to be
divided. The majority of authors consider it as very excep¬
tional. Brierre de Boismont,( 9 ) however, speaks of it as a not
uncommon initial symptom. And this is also the view of
Mendel,( 10 ) who even suggests that an important proportion of
suicides in middle life are to be attributed to this disease in its
prodromal stage; in 180 patients observed by him, 12 had
attempted to commit suicide, and in 7 of these cases the sub¬
sequent symptoms were of the exalted type. Kaes( 11 ) in a recent
analysis of the anomalies of conduct in general paralysis found 3 3
cases of suicidal attempts in a series of 268 men, and 12 cases
in a series of 69 women. Kaes and Mendel agree in assigning
suicidal tendency in the early stages of the disease mainly to
the sense of cerebral incapacity, and the consequent feeling of
anxiety for the future ; suicide in these conditions is not an
impulse of directly morbid origin, but rather a last act of
reason.

Regarding the later stages of the malady, there is practical
unanimity that suicidal acts are very rare. As a rule,
genuinely suicidal attempts are met with only in melancholic
cases, and are of directly affective origin. It sometimes
happens, however, in exalted paralytics that opposition to the
patients* desires and pretensions leads, in the emotional insta¬
bility of the disease, to more or less serious suicidal acts.

Generally the suicidal attempts of the paralytic, like their
other actions, are marked by the essential dementia of the

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1902.]

BY W. C. SULLIVAN, M.D.

disease, and are clumsy, absurd, and liable to arrest by inter-
current impressions. Mendel ( 15 ) mentions a characteristic case
where a patient with hypochondriacal ideas walked into the
water with the intention of drowning himself, but was checked
by the recollection that he suffered from rheumatism.

Suicidal attempts of a more determined and skilful character
are very rare; and the number of actual suicides by paralytics
recorded in medical literature is extremely small.

Voisin and Burlureaux ( 1s ) report the case of a woman who
hanged herself in the prodromal stage of the disease ; she had
had systematised delusions of persecution for at least eighteen
years previously, and these delusions persisted after the onset
at the menopause of symptoms of general paralysis. Kaes ( M )
mentions (without details) that one of his paralytics committed
suicide by hanging. In a very remarkable case reported by
Sezaret filsQ*) the patient, aet. 50, suffering from tabetic
general paralysis, had hypochondriacal ideas and delusions of
culpability, and after two abortive attempts, succeeded in killing
himself by thrusting a piece of wood into the pericardium.
Monestier ( 16 ) has recorded a case of suicide (hanging) by an
exalted paralytic where the cause may perhaps have been the
patient’s irritation at the refusal of his liberty. I do not know
of any other published cases.

Homicide .—Most of what has been said in reference to
suicide applies equally to acts of violence in general paralysis.
The only exception is that the reasoned suicide from the con¬
sciousness of commencing brain failure has no counterpart in
homicide; and even this exception is not perhaps absolute, for
at least one case of murder and attempted suicide by a para¬
lytic is on record (see Fritsch’s case below) where such a feeling
may have entered into the causation. In other respects the
parallelism is complete.

Acts of violence, like suicidal attempts—and very much
oftener than such attempts—may be committed by paralytics
when their expansive tendencies meet with opposition. In this
way originate a good many assaults of more or less gravity,
and sometimes, though rarely, offences of a more serious
character (see cases of Marondon de Montyel and Max Simon
below).

Occasionally, too, the paralytic dement may attempt murder
under the influence of a simple suggestion ; one of Kaes*

XLVIII. 3

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CRIME IN GENERAL PARALYSIS,

[Jan.,

patients/ 17 ) for instance, nearly choked a child because he had
read in a newspaper that death by strangulation only occurred
after nine minutes, and he wished to verify the statement.

The large majority, however, of grave acts of violence
depend on a primary homicidal impulse, and are related to
more or less persistent states of emotional depression. This is
the view of all writers on the subject, and it is fully borne out
by the few observations recorded in medico-legal literature.

The following summary of a number of the recorded cases
will give an idea of the conditions under which the impulse
appears in paralytics. In one or two of the cases, it will be
noted, the diagnosis is, perhaps, open to question.

1. Ebers.( l8 )—A soldier, aet. 47 ; chronic alcoholism and gout; placed
in an asylum owing to an attack of hallucinatory delirium, was found
to be suffering from general paralysis. Discharged on remission of
symptoms, murdered his wife, of whose fidelity he had suspicions.

2. Hagen.Q 9 )—Well-known case of Count Chorinsky, who, in pro¬
dromal stage of general paralysis, poisoned his wife. He acted in collu¬
sion with his mistress, whom he desired to marry; had also a pecuniary
motive. Crime cleverly planned and executed.

3. Sisteray.f*®) —A man, aet. 43; as a result of head injury had
developed persecutory ideas, in connection with which he made well-
planned attempts to murder, on one occasion, a relative, and on another a
neighbour. The mental symptoms existed some ten years prior to the
crime. The grounds for diagnosis of general paralysis appear very
slight

4. Kraft-Ebing (quoted by).( 21 )—A man, aet. 46; history of alco¬
holism. Had mixed delusions of exaltation and of persecution by his
wife, and had often threatened to get rid of her. Strangled her, and
tried to represent her death as natural. Typical delire des grandeurs
developed subsequently.

5. Lotz.( 2 -) —Policeman, aet. 50 ; history of alcoholism. Murdered a
woman by shooting her with a revolver, subsequently firing on people
who attempted to arrest him. Wanted to marry the woman, whose
family opposed the union. Stated that the woman had agreed to a
double suicide; this assertion was not in accord with her letters.
Diagnosis of probable general paralysis rested on symptoms of increasing
dementia, ataxic speech, paresis of right side, oscillatory emotional
state.

6. Schmidt .( 2S )—Woman, aet. 45 ; insane heredity; always eccentric;
symptoms of general paralysis dated from childbirth three years before
crime. Murdered her husband with an axe, and buried his body in

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1902.] BY W. C. SULLIVAN, M.D. 35

garden. Pleaded that she acted in self-defence, her husband in a state
of drunkenness having attempted to kill her.

7. jFritseA.( u ) —Shoemaker, aet. 43; head injury twenty years pre¬
viously ; alcoholism. Murdered his wife and four children during their
sleep, and attempted to commit suicide. Had been worried about
work for some time. Alcoholic symptoms marked at time of crime.
Exaltation appeared a little later with characteristic physical signs.

8. Baume .(**)—Symptoms of general paralysis did not appear until
fourteen years after the crime—the murder of a friend—committed
under the influence of systematised delusions of persecution.

9. Marondon de Montyel.i™) —Workman, aet. 45. Made a murderous
assault on a girl with the object of robbery. Clumsy defence. General
paralysis of exalted form.

10. Marondon de MontycL —Man, aet. 39, in early stage of exalted
general paralysis, made a well-planned attempt to murder one of his
friends. It appeared that the murderer had offered to his victim, who
was about to be married, the loan of his penis, to which he attributed
very exceptional qualities ; losing the power of erection soon after, he
suspected that his friend had kept possession of the organ.

11. Villard.i*) —Farm labourer, set. 45; history of alcoholism.
Entered a farmhouse where the people were at supper, saluted them in
a friendly way, and a few minutes later made a sudden attack on one of
them with a bill-hook, after which he ran away. Went next day to the
doctor’s house to ask about his victim’s state ; spoke very ill of the man,
accusing him among other things of being the author of a fire in a
neighbouring village thirty years previously; when it was pointed out
that the man had not then been born, said “Well, it was his grand¬
father.” A few weeks later his ideas were exalted, he was quite unable
to suggest a motive for his action, and was unwilling to believe that he
had been guilty of it

12. Ballet .(**)—Female, with hereditary taint, always eccentric, and
with vague persecutory ideas, committed a cleverly planned murder in
the prodromal stage of general paralysis.

13. Camuset.( ®)—Magnan quotes without details an observation of
Camuset where a general paralytic committed a mufrder in a phase of
automatism resembling that of epilepsy.

14. Max Simon.i^) —A general paralytic in the advanced stage,
annoyed by the groans of the patient next him, crawled out of bed, and
beat out the disturber’s brains with a wooden shoe.

It is interesting to note that in nearly all these cases where
the homicidal act was not incidental to an acquisitive intent,
there existed some special circumstances apt to modify the

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CRIME IN GENERAL PARALYSIS,

[Jan.,

emotional tone. Several of the patients, for instance, were
alcoholic ; others had a history of antecedent persecutory ideas ;
others ( e . g . Marondon de Montyel’s second case) acted under
the influence of a disorder in visceral sensation. This point
will be discussed more fully later on.

Sexual offences .—In the early stages of general paralysis,
particularly in the optimistic form, genital excitement is fre¬
quent, and leads not uncommonly to criminal acts.

All varieties of sexual crime—rape, defilement of children,
sodomy, bestiality, minor offences against public decency—
have been observed in paralytics ; but there is not sufficient
statistical information to show what is the predominant form
of the sexual impulse in the disease, and in what way
differences in the direction of the impulse are related to
differences in the emotional state. It is, however, interesting
to note that in several recorded instances of defilement of
children by paralytics ( 81 ) the disease was of the melancholic
type. If this association is a general rule, it shows another
striking correspondence between the depressed form of paralysis
and the dementia of alcoholism and senility, in which the same
variety of sexual crime is particularly common.

Other offences .—Of offences not included in the foregoing
classes, malicious injuries to property are most frequent.

Paralytic dements, particularly in the lower classes of the
population, frequently incur punishment through ^wf-criminal
offences—drunkenness, vagrancy, and various social sins of
omission. These do not call for special remark.

It remains now to consider the causes which determine the
special directions of the will in general paralysis, and to explain
the contrast in conduct between that disease and the dementia
of chronic alcoholism and of senility. The discussion will be
confined to acts of acquisitiveness, acts of violence, and suicide.
Sexual offences, which form the only other important group,
will be treated apart.

Restricting our attention, then, to the forms of conduct just
mentioned, and considering only the nature of the primary
impulse, we recall, as the chief result of our inquiry, that acts
of acquisitiveness are almost always related to the optimistic
form, or to optimistic phases of the disease, while acts of
violence to self or others are generally related to the melan¬
cholic form of the disease. Impulses of acquisitiveness are, in

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1902 .]

BY W. C. SULLIVAN, M.D.

fact, the expression in the will, as the delirium of exaltation is
the expression in thought, of the optimistic emotional tone.
And here, as always, the impulse is the earlier and more
constant expression of the emotion, of which, indeed, it is
rather a constituent, while the corresponding thought is later
in appearing, or may not appear at all.

Of course, in the large majority of cases of general paralysis,
the affective tone is constantly or predominantly optimistic.
This is obvious in the exalted paralytics of the classic type;
it is evident, too, though less obtrusively, in the more numerous
cases of simple dementia, most of which exhibit a facile, con¬
tented mood, and show in conduct the acquisitive tendencies
which we have seen to be characteristically related to that
mood. Only in a small minority of cases—27 per cent, in the
highest estimate that of Kraepelin ( 3S )—is the prevalent mood
one of depression.

It is, then, because the affective tone in general paralysis is
most usually optimistic that impulses of acquisitiveness are
frequent, suicidal and homicidal impulses rare. In senility and
in chronic alcoholism, on the contrary, where the affective tone
is generally pessimist, impulses of violence are relatively
common.

The explanation, therefore, of the character of conduct and
thought in general paralysis enters into the larger problem of
the origin of the affective state in the disease.

Many solutions of this problem have been suggested. In
the limits of this paper it is not possible to give more than the
briefest summary of them.

The earlier observers, who regarded the delirium of exalta¬
tion as characteristic of the disease, appear to have had no
hesitation in connecting this symptom in all its elements with
the cerebral lesions. In this view the difficulty was to account
for the occurrence of melancholic cases. The first mode of
explanation was to attribute the hypochondriacal delirium to
special visceral disorders. Bayle (**) suggested this origin in a
case where the depressed form of delirium occurred in a
patient with chronic gastritis. The theory was elaborated
by Mich£a (**) and others, and it has been accepted as at least
a partial explanation by most subsequent writers.

Others have tried to meet the difficulty by supposing a
difference in the site of the cerebral lesion, or in its nature in

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38 CRIME IN GENERAL PARALYSIS, [Jan.,

melancholic cases. Mairet^ 86 ) for instance, held that exalta¬
tion accompanied meningo-encephalitis of the vertex, and
depression the same lesion affecting the base. Austin ( 36 )
attributed the melancholic form to visual hallucinations de¬
pending on congestion of the optic thalami. Luys,( 87 ) assuming
a localisation of visceral sense in the ventricular region, regarded
congestion of that region as the cause of the hypochondriacal
delirium. These views, however, to say nothing of the fallacies
of their psychological analysis, are entirely unsupported by
pathological evidence; their interest is now purely historic.
And the same may be said of such theories as have yet been
put forward to connect the emotional tone of the delirium
with peculiarities in the intimate nature of the brain lesion.

The origin of affective depression in paralysis has also been
looked for in the influence of painful moral impressions acting
as the exciting causes of the disease. Voisin^ 88 ) to a certain
extent, leans to this view; but most observers have failed to
discover any confirmation of it. Lunier,( 8v ) for instance, out
of 65 cases of general paralysis developing during, or soon
after, the Franco-Prussian War and the Commune, and at¬
tributed to the stress of these events, found only six which
at any stage of the disease presented melancholic symptoms.

These various hypotheses, it will be noted, set out with the
assumption that the optimistic delirium at all events is directly
connected with the cerebral lesions ; and this position is still
taken up by some authors, who regard the delirium of exalta¬
tion as the “ psychic equivalent of a cortical hyperaemia,” the
“psychic function of a nutritively over-stimulated thought-cell”
(Schiile).

In the more radical theory of Baillarger^ 40 ) on the contrary,
it was admitted that there was no better warrant for attributing
the optimistic delirium directly to the brain lesions than there
was for so attributing the delirium of depression. Whatever
value may be attached to the constructive part of Baillargeris
theory—that concerning the folie paralytique —it is certain that
criticism has not hitherto in any way weakened the funda¬
mental proposition that the known cortical changes cannot
account for any psychic symptom except the dementia.

And the same statement will apply to the other organic
dementias.

The recent researches in cerebral pathology which have

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1902.]

BY W. C. SULLIVAN, M.D.

added so much to our knowledge of the minute anatomy of the
paralytic, the alcoholic, and the senile brain, have shown nothing
to connect the active psychic symptoms in these diseases with
the visible cortical changes, even when these latter are eked
out with fanciful hypotheses. There is no evidence to suggest
that the cerebral lesions in melancholic paralysis differ from
those in paralysis with exaltation. There is nothing in the
pathological changes in the brain in chronic alcoholism or in
senile degeneration to explain why the affective tone is as
ordinarily depressed in these diseases as it is exalted in general
paralysis. In short, whatever be the nature of the cerebral
conditions which underlie the different affective moods, there is
no reason to suppose that any of the visible brain changes in
the organic dementias can be regarded as morbid reproductions
of these conditions.

So far, then, the assumption of special brain lesions to
explain the varieties of feeling and thought in general
paralysis is unsupported by direct evidence. And we
may go beyond this negative position, and maintain that
such an assumption is unnecessary. What is pathological in
the exaltation or depression of the paralytic—the quality of
excess—is a character of dementia, a result of the brain
dissolution, and does not at all imply that the emotional tone,
as such, arises otherwise than in normal conditions,—that is to
say, from the state of the organic life. This simpler explana¬
tion can be, to a certain extent, tested by clinical evidence.

Take first the melancholic form of the disease. The chief
conditions under which depression appears in general paralysis
may be classed thus:

(a) Age .—Kraepelin ( 41 ) has pointed out that general
paralytics of the melancholic type are usually above the
average age for the disease, and frequently show signs of
premature senility. Cullerre,( 4 *) in his observations of general
paralysis with diffused atheromatous disease, notes the con¬
stancy of emotional depression in such cases.

(p) Intoxications .—Depression is the rule in general paralysis
with a history of alcoholism. Talon C 43 ) in ioo alcoholic cases
of the disease, found only 12 with expansive delirium.

Similarly, when general paralysis develops in patients
suffering from lead-poisoning, Devouges ( u ) has pointed out
that lypemania is constant in the early periods, and R£gis ( a )

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40 CRIME IN GENERAL PARALYSIS, [Jan.,

indicates the pessimist and malevolent temper as a distinctive
character in saturnine general paralysis.

(c) Visceral disease .—As already mentioned, hypochon¬
driacal delirium is often related to visceral disorders. Clous-
ton ( 46 ) says that his “ belief and experience is that in almost
all these cases with melancholic symptoms there is some
organic visceral disease or disturbance, which transmits to the
convolutions sensations which are disagreeable and depressing.”
He notes that nearly all his paralytics who had tubercular
disease were melancholic. Mendel,( 47 ) in several of his
observations, found the delirium of depression associated with
heart disease. Voisin and Burlureaux^ 48 ) Mickle,( 49 ) and
others, express similar views. The frequency of depression in
tabetic cases is a fact of the same order.

( d ) Vesanic antecedents .—We have seen that even intense
emotional states, arising as normal reactions to external
stimuli, do not influence the affective tone when general
paralysis subsequently develops. It is otherwise when such
states are of morbid origin. For instance, when general
paralysis supervenes in a patient with chronic persecutory
delirium, the ideas, the affective tone, and the impulses of that
delirium, are likely to persist until late dementia. Several
of the homicidal cases quoted above are instances of this
influence.

And, further, as Magnan ( 50 ) has proved, where there is
merely a latent aptitude to persecutory delirium in a degenerate
subject, the onset of general paralysis is likely to hasten its
development, and its symptoms will then colour the paralytic
dementia. This is probably the origin of the melancholic tone
in a good many instances, since it has been latterly shown,
especially by Nacke,( 51 ) that the disease is very frequently
related to the degenerate organisation.

With the possible exception of the last group, we see
accordingly that the ascertainable causes of depressed affective
tone in paralytic dementia are those that influence unfavour¬
ably the state of the organic life. Of course, the clinical
method can only detect the grosser and more obvious of these
causes, but the evidence it gives is strong enough to suggest that
the undetected causes which generate that tone in other cases
are probably of the same nature. There is a perversion of the
chemical or mechanical processes which cause the internal

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1902 .]

BY W. C. SULLIVAN, M.D.

sensations—a perversion probably similar to that which occurs
in the organic decadence of age or in general intoxications;
and therefore the affective tone is depressed, and the emotions,
impulses, and thoughts of these paralytic dements are like the
emotions, impulses, and thoughts of the chronic alcoholic or of
the senile.

Conversely, when these special conditions are absent, and
the state of the organic life is healthy, the emotional tone will
be optimistic. And this optimism will be manifest in impulses
and ideas, more or less intense, more or less extravagant,
according to the organic energy which inspires them, and the
degree of the dementia which allows their development.

This optimistic form is that which general paralysis more
usually takes, because it is typically a disease of the years of
fullest vital activity; the period 30—55 is given by most
authors as that of its maximum incidence.

It follows from this hypothesis that similar optimistic
symptoms should attend other forms of dementia with sound
organic functions, and this is, in fact, what occurs.

When, for instance, by exception, chronic poisoning by
alcohol, instead of producing general visceral disorder, limits
its action mainly to the brain, dementia with optimism will
ensue, and the clinical features of exalted general paralysis
will be more or less exactly reproduced. At all events, if I
may trust my personal experience, exaltation in chronic
alcoholism is regularly associated with a relatively healthy
state of visceral function ; and though observations bearing on
the point are scanty in medical literature—reference to the
visceral condition being usually omitted—such information as is
accessible tends in the same sense. R£gis,( 52 ) for instance,
has published a remarkable case of a chronic alcoholic who
presented typical physical and mental symptoms of exalted
general paralysis, including the impulses of acquisitiveness ; at
the post-mortem none of the appearances of that disease were
found ; there was atheroma of the brain-vessels, and “ no
lesions in the thoracic or abdominal organs” An almost
parallel observation has been recorded by Camuset^ 63 )

And a somewhat similar interpretation suggests itself in
those cases where chronic drunkards presenting at first the
normal depressed delirium of alcoholism, develop exaltation
when they have been for some time under treatment. In such

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42 CRIME IN GENERAL PARALYSIS, [Jan.,

cases the graver incidence of the poison on the brain leaves a
lasting dementia; the damage to the viscera is slighter and
transitory, and when it passes away and normal function is
restored, the affective tone changes correspondingly from
depression to exaltation. A case published by Bonville Fox ( M )
is a good example of this evolution ; a chronic alcoholic on
reception was suffering from chronic gastritis, and had a
delusion that the stomach of a corpse had been put into him ;
after four years* treatment this delusion disappeared and was
succeeded by ideas of exaltation.

In dementia due to other forms of organic brain disease, the
dependence of the affective tone on the visceral state appears
in exactly the same way. Diseased conditions of various kinds
affecting the prefrontal lobes, for instance, when extensive
enough to cause mental symptoms, give rise to a state of
enfeeblement, which is accompanied sometimes by exaltation,
sometimes by depression. J astro witz( 66 ) found that in such
cases the dementia was associated with gay excitation (moria);
while Burzio,( 66 ) Voegelin,( 57 ) and others have published ob¬
servations where the emotional tone was melancholic. These
differences in the affective tone cannot be traced to differences
in the character of the brain lesion ; they are, on the other
hand, easily explicable as reflections of differences in the con¬
ditions of the organic life. Thus, in Burzio’s case—softening
of the left frontal lobe with dementia, melancholia, and
epilepsy—the patient was a chronic alcoholic, with cirrhosis of
the liver and general visceral disease, and to these conditions
one may safely attribute his melancholia. In Voegelin’s case,
again, where a tumour growing from the hypophysis produced
cortical changes in the frontal and, to a less extent, in the
occipital lobes—other parts of the nervous system being
normal—the melancholic symptoms were associated with the
onset of the menopause.

In senility one finds the same thing ; usually the dementia
of age is accompanied by emotional depression, the reflection
of the failing organic life ; more rarely the affective tone is
optimistic, and in these cases there is, as a rule, a remarkable
retention of visceral health.

So far, then, as it goes, the clinical evidence from these
various sources leads to the same conclusions. In all these
conditions—general paralysis, alcoholism senility and the

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1902.]

BY W. C. SULLIVAN, M.D.

rest—the dementia is the only direct result of the brain lesions,
and is proportionate in degree to their extent. The active
psychic symptoms in impulse and in thought, which colour the
dementia, are not direct effects of these lesions ; they are the
expression—thanks to the dementia, a greatly exaggerated,
expression—of the influence of the organic life “ in which the
emotions and the will are rooted ” (Maudsley).

That is to say, the simpler conditions of dementia only make
plainer and more gross the same relation that governs at least
a great part of the normal operations of the mind. “ It is the
association of the emotions, and, with the emotions, that of the
impulses, that determines the association of ideas/' On
the coenaesthesis depends the grouping of the memories which
go to constitute the delirious impulses and ideas. When the
organic stimuli which make up the coenaesthesis are normal,
pleasurable, as they are more usually in general paralysis,
exceptionally in alcoholism and in senility, then the emotional
tone is optimist, the impulses of acquisitiveness, the ideas of
exaltation. When, on the other hand, the stimuli are of
disordered function, as they mostly are in the senile and the
alcoholic, and sometimes in the paralytic, then the emotional
tone with its accompanying impulses and related delusions is
pessimistic.

f 1 ) Joum. of Ment. Sc., April, 1898; ibid., April, 1900; ibid., Oct., 1900.
Comptes rendus du Congris pinit. de Bruxelles, 1900.—( a ) Reports of Commis¬
sioners of Prisons.—{ 2 ) Lancet, 1875.—( 4 ) Ann. medico-psych., 1875. —( 6 ) Journ. of
Ment. Sc., 1873.—(•) Ann. d’hyg. publ. et de mid. Mg., i860.—( 7 ) La paralysie
ghUrale, Paris, 1894.—(*) Art. “ Paralysie g£n6rale ” in Jaccoud’s Diet . de mid. et
de chir., Paris, 1878.—(*) Op. cit.—( ,9 ) Die progressive Paralysie, Berlin, 1880.
( u ) Allg. Zeitschr.f. Psychiatric, 1896.—( ,a ) Op. cit.—( u ) De la milancolie dans
ses rapports avec la paralysieginirale, Paris, 1880.—( u ) Op. cit.—( u ) Ann. mid.
psych., 1892.—( w ) Ann. mid. psych., 1900.—C 17 ) Op. cit.—( 1S ) Die Zurechnungs -
f&higkeit, Glogau, i860.—( 19 ) Chorinsky, Erlangen, 1872.—(") Ann. mid. psych.,
1873.—( a ) Mid. lig. des aliinis, £dit. fran^, 1900.—( M ) Arch. f. psych.,
1877.—( 3 ) Arch. f. psych., 1881.—(**) Wien, media. Presse, 1881.—(") Ann.
mid. psych., 1881.—(*) Ann. d’hyg. pub. et de mid. lig., 1888.—(**) Ann. d’hyg.
pub. et de mid. lig., 1889.—(**) Ref. in Arch, d’anthropol. crim., 1891.—(*®) Quoted
in Magnan et Sirieux, op. cit.—(*°) Crimes et dilits dans la folie, Paris, 1886.—
(*) Ann. mid. psych., 1879.—(**) Psychiatrie, ed. 5 t Leipzig, 1896.—( M ) Traiti
des mal. du ceroeau, Paris, 1825. -(*•) Ann. mid. psych., 1864.—( 34 ) De la dimence
milancolique, Paris, 1883.— (*) Quoted in Voisin et Burlureaux, op. cit.—C 37 )
Traiti des mal. mentales, Paris, 1801.—(**) Op. cit.—C 39 ) Ann. mid. psych., 1874.—
(*) Recherches sur les mal. mentales, vol. ii, Paris, 1890.—( 41 ) Op. cit.—( 4 *) Ann.
mid. psych., 1882.—(*) Ref. in Ann. mid. psych., 1883.—( 44 ) Ann. mid. psych.,
1857.—(**) Ann. mid. psych., 1880.—l 46 ) Mental Diseases, ed. 5, 1898.—( 47 ) Op.
cit. —( m ) Op. cit. —("•) General Paralysis, ed. 2, 1886.—(*°) Lemons sur les mal.
mentales, 1897.—(* ! ) Neurol. Centralbl., 1899 and 1900; Allg. Zeitsch. f. Psych.,
1879 and 1899.—-( M ) Ann. mid. psych., 1881.—(**) Ann. mid. Psych., 1883.—
(**) Journ. of Ment. Sc., 1884.—( u ) Deut. med. Wochenschr., 1888.—( M ) Archivio di
Psichiatr., 1900.—( l7 ) Allg. Zeitschr. f. Psych., 1897.

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CRIME IN GENERAL PARALYSIS.

[Jan.,

Discussion

At the General Meeting, London, November 21st, 1901.

Dr. Robert Jones said the paper dealt with very valuable material in the field
of medico-psychical research in which the majority of those present had no
experience, i. e. those who came to asylums from the prisons. Dr. Sullivan had
touched upon the relation of exaltation and depression. Bevan Lewis endeavoured
to explain that, physically, a process of reduction took place in the nerve-
cells, which was described as a dissolution of a greater depth in the exaltation of
mania than took place in the depression of melancholia, the difference in the
nerve-cells being essentially one or degree. He was interested in hearing that
those forms of general paralysis which came under Dr. Sullivan’s care were of a
mentally depressed type. Such had been his own experience. He had had several
cases transferred from Broadmoor to Claybury, and his experience agreed with
Dr. Sullivan’s. He thought very little was known about the relation of insanity to
organic life. Ford Robertson had worked at the subject of the condition of the
intestinal mucous membrane in cases of general paralysis, and it was interesting
to see that he accounted for digestive abnormalities and diarrhcea as being probably
caused by the same toxaemic changes which caused general paralysis itself. At
Cheltenham, that gentleman showed beautiful preparations of lesions in the intes¬
tinal canal dependent upon toxic changes in cases of general paralysis of the insane.
With regard to the emotional character of senility, it was somewhat difficult of
explanation. So much depended on the balance between action and inhibition,
and when that was disturbed, the slightest stimulus, otherwise insufficient, was
likely to give rise to some fleeting effect. One found that particularly so in old
people, in whom there were marked senile arterial changes. Such persons were
irritable, and would be pleased or irritated momentarily by trivial causes. Pos¬
sibly at the root of these changes was an abnormal involution in the arterial
system. He said, in conclusion, that he felt very much interested in Dr. Sullivan’s
paper, for it suggested the necessity for further investigation into a fertile field
hitherto but little worked upon, viz. the psychology of the emotions as bearing
upon action, normal and abnormal.

Dr. Seymour Tuke said he would like to mention one case which he thought
might interest Dr. Sullivan. That gentleman mentioned fifty-five years as being
the limit of age, and he referred to depression in people who were of a certain
age as being a special attribute of the general paralytic. He, Dr. Tuke, last year
had a very interesting case, that of an old gentleman who was the most mag¬
nificent type of old man that he had ever seen. He was, and always had been,
very keen on athletic exercises and massage. He was in the habit of massaging
himself thoroughly every morning, from the head downwards. He was sixty-two
years of age, and had a typical attack of general paralysis, with the most extra¬
ordinary exaltation. He was exalted from the commencement, and even in his
dementia he was not known to be once really depressed. He was always full of
the idea of driving a four-in-hand, and going about in steam launches. He
had done a good deal of that sort of thing in his earlier years. He went through
all the typical stages of general paralysis, and throughout his optimistic
delusions persisted, as well as his idea of his own youth.

Dr. Sullivan, in reply to the observations of Dr. Robert Jones, said he
gathered from Bevan Lewis’s account of his work, that in his endeavour to explain
the mental symptoms related to alcoholism by reference to the brain, he had
appealed to certain facts of autopsy and conditions of the brain-cell, about which
there was a lack of absolute unanimity. Some others, who had also endeavoured
to explain emotional states by the condition of the brain, notably Dr. Turner, had
mentioned similar conditions, but they explained the influence of those conditions
on the emotional tone in an opposite manner. There must, no doubt, be an
underlying cerebral condition for the affective tone, but that was still a matter of
pure speculation. He thought one could sufficiently explain impulse and thought
in conditions of dementia without supposing that impulse and thought depended
on changes in the brain ; that all the changes in the brain did was to allow the
ordinary emotional conditions to develop in a more exaggerated form than they
otherwise would, and that consequent upon those emotional changes was the
condition of thought in the disease.

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1902.]

NOTES ON HALLUCINATIONS.

Notes on Hallucinations . /. By Conolly Norman^ 1 )

Although hallucinations are so common and universally
recognised as an indication of insanity (Esquirol reckons,
probably truly if we count every stage of every case, that
they occur in 80 per cent, of cases of mental alienation, and
we all know that even with the general public there is no
proof of aberration more convincing), yet there are many
points connected with the study of hallucination which are
worthy of more attention than they generally receive.

In any individual case in which hallucinations are a
prominent symptom, one of our first inquiries will be whether
they owe their special interest to an unusual extension over
the entire sensory field or to an unusual distribution within
some division of sense. There are not a few cases in which
every sense and many subdivisions of senses, if this phrase is
allowable, are attacked ; others in which one or more stand
out as being the only senses involved, or as being so pre¬
eminently engaged that the involvement of the other senses is
dubious or is concealed.

In the present memoranda I propose to consider the points
which arise in a particular case now under my observation.
This case is not very complete with regard to extension, inas¬
much as the engagement of two of the senses is somewhat
doubtful, as will be shown hereafter. One of these is vision
and the other the sense of mental action. No one will deny
the importance of the sense of vision in respect of our
relation to our environment. The sense of mental action, on
the other hand, is one which has escaped the notice of the
physiologist because it is of no great importance in the normal
state, when it rarely appears above the threshold of conscious¬
ness. The conditions under which we are conscious of mental
action usually approach the abnormal. Thus, when we are
very tired, when the attention is exhausted by prolonged
occupation with one topic, or fatigued by the strain of
endeavouring to fix the thoughts on one subject while another,
perhaps reinforced by strong emotion, is constantly obtruding
itself into the mind, we feel that our thoughts cannot be
controlled, or we feel an intense sense of mental weariness.
Perhaps distinct obsession is too absolutely pathological a con-

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NOTES ON HALLUCINATIONS,

[Jan.,

dition to be classed together with normal phenomena, but the
state analogous to obsession in which the sight of a train
coming into a station or the looking over a precipice produces
a curious feeling of impulse to precipitate oneself is probably
due to an interference with the sense of mental action.
Ordinarily, however, and in most matters, we use our minds
without any distinct sense of mental action. Nevertheless, in
paranoia where we see many of those dissections through
disease which often throw unexpected light upon normal
function, the sense of mental action is often of great im¬
portance, since its morbid manifestations serve to reinforce
delusions of malign and occult influence. Nothing is more
common among patients of this class than the complaint that
their thoughts are influenced, that they are compelled to think
in certain ways or are rendered incapable of thought or the
like. It is often obvious that we are not dealing with a mere
inference in these cases, but that the feeling (sense) of mental
action (taking place in an abnormal way) is as distinct as the
hallucination of any other sense.

The following is a brief abstract of the case on which I
desire to comment on this occasiori:—G. L—, a single woman,
who had formerly been a servant, whose age was 60, was
admitted to the Richmond Asylum towards the end of October,
1901. There was absolutely no history further than that she
had been four years in the workhouse whence she came.

She was a well-nourished person presenting no physical
indications of disease. The skin of the face, backs of hands,
and forearms was much tanned, as if from exposure to the
weather. The left pupil was somewhat larger than the right.
Both were normal in outline, and responded normally to
light and accommodation. Vision good in both eyes.

The facial expression was intelligent and cheerful ; she
was tranquil and free from confusion ; she conversed with in¬
telligence. Replying to questions about her condition, she
revealed numerous hallucinations, together with delusions of
the common organised paranoiac type. Enumerated sys¬
tematically, the following were the hallucinations found :

General sensibility .—Sharp pains all over the surface, de¬
scribed as “ pricks/* “ stabs of pain/* “ stitches/* “ darts ** of pain,
“ like hot sparks from an anvil/* together with more constant
aching pains in the joints and muscles. Sometimes the sharp

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1902.]

BY CONOLLY NORMAN.

pain seems to be all over the surface, so that she feels as if
surrounded by fire, as if her bed were on fire.

Temperature sense .—Besides the feeling of burning or pain¬
ful heat, a sense of warmth and flushes of sudden heat are
shot over her, or sudden chills and sensations of icy cold.

Muscular sense .—Extreme feeling of lassitude and weariness
without cause. The limbs feel like lead, so that the patient is
surprised that she can walk, so heavy are her legs, or lift her
food to her mouth, so heavy are her arms.

Tactile sensibility .—Here she complains of a peculiar sensa¬
tion which I have not before found in cases of hallucination.
Her hands from time to time feel dry and glossy. The
dryness she describes is not a harsh dryness, but a smooth
dryness. She states that it is as if her hands were polished, as
if they were covered with a thin layer of dried gum, or
varnished. Again, she describes the surface as “ glassy ” or as
“ silky.” This sensation she obtains by rubbing her finger tips
together, or touching the fingers of one hand with those of the
other.

Now, besides being most likely very rare, this sensation
is of singular interest, as corresponding precisely to the
sensation produced in patients who are taking belladonna.
That the feeling in the latter case may be in part a
nervous one is possible, but it is more likely that it is
conditioned by the dryness of the skin arising from the
suppression of perspiration produced by the drug. It is
scarcely necessary to say that my patient has not taken
belladonna. Neither does she present that dryness of the skin
of the hands which would account for the sensation she
describes. There is no reason to believe that she can have
associated with a person presenting this silky dryness of the
skin ; all the probabilities are against suggestion of this sort.

Gustatory .—She tastes intensely acid tastes ; also the taste
of alum, a strongly astringent taste. These tastes are not
stated to be confined to the back of the tongue, as one has
occasionally found such gustatory hallucinations to be. The
physiological writers state that the true tastes are but four—
sourness, sweetness, saltness, bitterness. It appears to me
that this list ought to be increased by the addition of two
others—astringency and pungency. The sensation of astrin-
gency (in this case compared to alum) is certainly a taste. It

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4 8

NOTES ON HALLUCINATIONS,

[Jan.,

has nothing to do with smell. Its connection with general
sensibility is remote if it can be said to exist at all, for the
sensation that alum produces on the tongue seems absolutely
of a different order from that produced by astringent and
desiccating substances applied to the skin or mucous mem¬
brane elsewhere than in the mouth. I am not so clear as
to pungency. Of course the savours which distinguish
different pungent substances from each other are largely a
matter of smell, but with regard to the underlying pungency
itself, it seems to somewhat closely resemble the smarting
which similar substances produce when applied to the surface.
Perhaps this sensation of pungency or acridity may be called
the least differentiated branch of taste—may, as it were, furnish
a connecting link between general sensibility and taste.

Olfactory .—She is worried with odours of faeces and such¬
like filthy substances, or she smells the scent of fruit, more
specifically of lemons.

Respiratory .—There are a series of sensations connected
with respiration which I believe ought to be regarded as a
separate sense. We are little conscious of them in the
normal state, but they readily come prominently into con¬
sciousness when respiration is impeded, and disturbances in
this region of sensibility are common in the insane. They
are frequently associated with olfactory hallucination, but they
may exist alone. In the case before us the patient suffers
from the feeling that she is, as she expresses it, being
fumigated ; her breath is caught. She has also " chucking ”
sensations in the throat, as if her wind-pipe were being forcibly
dragged up.

Visceral sensibility .—Sensations of movement in the ab¬
domen and of torsion. “ It is like as if a stick was thrust
up through me and twisted round.” Similar complaints are
common among paranoiacs and hypochondriacs. They probably
connote the appearance in consciousness of disturbances in
regions commonly below its threshold.

Genital sensibility .—An electric wire is thrust into the
vagina, and causes much distress, by producing not only pain,
but specific sensations.

Visual .—No visual hallucinations appear to exist now and
none have existed recently, but the patient says that four years
ago, when, as she states, probably correctly, the annoyances

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1902.]

BY C0N0LLY NORMAN.

began, she had a vision once of an angel with a drawn sword.
This vision occurred in church. I am not sure how far this is
to be regarded as a true hallucination. As is so frequently
the case, the patient seems to attribute something less of
reality to it than she does to her auditory hallucinations. The
latter she hears , the former she does not say she saw , but she
had a vision of. It is interesting to note that while in some
cases visual and auditory hallucinations coincide as to time
and are often closely associated together, it very frequently
occurs that hallucinations of vision cease comparatively early,
while the auditory remain. In some cases we are told of
visions, or what are apparently visual hallucinations, appearing
but once and intimately associated with the building up of a
whole scheme of delusion. Thus in a case at present under
my care the patient relates how a man whom he had never
seen before but whose appearance he describes came into the
room where patient was working one day. Nothing particular
happened then, but the following night voices began to torment
the patient as well as all other kinds of sensory disturbances,
and these he attributes to the unknown visitor, though he
never saw him again nor has he had any further visual images
of persons. In such a case, however, unless one should have
trustworthy contemporary evidence of the vision, it would seem
probable that the sequence of the events is not as described by
the patient, and that the vision was not an hallucination but
merely a delusion by reminiscence arising out of an endeavour
to explain subsequent experiences.

Sense of Mental Action .—Besides the senses ordinarily
recognised, disease at least seems to show, as we have said
above, that there is a sense of mental or cerebral action.
TKe very frequent complaints of paranoiacs that their thoughts
are interfered with, that they are made stupid, that they are
made say, do, and think things that they know to be wrong,
and that they do not wish to do, do not present themselves in
this case. The nearest approach is “ they sometimes make me
stupid with the tar gas which they make me smell ; ” but as
she appeals to the fact that at such times the eyelids feel
heavy, as a sign that she is stupefied, there is probably little
true sense of interference with thought. What exists is
rather an inference than a sensation.

Auditory Hallucinations .—She hears sounds of buzzing and

XLVili. 4

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NOTES ON HALLUCINATIONS,

[Jan.,

whirring, rolling of wheels and peculiar clattering, all of which she
is confident are the sounds produced by the action of electric and
magnetic machines. She also hears voices, which talk about
her doings and her affairs, which abuse and threaten her,
which are often horribly obscene and blasphemous. They
talk also of the mode in which they torment her—“ now we
will put on the machine,” u now we will give it to her,” and the
like. Further, she sometimes hears voices which remonstrate
with the others, and speak in her favour.

The auditory hallucinations present many characters, which
are frequent. They consist mostly of “ voices,” and the voices
are as usual personal, abusive, indecent, and blasphemous.
These characters are sufficiently accounted for by the “ ego¬
centric ” suspicious nature of paranoiacs, and by the fact that
the patient is a respectable elderly woman. Besides the
voices (verbal auditory hallucinations) she hears the sound
of the machine that is working upon her, and she distinguishes
the whirring of wheels, etc. (common auditory hallucinations).

It will be remembered that S£glas has divided auditory
hallucinations into three classes: elementary (vague noises);
common (sounds associated with definite objects) ; and
verbal (where a voice is heard). These three orders, as he
points out, indicate the engagement of physiologically separ¬
able functions, the hearing of noise, the recognition of sound,
and the comprehension of speech. They are correlated to the
conditions existing in another series of pathological states,
where we have respectively cortical deafness, psychical deafness,
and verbal deafness.

This patient also shows, among her auditory hallucinations,
the interesting phenomena of a voice which takes her part
against those who abuse and defame her. This has been
regarded as a malum signum and an indication of chronicity,
and my experience coincides with the notion, though I fail,
as I have pointed out elsewhere, to perfectly appreciate the
theoretical explanation which has been given for its grave
prognostic importance.

The points, however, of special interest are that the patient
is only conscious of hearing sounds of machinery and the
voices of her persecutors, etc., with the right ear, while she is
in fact absolutely deaf of that ear. The voices, etc., seem to
her to proceed from a point about a foot to the right of her right

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BY CONOLLY NORMAN.

ear. She was, when 1 first saw her, conscious of being some¬
what deaf of her left ear, but did not recognise till 1 tested her
hearing that she was deaf of the right. I gathered that the
constant hearing of voices on the right side satisfied her of the
soundness of her hearing on that side. Nevertheless I found
that she could not hear a watch on the right side, even when
touching her ear, nor when pressed against the skull. Being
anxious to obtain a skilled opinion about the aural condition,
I sent the patient to the well-known specialist, Dr. R. H.
Woods, who very kindly examined her for me and courteously
wrote to me as follows :

“In the left ear there was no cerumen, the drum was
slightly anaemic but otherwise normal in appearance. The
hearing distance* with a watch was i ; Rinne’s test was ££
normal. The tuning-fork placed on the vertex was heard
only in the left ear. The right ear was plugged with cerumen ;
the drum normal in appearance, but would probably look a
little anaemic if sufficient time elapsed after syringing. The
hearing distance of a watch was lost, Rinne’s test was
There was no Eustachian obstruction in either ear. The con¬
clusion, therefore, that I draw is that she is suffering from
either auditory or labyrinthine deafness in her right ear, the
hearing in the left being very fair.”

The association of hallucinations of hearing with deafness
has long been observed. It was noted by Calmeil some sixty
years ago. Brierre de Boismont repeats the observation in
his book on hallucinations. Ball more recently goes so far as
to mention deafness as a cause of hallucinations of hearing.
Savage endeavours to account for the association through the
tendency to suspicion that naturally seems to spring up in
people who have grown deaf. It is apparently intelligible that
the irritation produced by a growing defect, the liability to think
that that conversation which is not heard relates to oneself,
and the constant straining of the attention in an effort to hear
should combine to bring about hallucination. To accept this
it is not at all necessary to refer to the old psychic theory of
hallucination. It is an equally plausible doctrine if we accept
with, no doubt, the majority of modern thinkers, the theory of
Tamburini. However explained, the association is one that is
quite familiar to most alienists, though it does not appear to
have attracted much attention among otologists. It has been

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NOTES ON HALLUCINATIONS,

[Jan.,

suggested that tinnitus, the noises arising from cerumen, etc.,
may give rise in some cases to auditory hallucination by the
transitional path of delusive interpretation, but against this
notion it may be argued that in the most familiar examples of
delusive interpretation there is little that is analogous to the
conversion of a vague sound arising in the ear into a distinct
verbal hallucination. Besides, in my experience, it has certainly
not been with cases where there was tinnitus, etc., that
hallucinations were markedly associated, but with cases of
complete deafness.

Unilateral hallucinations, either occurring alone or occurring
in cases where other hallucinations existed, have been
occasionally described. I think they are rare, though Dagonet
may be right in saying they are often overlooked. Ball, and
subsequently R£gis, wrote accounts of a case of unilateral
auditory hallucinations coinciding with otitis media of the
same side. Mabille has described a case in which a melan¬
cholic woman suffered from right auditory hallucinations and
was found to have a foreign body in the right external auditory
canal. When the foreign body was removed the hallucinations
ceased, but the patient remained melancholic. F<£r£ has
recorded a case of unilateral hallucination of hearing associated
with herpes in the trigeminal region. In such cases peripheral
influences seem undoubtedly to have some share in bringing
about hallucination. How they act it is not easy to see.
Raggi, some years ago, described two cases in which it is
difficult to find a common explanation. In one an elderly
drunkard, unaffected with any discoverable ear disease, had
unilateral hallucinations of hearing and bilateral of vision. In
another an old woman had visual hallucinations confined to
the right side, the right eye being affected with cataract. After
cataract operation the hallucinations disappeared, but recurred
shortly afterwards in a worse form than before.

The suggestion that functional disease is more liable to
appear in a centre thrown out of gear by the absence of the
normal stimulation might be plausible in some cases of
auditory hallucination in deafness, whether unilateral or
bilateral, but it does not seem to meet certain other ex¬
periences. Thus. v. Grafe’s case points rather to peripheral
irritation. Here a middle-aged man, who had lost the sight of
both eyes apparently through panophthalmitis, developed visual

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BY C0N0LLY NORMAN.

hallucinations. Both eyeballs were atrophied and contained
calcareous deposits. Neurotomy was performed and the
hallucinations at once disappeared. It does not seem that the
patient had other hallucinations, but he would appear to have
accepted the truth of the visual hallucinations while they
existed.

It is to be observed that in the case which I have
endeavoured to describe, none of the hallucinations are uni¬
lateral save those of hearing. Dismissing the doubtful visual
hallucinations, and assuming that the auditory took the lead in
time, we are on the horns of a curious dilemma. If peripheral
irritation or injury was an important element in producing
unilateral auditory hallucinations, why should bilateral hal¬
lucinations of many other senses appear? On the other hand,
with a strong tendency to hallucination of all the senses, why
do auditory hallucinations, so common in those that hear and
in the deaf, only appear in this case on the side which is
deaf?

As I have mentioned, the delusions existing in my case are
quite of the classical type. The patient does not know (but
suspects that I know) who are her persecutors. She talks of
“ this system of annoyance and defamation ; ” dates events
from the time when “ they began to practise upon me; ”
believes that the annoyance and “ practice ” are carried out by
means of electricity, magnetism, and “ mesmericks. ,, She
pities the officers of the asylum who are unable to control the
“ practice ” to which she is subjected, and she describes their
personal eccentricities with some astuteness and a marked
absence of favourable prejudice.

f 1 ) Read at a meeting of the Medical Section of the Academy of Medicine in
Ireland, November, 1901.

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CLINICAL NOTES AND CASES.

[Jan.,

Clinical Notes and Cases.

Case of Unilateral Halltuinations of Hearing , chiefly
Musical; with Remarks on the Formation of Psycho-
cerebral Images . By Alex. Robertson, M.D., F.F.P.S.G.,
Consulting Physician, Glasgow District Asylum, Gartloch.

In supplement to my paper on one-sided hallucinations in
the Journal of Mental Science for April, 1901, the following
case of a similar kind, but presenting special features, is, I
think, of sufficient interest to be recorded. The patient is an
inmate of the Glasgow Old Men and Women’s Home, and is
a man of some literary ability, as is shown by his still continu¬
ing to contribute articles from time to time to journals published
in London. The Home, it need scarcely be said, is for people
of sound mind, though many manifest indications of the ordinary
mental decay incident to old age. The patient referred to is,
however, acute and intelligent, and free from all suspicion of
mental weakness or disorder. The account of his experiences,
which he submits, may therefore be regarded as very reliable.
It seems preferable to give it in his own language, only pruning
it a little from unnecessary detail. The form in which it
appears is due to his great deafness, on account of which the
desired information could only be obtained from him as replies
to written questions.

The appended report by Dr. Barr, author of a well-known
treatise on diseases of the ear, on the condition of the patient’s
hearing, along with his remarks on that and other like cases in
people of sound mind, will be regarded as of considerable
importance and value.

A. L—, set. 76, merchant.

Questions and Answers. —1. Which ear are imaginary musical or
other sounds heard in? A ns. The right ear only.

2. Are they always heard in that ear? A ns. Yes; the left ear seems
impervious to all sounds.

3. Do the sounds ever appear like voices ? and, if so, what do the
voices say ? Are they men’s or women’s voices, or both ? Ans. No;
they do not resemble the human voice, but instrumental sounds only.
(Answer to question 5 modifies this answer. It there appears that he
has heard “ voices,” but only as singing.)

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CLINICAL NOTES AND CASES.

4. Describe the musical sounds in some detail, such as the character
of the instruments, and particularly if they are high or low notes.
Whether are the high or low notes heard best? A ns. They are those
of orchestral brass instruments, and the middle notes inclining to the
lower seem predominant

5. During how many years have these sounds been heard ? Have
they been constant during these years, or sometimes absent ? What
time of day generally? A ns. It is about ten or twelve years since
these sounds began to manifest themselves. Then they became very
troublesome and intermittent, and this led to the fear that the brain
was being affected. Often during the day, while at business, I heard
the sounds as of an orchestra, which suggested the presence of a
German band, and I would look out to see if it were playing in the
street. Even at night, 10 or n o’clock, the same effects would be
produced, and I have opened the windows for the same reason, to find
it was only illusory. On one occasion, at Queen’s Terrace, I seemed to
hear strains of music in the next house, and could discriminate the
various instruments, the music that was being played, and a very fine
baritone voice singing along with the instruments. I called the atten¬
tion of Mrs. S— to it, and asked her to listen, which she did, but told
me that she could hear nothing. I persisted, however, in saying that I
could follow the music with perfect confidence, and it was only by
perceiving that the National Anthem was being too often repeated that
I came to the conclusion I must be in the wrong. It happened
frequently that after getting into bed I heard a rushing sound, as if
the room was crowded with bats violently flapping their wings, at which
I would sit up till the sounds gradually disappeared. It was about the
same time that my sleep was much disturbed by unpleasant dreams and
visited by frightful spectres, which would give me no rest. This
distressing state has quite disappeared, but there still remains in the
left ear a faint sound as of falling water, which was the first indication
of my ear trouble ; and in the right ear when I hum to myself, especially
in bed, there is the sound of a harmonium, soft or loud, according to
the pressure on the ear. In attending church now I use an ear-trumpet,
but derive little benefit from it. I hear two voices in church, the first
being the natural voice, the other of a different kind, which overlaps
the natural voice and destroys all articulation, which is quite lost.

6. Are you always conscious that the sounds are imaginary, or do you
think them real sometimes ? A ns. I am now convinced that they are
wholly imaginary, as I cannot hear the sounds really produced, unless
through the ear-horn.

Note by Dr. Barr.

First saw patient eight years ago when very deaf in both
ears, with a constant rushing sound in left ear. At that time
there was a history of defect in the left ear for ten years, and
in the right for two years. Now the hearing is extremely
defective. A watch heard ordinarily at forty inches from the

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CLINICAL NOTES AND CASES.

[Jan.,

ear is not perceived in pressure on either ear. On left side loud
speech close into the concha is not understood. On right side
such speech is only heard and understood very near to the ear.
A Galton’s whistle is not heard at any degree of pitch. There
is nothing in the external or middle ears to account for such
an extreme degree of defective hearing. The Eustachian
tubes, as tested by the catheter, are quite permeable. The
examination therefore points to an affection of the nerve
structures as the cause of the defect. Whether this be central
or peripheral (in the labyrinth) cannot, I think, be determined
with any degree of certainty. No doubt the idea of a central
lesion is suggested by the peculiar subjective sounds or halluci¬
nations of hearing which he experienced for a considerable
time. These took the form of complete tunes (described in
his own statement).

In a note accompanying above report Dr. Barr remarks, “ I
had a lady under my care (now dead) who assured me that
she heard constantly going on in her ear (or head) the tune
usually heard with the singing of the metrical version of the
i ooth psalm. This had gone on for years, and followed a fall
on the pavement, when her head struck the kerb-stone violently.
There was no explanation in the ear so far as it was accessible.
I now know a gentleman (I think also known to yourself) who
hears the sound of an electric bell at definite and perfectly
regular intervals of time in his ear. I had also a case a few
months ago, of musical compositions being heard in the ear.
I cannot at present find my note of this case.”

“ Apparently Mr. L— is a man of distinct musical gifts, and
has also evidently some literary power.”

Remarks by Dr. Robertson.—In accordance with accepted
doctrine regarding the functions of the cerebrum, it is probable
that a complex combination of sounds such as constitute a
complete tune or other piece of music, assumes a definite shape
and enters into consciousness in the related perceptive centre in
the temporo-sphenoidal lobe. There may probably be a certain
arrangement of impressions in the labyrinth and auditory nerve,
but it is not likely, considering the structure of these parts, that
this will go beyond such an assortment as will prepare them
for fitly taking their place in the central blend that constitutes
the fully developed form.

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CLINICAL NOTES AND CASES.

The reappearance in the mind, from time to time, of the
same combination of impressions as in Dr. Barr’s case of the
recurring psalm-tune, or the words, “ come this way, come this
way,” in one of my own cases/ 1 ) raises a question of still
greater difficulty than the one just referred to, viz. how on
the physical side is the revival produced ? The same problem
is involved in the memorial recurrence of all sensory images,
and, indeed, in the exercise of thought. Some light may
ultimately be thrown on the subject by the study of simple and
one-sided phenomena, such as are recorded in this and the
previous paper, or we may at all events be able to formulate a
working hypothesis as a platform for further investigation. It
would, of course, be out of place in the present connection to
attempt a discussion of questions of such magnitude. I may,
however, in accordance with the most generally accepted views
of the neuron and its associations, briefly indicate the direction
in which, as appears to me, progress is most likely to be made.

In the higher animals the gemmae of the protoplasmic
processes and collaterals of the axis-cylinders are discon¬
tinuous, though in close proximity to each other, and are
thus open to receive impressions coming by different routes.
It is further to be noted that in immediate relation to the cell-
body of the neuron there is a pericellular reticulum, which is
in intimate association with the similar reticula of at least
neighbouring nerve-cells. In these structural conditions there
seems to be a mechanism fitted to combine and unify the
elementary parts of images into one harmonious whole. Again,
it is to be borne in mind that the molecules of matter are
believed to be in constant motion—motion that is under the
plane of observation with our present powers.

Turning now to the formation and renewal of cerebral
images, we may conceive that impressions coming from
external objects are transmitted as waves of subconscious
vibration to the reception-centre, where a group of neurons,
through the reticula surrounding their cell-bodies, enter into
corresponding or related vibration, as a result of which the
complete form is presented to the mind. Further, just as the
combined action of nerve and muscle in any movement
facilitates the repetition of that movement, so the impress
produced on living nervous matter in the production of the
image will dispose to the recurrence of the same combination

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CLINICAL NOTES AND CASES.

[Jan.,

of neurons and the same character of vibration in them with
the revival of the image in consciousness.

Thus, then, we may entertain the thought that memorial
representations of all kinds, on their physical side, are vibratory
in their nature, and that the vibrations occur in definite
associated groups of neurons. We may further suppose that
with the changes in the countless images that pass before the
mind, there is a corresponding kaleidoscopic change in the
mutual relations of the neurons concerned in their production.

(*) Journal of Mental Science, p. 281, April, 1901.

Degeneration of the Optic Thalami (Preliminary Note).
By J. B. Blachford, M.D., Assistant Medical Officer,
City and County Asylum, Bristol.

T. W—, shorthand writer, admitted January 16th, 1899, suffering from
mania.

Family history. — Father alive; mother died of heart disease.
Brother: one, alive and well. Sisters: two, both died of scarlet fever.
Children: one girl set. 7 years, alive and well. One child died;
death certified as being due to syphilis. Wife has had three or four
miscarriages. Mother’s sister very neurotic

All mother’s brothers had something wrong in their head. Some had
“ water on the brain.”

Personal history. —Patient has been a heavy drinker, has no history
of cough or fits; has been engaged as a clerk, but sight has been
failing for three and a half months. Vision began to fail at periphery
of field; he has been under Dr. Critchett and Mr. Cross for optic
atrophy.

On admission, patient’s thoracic and abdominal organs were
apparently normal. There was an old ulcer and pigmentation scar on
left shin, four inches by three. Knee-jerks absent; gait not ataxic; no
plantar reflexes; no Romberg’s symptom; pupils did not react to light;
there was right external strabismus; patient was quite blind.

He was ordered Hyd. Perch, and Pot. Brom. For a time he was
restless and excited, striking at imaginary persons, and had to have a
sleeping draught at night He took his food well, and on January 28th
is noted as being quieter but very lost. He gradually got weaker and
died on February 2nd, 1899, just twenty-nine days after his admission.

At the post-mortem examination the following appearances presented
themselves. Skull-cap, average thickness; dura mater, average thick¬
ness ; pia mater very congested, slightly thickened, stripped in patches ;
no adhesion to cortex. Brain weighed 1341 grammes, vessels healthy.
Circle of Willis complete and symmetrical.

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CLINICAL NOTES AND CASES.

Grey matter very congested and soft; white matter congested, soft
and oedematous. Ventricles full of fluid; ependyma granular, very
congested. Choroid congested; fornix soft; velum interpositum con¬
gested ; ependyma of fourth ventricle very granular.

The basal ganglia and capsules were soft and congested. After these
had been hardened in picro-formalin the whole of both optic thalami,
and to a certain extent the anterior corpora quadrigemina, presented on
section a marbled appearance, having various-sized lighter patches
scattered throughout them, and on being treated by Lord's modification
of Nissl's method a number of the cells appeared to have degenerated,
but owing to other work pressing at the time only a few sections were
examined, and careful investigation was not made with a view to locating
the more extensively diseased parts.

A. H—, set 39, married, gas stoker, admitted September i6th, 1897,
suffering from dementia.

Family history. —A niece on his father's side is subject to fits. Patient
has six healthy children alive, and four died of convulsions at various
ages.

Personal history. —Patient has been a heavy drinker. Five years ago
was seized with a strong fit, after which he kept well for a year, when
he had a second; then for a time he had them frequently. For the
past twelve months has been going gradually blind and has been
deluded for six months.

On admission his thoracic and abdominal organs were apparently
healthy, knee-jerks brisk, pupils reacted to light but slowly, and he
was blind.

Present condition very demented, laughs foolishly on being spoken
to. Disc atrophied, pearly white; can stand, but cannot walk without
assistance, and then drags his right leg somewhat. Right hand partially
paralysed. Some anaesthesia of right forearm and outer side of right
thigh. Knee-jerks equal, brisk, no clonus. Pupils equal, average size,
fixed.

G. B—, 33, single, labourer, admitted August 14th, 1901, suffering
from dementia.

Family history. —Father and mother both dead; brothers (four) all
alive and well; sisters (five) all alive and well. No history of insanity,
paralysis, epilepsy, or drink in the family. One of mother's sisters died
of phthisis.

Personal history. —Patient was in the army for seven years; left
about ten years ago ; he used to drink a fair amount of beer. (Says he
has had syphilis.) Four or five months ago he complained of pain in
the back of his head ; this got better in a few weeks' time, and he went
to work again for the next few weeks ; he then became worse and went
to bed, where he has been for the past fifteen weeks. During the whole
of this time his eyesight has been gradually failing.

On admission , lies quietly in bed, taking no interest whatever in his
surroundings. It is difficult to attract his attention, and he shows no
sign of understanding what is said to him, except by protruding his
tongue when requested. When any movement is required he has to be

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CLINICAL NOTES AND CASES.

[Jan.,

assisted ; put out of bed he would fall if unsupported. His gait could
not be tested as he would make no attempt to walk. He moves his
arms about aimlessly, coarse tremors accompanying these movements.
No tremors of the head, face, or tongue. Pupils widely dilated, equal;
do not react to light. Sudden approach of an object to the eyes causes
no reflex contraction of lids. Knee-jerks exaggerated; no clonus;
vision very defective. He has a puckered scar over top of the manu¬
brium sterni, and another behind the right shoulder, and has, since his
admission, stated that he had syphilis some years ago.

On August 16th he was put on Pot. Iod. and Hyd. Perch.

August 26th.—Has distinctly improved under treatment. Vision some¬
what better.

September 3rd.—Answers questions quite smartly, and has a bright
and cheerful manner. Vision improving, but still defective. Gait
fairly good ; stands and turns without difficulty ; stands alone with eyes
shut, touching tip of nose with index finger easily with eyes shut;
pupils equal, regular, react to light, accommodation, and consensual
reflex. Plantar reflexes equal, normal. Knee-jerks equal and brisk.
No clonus. Sensation unimpaired.

G. M—, 48, single, labourer, admitted July nth, 1901, suffering
from dementia.

Family history .—Father died of apoplexy, otherwise there does not
appear to be any history of insanity or neurosis in the family.

Personal history .—Patient was in the army for fifteen years ; he left
it six years ago, since then he has been doing labourer’s work. He has
been a fairly heavy drinker, and had syphilis twenty years ago.

On admission , thoracic and abdominal organs apparently normal.
He is unable to stand ; vision very defective ; mentally, very demented ;
memory almost gone ; pupils equal, regular, react to light readily; knee-
jerks equal and brisk. On attempting to stand sways in every direc¬
tion, but chiefly backwards and forwards. Sensation apparently normal.
Shortly after admission was put on Pot. Iod. and Hyd. Perch.

September 8th.—Gait improved; mentally much clearer; vision im¬
proved.

Present condition (October 2nd).—Answers questions smartly and
intelligently; works usefully about the ward; vision much improved,
that of the left eye still rather defective.

These four cases may be summarised thus:

Mental

condition.

Vision.

Pupil

reflexes.

Gait.

Sensation.

Knee-jerks. Syphilis.

i. Mania

Blind

Absent

No ataxia

Absent 1

2. Dementia^)

Blind

Sluggish ;

—

Brisk 1

absent 1

3. Dementia

Defective;
improved
Defective;
improved

Absent;
normal

—

; Normal

Brisk ' 1

4. Dementia

Normal

Ataxic

j Normal

Brisk 1

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CLINICAL NOTES AND CASES.

The first is the only case in which the diagnosis could be
verified by post-mortem examination, and in it, as above stated,
there was ample evidence of degeneration of the optic thalami,
and, to a less extent, of the anterior corpora quadrigemina.

The symptoms, however, in the three following cases are so
like those in the first that I think we shall be justified in
attributing them to a similar cause ; and, from the facts that in
three of the cases there is a distinct history of syphilis, and in
the last two marked improvement occurred under anti-specific
treatment, the primary cause would appear to be degeneration
of the neuron brought about by that disease. If, after more
extended experience, we find this to be so it will be interesting
as marking off a distinct form of nervous affection which in the
past has no doubt at times been attributed to general paralysis,
at others to cerebral tumour, and, perhaps, even to that
amaurosis which is a frequent accompaniment of Bright’s
disease, and less so of chronic nicotine poisoning. Evidence,
which has been accumulating for some years, now tends more
and more to compel us to believe that syphilis is the great cause
of degeneration of the neuron in locomotor ataxy, and perhaps
also in general paralysis; and other facts which strike one as being
significant in this connection are that all these diseases appear
to be more common in men than in women, and that they
affect similar periods of life, namely, the middle adult, and
also that in the case of T. W—, in which a post-mortem exa¬
mination was made, the ependyma of the ventricles was very
granular, especially that of the fourth, a condition which has
always struck me as being more frequent in general paralysis
than in any other disease.

The clinical symptoms appear to be few, being practically
limited to rapidly increasing dementia and loss of vision, with
a slight amount of ataxia, indicated more by swaying to and
fro than by inco-ordinate movements of the legs. The knee-jerks
were noted as being absent in the first, and exaggerated in the
remaining three, but except in spinal diseases, they are at the
best very dubious guides to diagnosis. The absence of other
symptoms is no doubt to be accounted for by the localised
position of the part affected, and by that affection not being of
such a nature as to cause pressure on surrounding parts. There
is, however, one particularly interesting anatomical point which
is difficult to understand. Why is sensation apparently so little

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CLINICAL NOTES AND CASES.

[Jan.

affected? The fillet, which carries up all sensory impulses
except the visual and olfactory, is divided into three parts: the
lateral, carrying impulses from the auditory apparatus, terminates
in the posterior corpora quadrigemina, sending a few fibres to
the anterior; the crustal fillet, receiving the impulses from the
sensory nuclei of the cranial nerves, terminates in the globus
pallidus of the lenticular nucleus of the striate body; while the
central or spinal fillet, receiving all sensory impulses from the
trunk, terminates in the optic thalamus. Under these circum¬
stances one would expect that any general degeneration of the
thalamus, such as, at any rate, occurred in the first case, and
which went so far as to cause absolute blindness, would have
for one of its early symptoms general trunk anaesthesia, but
this does not appear to be so. The condition of the pupils is
also interesting, but is probably more easily explained. In the
first case the patient was blind on admission and his pupillary
reflexes were absent. In the second the patient was blind but
could distinguish light from dark, and was not so far advanced
as the first; the reflexes are noted as sluggish, and later on
absent. In the third vision was defective and reflexes appa¬
rently absent, but as vision improved the reflexes returned and
became normal, although vision did not do so ; and in the last,
vision on admission was defective, but pupillary reflexes normal,
and this was the least advanced case. I think that the explana¬
tion of these phenomena consists in the difference in function of
the optic thalami and anterior corpora quadrigemina. If we
consider the latter to be chiefly reflex ganglia, while the former
are intercalary ganglia, between the optic tracts and the visual
centre in the cuneus, we can understand that the predominance
of visual over reflex symptoms and vice versA will depend
upon which centre is first affected.

From a clinical view one point is of special interest, namely,
the rapid improvement in early cases under antisyphilitic
treatment, although the last two cases, which are those to which
I am now referring, have not yet recovered mentally, and
probably never will quite recover their vision. They both
have so far improved that they will probably shortly be able
to be discharged as recovered, and the loss of vision has
certainly not only been checked, but a certain amount of re¬
cuperation has been effected.

I can find very little written, at any rate in English papers,

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1902.]

CLINICAL NOTES AND CASES.

with regard to the function of the optic thalami. Experiments
of M. J. Sellier and N. H. Veryer apparently go to prove that
their r 6 le is sensory, but according to these two observers this
does not include sensibility to pain (October number of Archives
de Physiologic , 1898). Dr. Henri Engel, in the Philadelphia
Medical News , describes a case of gliomatous tumour growing
from the fornix, and spreading back over both thalami, in
which the symptoms were pain in the head, staggering gait,
anaesthesia of right side of body, loss of sense of taste on right
side. Nine days later complete loss of taste and smell on both
sides and deafness in both ears were observed, and two days
subsequently there occurred sudden blindness in both eyes and
convulsions followed by death. It is difficult to say which of
these symptoms were due to pressure on the thalami and which
to pressure on surrounding parts; and the same may be said of
the following case recorded by Dr. A. J. Edwards in the
Lancet for August 3rd, 1895. This was a case of tubercle
of the left optic thalamus ; there was trembling of the right
hand with dragging of the right leg, headache, and vomiting.
No nystagmus or syllabic speech ; no facial paralysis. There
was ankle-clonus on the right side but not on the left; gait was
ataxic, but sensation was universally normal ; there was defective
vision and optic neuritis.

(*) Since writing the above I have seen Dr. Flemming, by whose courtesy 1 have
been enabled to publish these cases, which are at the present time under his care,
and he informs me that A. H—, the second case, has had syphilis, but that the
condition of his choroid is not suggestive of syphilitic choroiditis ; this is, there*
fore, further evidence in favour of the syphilitic origin of the disease, and would
also seem to imply that the loss of sight was not primarily due to disease in the eye
itself, but was of more central origin.

Discussion

At the Autumn Meeting of the South-Western Division, Bath, October 22nd, 1901.

Dr. Bullen said he was afraid he could add very little to a paper so full of
detail. He saw two of the cases at Fishponds this summer. From a practical
point of view, one would certainly, many years ago, not have regarded one of the
cases—the third one—as a general paralytic, but as one grew more acquainted with
the type of general paralysis one was more inclined to accept the diagnosis.
The marked difference in the patient's condition under syphilitic treatment was
striking, and it was questionable whether, even when there was no trace of syphilis,
the treatment should not be applied. He tried it systematically, but he could not
say there were any good effects,—in fact, some patients seemed to get worse.

Dr. Goodall, in commenting on the paper, remarked that if any more cases
should come to an autopsy, it would be interesting to see the connection between
the optic thalami and the cortex. The connections were very obscure, and they
would like to know whether the fibre could be held to have degenerated.

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CLINICAL NOTES AND CASES.

[Jan.,

Dr. MacDonald said that the cases were most interesting; the great regret was
that Dr. Blachford was not able to satisfy himself more often on the post-mortem
table. He (the speaker) wondered if he could do anything to find out the con¬
dition of these not very important bodies, the optic thalami, and he had gone
through the records of all the post-mortems made in his time at Dorchester
Asylum, numbering over 600. While he was not prepared to state that every fact
had been carefully gone into as regarded the optic thalami, it might be taken for
granted they were not overlooked in the examination of the brain any more than
any other part of the brain or organs of the body. Out of these 600, he found in
nine cases only were they able to detect and satisfy themselves that there was actual
degeneration of the optic thalami. In four cases the right optic thalamus was
absolutely and entirely degenerated ; in two cases the left, and in three both. The most
common form was the haemorrhagic condition. As to the mental condition of these
patients, five were chronic maniacs, one was a general paralytic, one was a melan¬
choliac, and two were dements.

Dr. Blachford briefly replied.

Two Cases of Lipoma of the Brain . By Ad£le de

Steiger, M.B., Assistant Medical Officer, Essex County
Asylum, Brentwood.( l )

Case I.—L. M. W—, aet. 37, admitted June, 1901, died eighteen
days after admission.

History .—Has had two previous attacks, 1897 and 1899, and was
treated in Colney Hatch Asylum after birth of the eighth and ninth
children. Present attack, duration six to seven months. Cause,
puerperal state after birth of tenth child. The attack began five
weeks afterwards.

Condition on admission. —Does not sleep, will take no food volun¬
tarily, will not speak or do as she is told, strongly resists being exa¬
mined. Reflexes : Knee-jerks exaggerated. Pupils equal, she is too
obstinate for reaction to be tested. Fairly well nourished, sordes on
lips, and saliva dribbling.

Progress. —After a day or two patient talked in a surly, disagreeable
way, and would take liquid food. She then developed symptoms of
pneumonia, and died.

Autopsy. —Skull-cap thick and tough. Dura mater firmly adherent
to the skull-cap over the vertex. Meninges clear, not adherent.
Tumour : Lying over the corpus callosum and curling round the knee
posteriorly was a firm yellow mass. Size, quarter-inch thick, and as
long as the corpus callosum; on section the mass was almost round
in circumference. In the choroid plexus of the right ventricle was
also a firm yellowish nodule about the size of a split pea.

Microscopic .—Both masses were found to consist entirely of adipose
tissue, enclosed by a capsule of fibrous tissue, thicker in some parts
than others. There were numerous blood-vessels in the mass and in
the capsule. Between the tumour and the corpus callosum was some
very gritty material, apparently calcareous deposit.

Other organs. —Liver, distinct fatty infiltration. Kidneys granular.

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1902.] CLINICAL NOTES AND CASES. 6 5

Case II.—E. J—, aet. Ji, male. Admitted June, 1899, died August,
1901. General paralysis.

Condition on admission .—State of mania with delusions of persecu¬
tion, owns to habits of intemperance ; well-nourished. Reflexes : Knee-
jerks very slight. Pupils : Left, + irregular, Argyll-Robertson. Speech
distinct.

Course. —Later on patient became very dull and apathetic. August
19th, 1900 : Had a “seizure,” with strong convulsive movements of the
left side ; these continued for some days and some paralysis of left arm
and leg persisted. September, 1900 : Another “ seizure.” August, 1901:
“ Seizure,” with again twitchings of left side ; she remained unconscious,
with absence of conjunctival reflex on left side, and twitchings for three
days. Temperature irregular, 99 0 to 103° F. Died on August 21st,
1901.

Autopsy. —Skull-cap: Membranes very congested, not adherent to
the cortex, but to each other over inner surface of frontal lobes. Gyri
small, shrunken, and closely packed. Right side: over the superior
parietal lobe was a patch of softening, with adherent membrane.
Cortex thin and pale; ventricles dilated; granulations in floor of fourth
ventricle.

Tumour. —Over and adherent to the posterior perforated space lay a
hard, yellowish growth, about the size of a small bean. Micro¬
scopically this was found to consist of adipose tissue, with numerous
blood-vessels and a distinct capsule of fibrous tissue.

Other organs. —Heart, flabby, small; liver, pale and soft; kidneys,
granular.

Cases of lipoma of the brain have been reported by
Benjamin, Bernhard, and Taubner. In Benjamin’s case part of
the tumour was ossified.

Dr. Gowers reports a case of myolipoma of the spinal cord,
and says, “ Very few examples have been met with of fatty
tumours connected with the nerve centres,” although “the
cellular structure of the subarachnoidal tissue might be con¬
ceived to offer a ready field for fatty infiltration.” It may be
doubted whether simple fatty tumours ever cause damaging
pressure upon organs . The effect of pressure is to limit the
infiltration of the cells of the growth, rather than to injure a
resisting structure.

Muller (on cancer) describes a fatty tumour between the
optic nerves and corpora albicantia. Osier, W. A. Turner, and
Obermeier all refer to the “ rareness ” of fatty tumours of the
brain.

Bland-Sutton (on tumours) describes a case of fatty tumour
within the spinal meninges, but makes no reference to the
brain.

XLVIII. 5

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CLINICAL NOTES AND CASES.

[Jan.,

Probably in none of the cases had the fatty tumour any bear¬
ing on the origin or course of the symptoms (mental or physical).

These cases are recorded merely on account of their rare
occurrence.

(*) Read at the Autumn Meeting of the South-Eastern Division at the Holloway
Sanatorium, October 16th, 1901.

A Case of Epilepsy following Traumatic Lesion of
Prefrontal Lobe. By A. R. Urquhart, M.D., and

W. Ford Robertson, M.D.

No. 2345, set 27, transferred from Saughton Hall to Murray’s
Asylum, Perth, on June 4th, 1897. An unmarried male.

Personal history. — Strong and healthy, except for occasional
blepharitis. As a boy he was shy and emotional, and gave some
anxiety on account of his running away from home on several
occasions. His education was meagre, and he went to sea at an early
age. Specific disease was not admitted and may be excluded from
consideration.

Family history .— Hereditary tendency to insanity was denied.
Father died of apoplexy, aet. 60; mother alive and well, aet. 60 in June,
1897. The eldest of the family is a girl, who had been epileptic since
1892; the second married, with one healthy child; the third was the
patient; the fourth reported normal. Thus two were epileptic, a male
and a female, and two were healthy, a man and a girl.

History of malady .—In 1885, at the age of 18, the patient fell into
the hold of the vessel on which he was then serving as apprentice.
He sustained severe injuries of the head and lay unconscious for some
weeks in the Melbourne Hospital. Two years later, after great heat in
Calcutta, he began to suffer from epilepsy. These fits were followed
by a maniacal attack, and he was placed in the Dumfries Royal Asylum.
After some time at home, where he was regarded as dangerous and
troublesome, he was sent to the Carlisle Asylum, whence he was
transferred to Saughton Hall.

Up to the date of his last transfer (1897), the patient had an
epileptic seizure generally once in every two months, and these were
followed by maniacal storms of diminishing severity in the course of
the eight and a half years during which the malady had persisted. He
was regarded as troublesome and dangerous, and his mental state was
characterised by untruthfulness, low cunning, and deception. He
fought with attendants and other patients, stole a knife and gave it to
a suicidal patient, and attempted to set the house on fire.

Physical condition .—On admission it was noted that the patient
possessed good muscular power, and that his condition generally was
satisfactory. There was oedema of the hands, and some irregularity of

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CLINICAL NOTES AND CASES.

I 902.]

cardiac action. No scar was visible on the scalp, but there was
apparent tenderness at a point a little in front of right parieto-occipital
suture; and running parallel with this suture a slight depression was
evident. A scar was noted under the right orbital ridge. Sensation
was somewhat dulled, and the left plantar reflex was diminished. The
pupils were rather dilated (the right more than the left); both reacted
well to accommodation, but sluggishly to light (especially the right).
This may have been due to belladonna given medicinally. He com¬
plained of seeing black spots at times, was deaf on the right side, and
awkward in gait. Mental condition generally enfeebled. Confusion
and impaired memory were specially noted. He had a dull, stupid
appearance, and was furtive and tiresome in his conversation.
Mentalisation slow.

During his stay in Murray's Asylum the patient gradually
declined in health, mental and bodily, the epileptic seizures
became more frequent, and were not marked by maniacal
attacks. Ninety-five fits were recorded in twenty-seven
months, finally culminating in the status epilepticus which
closed his life on September 28th, 1899. During the first
half of his residence in Perth the fits averaged two or three
monthly, and were generally diurnal ; latterly the seizures
were frequently nocturnal, and increased in number. The
aura was marked ; it consisted in a feeling of lightness in the
head and weakness in the knees. The latter persisted after
the fit. ’ During the fit it was certain that the spasms began
in the left arm, and spread to the left facial region, and so
became general. As a rule the convulsions were more intense
on the left side. His head was. turned to the left, and there
was conjugate deviation of the eyes to the left The clonic
contractions passed away from the left side of the body before
the right became exhausted. The fits were always followed
by a stuporose condition, and this was succeeded by a period
of greater irritability.

Certain indefinite trophic disturbances were noted, e . g\ occa¬
sional tenderness of the external ear, and unaccountable
blisters on the right hand.

The cessation of bromides invariably resulted in increased
epilepsy.

The question of operative interference was raised, but the
patient's mother objected. He himself earnestly desired to
take his chance of relief by surgery, but in the circumstances
the question was considered as settled by his mother's
attitude. The matter could not be pressed in view of his

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CLINICAL NOTES AND CASES.

[Jan.,

unsatisfactory boyhood, the slight signs of external injury, the
lapse of time, and above all, the existence of epilepsy in his
sister.

Examination of Hardened Brain and Spinal Cord .—There
was a slight degree of thickening and opacity of the pia-
arachnoid over the convexity of the hemispheres. On the
mesial aspect of the right frontal lobe, extending from near
the lower border upwards for about 20 mm., there was a
slightly depressed, rounded area, over which the membrane was
thickened and puckered. The spinal dura mater was much
thickened, more especially in the upper cervical region, where
it attained in places a breadth of 3 mm. It was not adherent
to the # pia-arachnoid. On horizontal sections of the brain
being made, a large area of softening, of a pale yellow-grey
colour, was found in the right frontal lobe, subjacent to the
depression on the mesial surface. It first came into view on
a section being made immediately above the level of the upper
surface of the corpus callosum, appearing as an area 5 mm. in
length at the anterior extremity of the white matter. Below
this level the softening increased considerably in dimensions,
gradually involving the adjacent mesial cortex, and appearing
at the surface. At a distance of 40 mm. from the under
surface of the lobe it measured 25 mm. antero-posteriorly, and
15 mm. transversely (Fig. 1). At a distance of 2 5 mm. from
the under surface of the lobe the area attained its greatest
dimensions, measuring antero-posteriorly 30 mm., and trans¬
versely 25 mm. It here involved the whole depth of the
mesial cortex. Posteriorly it faded away in the grey matter
of the anterior end of the lenticular nucleus (Fig. 2). Below
this level the softening rapidly diminished in extent, and did
not quite reach the under surface of the lobe. No other gross
lesion was found. Microscopical examination confirmed the
observations made with the unaided eye, except that it
revealed an involvement of the cortex in front of the softened
tissue (Fig. 2). Unfortunately a minute investigation of the
course taken by the degenerative process in the medullated
fibres behind the softened area could not be made, owing to
the circumstance that the formalin solution in which the brain
was hardened had not penetrated the deeper tissues in time to
fix them properly. There was no general sclerosis of the
brain. The first layer of the cortex presented in both hemi-

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1902.

Fig 1.

Horizontal section of anterior part of right frontal lobe, 40 mm. above under surface of lobe,
(a) Mesial surface. (6) Outer surface. (c) Softened tissue.

Fig. 2.

, r m t if ;mt< n part of right frontal lobe, 25 mm. above under surface of lobe.
M -.. t ) .nrf.tr,-. (/-! (>ut.T surface, (c) Softened tissue, (d) Anterior extremity of lenticular
nirleiiR. Weigert-Pal Staining.

To Ulnrtrate paper by Drs. Urquhart and Ford Robertson.

Jlale ami Danielsson, Mil.

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1902.]

CLINICAL NOTES AND CASES.

spheres a slight degree of neuroglial overgrowth. A large
proportion of the cortical nerve-cells (motor areas) showed
well-marked recent degenerative changes, such as are con¬
stantly associated with the occurrence of death in status
epilepticus. The cells were not perceptibly diminished in
number. Some of the vessels of the first layer of the cortex
showed fibroid thickening. The thickened spinal dura had
throughout a dense fibrous structure without demarcation into
layers. The spinal cord was practically normal.

It seems clear that in this case the softening in the frontal
lobe was the result of a traumatic haemorrhage. A quantity
of blood must have escaped into the subdural space and
formed on the inner surface of the cerebral and spinal dura a
false membrane, which in course of time became replaced by
fibrous tissue. The special interest of the case lies in the fact
that though the traumatic lesion did not primarily involve any
motor area of the brain, the accident was followed by general
epilepsy after some years. Several cases of this kind have
lately been recorded. Thus Angiolella (*) has described the
case of a man who became epileptic ten years after having
been injured on the forehead by a blow with a hatchet, and
who died some years later in status epilepticus. He found, in
addition to a destructive lesion of the anterior portion of the
left frontal lobe, certain general histological changes in the
hemispheres which seemed to him to indicate an extension of
an inflammatory process from the focal lesion. He considered
that the development of the epilepsy might be explained
by involvement of the motor areas in this inflammatory
process. Ventra(*) has described the case of a man who
developed epilepsy at the age of twenty-one, six years
after having been shot through both frontal lobes. Pastro-
vich and Modena (*) have recently fully reported a case
in which epilepsy appeared at the age of fifteen, four
years after a similar injury of the anterior third of the right
middle frontal convolution. The microscopical changes were
entirely confined to this area, and did not involve the motor
regions. References to some additional cases of the same
nature recorded in literature will be found in the papers of
these writers. In the case we have described, the motor
disturbance arose two years after the receipt of the injury.
As in the case of Pastrovich and Modena no important

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OCCASIONAL NOTES.

[Jan.,

histological changes of a chronic nature were found in the
motor regions. It is quite possible, however, that localised
changes, of the nature of those described by Angiolella, may
have escaped observation.

(*) Annali di Nevrologia , 1898, p. 277.—( 2 ) Rivista Sperimentale di Freniatria ,
1900, p. 896.—(*) Rivista Sperimentale di Freniatria, 1900, p. 723.

Fig. i.—H orizontal section of anterior part of right frontal lobe, 40 mm. above
under surface of lobe, (a) Mesial surface. ( b) Outer surface, (c) Softened
tissue.

Fig. 2.—Horizontal section of anterior part of right frontal lobe, 25 mm. above
under surface of lobe, (a) Mesial surface. ( b) Outer surface, (cj Softened
tissue, (d) Anterior extremity of lenticular nucleus. Weigert-Pal staining.

Occasional Notes.

Wameford Asylum .

The Warneford Asylum has recently been subjected to a
considerable amount of unjust censure which yields a good
illustration of the prejudices of the public mind in lunacy
matters, and the consequent inability of forming just con¬
clusions in relation to them.

The foundation of the censure was a case of homicide and
suicide by a patient recently discharged on trial. The coroner,
without a word of evidence in regard to the circumstances of
the patient’s discharge, remarked on the loose way ” in which
the patient had been turned out on society. According to one
newspaper report he even made, in the absence of all evidence
on the point, an invidious comparison between the precautions
taken in this and another asylum. We can only conclude that
he was as ignorant of one set of precautions as of the other.

The coroner’s remark, although obviously founded on no
scrap of evidence, was eagerly seized on for very invidious
comment by the daily press, in the time-honoured manner on
such occasions.

The committee of the asylum, however, forwarded a full
statement of the circumstances under which leave of absence
was granted in the case in question to the Commissioners

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1902.]

OCCASIONAL NOTES.

in Lunacy. The Commissioners, after considering what they
term the “ full and detailed report/* write that “ it appears to
prove that the medical superintendent exercised due care and
showed good judgment in the matter, and that the unfortunate
incident which occurred did not result from any failure in the
exercise of those qualities.**

The judgment of the Lunacy Commission, formed after a
due consideration of all the circumstances, must outweigh
a thousandfold the emotional expression (for it cannot be
dignified as a judgment) of the coroner, founded neither on facts
nor experience.

If the coroner had obtained evidence from the asylum he
would certainly have been saved from falling into such an error,
and from committing an injustice to the medical officer, who has
now been so fully and amply exonerated.

The lesson inculcated is that in all such cases evidence from
the asylum should not only be tendered but pressed on the
coroner. The pressure was impossible on this occasion, owing
to the absence from England of the superintendent.

Such evidence would gradually educate the public to under¬
stand that the discharge of recovered patients is always at¬
tended with risk of relapse, and that occasionally, in spite of
the greatest care and the exercise of the best and wisest
experience, such regrettable incidents must from time to time
occur. The public have to be brought to understand that dis¬
charges cannot be made without relapses, and that relapses
cannot occur without occasional danger.

Lunacy Statistics .

“ Statistics may be made to prove anything *’ is a common
assertion, and it might also be asserted that they may be made
to prove nothing. Such results, however, can only arise from
the tabulation of facts too heterogeneous to be of value, or
from the wilful or ignorant misuse of really valuable. figures.
Statistics of rightly chosen facts, when rightly used, can
demonstrate, with reasonable certainty, general laws and
averages of the utmost value.

The early years of a new century, like the early days of a

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OCCASIONAL NOTES.

[Jan.,

new year, afford a good pretext for considering old habits.
Statistics of lunacy, being a very important annual habit with
many of our members, seem the first to demand attention.
Inquiry may fairly be made whether these have yielded, and
are yielding, satisfactory results. Have they given answers to
questions of fundamental importance ? For example, to the
inquiries whether lunacy is increasing, whether the recovery rate
is advancing, whether the causes of insanity are changing,
whether the type of insanity has altered, and to many others
of almost equal value. The response must be, we fear, that
our statistics do not yield clear answers on these points.

Lunacy statistics having now been compiled on a large scale
during the last half-century this cannot be held to be a satis¬
factory result, and it suggests that some reconsideration is
necessary to ensure that the form of the statistics and the
method of dealing with them shall be improved, so that more
definite results may be obtained, if it be possible.

The Lunacy Commission, as at present constituted, is so
undermanned that its energies are absorbed in the attempt to
carry out its routine duties of inspection, etc., and it cannot be
expected, whilst so burthened, either to originate new methods
or to delve in the vast stores of facts already accumulated.
As this condition may continue for some years it seems worthy
of the consideration of the Medico-Psychological Association
whether our members should not make an effort to initiate
some improvement.

The Association is already responsible for the statistical
tables which are generally in use in asylums, and it would seem
that the analysis of the results of these tables is as worthy of
attention as their construction.

Statistical tables should certainly not be disturbed fre¬
quently or without good reason, but the existing tables
have now been in use long enough to justify a reconsidera¬
tion. Since they came into operation great progress has
been made in every branch of the study of mental disease.
Medical officers of asylums have been greatly increased in
number, so that statistical efforts are now easily possible
which at the time of the issue of the tables would have
been a grievous tax on the then insufficient medical staff.

Statistics have reached to the eminence of a science, and if
such a reconsideration of lunacy statistics is made, it would be

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1902.]

OCCASIONAL NOTES.

very desirable, if not absolutely essential, to obtain the assistance
of a scientific statistician. Such assistance, if procurable, would
possibly help the Association to avoid the accumulation of
useless facts, the making of erroneous analyses, and the formula¬
tion of indefinite conclusions.

British lunacy statistics, unless continuously watched, and,
when necessary, improved, will certainly fall below the standard
of efficiency which is constantly rising in other countries.
Indeed, critics are not wanting who assert that this is already
the case. Vigilance in this matter should be exercised both
from scientific motives and from feelings of patriotism.

The National Mental Health and the War .

In the review (in our present number) of the Scottish
Lunacy Report, the reviewer gives some very striking statistics
in relation to the national mental health in the last three
years.

The rate of accumulation has diminished in England, Scot¬
land, and Ireland. The rate of primary admissions has not only
shown great arrest but even slight diminution in Scotland.
The Irish figures correspond, and in England, if statistics were
available, it is almost certain that the same result would be
demonstrated. The reviewer also draws attention to the
similar results recorded in France in 1870 and in the
American War (1861).

It is desirable to specially emphasise these figures, since an
eminent alienist has been quoted in the English lay press and
in Continental journals as having stated that there had been
an enormous increase in insanity in London in 1900, due to
the war.

The war, we may conclude therefore, has been a national
mental tonic, and once again the malice, hatred, and all
uncharitableness which everything British excites in the minds
of our Continental friends, and, alas! in some home-bred “ men
and brethren,” would appear to be, as they have often proved
before, merely the rubbish of which mares build their nests.
In many public libraries the curious reader may still find among
the volumes of the original Sydenham Society’s translations

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OCCASIONAL NOTES.

[Jan.,

Feuchtersleben’s treatise on medical psychology. Here he
will discover many legends illustrating the craziness of
Englishmen. He will learn that that exquisite book illus¬
trator, “ Phiz ” (Hablot K. Browne), in trying to catch
caricature expressions, made such ugly faces at himself in the
glass that he committed suicide in despair. The translator,
oddly enough (suffering perhaps from “ the bias of anti¬
patriotism ”), omits to note that at the date of the translation,
let alone of the original, “ Phiz ” was alive and well, and
making a handsome income by his work. Who knows ? May
be he had given up the glass and taken to water instead, like
Narcissus, the last previously recorded instance of suicide
through contemplation of one’s own beauties. In the same
amusing volume may be found an account of how there once
was a beam in a corridor in a great general hospital in London
(name not specified), but it had to be taken down or built up
(may we be pardoned for forgetting which ?) because as soon
as November set in the unhappy islanders, overwhelmed with
fog and spleen, flocked daily from the wards to hang them¬
selves in the corridor!

Organisation of Medico-Psychological Research.

The “American Retrospect” describes the efforts being made
in the United States to form an advisory board of scientists
representing all specialities interested in or related to psychiatry.
The names given promise success in this new departure, which
has our heartiest good wishes.

Such an organisation in Great Britain at the present moment
is not possible, but consideration might with advantage be
given by those concerned to the possibility of organising patho¬
logical research.

London and Edinburgh have representative pathological
laboratories, and (in the immediate future) Dublin will be
similarly equipped, while many smaller ones exist in connection
with public asylums. Might not the leaders of the work asso¬
ciate together with a view to increasing and stimulating the
more isolated workers in the country asylums ?

This would at least be a foundation for that wider organ¬
isation which may follow in a more or less distant future.

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1902.]

OCCASIONAL NOTES.

Roll of Honour for Asylum Workers .

Rolls of honour for those who have fought and fallen for
their country are now being established in many places. If
such a roll were formed for attendants on the insane, the list
might well be headed with the name of Isabella Sime, of
Perth District Asylum. This gallant and devoted nurse
sacrificed her life in an attempt to save that of her patient.

Such acts of self-sacrifice in the performance of duty, many
of which have been noted in this JOURNAL from time to time,
ought surely to be recorded in a more accessible form, to the
end that the public might have a truer conception of the spirit
that animates asylum workers. Their estimate, at present, is
too often founded on the reports of the prosecution of the
occasional black sheep.

Mind !

To what hand we are indebted for this delightful set of
parodies and jeux d % esprit we know not, but whoever he is he
has our most cordial thanks for an immense amount of amuse¬
ment. There is not a line from the top of the front cover to
the bottom of the back cover that one can afford to skip. It
is all clever and inexpressibly funny. Where all is so good, it
is invidious to single out articles for special praise, but “ The
Place of Humour in the Absolute,” by F. H. Badly, is an
extraordinarily clever parody upon the writings of a well-known
psychologist, and the “ Critique of Pure Rot,” by I. Cant, in no
way falls below its title. “ Elizabeth’s Visits to Philosophers”
might have been written by Barry Pain, and higher praise
could scarcely be given. The fun is carried into the smallest
details, and the answers to correspondents and the advertise¬
ments are by no means the least delightful. The advertisement
of Moneyism hits off a trans-Atlantic author to a nicety, and
too wide a diffusion cannot be given to another advertisement
on the same page—“ Lee’s Patent Anti-fad. Try it! Try it!!
Try it! !! For the Church, the Army and Navy, and all the
Learned Professions. Prof. X—, F.R.S., etc., writes: ‘ Since
taking ONE BOTTLE I have given up ALL MY MOST
CHERISHED CONVICTIONS.’ ” It would be unfair to our amusing
contemporary to regard it as merely facetious. There is a deal
of solid wisdom concealed beneath its jokes.

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REVIEWS.

[Jan.,

Original Research in Epilepsy.

The Craig Colony Prize on the above subject, particulars of
which are printed in “ Notes and News,” has been awarded in
the present year to Professor Carlo Ceni, of Pavia. Mention
of his essay on “ Serotherapy in Epilepsy ” is made in the
“ Italian Retrospect,” and its publication will be awaited with
interest.

Epilepsy is so great a factor in our large asylums that it is
to be hoped some of the medical officers of those institu¬
tions will undertake research in this direction, not only for
the sake of science but for the honour of British psychiatry.

Psychology—Normal and Alorbid.

We heartily congratulate Dr. Mercier on the publication of
his magnum opus. We hope that it will be read by every
physician engaged in the practice of our specialty, and mean¬
while refer our readers to the admirable review of this
important work by Dr. Leslie Mackenzie, which will be found
in this number of the JOURNAL.

Part II—Reviews

The Fifty-fifth Report of the Commissioners in Lunacy for
England, July ist, 1901.

The Report states that the total number of lunatics within the
knowledge of the Commission on January ist, 1901, was 107,944, and
this leads us to re-utter the protest as to the practice of taking a censal
estimate of the insane annually, therefrom to draw deductions. Is not
such an estimate altogether a false basis on which to build arguments ?
The diminished increase—that of 1333 as compared with that of 1525
last year—is regarded as a “ satisfactory condition ” ! Is it imagined
that were this census taken every June, for example, the same differential
variations would be obtained ? Previous annual reports have proved
that the incidence of insanity, so far as was justifiable by deductions
from the number of insane reported as such to the Lunacy Office,
showed remarkably irregular seasonal variations, and yet a date is
selected and a census taken thereon so as to compare it with a similar
censal estimate on the same date of another year. It is just as valuable
a piece of information as the statistics supplied by the daily press of
the tonnage of vessels passing through the Suez Canal on any one day

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1902.]

REVIEWS.

as compared with the tonnage passing through the same canal on the
sa me day last year. As we have in previous reviews so strongly con-
tended, the only fair estimate of the amount of work the Commissioners
have to perform (for that, after all, is the only valuation to be placed
on any aggregation of figures dealing with the insane so long as all
cases of insanity in the kingdom are not reported officially) is to
make a comparison between the totals of the average daily number
resident in all asylums, institutions, etc., in the kingdom. In the
remarks on this census of the insane the Report states that “ besides
the patients enumerated there were a number found lunatic by inquisi¬
tion, who were residing in their own homes or with their committees.
The number of these we have been unable to ascertain exactly, but it
was about 280.” Surely accurate information as to these numbers
could be supplied by the officials of the Lord Chancellor’s office with¬
out great difficulty.

Table IV, that dealing with the admission into all institutions and
private care, is the first of the summaries of this Report worthy of serious
notice. The variations as to increase and diminution under the
various modes of treatment are here set forth as in previous years :

County and
borough
asylums.

Registered

hospitals.

Metropolitan

licensed

houses.

Provincial

licensed

houses.

Naval and
military
hospitals.

Criminal

asylums.

Private

single

patients.

Idiot estab¬
lishments.

Totals.

Increase . .

1 Diminution .

705

29 ] -

834

287

Total increase — 547.

Of the total number of admissions during 1900, viz. 20,067, 16,192, or
80*19 P er cent., were first admissions, an increase of 440 first admissions
on the number last year. The large diminution in metropolitan
licensed houses is noteworthy, but is probably mainly among the pauper
classes, for the Report states in another table that the total decrease of
private patients in these institutions during the year was but twenty
nine. Of the 17,602 admissions into county and borough asylums 577
were private patients, an increase of but eight on the private patient
admissions into those asylums in the previous year.

Again we have to plead for an analysis of the “ transfers table.”
May we suggest that the Report should state in a supplementary table
(a) the reasons for each transfer, ( b) the results of such transfers, (c) the
period of time the patient had been in the one institution before being
transferred to the other, and ( d) the nature of each case so transferred ?
we shall be content with the present classification of mental disease.
If other countries can indulge in such analyses, why cannot we ? The
great value of such a summary in guiding alienist physicians to a due
appreciation of the practical utility of transfer as a mode of treatment
need not be enlarged upon here.

The table dealing with the re-admissions on fresh reception orders
under Section 38 of the Lunacy Act has apparently been omitted.

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REVIEWS.

[Jan.,

Next year, unless there is adopted the very wise precaution of issuing a
circular notice to all asylum managers warning them that every case
admitted prior to the passing of the Lunacy Act will need a statutory
report, there will, we fear, at the middle of the year be found a sudden
influx of work for the officials at the Lunacy Office which will surprise
them. We learn from another set of tables that the total number of
re-certifications under this section was apparently 76, which shows a
distinct improvement on the number last year, viz. 125.

Recoveries during 1900 numbered 7612, an aggregate increase of
but 37 on the number of the previous year, county and borough
asylums (135) and naval and military hospitals (44) presenting the
largest increases, while metropolitan licensed houses, provincial licensed
houses, and registered hospitals all show a diminished recovery
aggregate. The recovery rates to admissions fell from 39*26 per cent,
in 1899 to 38*37 in 1900, the average for the last decade being 38*83.
Another view of the recovery rate, namely, in relation to the average
number resident, gives a percentage of 9*27 in 1900 as compared with
a ratio of 9*37 in 1899. There can be no doubt that this diminution
in the recovery rate is due principally to the accumulation of senile
cases in all large institutions, and in a minor degree to the low
proportion rate of recoveries among private single patients. The
Report notes that “ as regards recoveries, it will be observed that the
proportion taken in respect of admissions is very constant, while that
calculated upon daily average numbers shows a considerable decline,
and this results, no doubt, from the great accumulation of chronic and
incurable cases.” We go further, however, and maintain that, con¬
sidering the magnitude of the yearly aggregate increase in non-
recoverable cases, and the merely fractional diminution in the recovery
rate, the inference that the asylums show no improvement in their
recoveries is altogether a false one. There should, if this contention
were sound, be a far more pronounced decline in the general calculated
rate; the mere fact that it remains at nearly the same figures annually
is an indication that there is actually a slight progressive improvement
Considerations as to the recovery rates of various institutions, or of
institutions en masse , so long as they are conducted on these lines,
belong rather to the realm of speculative arithmetic, for the relation
between the actual number of recoveries per annum on the one hand,
and the admission rate or the daily average number resident on the
other, is a somewhat distant one. True, they are the only sets of figures
available for rapid computation ; but the soundest method of all is to
follow out the fate of every admission into each institution for suc¬
cessive quinquennial periods, their classification being carried out
thus :—Of patients admitted during the quinquennial period there were
(A) a certain number discharged from the institution (a) recovered,
(b) improved, (c) not improved; (B) a certain number detained in
the institution, these being classed as (a) improved, and (b) not
improved; and ( C) a certain number of deaths. By this means a
recovery rate as well as a death rate of, not on, the admissions quin-
quennially for each institution would be obtained with results far more
reliable than our present uncertain methods, for they would be actual
and not approximate ratios.

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REVIEWS.

1902.]

The deaths during 1900 rose from 8160 to 8394, the increase being
mainly in pauper asylums, the percentage proportion of deaths to daily
average number resident being raised from 9 87 to to per cent. The
remarks above made are applicable here, and the discrepant death
rates of various modes of care would be considerably modified. On
the present basis of calculation, /. e the daily average number resident,
it would seem that metropolitan licensed houses, with a decennial death
rate of 11 *74, as compared with the 6 # 6i and 8*o6 percentages of registered
hospitals and provincial licensed houses, were occupying an unfavourable
position. Any attempt to explain these calculated rates would entail
theoretical speculations of but minimal value.

Other inexplicable figures, such as the low average ratio of female
deaths in registered hospitals and the high proportion of male deaths
in metropolitan houses, would, by the classification advocated above,
receive some elucidation.

We append, as usual, a table calculated from the figures supplied by
the Report, not as a reliable guide, but merely to serve as a comparative
purview of the relation between the death rates of the insane and sane.
It is a general numerical proof of our contention that the apparent
death rate among the insane tends to approximate to the estimated sane
death rate as age advances, especially in females. On comparison of
this table with that of the previous years it may be noted that the
approximation towards a sane death rate is slightly more marked in the
age decades above fifty-five than in years prior to 1899.

Age periods.

Death rate per 1000
reported insane 1899.

Death rate per 1000
whole population
(estimated) 1899.

Proportionate death
rate insane to sane.

Under 5 .

M. —

F. —

M. 60*4

F. 507

M. —

F. —

5-9 • • • •{

M. 355

3*8

M. 9*3 to 1

F. 431

3*9

F. ii*o to 1

10—14

M. 467

2*2

M. 21*4 to 1

F. 3«-9

2*3

F. 13*8 to 1

*5 —*9 {

M. 621

3*6

M. 17*2 to 1

F. 584

3*3

F. 177 to 1

20—24 . |

M. 564

5*3

M. 10*6 to 1

F. 53'3

4*3

F. 12*4 to 1

* 5-34 ‘ • {

M. 725

7 *i

M. 10*2 to 1

F. 554

6*i

F. 9*0 to 1

35-44 ■ • •{

M. 112*4

M. 12*3

M. 9*i to 1

F. 6r8

F. 100

F. 61 to 1

45—54 (

M. 1058

M. 20*0

M. 5*2 to 1

F. 620

F. 154

F. 4*0 to 1

55-64 {

M. 120*2

M. 37*2

M. 3*2 to 1

F. 86*9

F. 29*8

F. 2*9 to 1

65—74 •{

M. 234*9

M. 69*8

M. 3*3 to 1

F. 1598

F. 61 *5

F. 2*5 to 1

75—84 . {

M. 403*3

M. 152*6

M. 2*6 to 1

F. 293*8

F. 1426

F. 2 0 to 1

85 and apwards. . j

M. 593*8

F. 435*3

M. 300*3

F. 272*0

M. 1*9 to 1

F. 1*6 to 1

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REVIEWS.

[Jan.,

Table XIV exhibits no improvement in its nomenclature. A com¬
parison of this with the similar tables of previous years shows that the
Report merely classifies the stated causes of death in terms supplied by
the medical officers of asylums, whose “ causes of death ” are some¬
times quaint, instead of maintaining a fixed tabular standard on
the Registrar-General’s basis. We can thus only take the principal
causes of death for purposes of comparison. The percentage ratios of
each cause to total deaths are here given, together with similar ratios
for the five preceding years. The proportion of deaths from general
paralysis shows some diminution.

Causes of death.

1895.

1896.

1897.

1898.

1899.

1900.

General paralysis

. . 2000

2041

18 97 ! 17 44

1774

1608

Phthisis pulmonalis

. 1488

•3'88

* 4'57

•438

* 4*37

1418

Senile decay .

. 771

869

9 ‘ 3 I

910

9*12

899

Pneumonia

701

6 ' 3<5

613

696

715

8*24

Epilepsy ....

• 1 S'«6

489

466

5*23

496

518

Cardiac valvular disease.

• 478

573

602

< 5'45

, 5*76

605

Exhaustion from mania and melan- ; 3 87

362

365

337

366

3 "

Apoplexy

Chronic Bright’s disease.

• • | 316

• , 3 ' 9 a

| 3 ’ 2 i
256

313

272

290
2 06

374

3‘12

2*84

3’05

Bronchitis

289

1 246

2*09

358

I 275

374

Organic disease of brain .

. , 2*60

I 3*50

346

3*25

{ 3*62

302

Cancer ....

201

256

213 |

2’11

2*12

2*22

Accident....

. * 0 40

0*42

0'45

047

0*45

o *37

Suicide ....

. oa 5

• 014

0*28 1

0*29

! 0*27

0*17

Other maladies

• | * 3 ' 3 ®

21 57

22*43 j

2251

1 22*17

23*76

The number of post-mortem examinations amounted to 6489, or 77*6
per cent, of the total recorded number of deaths, a slight improvement
on the percentage of the previous year. From other tables and
remarks we find that the number of post-mortems in county and
borough asylums alone rose from 79*7 to 80*8 per cent.

Table XV, that dealing with occupation ratios to population, main¬
tains its utterly worthless characteristics. It is true the Report does
not now give ratio calculations on numerical population estimates of
thirty years back—the ratios are apparently all calculated on the
actual census enumeration of 1891. The average number of admissions
into asylums of, say, tailors and carpenters for the five years 1895—
1899 is made comparable with the censal enumeration of 1891. There
have therefore been no additions to the ranks of tailors and carpenters
during the past ten years!

The percentage proportion of the average admissions for the five
years classified as “ first attacks ” numbered 71*3. It is a pity that all
“ first attacks ” are not classified and analysed annually. The authorities
of other countries supply every year a set of tables giving particulars
of interest relative to every admission, and the value of such a state¬
ment would be far greater than “the ratio per 10,000 of thfe yearly
average of patients admitted during 1895—1899 to the whole population
at the time of the census (1891) according to their ages and condition

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as to marriage,” on which a page of the Report is expended. Those
admissions, moreover, which are “ not first attacks ” equally merit
classification, for, as we indicated last year, there must be a precious
mine of information in the Commissioners’ offices, hitherto unexplored,
the thorough investigation of which would undoubtedly bring to light
much fresh information relative to the remittent, intermittent, recurrent,
relapsing, and circular insanities.

The Report directs attention to the fall in the proportion of the
general paralytics, epileptics, and suicidal cases among the yearly
average of patients admitted into all institutions. For the quinquen¬
nium 1890—1894 the ratio was, for general paralysis, 127 per cent,
males and 2*8 per cent, females; for epilepsy, 8*2 per cent, of both
sexes; and for suicidal cases, 25*4 per cent, of both sexes; while for
the quinquennium succeeding (1895—1899) the ratios are, for general
paralysis, 12*2 per cent, males and 2’6 per cent, females; for epilepsy,
77 per cent, of both sexes; and for suicidal cases 23*6 per cent, of
both sexes. Now this is quite an artificial diminution. We are perfectly
justified in assuming that with the larger number of incurable admissions
into asylums and the ever-growing insane residuum in institutions these
figures should show a natural depreciation—an arithmetical diminution
due solely to the steady increase of the fractional denominator in each
instance; we cannot, as does the Report, arrive at the conclusion that
there are fewer general paralytics, epileptics, and suicidal cases actually.
It is apparently not appreciated that rational proportions of quin¬
quennial averages are totally different from pure aggregates.

The table dealing with assigned causes of insanity in the cases of all
patients admitted (XXIII) continues to be cast in a quinquennial
yearly average form. It would be far more useful, even if the obsolete
list of “ moral ” and “ physical ” causes be retained, to give the causes
of the admissions, etc., in each year, carefully differentiating first from
other attacks. An average table is almost useless. Reviewers of this
Report in contemporary medical and statistical journals lose sight
entirely of this fact, and take the trouble to remark on the percentage
of cases in which certain causes operated, as if this table were the
annual statement of insanity’s causation. Here first and second attacks
are mixed together, and all one can do is to make the broad and
general statement that a nominal percentage proportion of cases
probably had as a main cause (direct or indirect) a certain
determined factor—there is no possibility of certainty in our estimate.
A comparison of this table, however, with the similar table in the
Report for 1896, wherein the quinquennium 1890—189^ is dealt with,
shows that the per centum proportion of admissions in the latter due to
alcoholism stood at i 8'5 for private males and 7*0 for private females,
21*2 for pauper males and 8*2 for pauper females; while in this year’s
Report the figures are 20*8 for private males, 9 4 for private females,
227 for pauper males, and 97 for pauper females.

We are pleased that the tabulation of the causes of general paralysis,
to which we have so often objected, has been omitted.

Of the patients admitted into all institutions during 1899, 4 2 *8 per
cent, suffered from some form of mania, 28*3 per cent, from melancholic
types of insanity, 4 per cent, from delusional insanity, 6*4 per cent, from

XLVIII. 6

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REVIEWS.

[Jan.,

general paralysis, and 4*9 per cent from senile dementia. The propor¬
tions given in this table are not in accordance with its heading, which
runs “Proportion (per cent.) to the total number admitted during the
year ”—this would give the ratio of private males with maniacal affec¬
tions as 4*1 per cent.; it should read “Proportion (per cent.) to the
total number in each class and for each sex admitted during the year.”

The number of voluntary boarders remaining in registered hospitals
on January 1st, 1901, was 84, in metropolitan licensed houses 14, and
in provincial licensed houses 42. Of the number admitted during
1900, viz., 295, 27*4 per cent, had to be certified.

Table XIII, Appendix B, is one in which the Commissioners say they
“ try to show by percentages the degree of attention given in asylums
to various matters affecting the treatment and welfare of the insane.”
There is much in this table to which we might raise objection, merely
because its figures are so evidently imperfect. The only fair way of
dealing with this table is to obtain information from the respective
superintendents as to the percentages of each heading. This, surely,
would be better than to cull the figures from the Commissioners*
visitation reports, the interim period to which they relate frequently not
embracing a whole year.

The admissions into county and borough asylums during 1900
numbered 17,602, of which number 18*6 per cent had previously been
discharged from institutions for the insane. The recoveries numbered
6704, and the deaths 7766. Post-mortem examinations were made in
8o*8 per cent, of the total number of deaths. The suicides in county
and borough asylums are stated in the Report to have numbered fourteen;
“ in three instances the patients were absent from the asylum on leave
or on trial, and in two the act, which subsequently resulted in death,
was committed before admission ; ” but Table IV, Appendix B, states
that there were sixteen suicides in county and borough asylums, two of
which were after escape, six in which the act was committed before
admission, and four in which the act was committed while the patients
were absent on leave. These figures, therefore, do not tally. On
going through their annotations on asylums, we can find but twelve
suicides accounted for by the Commissioners. Of these, five (all males)
died by strangulation; two (one of each sex) by precipitation under
trains; one (male) by cut throat; one (female) by swallowing broken
crockery; one (female) by drowning ; one (female) by suffocation; and
one (female) by evulsion of the tongue.

In their remarks on registered hospitals the Commissioners say:
“ Although the need of further accommodation at low rates of payment
for persons above the position of paupers, but of small means, is
rather growing than diminishing, its provision still fails to appeal to the
public as a desirable form of practical philanthropy.” Of course it
does when the public given to practical philanthropy read in their
Report of the previous year that some of these institutions have hitherto
“inadequately discharged the functions of benevolent establishments,
and in the application of their—in some instances—very large incomes
have shown a comparative disregard of the principles upon which they
were founded.” How can they possibly expect the charitable to provide
additional material for official rebuke ? Let these institutions first be

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1902 .]

REVIEWS.

set in due order, and when they all can be reported upon as doing a
proper amount of charitable work, then let an appeal be made to the
generous for additional accommodation. At present the position of
some of these registered hospitals is, to say the least of it, anomalous.
They pose as charitable institutions with a minimal inclination to
charity. Not a single suicide is on record in these asylums during 1900,
a fact which redounds to the credit of their management, while the
recovery rate (on admissions), 44*8 per cent., and the death rate (on
average number resident), 6*9 per cent., compare, so far as comparisons
are warrantable with such calculations, very favourably with other classes
of institutions.

There was but one suicide in licensed houses during the year, that of
a female (cut throat), and the control of these institutions appears to have
merited the commendation of the authorities.

The Commissioners have this year drawn the special attention of
local authorities in an economic and minatory article to the need of
strict economy in the building, finishing, fitting, and furnishing of
asylums, “ that all extravagant and therefore unsuitable decoration both
inside and out should be carefully avoidedand they seriously threaten
that “an obvious departure from this principle” will cause them to
advise the Secretary of State to refuse his approval of all such plans.
The standard of “ extravagant decoration ” will, we fear, be difficult to fix.
We cordially agree, however, with the expressed opinion that separate
institutions for the chronic insane—demented cases, imbeciles, quiet
epileptics, etc.—and for acute cases, or such as need more skilled and
constant surveillance, would be an economy in the long run.

Some important points referring to the detention of lunatics in work-
houses, the result of the deliberations of the law officers, are furnished,
and the Commissioners give special consideration to the occurrence of
infectious maladies in asylums, their summary of the deaths in county
and borough institutions due to tubercular disease being deeply
interesting.

We share in the regret expressed by his colleagues at the death of
Mr. W. E. Frere, who for twenty-two years had actively engaged in the
duties of a Commissioner, while quite recently we published our
obituary of another conscientious worker in the field of lunacy—Mr.
J. D. Cleaton.

The Report, as a whole, does not reflect credit on a body of officials
who are, without doubt, zealous and earnest in the performance of their
routine official duties. That the vast mines of statistical information at
the command of the Commission are not worked to a more productive
result can be ascribed only to the lack of power, due to undermanning,
especially in the medical element

We can only repeat the oft-reiterated hope that a large addition to
the medical strength of the Commission will shortly enable it to grapple
with many problems, which the present inadequate staff is unable to
attack, in a manner worthy of the twentieth century.

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[Jan.,

Forty-third Annual Report of the General Board of Commissioners
in Lunacy for Scotland (1901).

The well-being of the insane and the economic aspect of pauper
lunacy are not by any means matters of such real and paramount
interest as the larger social question of the state of the national
mental health. Is there, or is there not, in these annual human
documents, the Lunacy Blue Books, any evidence of any amendment,
however slight, in the prevalence of lunacy? That is the point of
real and essential interest.

The recently published Preliminary Census Reports enable one to
form an approximately correct estimate of the changes which have
been taking place of late years in the amount and the occurrence of
the country’s lunacy, and, taking a broad and general view of the
Reports of the three divisions of the kingdom, one cannot help being
struck by the fact that 1900, the year under review, stands out in quite
unmistakable fashion from other years.

The following tabular statement gives the proportion of the total
official lunatics on January 1st per 100,000 of the estimated popu¬
lation in the middle of the same year in the United Kingdom and
each of its three divisions.

Year.

United Kingdom.

England.

Scotland.

Ireland.

1891

3°5

298

3°4

346

1898

337

323

331

433

1899

344

330

343

45 1

1900

347

331

345

466

1901

348

33 1

345

476

The diminishing character of the increase is everywhere evident. In
the whole kingdom the increase for the ten years amounts to 43 per
100,000, while that for 1901 over 1900 is only 1. In England the
increase for 1899 over 1898 amounts to 7, and that for 1900 over 1899
is only 1, while in 1901 the proportion has undergone no change. In
Scotland very much the same movement is observable, the increases
for these same years being respectively 12, 2, o. In Ireland the ten¬
dency, though not so marked, is in the same direction, the increases
being 18, 15, 10. Such are the changes which have taken place in the
collective mass of the kingdom’s lunacy. Is there any evidence of a
like change in its occurrence ? Taking first admissions as an index of
occurring insanity these are the facts which are revealed in the Reports.
The proportion of first admissions per 100,000 of the estimated popu¬
lation in the middle of the same year is as follows :

Year.

United Kingdom.

England.

Scotland.

Ireland.

1890

. —

—

522

51*9

1898

• 517 •

49*2 •

61 *5 •

59 * 1

1899

52-2

49*4

605

63‘5

1900

52-6

50*2

6o'8 .

61 *9

In the United Kingdom the increase in 1899 amounts to *5, while
that for 1900 is only *4 per 100,000. In Scotland, while the increase

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between 1890 and 1900 amounts to 8*6, that for 1900 compared with
the preceding year is only *3, and if the last two years are taken
together, there is an actual decrease of *85 as compared with 1898.
In Ireland the ten years’ increase amounts to 10 per 100,000, but the
year 1900 shows a decrease of r6 when compared with 1899. In
England, where returns of first admissions are only available for the
past three years, there is the very slightest increase, but judging from
the total admissions there is here also evidence of change in the right
direction. The rate for these in 1890 was 56*3 per 100,000, and that
for 1900 is 61 *5, an increase of 5*2, while the rate for the two years
1899-1900 shows a diminution of *2 when compared with 1898.
All round, then, there is quite unmistakable evidence of an improved
condition of affairs as regards the nation’s mental welfare.

Life is defined as “ the continuous adjustment of internal relations
to external relations.” Something in the nature of an alteration of the
external relations must have occurred to bring about this modifica¬
tion of the internal relations so noticeable in the mental life of the
nation, and the question is, What? It must have been something
which has affected not one division of the kingdom alone, but all
three in greater or less degree, for the modification is not confined to
any one of the three. The past two years have been years of prosperity,
and there has been no outstanding domestic-political event. Singe the
latter part of 1899 that which has undoubtedly been occupying public
thought more almost than anything else has been the war which the
Empire has been waging against its common enemies of the Transvaal
and the Orange River Colony. This, and this alone, constitutes the
one outstanding feature of the past year, and there can be little doubt
that it is this, and this alone, that is responsible for the change which
is so noticeable in these reports of the nation’s mind.

This same influence df war upon the prevalence of insanity was
noticed in the American War of 1861 and in France in 1870, but no
opportunity for its illustration has transpired in Britain until the present
occasion. The present outbreak of hostilities is seemingly proving
beneficial to the British race, exerting as it does a tonic and bracing
effect upon the mental constitution, an effect which shows itself in the
improved returns of the lunacy of the country. And, further, it is not
only in this direction that the good effect shows itself. It has been
shown by Durckheim that one of the effects of war is a diminution in
the number of suicides, and this is found to be true of England on the
present occasion. The outbreak of hostilities occurred on October
1 ith, 1899, and its effect was such as to colour the returns for the whole
of that year. The number of suicides was 70 less than that for the
preceding year, a reduction of 2*4 per cent. The known attempts to
commit suicide in December of 1899 show also a falling off of 2*5 per
cent., as compared with the same month of 1898. In the same way
there is a falling off in the number of all serious offences known to be
committed in that same month amounting to 3*4 per cent, compared
with the preceding year. In Ireland there was a decrease of 8*5 per
cent, in serious crimes in 1899, and of 7 9 in suicides in 1900, but in
Scotland there was an increase of crime so great as to make 1899 a
Tecord year, though we doubt that this will be found to apply to the

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[Jan.,

last month of the year, and here also suicide decreased to the extent of
6*4 per cent.

It might almost be said that the same effect is noticeable even in
such a comparatively small matter as the occurrence of general paralysis
of the insane. In England the percentage proportion to admissions,
which in the two quinquenniads ending 1898 and 1899 was respectively
7*9 and 7*6, fell in the year 1899 to 6*4. In Scotland, while the total
deaths in establishments increased 29 per cent, in 1900, the deaths
from general paralysis decreased 30 per cent., and in Ireland the
general paralytics, who constituted 1*19 per cent, of the admissions of
1898, decreased in the two years 1899-1900 to no.

Such, in general terms, have been some of the results of the growth of
the spirit of patriotism and militancy which have been such striking
features in the country since war was declared. Whatever interpreta¬
tion is attached to these facts it is just as well that they should be
noticed, and it would be a good thing if our Continental friends w'ere
made cognizant of them, for very garbled statements on this, as on other
matters, are not unknown, even in scientific Continental periodicals,
one of these in all gravity publishing an extract from a well-known
lay journal to the effect that the number of the insane in London
had increased in 1900 from 16,353 to 21,369, and that Dr.
Claye Shaw attributed this increase to the influence of the Transvaal
War !

Whatever the explanation of the improved condition of affairs, Scot¬
land is to be congratulated no less than the other two divisions of the
kingdom. This effect of the war is unlikely, however, to prove other
than temporary, but if it is productive of even a temporary steadying
of the mental and moral character of the nation it will not have been
in vain.

It must not be forgotten that while the country as a whole show’s this
general improvement of its mental health it does not by any means
apply to all parts of it. In some there is a very manifest improvement,
while in others the condition of affairs goes on steadily from bad to
worse. Taking the Preliminary Census Returns as a basis, the counties
of Scotland arrange themselves into three groups: (1) those in which
the population is diminishing; (2) those in w r hich there is an increase,
but under the average ; and (3) those in w'hich the increase is above the
average. In the first group, which comprises 14 counties, having 13
per cent, of the population, the intercensal decrease amounts to 4^4
per cent.; in the second, with a percentage of the population amounting
to 21 and comprising 10 counties, the increase is 3*5 ; in the third,
comprising 9 counties, with 66 per cent, of the population, the increase
amounts to 37 per cent., the increase for the whole country being in.
What changes have taken place in these three groups as regards pauper
lunacy in the past ten years ? Calculated on the census populations
the increase of pauper lunacy for the w'hole country amounts to
37 per 100,000; in the first group it amounts to 68, in the second
to 38, in the third to 35. What significance is to be attached to
these figures ? Not for the first time has it been pointed out that
the position of the poorer and insaner counties, wnth but few exceptions,
grows increasingly grave, and that the richer and increasingly populous

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»7

counties profit at the expense of their less well-to-do neighbours. It is
a sad prospect that faces the poorer districts, and it promises to be an
increasingly hard problem to deal with, that of their pauper lunacy and
its financial burden. The tide of emigration still sets strongly towards
the large industrial centres, with consequences increasingly disastrous
to the depleted districts, and the remedy is hard to seek.

Allusion has already been made to the subject of general paralysis.
In the interesting section of this Report dealing with deaths from this
cause the diminution of the disease in the year 1900 is brought out
very unmistakably, .the deaths from this cause being 9 2 per 1000
patients resident as compared with ii*6, the average of the five
preceding years ; and it may be anticipated with some confidence
that the year 1901 will present characteristics in this respect not
dissimilar to those of the year reported upon. In dealing with a
disease such as this it is necessary to keep in mind the important part
that age plays in its genesis. There can be little doubt that the
removal of so many men necessitated by the South African campaign
has had not a little to do with the decrease of this affection, which is
noticeable in all three divisions of the kingdom; and one at least of the
reasons for its greater prevalence in urban communities is to be found
in the fact that there is a much greater proportion of both men and
women of what one might call the general paralysis age in these than
there is in the purely rural districts. Unless this age factor is taken
into account fallacious conclusions may be drawn. It sounds un¬
commonly like rank heresy to say, as the Commissioners do, that “ the
greater prevalence of the disease among the male sex does not neces¬
sarily prove a greater inherent liability of that sex to the disease, but
merely points to the fact that the male sex is much more exposed to
the injurious social influences which cause it.” To say so does not
serve to dear up the mystery of the origin of this affection, but merely
puts the explanation in another form. It is tantamount to saying that
there is an inherent liability of the male sex to expose itself, or to be
exposed, to the injurious influences which are productive of the disease,
which is just the same thing in different words. There is no getting
away from the fact that there is an undoubted proneness, whatever the
explanation, on the part of the insanity of the male sex during the
reproductive period of life to assume this particular form, which con¬
trasts strikingly with the comparative absence of such a tendency in the
female sex, at least that section of it which is reproductive. From
the language used one would infer that the general paralytic is merely
the passive and pitiable victim of the injurious influences exerted upon
him by the society of which he is an individual, and that his own
conduct has no art or part in the production of the disease. That
may be so in the case of those females who develop the affection ; that
it is so, equally and likewise, in the case of males is matter for doubt.
Society does not compel any of its individual male members to be
exposed, or to expose himself, to either of the two conditions which
are recognised as agencies in the production of the disease. There
is the further difficulty, too, that not all who commit excesses, sexual or
alcoholic, or who contract syphilis, become victims of this disease, which
argues that there is some additional and necessary individual factor,

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[Jan-.

u <?., the inherent liability. As a French observer puts it, paralyticus
nasdtur % non fit .

The returns of the year under review reveal the same general tendency
towards diminution in the numbers of the insane poor who are accom¬
modated in private dwellings which has prevailed during the past ten
years. In 1890 the percentage so provided for amounted to 24; in
1900 this had fallen to 20*6, and the decrease applies to all parts of the
country, with the exception of only five counties, in two of which the
proportion remains the same, while in the other three there are increases
of no great amount. The advantages of the system are, as usual, set
forth strongly by the Commissioners, but apparently without avail.

The reports upon individual asylums afford gratifying evidence of a
prevailing spirit of progressiveness in the treatment of the patients, and
consideration for the staff. The increasing recognition of the arduous
and responsible nature of the duties of the attendants especially is a
point which ought to meet with approval of the heartiest sort. In the
past ten years, while the average number of patients in district asylums
has increased 100 per cent., the increase in the staff amounts to over
133 per cent., giving 1 to 6£ patients instead of 1 to 7$. In the same
period the total net maintenance expenses have increased no per cent
The increase under the heading of salaries and wages amounts to 120
per cent., and is entirely accounted for by the additions to the wages of
attendants and servants, for the increase in the total expenses under
that heading amounts to no less than 200 per cent., that for officers and
artisans being only 76 per cent. The changes in the dietary tables, too,
indicate increasing additions to the solid comforts of life, and a com¬
parative luxuriousness which ought to be a sort of consolation and com¬
pensation to those unfortunate enough to be denied the delights and
blessings of the private dwelling life.

One would fain have hoped that these additions to the staff and
dietary, and the increased remuneration of the attendants, would have
helped to influence for good the recovery and death rates in asylums;
but such, so far, is not the case, for neither of these show any sign of
change in the direction of improvement, but rather the reverse. There
is no improvement even in the number of suicides which take place in
asylums, a matter in which Scotland compares unfavourably. The
deaths from this cause in English county and borough asylums in the
quinquenniad 1891-95 give a rate per 10,000 resident of 2*03, and in
1896-1900 of 2*02; in Ireland the corresponding rates are 3*08 and 1*87,
but in Scottish establishments the rates are 5*06 and 6 # o6. The greater
prevalence of these regrettable deaths in Scottish institutions is, in all
probability, to be explained largely by the greater amount of liberty
allowed to the patients, and not to be attributed to negligence on the
part of those who have the care of the inmates, and would seem to call
for still further addition to the staff. The self-sacrifice of the brave
nurse, Isabella Sime, of the Perth District Asylum, in her heroic
endeavour to save her charge from suicide by drowning in the flooded
river, which is recorded in this Report, is only one more of the already
not few illustrations of praiseworthy devotion to duty, the extremely
trying and onerous nature of which the public do not sufficiently realise.

We have only dealt in the most general terms with what seem to us

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to be the outstanding features of this Report, compared with those of
previous years. There is evidence in plenty to satisfy the most exact¬
ing Scottish public that the safety and well-being of its insane poor are
jealously safe-guarded, and that at the same time due regard is had to
the economic aspect of the ever-increasing burden of its pauper lunacy.
It is without exception the most encouraging and most promising
Report that we have seen. To be able to record an improvement in
the nation's mental health, however slight, is a matter of the greatest
import, and one could only sincerely wish that this might turn out to be
other than merely temporary.

Fiftieth Report of the Inspectors of Lunatics (Ireland) for the year
ending December 31^/, 1900.

For two successive years the inspectors have been able to record a
substantial diminution in the rate of increase of the insane under care
in Ireland. The total increase, computed on the numbers on register
on December 31st, in 1900, was 306, a figure which is not only con¬
siderably under that of the previous year (559), but is 186 less than
the average for the past ten years, which was 492. It is, moreover, the
smallest total increase since the year 1893. Last year, in commenting
on the Report, we ventured to express a hope that the high water mark
in the increase of lunacy had been reached in 1898, when the annual
increment had risen to 714. Can we regard the fact that there has
been a very material reduction in the increment for two years in
succession as an indication that the tide is really on the ebb ? A some¬
what lengthened experience in the fallacies of lunacy statistics suggests
caution in the making of forecasts, and for some years, at least, it is
wisest to act on the time-honoured maxim—never prophesy until you
know.

That a reduction in the rate of increase, however, did take place two
years ago, which has repeated itself in the past year, is at least a
matter for congratulation. The yearly crop of insanity cannot go on
increasing indefinitely. Such a prospect is too appalling, and is not in
the nature of things. “ Survival of the fittest ” is not yet an exploded
doctrine. Sooner or later a limit must be reached; sooner, if the
general public—the “ man in the street ”—begins at last to learn, and
having learned, to act upon the principles of mental and moral hygiene;
and, on the physical side, to adopt much the same methods as are em¬
ployed—and with these latter he must be to a large extent familiar—in the
raising of healthy stock. As regards the former, there is far too much
ignorance for an age which deems itself so enlightened in other respects.
But “ how shall they hear without a preacher ? ” This is not a point¬
less question to submit to the Lunacy Office. When an invasion of
plague or cholera is believed to be imminent plain directions are issued
by recognised authorities, and disseminated amongst the public, indi¬
cating the best means of prevention, precautions to be used, things to
be avoided, and so forth. By this means unreasoning panic is allayed,

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90 reviews. [Jan.,

and the public are encouraged to act sensibly, and to adopt rational
measures to meet and overcome the threatening peril. Insanity is no
occasional visitant like plague or cholera, it is always with us. Its
lineaments are but too familiar; and perhaps on account of this very
familiarity we have come to tolerate it easily, although, not so much
on humane grounds as on account of the huge expenditure which it
involves, the ever increasing mass of insanity in these countries is fast
becoming an intolerable incubus. Now, in the presence of this vast
brooding evil, which causes so much misery, and costs this small island
annually over half a million sterling, an expenditure which has about
doubled itself in the course of the last ten years, and which still keeps
mounting higher and higher—in the face of this deplorable state of
things any and every means should be tried, exhaustively tried, which,
even if it had not the effect of immediately checking, would, at least,
tend to check the growing evil. The enlightenment of the public on
the subject of insanity generally is one such means, and, in proper
hands, might be made a powerful means. But how little of this en¬
lightenment is even attempted ! Apart from scientific contributions,
which are only addressed to expert hearers, the reports of medical
superintendents are almost the only literature on the subject. These
are read by comparatively few, of whom probably most are only, or
chiefly, interested in the financial aspect of the question. There
remains, then, the ‘ Annual Report of the Inspectors of Lunatics.' But
to that the public, up to this, have looked in vain for guidance. No
note of warning, no word of counsel accompanies the dry chronicle of
events in the world of lunacy, which is only characterised by a dreary
monotony repelling in itself; and if a long-suffering public were to read
any of these Blue Books from cover to cover they would not find a
single hint or suggestion as to what they themselves might do to check
or counteract this scourge of the human race. The oracle is dumb.
Should this be so ? Is it right ? Why should not those who are in a
position to speak with authority use that opportunity to the best
advantage ? Why should they not set out plainly and clearly, so that
he that runs may read, the main facts bearing on the subject of in¬
sanity, which have a vital and practical interest for the public ? Why
confine themselves to the bald enumeration of figures, the number of
admissions, discharges, and deaths of patients sent in on warrant or
ordinary certificate, the amount of land attached to each asylum, with
the profits derived therefrom, etc. These are, no doubt, necessary
returns to have printed and kept on record, but as an aid to the public in
the way of enlightenment on the subject of insanity, or assisting to put
a stop to its advancement, they are absolutely barren and profitless.
The inspectors' office is the central bureau of lunacy matters.
Common sense would suggest that one chief part of its business should
be to diffuse knowledge on that subject with which it is supposed to be
specially familiar. Were it to fulfil this mission, so far from lowering
its dignity (there might be a lurking hesitation on this score in the
official mind), it would undoubtedly largely enhance its value in the
eyes of the public, and it might develop into a really useful department
of State. An analogous case is that of tuberculosis, which is another
terrible scourge in this country. A notice has lately been issued.

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which is now being posted up broadcast over the country, giving in
simple terms a few of the most important facts about this disease, and
plain directions for the prevention of its spreading. Might not some¬
thing of this sort be done also in the case of insanity ? By keeping
the salient facts of the disease constantly before the eyes of the
people it is not unlikely that an impression would be gradually made
on the mind of the public which would eventually lead to practical
results.

What the public are asking, asking with more insistence each year as
the tale of insanity, like the ever-growing snowball, relentlessly con¬
tinues to increase its already huge dimensions, is, What is the cause ?
and next, What is the cure ? These are the two great, the two vital
questions, as far as the public are concerned. What enlightenment is
to be gleaned from the pages of the Blue Book ? As regards cure, in
the broad sense of a remedy or antidote for the increase of insanity, we
find not one word. As regards causation, this pregnant sentence satisfies
the official conscience:—“ Table XIV gives the probable causes of
insanity amongst those admitted in 1900.” On referring to this table
—the same old, antiquated, useless schedule of causes—what the wiser
are we ? Do we not rather feel bewilderment ? Are we to believe that
“ fright and nervous shock,” and nothing else, drove fifty-two persons
out of their senses, that a “ previous attack ” was the cause of subse¬
quent mental aberration in 278 cases? Does anyone in his sober,
senses believe that “puberty” drove nine young persons to frenzy or
despair? Puberty is a natural developmental period in the life of
everyone; a period, no doubt, when a certain small proportion of
brains, if constitutionally unstable, are liable to break down. But is it
not a misapplication of terms to call puberty the cause of insanity in
any single instance ? The list of physical causes on an setiological plan
of this sort does not go back far enough; the first heading should be
“ Birth.” A man cannot become insane unless he is bom, and from
that point of view birth is undoubtedly one cause—one prime cause—
of insanity. We have commented in previous years on the fact that
insanity is rarely, if ever, the product of a single cause; and a table of
this kind is not only utterly useless, but a positive imposition, wholly
discreditable to the authority which sanctions it. The fact is, and we
make the statement deliberately, that if a clean sweep were made of all
the causes enumerated in this table, and the simple proposition substi¬
tuted for that imposing array, there are two causes of insanity—
heredity and drink, while far from asserting that this statement is
absolutely correct, we do maintain that it would convey a far truer and
more accurate presentation of fact than the table supplies. Heredity
is stated to have been the cause in only 810 cases out of a total of
3546. Is this credible? Is it even an approach to accuracy? We
repeat, as long as only one cause is permitted to be given, omitting all
contributory causes—which are often equally potent factors with the
single one assigned—this table would be better omitted altogether.
Delenda est . Let it be either amended or expunged.

A table on page 15 of the Report gives the proportion per 100,000 of
estimated population of lunatics under care from the year 1880 to 1899.
But why not give the actual instead of the estimated population for the

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[Jan.,

census years? If we take the three census years 1881, 1891, and
1901, we get the following figures :

Year.

Population.

No. of lunatics.

Proportion per
ioo.ooo population.

Ratio of
increase.

1881

5.174.836

12,982

251

—

1891

4.704.750

; 16,251

345

37*4

I 9 ° I |

4456,545

| 21,169

475

37*6

In other words, in 1881, one out of 398 persons was a recognised
lunatic; in 1891, one in every 290; and in 1901, one in every 210.
The insane in private dwellings and those wandering at large are not
included. If these numbered, say, 1000 in the whole of Ireland, the
proportion of insane would be one in 200. It is hardly likely to rise
higher than this. The ratio of increase during each of the last two
decades was practically the same, viz. 37^ per cent. If this rate were
to continue, to follow up a no doubt somewhat fanciful idea, though
one not altogether devoid of interest, computation shows that in 170
years from this, the population of Ireland would consist of exactly an
equal number of sane and insane.

In 1880, the proportion per cent, of total numbers under care was :—
In district asylums, 67; in workhouses, 27 ; in private asylums, 6.
In 1901, these ratios had altered to 77, 18, and 5 respectively.
That is to say, in twenty years the proportion of insane in district
asylums had increased by 10 per cent.; that in workhouses had
decreased 9, and in private asylums and other institutions by 1 per
cent. The obvious deduction from these figures has been frequently
adverted to, and is corroborated by the fact that the number of
admissions from workhouses into district asylums has, during the past
decade, increased from 12*66 to 20*47 per cent, of the total ad¬
missions.

The total admissions for 1900 exceeded those of 1899 by only three,
as compared with an increase of eighty in the previous year. There
was a decrease of three in the case of district asylums, where there was
a decrease of eighty-five in first admissions, and an increase of eighty-
two in the re admissions. In 1899, on the other hand, the fresh cases
increased by 180, while the re-admissions decreased by 100. The
truly baffling nature of lunacy statistics could hardly be more strik¬
ingly shown.

The following table, compiled from that on page 17 of the Report,
gives the respective increments for five-year periods from 1881 to
1900 :

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5-year periods.

Average first
admissions.

Increase
per cent.

Average re¬
admissions.

Increase
per cent.

Total

admissions.

Increase
per cent.

1881-5

2163

—

524

—

2687

—

1886-90

2270

1 49

625

19*2

2896

*891-5

2426

6-8

743

188

3168

9*3

1896-19OO

2683

10*5

752

3435

8 ‘4

i 1

The sudden drop in the ratio of re-admissions during the last
quinquennium is difficult to account for.

Of a total of 3546 admissions, 2415, or over two thirds, were sent
in on magistrates’ warrant. Further comment on this system of
criminalising the insane, which is the practice of Ireland alone of all
civilised nations, would only be waste of time. The Lunacy Department
seems to have settled down into a condition of perfect contentment as
regards this indefensible procedure : fy suis , fy reste .

The recoveries show a percentage of 36 3 on the admissions, and
the deaths one of 7*9 on the daily average. For some years past some
useful tables have been making their appearance in the body of the
inspectors’ reports giving statistics for a series of years. We welcome
their advent as a really valuable innovation, for which we have been
pressing with more or less persistence, and which we hope to see
extended still further as time goes on. For instance, a table showing
the recovery rate, and another showing the death rate for, say, the last
twenty years, would be of distinct value. Such tables appear regularly
in the English Blue Book. They go back to 1873, and give not only
the percentage for each year, but the averages for each period of
five years. Why should we not have the same for Ireland? Over
27 per cent of the deaths were due to consumption, and 3 per cent, to
general paralysis. An extra column in the table on page 20, giving
the percentages of mortality from these diseases for a succession of
years, would be a useful addition. Two deaths occurred from suicide,
two from homicide, and three from misadventure, all these latter being
the result of scalding in baths. Such accidents might be avoided by
having baths fitted with patent taps, controlled by a key which turns on
the cold water before any hot can flow. With these there is no
possibility of the patient being scalded.

The highest death rate, 15 2, was in Limerick Asylum; the lowest,
47, in Letterkenny. The high mortality in the former does not appear
to have been due to zymotic disease, as phthisis (31*8), heart disease
(14*0), and general debility (24*0) account collectively for 82 per cent,
of the deaths. The sanitary condition of Ballinasloe is stated to be
very unsatisfactory, “as cases of zymotic disease occurred in every
month of the year.” This appeared to the inspectors to be due to
overcrowding, and a dilapidated condition of one ward on the ground
floor. It would be satisfactory to know if this asylum is provided
with a proper drainage system, and whether its water supply is above

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suspicion. There was a good deal of dysentery in Cork, Downpatrick,
and Richmond, but on the whole the Irish asylums show a very fair
record as regards zymotic disease.

Post-mortem examinations were held in 327 cases, as against 311
in the previous year. This increase is evidently regarded favourably
by the inspectors, but if we take the number of deaths in each year
into account, we find that in 27-4 of those of 1899 post-mortems were
made, and in only 25*6 of the fatal cases in 1900, so that the record
can hardly be considered satisfactory.

In connection with this subject, the inspectors “ are glad to notice
that the Irish asylum authorities have originated a proposal to establish
a central institution for the study of mental pathology, and to enable
the local committee to contribute towards the maintenance of such an
institution.” “ Asylum authorities ” is a rather vague expression, which
usually is taken to mean the asylum committees, who, as a matter of
fact, have taken no action whatever in the matter. The first move
towards this important object emanated from the Irish Division of our
own Association, who appointed a committee for the furtherance of it,
which, having obtained the support of the Colleges of Physicians and
Surgeons and some of the medical societies of Dublin, memorialised
the Chief Secretary, and subsequently sent a deputation to wait upon
him, with the result that the application by asylum committees of
funds for the purpose has become legalised, and it is to be hoped that
all the committees may be induced to join in the movement, and so
materially aid the progressive and enlightened study of insanity in this
country on similar lines to those which are being followed in the case
of the London asylums, and other groups of asylums in England and
Scotland.

The average annual net cost per patient for maintenance was
^25 13 s. 6 d., which is £2 3 s. to d. higher than in the previous year.
This the inspectors attribute to increased cost of necessaries. In the
tables given on pages 30 and 33 of the Report, the daily averages for
1899—1900 and 1900—1901 are given as 15,785 and 16,283, whereas
in Table II of the General Statistics (Appendix) the figures for 1899
and 1900 are 15,682 and 16,114 respectively. Which is correct? and
if both are so, how are the former figures arrived at ?

The condition of the workhouse lunatic is still anything but satis¬
factory, and in many instances deplorable. Guardians do not seem to
trouble themselves much about this saddest class of the insane. They
are, we fear, never likely to be better oflf until they are transferred from
under the control of the bodies under whose charge they are at
present and placed either in district asylums or in institutions where at
least some adequate provision will be made for their proper treatment
and comfort. Although under the 76th section of the Local Government
(Ireland) Act power is given to county councils to provide for the
chronic and harmless insane by utilising a workhouse or other suitable
building as an auxiliary asylum, in one case alone, that of Youghal,
has any attempt been made to carry out this object. As the old style
of workhouse is, as a rule, ill-fitted for the accommodation of insane
patients without more or less costly alterations, the inspectors are of
opinion that it would be preferable to establish special buildings as

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annexes to the existing district asylums of a simple and inexpensive
style for the insane now located in workhouses. With this opinion we
are inclined to concur.

During the twenty years from 1880 to 1900 the number of patients
in private asylums has increased by 87, but the increment has been
confined altogether to male patients, who have increased by 89,
whereas the number of females has decreased by 2. The average
number of annual admissions has advanced from 157 in the first
decade to 184 in the last, a rise of 17 per cent. The condition of the
private asylums generally which were reported on by the inspectors
appears to be, on the whole, satisfactory, and does not call for any
special comment.

Psychology : Normal and Morbid\ By Charles A. Mercjer, M.B.,
M.R.C.P., F.R.C.S., Lecturer on Insanity at the Westminster
Hospital Medical School, and at the London School of Medicine
for Women, etc. London: Swan Sonnenschein and Co., 1901.
p. xvi, 518. Price 15s.

Some eleven years ago I had the privilege of reviewing for Mind
(No. lx, October, 1890) Dr. Mercier’s Sanity and Insanity. His
point of view and his method had been more or less familiar to the
psychological world before then. I still recall vivid impressions
of the novelty of system involved in his “ Classification of Feelings ”
contributions, afterwards embodied in his Nervous System and the
Mind . In that work, Dr. Mercier modestly professed to “do into
science” the leading results of Spencerian and Jacksonian speculation.
He carried out his aim with much thoroughness and lucidity. He
was, it is true, somewhat dogmatically familiar with cerebral mole¬
cules and their marvellous evolutions and repositions in the dance of
mind, and he has been twitted—not, I think, quite legitimately—with
assigning to those intimate mechanisms more than a conceptual value
for the particular science he was at the time handling. The neuron
and its ramifications and interconnections and new “ amcebisations ”
(if I may coin a word for the occasion) had not, in those days, passed
into the “ psychologies.” The term “ molecules,” with their decom¬
position and recomposition, served the purpose of scientific “ scaffolding”
to let the builder proceed. But even the neuron, though not there
in name, was there in reality, and one of the most striking points of
Dr. MerciePs book was the speculative use he made of new passages
in the “ground substance” as the physical correlatives of fresh
acquisitions in consciousness. After all, the functions o t the neuron
are the functions of nerve-cell and fibre writ large, and the “ground
substance” forms still the matrix where that infinitely delicate jelly¬
fish, the neuron, ventures forth its tentacles under stress of
stimulus. These matters I mention mainly to secure an “ orientation ”
for Dr. Mercier’s new book, Psychology , Normal and Morbid. The
two former works were also Psychology , Normal and Morbid. In
them, Dr. Mercier, following the Spencerian analysis, reduced the

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[Jan.,

fundamental process of thought to the establishing of relations between
feelings, or, may I say ? sensations. Comparison is the fundamental
feature of thinking. From the most rudimentary feeling to the highest
involutions of thinking the process is continuous, and the special
work of an analytic psychology is to decompose into those funda¬
mental forms the apparently stable compounds that constitute
experience. The value of this analysis, as set forth by Dr. Mercier,
was that it made possible a continuity beyond the normal to the
abnormal. As the method tackled each grade of fasciculated relations,
the continuity of growth and integration became obvious; the system
set forth revealed possibilities of lapse and defect, and the defects were
the basis of the insanities. These, however, arose out of a fundamental
relation not yet referred to—the relation between the organism and the
environment. The failure to adjust certain internal (may I say psycho¬
physical?) complexes of relations to certain complexes of external relations
was the basis of insane conduct and of insanity generally. The same
conception was worked out in detail in the Sanity and Insanity , and
that is why I said of it, “ he has laid down, as it were, the institutes of
insanity. ,,

The fundamental thought of these two works has been continuously
active in Dr. Mercier’s mind, and the result is the new volume before
me. Although this is, in every way, a complete book, carrying on its
face all that is needed for the study of its contents, it yet should be
read as the sequel of the other two. Chronologically, they come first;
logically, this is first. Let the reader, however, work first by chro¬
nology ; he will thereby sooner reach to the science sub specie aeternitatis.
This book contains, in a system, the presuppositions of the other two,
and as presuppositions are the last to be discovered, in the order of
learning—hence all this bother about “ first principles ”—the learner
should begin with the more concrete and apparently simpler exposi¬
tions. He will then find himself less at sea among those algebraical
symbols of relation that form a leading feature of the first half of the
new volume.

What, now, are the general characteristics of the new volume—
Psychology, Normal and Morbid. “A system of philosophy,” wrote
James Frederick Ferrier, in the Institutes of Metaphysic , “ is bound
by two main requisitions—it ought to be true, and it ought to be
reasoned.” For positive science, truth has not quite the same “con¬
tent” as for philosophy, and I do not press that category on Dr.
Mercier’s book. But “ reasoned ” it is from beginning to end—from
postulate to application. And this means a great deal. Hegel used
to complain that certain opponents—Schelling, for instance,—shot their
“Absolute” out of a pistol, while his must be generated out of the “labour
of the notion.” The same is true of much popular psychology. Some
of it is nothing but the survivals of broken systems, pensioners drawing
pay for work they can no longer perform. It is true those fragments
from the middle ages have all the air of intelligence, of system, of
logical efficiency, but their claims always demand renewed scrutiny,
and one of the chief virtues of a book like this is that it attacks the old
notions afresh, and makes an effort to reason things from their true
postulates. I emphasise this because I anticipate a possible objection

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from the practical standpoint—that the book is too abstract, at least in
the earlier part. Abstract, as compared with the ordinary text-books,
it certainly is, but abstract for a purpose, and the reader will do well to
work straight ahead. He will, as a consequence, find his appreciation
of the concrete much more intimate. And let it be premised further,
the book is not easy reading, it demands thinking at every sentence.
I cannot help feeling, however, that in not dividing the subdivisions into
chapters, sections, and subsections in approximately logical subordi¬
nation, Dr. Mercier has lost in simplicity what he has gained in
continuity. He has made the mechanical fatigue of reading greater,
and I see no advantage to balance this. The chaptering of a book
logically is, no doubt, always a compromise, but it is an unquestionable
economy of attention, and notwithstanding the apology of the preface
I regret that Dr. Mercier did not divide, subdivide, subordinate, and
number a good deal more than he has done.

To come to the contents. In an introduction of six pages, Dr.
Mercier sketches the leading concepts of the book. The dawn of
consciousness in the midst of material objects, the development of
intelligence, the inchoate, then the complete, distinction of self and not
self, the correlation of consciousness with a nervous system, the grading
of this system, the concomitance of consciousness with the activity of
the highest grade of nervous organisation, the subdivision into subject¬
consciousness, which accompanies the activities regulating the internal
bodily organism (the visceral nerve circulation of the Sanity and
Insanity ), and object-consciousness, which accompanies the adjustment
of the self to the objective world, the fundamental functions of the
nervous system, the reception of motion (the physical correlate of
sensation), the modification of motion (the physical correlate of thought),
the emission of motion (the physical correlate of will), the absolute
interrelation of all three, the interaction of organism and environment,
—the favourable interactions being the correlates of pleasure, the
unfavourable of pain ; the teleological nature of an organism—strife
towards an end being the correlate of desire, hindrance of strife the
correlate of aversion ; memory, experience,—these are the stages in the
synthesis of the organisation named Mind.

“Thus, then, we triangulate the country that we have to explore in
detail. Moved by the desire to attain ends, and by aversion to the
obstacles which obviate attainment, man acts in the circumstances in
which he finds himself. The interaction between self and circum¬
stances is experience. Such experience as is an advance towards his
aim is pleasurable, such experience as baffles or hinders his advance is
painful. Every experience leaves in his organisation a change of dis¬
position, which is memory. The elements in every experience are
reception, emission, and redistribution of motion, which have their
conscious correlatives in sensation, will, and thought ” (p. 6).

Dr. Mercier then proceeds with the analytical account of sensation,
giving only the general characteristics, mentioning the evolutional
significance of the highly specialised senses, and leaving to the special
text-books the detailed analysis of sensations. His object is to show
at what point defect, error and disorder of sensation may supervene.
From this he passes to thought. “ The process of regulating conduct
XLvm. 7

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to circumstances is called intelligence” (p. 20). This term does not
seem to me quite happy; it is so intimately associated with the
purely mental aspect of nervous action that its application to the
process of adjustment, as such, without reference to the mental
accompaniment, is somewhat unusual. This, however, Dr. Mercier
recognises on page 27, where he passes from the more or less
stable adjustments—properly named mechanisms—to the formation
of entirely new adjustments, whose mental accompaniment is think*
ing. This is a very clear section. The issue of it is—thought is
essentially the establishment of a relation of likeness or unlikeness
among mental states. Numerous illustrations, symbolic and concrete,
are given to drive this generalisation home. The first establishment of
an adjustment is more difficult than the second ; the nerve-tissue
retains the effect of the process, and gradually new organisations
become permanent or relatively permanent. The analysis, then, clearly
must follow the sequence—What is the relation ? How is it established ?
How does it cohere after being established ? How is it related to other
thoughts ? We are thus introduced to the Forms of Thought (p. 40).
The reader must now keep his wits about him. Abstraction (p. 44),
generalisation (p. 47), and classification (p. 48) are now explained.
For teaching purposes I should myself prefer to begin with classifica¬
tion, but the sequence is immaterial. As Bain has it, the individual is
a “ conflux of generalities.” The three functions, abstraction, or con¬
centration on the point of likeness between individuals; generalisation,
or the combining of individuals into concepts based on the likeness ;
and classification, or the arranging of individuals in view of their like¬
ness and unlikeness, are all aspects of the same mental fact. They are
set forth here with excellent effect. They are subsumed under a single
term—synkrisis, which means comparison. Following on this are
illustrations of the corresponding errors, including errors of judgment,
errors of perception, and hallucinations, in so far as synkritical (to
expand Dr. Mercier’s term).

Under the heading Axiomatic Reasoning, we have a discussion of
the syllogism as a form of thought. When, at the first glance among
the pages, I caught sight of the bow-shaped lines of print that Dr.
Mercier uses to exhibit the fundamental relations of the three terms of
the syllogism I felt impelled to say with Cyrano, Que diable allait-il
faire en cette gallre 1 And now that I have gone over the ground in
detail I am not sure that my impulse has wholly spent itself. Dr.
Mercier is, I think, quite within his right, even from his own stand¬
point, in placing such great emphasis on the syllogism. He does not
need to apologise for dealing in detail with what Aristotle found
not beneath him. He need not scruple to ask of his readers something
more than the invincible ignorance of the “ average ass,” who regards
logic as scholastic jargon. But he has, I think, made rather too
much of Mill’s effort to fill the old bottles with the new wine.
Mill’s effort has helped to weld induction and deduction (including
the fundamentals of the syllogism) into a single system ; but, as Bain
pointed out (Mind, III, 137, Old Series), the syllogism properly deals
with consistency, not with material induction. The same view was
later expounded by Minto, who showed by a very simple reference to

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the history of Aristotle’s invention that the syllogism has to do with
consistency of granted propositions expressed in words. Mill raised a
wholly different question when he asked—How is the proposition con¬
taining the major term proved or established ? Dr. Mercier’s criticism
here is acute; but—again notwithstanding his preface—I think the
whole discussion is essentially logical, and only incidentally psycho¬
logical. I should like to see this section recast, condensed, and
mostly relegated to an appendix. His schemata could be made clearer
if the ordinary schemata of the syllogism were placed immediately side
by side. At this point, too, the symbols become rather numerous for
ready comprehension. Altogether, in spite of “my old wounds
burning ” at the criticism of Mill, I cannot feel that this section is other
than superfluous or on the wrong tack. Nor do the illustrations
of syllogistic fallacy seem to me to forward in any great degree the
book’s main purpose, which is to prepare the reader for the errors
prominent in the syllogising of the insane. Much the same is true of
the discussions on immediate and mediate inference; but the dis¬
cussion is stimulating, the illustrations, as illustrations, are analysed
with much point, and the dialectical gymnastic necessary to the study
of them is not a bad propaedeutic for the subtleties of the later sections.
Proportion forbids me to argue the points, or to test them by the later
criticism of Mr. Bradley or Mr. Bosanquet

From the “forms of thought,” Dr. Mercier passes to analyse a
sequence of states that as a whole may, with moderate appropriate¬
ness, be designated epistemology, or theory of knowledge. Perhaps I
should rather say that the categories in question—certainty, uniformity
in experience, likelihood, probability, expectation, truth, credibility—
are, psychologically modes of belief, and, logically, criteria of know¬
ledge. Dr. Mercier now enters on an extremely valuable series of
analyses. The practical alienist will do well to follow the analysis of
each category in detail, for at a subsequent stage each is used to
illuminate certain features of insane belief. Here, more than in the
discussions of the syllogism, the purpose of the book as a “ prolego¬
mena to any future psychiatry”—to parody Kant’s phrase—becomes
obvious. To go into full detail would be to write another volume. It
is enough to say that well-worn doctrines are stated with vigour and
lucidity from the new standpoint. The feature of certainty is the
resistance the state offers to the dissociation of its elements (relations).
This indissolubility of relations is the subject-counterpart of uniformity
in experience (p. 159). There are various grades of uniformity.
Hence the graded states—likelihood (p. 166), probability (p. 170),
expectation (p. 190), truth (p. 197), credibility (p. 210). Under
probability we get a very pertinent discussion on the value of
quantitative statements as a factor in establishing beliefs. Dr, Mercier
admits a certain value, but he very properly discounts the speculative
mathematician’s applications of quantities to matters that quantity can
little affect (pp. 175 et seq.). Under credibility we have a detailed
discussion of the evidential factors in belief. In all these categories
one thing is kept clearly forward, namely, that they are the formulae of
experience. The test of belief is practice—the reference to experience,
the reference to reality. Before, however, Dr. Mercier proceeds to

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the application of his categories to the analysis of the errors of
belief and delusion, he touches on originality (p. 238) and apper¬
ception (p. 244). Originality offers an opportunity for suggesting that
genius is an example of “high originality in discerning likeness”
(p. 244), and that talent is an example of “high originality in the
discrimination of difference ” (ibid.). Of course, neither difference nor
likeness is to be considered apart. The one always implies the other.
A feeble punster is for ever seeing likenesses, but the point of the good
puns is in the synthesis of likeness in differences. His criticism of
apperception (p. 274) is not quite convincing. The “ quasi- i n-
dependent entities ” of the “thorough-going apperceptionist” (p. 247)
are, after all, only quasi , not absolute; and if Dr. Mercier is to
use “ parasitic nervous mechanisms,” as he does to excellent purpose,
I cannot see that his position is much more tenable than that of the
apperceptionist. I quite agree that the notion has been run to death,
as association was a generation ago, and redintegration two generations
ago, when Hamilton dominated the terminology. But the term
apperception is an excellent one for certain features of the flowing mind,
and emphasises the fact that the least coherent phantasy is yet a system
—whether similarity or contiguity predominate being for the moment
disregarded.

And now we come to one of the most important expositions in the
volume—errors of belief (p. 248). There are four forms of belief—
experiential, evidential, authoritative, delusional. The first three are
normal, the fourth is morbid. What is the differentia of the fourth—
delusion ? Dr. Mercier’s argument here deserves, and will receive,
careful attention. To begin with, a delusional belief is indestructible,
even when contradicted by experience, testimony, or authority. The
delusion may have its beginning in a perfectly normal process—the
forming of an hypothesis to account for a sensation or other mental
state (pp. 262-3). But the relation formed in delusion becomes indis¬
soluble out of proportion to experience. And here the categories
referred to apply. Our thoughts are continually “ changing pickets ”
from inconceivability to credibility, from credibility to fact, from fact to
truth, and back again variously at the instigation of objective experience.
This is normal. In the morbid state, however, concepts “change
pickets ” in the mind without this reference to experience. This trans¬
ference constitutes delusion. But on what cue does the transference
occur if not at the instigation of experience ? This is the very nerve
of the theory of delusion. A final answer Dr. Mercier does not give.
His provisional answer is this:—“ Experience is not the sole source of
our beliefs” (p. 271), the “categories of belief” develop “with the
general development of mind” (p. 272), hence persistence of infantile
readiness pi belief or the production of such readiness by degenera¬
tion ; the physical basis is a dissociation of nervous centres—the
formation of a “ parasitic mechanism ” (p. 273). His provisional
hypothesis of the formation of this mechanism is that the branches
of different neurons get “ anchylosed ” (p. 273). This theory corre¬
sponds in general with Mr. Edmund Parish’s in Hallucinations and
Delusions (English edition). The consequences of this hypothesis
and the varieties of delusion due to the transference from category

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to category are well expounded. It is an unquestionable gain that
the rough division, according to those highly general categories, is of
distinct clinical value (pp. 267 et seg.\ particularly for prognosis. One
can readily see, too, that a minute analysis of particular delusions
would gain in purport from a consistent following of the method indi¬
cated. This volume deals with generalities; but one may hope that it
will stimulate some psychological clinician in Britain to imitate the
industrious subtlety of the SalpStrifere observers, particularly Dr. Pierre
Janet and Dr. Raymond. With Dr. Mercier’s earlier classification,
based on the association of delusion with emotion, we were made
familiar in Sanity and Insanity . He reverts to it here. The two
classifications can be made to assist each other. This section ends
with the following:

“ We find, therefore, that while there are wide and valid distinctions,
both clinical and systematic, among the various groups of delusion,
there is at the same time a link which connects them all together and
prevents the distinction from being in any case absolute, and that this
feature, which is common to all forms of delusion, is the cloudy
swelling of the subject—the exaggeration of the importance of the
self in the scheme of the universe” (p. 282).

This completes one great division—thought. We now pass to
another great division—volition. We are now on the “ outgoing ” line.
The pages, sixty or so in number, devoted to attention, effort, will, and
desire, free-will or choice, form, I think, the best exposition of the
whole volume. The argument moves from point to point with a
lucidity that reveals every articulation. To those that are familiar with
the stadia of the free-will controversy, it will be obvious that all the
essential points are caught up in their place. To those that are not
familiar, the division forms an admirable introduction. In substance,
Dr. Mercier is at one with Spinoza’s classical chapter. The expression
in terms of modern psychology will enable the reader to appreciate not
only Spinoza but also the many others. Pages 237 and 238 show
that a sentence may flow on for a page and a half without losing a
shade of its clearness. Every element in the analysis is afterwards used
to explain the disorders of attention, effort, instinctive determination,
and acquired determination. The parasitic mechanism ” is again in
evidence, and justifies itself by its capacity to correlate facts.

The very important divisions memory, pleasure, and pain, I must
pass over with a word. The study of memory includes a reasoned
account of structural memory, dynamic memory, active memory, con¬
scious memory, reminiscence, and faults of memory. The exposition
here, as elsewhere, is illustrated with much wealth of detail. The
formulae that were found so effective in the other departments—dis¬
tribution of motion and establishment of relation and determination—
are applied with decisive effect As with volition, so with memory—to
those familiar with the many discussions the division is an admirable
summary, with many original elements; to those unfamiliar it is a
well-proportioned introduction and interpretation of historical theories.
The same may be said of the sections on the various modes of pleasure
and pain.

The last division deals with subject-consciousness (p. 488). The

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various meanings of self are elaborated. The association of self—
the Subjectissimus, a happy term for the innermost self—with the
highest nerve-regions, the utter subjectivity of volition (p. 502), the
subtle changes that supervene in disorders of this highly complex
a gg re g ate unified sensations, emotions, thoughts, and volitions that
constitute personality, are a few of the topics illustrated copiously in this
section, which focuses the expositions of the whole book. To illus¬
trate at once the style and the restraint of speculation in this section, I
give another quotation:

“ We can form some dim and approximate idea that, as a current of
motion passes inwards along the nerves and reaches some destination—
breaks upon some shore—a sensation arises in the mind, but what
physical state or process underlies this 1 1 myself/ who feel, act, will,
and think, I can form not even an approximate concept; much less
can I conceive a modification or disorder of such a state or process.
That insanity is a disorder of the process of adaptation of the self to its
circumstances seems to me as true now as it did when I first put it
forward ten years ago, and every phase and factor of insanity, whether
disorder of thought, feeling, perception, emotion, volition, or conduct,
is expressible in terms of this formula ; but the formula is a descriptive
definition, not an explanation, and while it correctly indicates of what
process insanity is the disorder, it does not help us to a knowledge of
the process, or of the way in which it is effected.

“ Be this what it may, we have to recognise that in insanity there
are not only those disorders of the object-consciousness—those delu¬
sions, doubts, obsessions, and so forth which are described in the text¬
books—not only is there often an alteration in the feeling of well-being
—a melancholy or an elation—which is sometimes recognised to
belong to the subject, but there is, in addition, a more profound and
intimate change in the subject itself; a change in the mode of activity;
a change in the capacities or possibilities of acting; a change in the
direction of action; a change, in short, of the very self, which renders
the insane man a different person from his sane self. This is the
meaning of that 4 altered disposition/the ‘deterioration of character’
which is so often spoken of as a frequent sign of insanity. Of all
the pitiful statements that are made by the friends of insane persons
none is more pitiful than the frequent explanation, ‘ Oh, doctor, he
used to be so different! You would never believe it was the same
man.’ The same man he is, but not the same person. Within that
same body the personality is changed, and it is a new self that
looks out from those familiar eyes. The cursings and revilings that
come from those loved lips do not proceed from the old self—the self
endeared by kindness, sympathy, and affection,—but from a new self,
which has, perhaps, not even its object-consciousness in common
with the old. Thus insanity differs by its universality from all other
infirmities to which man is subject. It is a disorder neither of the
body alone nor of the mind alone, but of both. It is a disorder
neither of the subject alone nor of the object-consciousness alone, but
of both. It is a disorder not of the affection alone of the subject,
not of the sense of well-being alone, but of the degrees and modes of
activity as well. It is a universal disorder. In insanity, not only are

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103

mental processes wrongly conducted, not only is the sense of well¬
being unadjusted to the circumstances, not only are the products of
mental activity erroneous, but the bodily processes also are modified,
often profoundly modified. We can observe the skin, macerated in
its own sweat, desquamating and stinking. We can observe the fingers
and toes in one large bleb from chilblains. We can observe the
distorted nails, the harsh and staring hair, the pigmentation and the
changes of complexion that so often occur in insanity. But we cannot
observe the internal changes, the alteration of metabolism, the subtle
changes of visceral function, which go along with the changes that we
do see. All experience leads us to infer that such changes there are,
and that with the mens insana is invariably conjoined a corpus insanum”
(p. 51a).

In this short sketch, I have endeavoured to hint at the importance of
this distinguished essay in psychology. It ought to become, it will
become, the constant companion of the clinical psychologist, who will
find at once a guide in reflection and a criterion of observation. It
will prove to him, by innumerable hints, that in the manifestations
of mind there is nothing common or unclean; that the gross and
unthought-out characterisation of the ordinary clinical records are
not the only analyses possible to the sympathetic and patient observer ;
that as a sound therapeutics must always rest on a sound physiology, so
a scientific alienism must rest on a scientific psychology. And now for
the future. This book sets forth a plan of ideas. There is room for
yet another to work out the ideas in concrete studies. The raw
material for analysis and descriptive synthesis lies there to hand in
appalling quantities. May I express the hope that Dr. Mercier’s book
will be a stimulus to himself or to others of his dialectical subtlety to go
forward, in detail, on the lines of positive study here set forth ?

W. Leslie Mackenzie.

Science and Mediaval Thought : the Harveian Oration of 1900. By
Thos. Clifford Allbutt, M.A., M.D., F.R.S., etc., Regius
Professor of Physic in the University of Cambridge. London:
Clay and Sons, 1901. Crown 8vo, pp. 116.

At every railway station may be seen the semblance of a huge ox apos¬
trophising a tiny cup of beef tea in the words “ Alas ! my poor brother! ”
and we can well imagine that with similar emotion the little volume
under review might be apostrophised by the mighty tomes of Lewes and
of Ueberweg, for it is a history of philosophy within the limits of a
pamphlet. It is very far from being a mere concentrate, however. It
is crammed and stuffed not only with erudition but with illuminating
thought, and there is scarcely a page that does not contain some
aphorism which summarises a phase or an era in the history of thought,
and by captivating our admiration sticks in the memory.

Professor Allbutt sketches the evolution of mediaeval into modem
thought. He shows how the greatness of Harvey consisted in his return
to the experimental method of Galen, since whose time the gap of

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centuries had been filled by the controversies of the schoolmen respect¬
ing realism and nominalism and the nature of universals. The author
first sets forth the huge overwhelming mass of dogma, of authority, of
tradition, custom, and faith, whose weight had so long crushed down
upon the seed of natural science and stifled its germination. He
shows how the riddle to which the theory of universals was the answer
is the eternal riddle of the connection between form and matter, force
or energy, or pneuma and matter, soul and body, determinative essence
and determinate subsistence, male principle and female element,
archaeus and body, the potter and the clay of the potter, type and in¬
dividual, cause and effect, law and nature, becoming and being, thought
and extension—the riddle which, throughout all these varied expressions,
demands an explanation of the static and dynamic aspects of things—
of the incessant formation of variable and transitory individuals in the
eternal ocean of existence. The answer of medievalism, in spite of
isolated protests of great thinkers such as Erigena, Roscellinus, Roger
Bacon, and Amaury, crystallised slowly into a rigid realism, and of all
the obstacles to the progress of knowledge this was the most formidable.
Looking back now we see that Harvey might well have adopted the
phrase of Gambetta, with slight modification— 44 Le Realisme—voilh
Vennemi / ” 44 Still,” says Professor Allbutt, 44 it stretches its withered

hand over us, in the nursery, in the school, and in the great arguments
of life. We profess Aristotle, and we talk Plato.”

Having set forth the history of the gradual solidification and fossilisa-
tion of opinion under the petrifying influence of realism, the author
next describes the origin and course of the stream of scepticism by which
the impregnable rock of dogma was undermined, excavated, and at
last crumbled away, leaving, however, many a huge block in mid-stream
to testify to its former dimensions. 44 Scepticism arises when beliefs
are put into formal propositions. Then, as experience and comparison
enlarge, we detect scepticism in three forms or degrees, namely, doubt
of a particular creed; doubt of all unverified propositions; and doubt
of the validity of reason itself, whether in respect of the supernatural
only or of all argument.” Even in the darkest ages some glimmer of
light still shone in the heavens; not even then did the indomitable
spirit of man lie under tyranny in silence. 44 Even in ages of most
prevalent faith some current of doubt has flowed under the surface.”
During all these ages the heated and often furious controversies of the
schools at least kept the lamp of reason burning; they kept men in
practice in the use of the weapons and tools of argument, and, in
encouraging dialectic, they so far encouraged the exercise of reason, of
thought; they kept alive the possibility of scepticism even while they
trampled out every sceptic spark that was temporarily enkindled. It
was soon found that 44 the issues of all schemes of thought led, indeed,
as inevitably to natural science as all ways to Rome,” and the Church
stuck at no means of repression, however bloody and cruel. But the
attack upon dogma was made not only from within, but from without;
was not only open, but insidious. 44 The faith, the chivalry, and the
learning of the Saracens led men to feel that without the Church all
might not be utter darkness.” A new fount of learning sprang out in
Spain, whither, from Antioch and Persia, from Alexandria and Bagdad,

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Greeks, Persians, Arabs, Syrians, and Jews carried the erudition of the
East to renew the learning of the West. The study of Rhazes, Avicenna,
and Averroes proved once more that wisdom was no monopoly of the
Church. This revival was but temporary, it is true, and was followed
by that thicker darkness which precedes the dawn. “With the fall of
Constantinople [in 1453], the stream of learning, driven eastward in
the first period of the Middle Ages, set westward again ; . . . the
political and commercial ambition of Venice, the Holland of Italy, of
which state Padua was the learned quarter, and the influx of liberal
thinkers from other nations, kept her aloof from the fury of the Catholic
reaction of the sixteenth century which ruined Paris.” And it was at
Padua that Harvey learnt whatever of medicine the science of that day
could teach.

The three great adversaries of natural science in the Middle Ages
are identified by Professor Allbutt as faith, realism, and that pride of
the human mind which led men to look upon physical nature as base
and degraded, and to concentrate their efforts upon speculations on
the infinite and the absolute. In a passage of rare insight and fine
inspiration Professor Allbutt elucidates the true character of what is
called materialism. “Analysis is a disintegrating function; the de¬
parture of the scientific inquirer is rather from below upwards; it is
not only his bias, but also his deliberate method to decline to use the
discipline and the methods of higher categories until he is satisfied that
those of the lower are inadequate. A certain natural process may not
be attributed to those of chemistry until those of physics are proved
to be inadequate; to another process biological conceptions and
methods are denied until those of physics first, and then of chemistry
have been tried and found wanting; psychological conceptions are
denied to another until in their turns the physical, the chemical, and
the physiological are exhausted, and so on ; and within each category
the same economy prevails. Now this scientific economy, perhaps
first formulated or effectively used by William Ockham in the phrase
entia non sunt multiplicanda —known as Ockham’s razor—is what is
nowadays called ‘ materialism.’ ”

With all his enthusiasm for natural science and his triumph at each
step of its victory over the fearful odds by which it was opposed,
Professor Allbutt is not without admiration and sympathy for even
these adversaries at whose defeat he rejoices. He recognises the service
done in their time and to their time by the scholastic philosophies, and
in this ample recognition he displays the just and equal balance of his
mind.

Of a book so full, not only of erudition but of profound and stimu¬
lating thought, it is difficult to speak in any terms but terms of praise;
but, as already said, the book is a concentrate; and all food, whether
physical or mental, that is highly concentrated is difficult of digestion.
While every sentence is clear, and many are epigrammatic, the general
argument is often difficult to follow. The author is apt to presume on
the part of his readers a knowledge of the general history of the subject
and a familiarity with names and dates which will not always be
justified. He carries us backward and forward from century to
century—from Spinoza to Erigena, from Augustine to Aquinas, from

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Albertus Magnus to Roger Bacon, from Alcuin to Abelard, back again
to Galen and on again to Occam, with transitions so rapid that they
become rather bewildering. For this appearance of disjointedness—for
it is an appearance only—his limitation of time was, of course, in large
degree responsible; but we cannot help regretting that Professor
Allbutt should not have carried his admiration of revolt against custom
and tradition and authority, beyond eulogy into practice, and have
printed the oration, not as it actually was delivered, as custom requires,
but as it would have been delivered if he had had time to say all that
he had to say. Chas. Mercier.

The Correlation of Mental and Physical Tests . By Clark Wissler,
A.M. (Monograph supplement to Psychological Review .) New
York : Macmillan Co., 1901. Octavo, pp. 62. Price 2 s.

The method of tests has become well established in psychology, and
it has been generally assumed that they furnish an approximate index
to related aptitudes and capacities of the individual, that a test for
quickness in one respect will indicate a tendency to quickness in other
respects, and so with accuracy, memory, etc. A number of investi¬
gators, with a bias in favour of this assumption, have hastily concluded
in favour of a connection—or correlation—between aptitudes that
seemed, or even that did not seem, obviously to suggest such a
connection. Usually, however, their conclusions have not been
reached by any sound scientific method. Now Mr. Wissler (with the
aid of Professor J. McKeen Cattell, of Columbia University, to whom
are due both the conception of the problem and the data made use
of) comes forward to inquire more carefully into the validity of this
assumption, making use of Pearson’s mathematical formulae. He seeks
to test the tests and to define their significance.

The data experimented with consist of the accumulation of routine
tests made on freshmen at Columbia College and on young women at
Barnard College. These tests include size of head, strength of hand,
fatigue, eyesight, hearing, reaction time, rate of perception (by marking
the A’s among a number of capital letters), rate and accuracy of move¬
ment, auditory, visual, and logical memory, etc.

It was found, as might be expected, that there was distinct correla¬
tion of stature and weight, short men tending to be light, and tall
men heavy. But when we turn to the mental tests for quickness and
accuracy correlation ceases to be distinct, and is, for the most part,
absent altogether. Thus, an individual with a quick reaction time is
no more likely to be quick in marking out the A’s than one with a slow
reaction time. A test involving the time required for naming colours
was found to show more correlation with other mental tests than any
other test in the series, but yet too little to be of much significance.
On the whole the rank of the individual in the whole series of time
tests seemed to be subject to chance. In regard to tests of accuracy,
again, the tests for accuracy of movement (striking dots) and for
perception of weight correlated neither with each other, nor with the

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tests for estimating size. Nor were any correlations found between
these tests and the accuracy of estimating time intervals, or of follow¬
ing a given rhythm. And when speed tests generally were compared
with accuracy tests no undoubted correlation could be demonstrated.
When we turn to memory tests there is no evidence of much correla¬
tion. Moreover, when the mental tests for quickness and for memory
are compared with the results of class standing, little or no correlation
can be traced. # In class standing itself there was some correlation,
especially between Latin and Greek, Latin and German, German and
rhetoric. There was no correlation between class standing and strength
of hand. Some correlation appeared between length of head and vital
capacity, and between stature and vital capacity, and between these
and strength of hand. There was also a rather striking connection
between long heads and good memories, though the author thinks this
may be accidental. Weak eyesight, as might be expected, tends to be
inaccurate, but the reverse is not true. Most of those reporting audi¬
tory hallucinations were classed as above normal in hearing ability.
The influence of age in mental tests is small.

These results are of very considerable importance. If, as the author
remarks, we accept the conclusions of the research as final, “an
individual must be regarded as the algebraic sum of a vast array of
small abilities of almost equal probability, the resulting combination
conforming to the laws of chance.” Cases of all-round quickness,
dexterity, etc., certainly occur, but the number of such cases would be
governed by accident. In classifying by “temperament,” also, we
should have to be careful to avoid any assumptions as to the definite
abilities involved by our “temperaments.” Mr. Wissler’s study cannot
be accepted as quite final, but it is an important piece of pioneering
work which cannot fail to lead to more elaborate investigations along
the same lines. The search for a test that really correlates in a high
degree will probably be stimulated, but in the meanwhile, though tests
still remain valuable, we must not too hastily assume that they mean
anything more than on the surface they profess to mean.

Havelock Ellis.

Studies in Human and Comparative Pathology . By Woods Hutchin¬
son, A.M., M.D. Edited by Dr. Edward Blake. London:
Glaisher, 1901. Pp. 340. Price 12s, 6 d. net.

This fascinating volume is a contribution of the first importance to
the young science of comparative pathology, a science in which Mr.
Bland-Sutton has been, in England, an energetic pioneer. It is, more¬
over, marked not only by its wide knowledge and scientific insight, but
also by the singularly vivid and charming style in which it is written,
though it cannot be added that the style is marked by classical
accuracy. This slight defect is, however, probably due to the lament¬
able fact that the author, who is professor of comparative pathology
and embryology in the University of Buffalo, has, in consequence of a
complete physical breakdown, been forced to seek the shores of the

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[Jan.,

Pacific, issuing his book in a less complete form than he intended, and
leaving its revision to the friendly hands of Dr. Blake.

As it stands the work consists of twelve chapters. The first
discusses the cell; the author believes that the pathology of the future
will insist even more than at present on the independence, vitality, and
“personality” of the cell, and also works out his conception of the
practical identity of excretion and secretion, the part played by the
cells of the intestinal epithelium, for instance, being probably as much
excretory from their standpoint as secretory from that of the rest of the
organism, so that we really live upon our own waste products. No less
than four chapters are devoted to the lungs, thorax, and their diseases,
more especially tuberculosis; some of these diseases are regarded as
reversionary, and the marked susceptibility of the lungs to disease is
attributed to their recent appearance in phylogenetic development.
Two chapters are devoted to tumours and two to the alimentary canal,
one to the heart and another to what the author terms the “ skin-
heart.” Prof. Hutchinson regards the blood-system of the skin as
a subordinate heart, with more than mere mechanical functions; he
suggestively works out this conception, not merely by appealing to the
phenomena found among the lower vertebrates, but by reference to the
remarkable effects of stimulation of the skin, as in the Nauheim system
of treatment; while the dicrotic wave of the pulse is explained in a
similar manner, the predicrotic oscillation being regarded as a merely
mechanical recoil of the elastic tissue, and the dicrotic wave proper as
an active contraction of the muscular coat.

The remaining chapter deals with the skin, more especially in its
sympathy with the kidneys, and constitutes a very interesting illustration
of the author’s methods. The author considers that the skin is an
organ to which justice has not yet been done; we do not realise all
that is meant in the fact that the skin gives origin by its infoldings to
the brain and nervous system, and to the alimentary canal with its
appendages ; a recognition of “ the dignity and importance of the skin
as an organ ” is, the author believes, a most important contribution by
evolutionary pathology to a knowledge of its diseases. Whenever we
come in contact with disorders of the skin we are brought back to its
hereditary relations and ancestral tendencies. He compares and
contrasts the epiderm of plants with that of animals, and remarks that
the power of the animal to invaginate its skin—to divert its metabolic
surface-sheet towards the interior—is probably the key-note of all animal
superiority, preventing death at the centre. We only have one
structure in the body which grows tree-fashion—the crystalline lens;
“cataract is the legitimate result of a plant-tissue in an animal body.”
Eczema and acne are chosen to illustrate in detail the ancestral
characteristics of the skin, the former as a form of the great “ exudation
reflex” of living matter, the easiest response of the skin to undue
pressure of the environment, and the latter as a disease of sebaceous
glands which have lost by evolution their primary function of hair-
follicles. Reference also is made to the facts which show that sympathy
between the skin and the nervous system still exists.

To some readers it may perhaps appear that Prof. Hutchinson over¬
estimates “the value of an intelligent use of the imagination in

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pursuing scientific problems,” but at the same time he is well aware
that the science of comparative pathology is still too young for more
than tentative conclusions to be possible in many directions. Enough
has probably been said to indicate that his book is full of facts and
suggestions that will be found helpful and stimulating to the student in
any branch of pathology. Havelock Ellis.

Beitrdge zur Pathogenese und pathologische Anatomic der Epilepsie
[Contributions to the Pathogenesis and Pathological Anatomy of
Epilepsy ]. By Dr. L. W. Weber. Jena: Gustav Fischer, 1901.
Octavo, pp. 96, with 2 plates.

This monograph is an interesting and useful contribution to the
pathological anatomy of epilepsy. It is based on a study of thirty-five
cases, in each of which both the clinical history and the pathological
changes found post mortem are summarised. The definition of epilepsy
given by the author, following Binswanger, Jolly, and others, is as
follows :—“ It is a chronic disease of the nervous system, which depends
on a general affection of the whole brain, but especially of the cortex,
and manifests itself in recurring seizures of a definite character,
disturbance of consciousness, and persistent changes in the psychical
personality.” This definition is necessary in order to have a correct
basis for the selection of his material. Following Liith, he divides
epilepsy into two forms, the early and late, and gives the pathological
changes associated with each. It is unnecessary to go into these in
detail, as at the end of his work he states his conclusions regarding the
correlation of clinical symptoms with pathological changes in the
following terms:

1. Recent changes in the blood-vessels and cells (haemorrhages,
oedema, and proliferation of nuclei) are found in all epileptics who
have died during a fit, in status epilepticus, from coma, or with
marked mental confusion, and account in part for the irritative and
paralytic phenomena observed in these states in the motor, vaso¬
motor, and respiratory organs.

2. Proliferation of the neuroglia in the form of spider-cells and
cellular proliferation in the vessel walls are met with if epileptic
seizures have been frequently present before death for a longer or
shorter time.

3. A pronounced increase in the neuroglia, especially in the form of
regularly arranged fibres, a connective-tissue increase in the vessel
walls, and the disappearance of many nervous elements is the
anatomical expression of a prolonged epilepsy leading gradually to
dementia.

4. An irregular association of all these changes of the paralytic
(G. P.) type is found occasionally in cases of rapid, steadily advancing
epilepsy, in which a coarser and more acute disease of the cortex is
not the cause.

Most investigators will agree with these conclusions. But one cannot
help having a feeling of doubt as to whether these changes are the

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cause of the clinical symptoms, or are not rather the consequence of
the morbid agency which is the causa causans of the epilepsy. The
author himself hints this, but goes no further. He refers to the toxic
theory without any attempt to discuss it.

One important omission is apparent in his work. There is no reason
to doubt that Bevan Lewis’s description of a state of “ developmental
arrest ” of the nerve-cells is the pathological basis of some cases of
epileptic idiocy. The author describes such a state, but is apparently
unaware of its significance and distinctive character. In this, as in
one or two other places, he shows a want of acquaintance with English
work. On the whole, however, the book is good, and well represents
the present state of our knowledge of the pathology of epilepsy, so far
as the changes in the nervous system are concerned.

James Middlemass.

£pilepsie: Traitement , Assistance et Medecine legale [Epilepsy:

Treatment , Public Aid\ and Jurisprudence ]. By Paul Kovalesky,

M.D. Paris : Vigot Freres, 1901. Pp. 290, small 8vo. Price 3 f. 50.

In this well-pi inted book our corresponding member, the Russian
physician, Dr. Kovalesky, states his conviction that for the successful
treatment of epileptics it is necessary not only to combat convulsions
by appropiate medication, but primarily to deal with the whole con¬
stitution of the patient. Diet and hygiene, in his opinion, are of
greater importance than drug treatment; inasmuch as regeneration of
irritable tissues is more effectual than merely calming their excitability
by bromides (which, however, he does not dispense with). Dietary
should be arranged so that the organism does not absorb that which
will tend to sustain the abnormal activity of the nervous elements, while
substances favourable to the regeneration of the tissues should form its
groundwork. At the same time metabolism should be promoted by
healthy exercise. After passing to review the experience of many
authorities on the subject of diet Dr. Kovalesky ranges himself on the
side of those who condemn the consumption by epileptics of strong
meats. Hare is proscribed as specially hurtful, its flesh containing
many extractive matters of an exciting character. A vegetarian regime
with plenty of milk, care being taken that only a moderate quantity be
given at a time, no alcohol, no coffee, and no tobacco seems to our
author the best. He rightly insists on the importance of occupation of
a suitable character both for children and adult patients. Drug treat¬
ment is discussed at some length, but we notice little that is original
beyond the fact that Dr. Kovalesky commences his course by a com¬
bination of tincture of strophanthus with bromide of sodium, and he
prefers the latter to the potash salt. The surgical treatment of epilepsy is
described, without, however, much in the way of commendation.
Nearly one hundred pages are given to a descriptive account of the various
establishments for epileptics in Europe and America, and the author
laments that in the whole Russian Empire, in which he estimates (on the
bases cited by Shuttleworth and others) that there must exist at least

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200,000 epileptics, there is only special accommodation for 200 ! We
heartily join with him in hoping that the day is not far distant when his
idea of a convent-colony for Russian epileptics may be realised, provided
that scientific and not merely ecclesiastical notions predominate in its
management.

In the concluding chapter the difficult subject of psychical epilepsy is
treated at some length from the medico-legal point of view as well as
the clinical. Kovalesky believes, with Legrand du Saulle, that between
the lucid epileptic who is responsible for crime, and the insane epileptic
who is irresponsible, there is a third class with diminished power of
moral resistance, but yet susceptible of being influenced by modified
punishment.

Le Traitement pratique de Pltpilepsie [Practical Treatment of Epilepsy\
By Professor Gilles de la Tourette. Paris : B. Bailliere et Fils,
1901. Small 8vo, pp. 95. Price 1 f. 50.

In this little manual, one of the series designated Les Actualitis
nUdicales, Professor Gilles de la Tourette sets forth the grounds of his
belief in the treatment of epilepsy by the bromides—more particularly
bromide of potassium—never intermitted and long continued. He
prefers mixed bromides in commencing doses of 1 gramme, combined
with benzoate of soda (tV gramme); but the sufficing dose in each
case is a matter of individual experiment, ranging from 2, 3, or 4
grammes daily to 10 or 12, or even 14. According to the author the
state of the pupil is a valuable criterion as to the sufficiency of the dose,
which should be pushed until the pupillary action is slow, though not
abolished, and the pupils remain permanently dilated. This last
seems to be the chief point of originality in the brochure, which,
however, contains a good resunU of the accepted treatment of epilepsy.

Psychologic de PIdiot et de PImbecile [Psychology of the Idiot and lmbecile\
By Dr. Paul Sollier. Second edition, revised. Paris: F 6 \ix
Alcan, 1901. Octavo, pp. 236, 12 plates. Price 5 f.

This is a new edition of Dr. Sollier’s work which embodies his study
of the psychology of idiots and imbeciles made when associated with
Dr. Bourneville at BicStre. In the opening chapters the definitions
and classifications suggested by various writers on the subject of idiocy—
more especially those of the French school—are weighed in the balance
and found wanting, and Dr. Sollier proceeds to give reasons why a
more practical classification can be based upon the degree in which the
power of attention is imperfectly developed in a particular individual.
Thus he divides all serious cases of original mental defect (not in¬
cluding those of backwardness and mere feeble-mindedness) into three
groups, viz. those of—

1. Absolute idiocy , in which power of attention is completely absent
and impossible.

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2. Simple idiocy , in which there is feebleness and difficulty of attention.

3. Imbecility , in which there is instability of attention.

The author is careful to explain that in speaking of attention he
refers to spontaneous attention rather than to voluntary attention, so
that he differs from the doctrine of S^guin that idiocy is, in fact, a
“lesion of the will.” Incidentally he refers with approval to Ferrier’s
suggestion that intelligence is proportional to the development of
attention, and is proportional also to the development of the frontal
lobe. But the point he makes with regard to the distinction between
idiocy and imbecility is “ that all idiots really present cerebral lesions,
whilst imbeciles do not manifest them.” Sollier, indeed, would have
us designate as idiots all cases in which intellectual defect is associated
with physical abnormality or pathological lesion, reserving the designa¬
tion of imbecility for those cases of mental weakness not presenting
such pathological features, but sufficiently marked to render the
subjects of them unfit to fill their appropriate social rdles. In these
days when the tendency (in this country and America, at any rate) is
to substitute euphemisms such as “ feeble-minded ” for the harsher
sounding “ idiot,” it is well to be reminded that the latter term has a
distinct connotation, though we should personally hesitate to apply it
to mild cases of mental defect, simply because of the association of
certain paralytic symptoms, for example.

Our author, however, elaborates the distinction between idiots and
imbeciles so as to class the former as extra-social , the latter as anti¬
social. The instability, that is, the intermittent character of the faculty
of attention in the imbecile, renders him unreliable in work, even for
which he has ability; and his extreme suggestibility renders him an
easy prey to moral contagion. In consequence Sollier is inclined to
regard imbeciles as useless and dangerous beings, who need to be
placed where they can do no harm to society, and to be made to work
so far as practicable; while idiots require to be assisted on the same
basis as all other chronically infirm people.

For those who wish to study the mental phenomena of idiocy and
imbecility from the purely psychological aspect we can strongly
recommend this analysis of Dr. Paul Sollier, who is evidently an
ardent follower of Ribot. The book is hardly what one would call
practical from the point of view of the administration of an institu¬
tion for idiots and imbeciles, but it is very suggestive as to modes
of noting abnormalities of mental action in these patients. Twelve
plates are attached to illustrate characteristic peculiarities in writing
and drawing by various grades of defective pupils.

G. E. Shuttlbworth.

Studii Clinici ed Anatomo-patologici sull 1 Idiozia \Clinical and
Pathological Studies upon Idiocy], Pel Dottor G. B. Pellizzi.
Torino: Fratelli Bocca Editori, 1901. Pp. 275. Six plates.

This is a reprint of a series of articles recently published in the Annali
di Freniatria (1899—1901). The work is divided into three parts,

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dealing respectively with (1) idiocy associated with tuberous sclerosis;
(2) the classification of the various forms of idiocy; and (3) idiocy and
epilepsy.

In the first part the whole subject of the cerebral tuberous sclerosis of
Boumeville (the “hypertrophic nodular gliosis” of Sailer) is most exhaus¬
tively gone into. The cases previously fully recorded in literature
(twenty-two in number) are first reviewed in considerable detail, and then
three cases examined post mortem by the author are very fully described.
There follows a minute analysis, based upon these twenty-five cases, of
the facts that have been ascertained regarding the disease. Its aetiology,
symptomatology, commencement, course, and termination, differential
diagnosis, associated physical anomalies, pathological anatomy,
anatomical differential diagnosis, pathogenesis, and its course and
symptoms in relation to its pathological anatomy and pathogenesis
are in turn considered. The author maintains that cases of tuberous
sclerosis form a variety of idiocy which has special clinical and patho¬
logical characters. He regards a neuro-psychopathic heredity as the
only factor that has indubitable importance in its aetiology. The clinical
picture is constituted chiefly by idiocy accompanied by epilepsy. Among
the many commonly associated physical anomalies, perhaps the most
remarkable are multiple “ renaf tumours,” which have been found in one
third of the cases. They have generally been regarded as true neoplasms,
but the author maintains that they are really developmental anomalies
derived from germs of the suprarenal capsules. The hypertrophic areas
at the surface of the brain have an appearance so characteristic that they
cannot be confounded with any other lesion. Microscopically they
consist essentially of a more or less dense neuroglia feltwork, generally
accompanied by a considerable number of nerve-cells, which show
various abnormalities of form and arrangement. As regards pathogenesis,
the author differs from previous writers, and advances a view which
certainly seems to be very strongly supported by his own anatomical
observations. He holds that the disease essentially consists in a dis¬
turbance of the histogenesis of the cerebral cortex, dependent upon an
insufficient endowment of its nervous elements with evolutive energy, in
consequence of which they are unable to attain those conditions of form
and arrangement that they normally have in the adult. The fault is
primarily in the nerve-cells ; the neuroglia changes are merely secondary.
The morbid process does not interfere with the formation of the
primary and secondary sulci, and therefore it must arise only after the
eighth month of foetal life, by which time these sulci are formed. It
tends specially to occur in those situations in which sulci of the third
order are normally most abundant.

The author’s suggested classification of idiocy is of much interest, and
certainly deserving of the most careful consideration. He criticises the
classifications given by Bourneville, Ireland, Shuttleworth, Fletcher
Beach, and Hammarberg, and sets them aside as unsatisfactory. His
own division is primarily based upon a recognition of the fact that such
defects of cerebral functional power must essentially depend upon one
or other of two fundamentally different abnormalities of cerebral
organisation, namely (1) those due to causes inherent in the brain
(endogenous), consisting in alterations, anomalies, or arrests of develop-

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ment of the brain; and (2) those due to causes operating from without
(exogenous), such as traumatism and pathological processes that directly
or indirectly injure the brain. The primary divisions of his classification
are therefore as follows:—(1) Idiocy dependent upon simple defects of
development of the brain, or idiocy from endogenous causes; (2) idiocy
dependent upon pathological processes affecting the brain or its envelopes,
or upon traumatism or idiocy from exogenous causes; (3) mixed
forms of idiocy. He makes numerous groups and sub-groups, and
explains the foundation for them at some length. In view of the present
uncertainty regarding the pathology of many varieties of idiocy it is only
to be expected that the author should lay himself open to much criticism
in the course of this tabulation. It is to be said, however, that he him¬
self fully recognises that his classification is in many of its details only
provisional, and one that is certain to require modification as knowledge
advances.

One can hardly read this work without being much impressed by its
thoroughness, originality, and scientific spirit. It throws much new and
important light, not only upon the form of idiocy with which it specially
deals, but also upon the pathology of idiocy in general. It is probably
the most important contribution to this subject that has yet been made.

W. Ford Robertson.

L'Hystirie et son Traitement. Par le Dr. Paul Sollier. Paris : Felix
Alcan, editeur, 1901. Pp. 294. Price 4 f.

Having in Genlse et Nature de PHystMe expounded his views on the
nature of hysteria—a localised (more or less generalised) numbness or
sleep of the brain—Sollier in the present book details his plan of
treatment. Embodying as it does the results of the twelve years*
experience (in treatment) of a competent practitioner living in daily
contact with his patients, it is an important contribution to the
literature of the subject.

In the first part of the book, dealing with the nature of hysteria, he
points out that there is no agreement among those who adopt the
psychological theory of hysteria as to the real psychological
characteristic of the disease, that a fair proportion of hysterical mani¬
festations are not susceptible of a purely psychological interpretation,
etc., so that one is led to adopt the physiological theory of the disease
which he has elaborated at length in his first work. According to this
theory hysterical patients are in a condition of 44 vigilambulism,” whom
one must awaken to cure them, the awakening bringing about the
disappearance of their disordered sensibility. This torpor or numbness
of the brain may be more or less generalised, various centres being
affected. Sollier claims to have defined visceral centres in the cortex
presiding over respiration, the heart, the stomach, the bladder, etc.,
torpor of which produces corresponding affections of those various
organs. Hysterical attacks, according to this view, are due to the more
or less complete loss at first, and to a more or less complete return after¬
wards, of sensibility. Moreover, by the help of his method of treatment,
called the awakening of sensibility, he believes that he has shown that

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the brain acts not only upon the functions of relation, but upon the
functions of nutrition, and that the various apparatus, the various
organs of the body, are there represented in various centres, which
may be put into action by the will of the subject during hypnosis.
Anaesthesia is the objective sign which reveals this pathological cerebral
torpor, and a second and most important consequence of it is
diminution or suppression of normal sleep.

In the second part are considered certain general indications regarding
the treatment of hysteria, such as the qualifications required from the
medical attendant, the importance of excluding family interference, etc.
Drugs in the treatment of hysteria are divided into two classes, the
useless and the noxious. Surgical interference Sollier considers is
always noxious, and often dangerous (/. e . in the case of utero-ovarian dis¬
orders). Much useful information is given on the question of isolation,
its advantages, the conditions under which it should be carried out, etc.
A specialist in the treatment of hysteria who lives in the same house as
the patient (where insane patients are not kept) is the ideal attendant.

Awakening the various functions is accomplished by suitable feeding,
physical agents (light, air, etc.), etc.; restoration of sensation by
mechanotherapy (forced passive movements which produce pain,
respiratory exercises, “ visceral gymnastics,” etc.). When improvement
occurs, we are told that not only do we get typical sensations and
motor reactions in various parts and organs corresponding to the
sensory excitations produced, but they are accompanied by psycho¬
logical phenomena, modifications of the memory, a retrograde re¬
appearance of various lost impressions, which extend back to the time
of onset of the disease, and, pari passu with this, a regression of the
personality. Massage is to be rejected in the treatment of hysteria,
and douches are only of use in mild cases. As regards psychological
treatment, the attention especially must be trained. On the subject of
hypnotism and suggestion, which have been so much vaunted in the
treatment of hysteria, Sollier has much to say. Hypnotic suggestion,
he believes, develops hysteria instead of combating it, and direct sug¬
gestion enfeebles the will and judgment of the patient, disorders her
personality, reduces her to the state of an automaton, and thus exposes
her to all kinds of dangers and to definite incurability. Indirect sug¬
gestion is often useful in awakening associations of ideas, reflection, the
attention, and judgment. Hypnotism should never be used in mild
cases, but it may be justifiable in dealing with obstinate hysterical
manifestations after other measures have failed. In profound cases of
vigilambulism it is quite legitimate.

He insists on the importance of thoroughly waking the patient after
each stance, and of obtaining the consent of the patient before beginning
hypnotism; a third person should be present, or quite close at
hand, during its performance.

The various measures referred to above (isolation, mechanotherapy,
etc.) may succeed, and do succeed in average cases, in reconstituting
completely the personality of the patient, when the patient can then
be said to be cured. During this process recollections which had
vanished reappear. But in many cases, and all inveterate ones, the
method of cerebral awakening (“ reveil c'ertbral”) is required ; this may

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be a simple injunction to the patient to “wake up” without prior
hypnotism, or after hypnotism, /. e. simple awakening, , or it may be the
more complex method, which the author calls “awakening by partial
restorations of sensation.” The patient here is fairly deeply hypnotised,
and her attention being drawn in succession to various parts of the
body, she is told to “ feel, feel more, feel still more, go on, etc. ...”
Apparently definite subjective sensations accompany the return of the
part affected to its normal condition, which the author considers are the
unmistakable signs of recovery, and occur invariably and in the same
order in different patients. Moreover, pain in certain spots, with
characteristic return of sensation, accompanies the awakening of the
various cerebral centres themselves when they recover after hysterical
affection. “No shadow of suggestion occurs.” Dr. Comar, of the
Villa Montsouris, Paris, apparently confirms all this, having adopted
Sollieris method, and found it answer. Months of this treatment,
four, eight, ten in bad cases, are necessary.

The third part of the work is devoted to the special treatment of
hysteria—attacks, disorders of sleep, fixed ideas, tremors, spasm, etc.,
i. e. to the treatment of its many and varied isolated manifestations.

In presence of these remarkable observations, all that one can say is
that only subsequent experience can enlighten us as to the real value
and efficacy of the treatment recommended. H. J. M.

Les grands Symptomes neurastheniques (Pathog/nie et Traitement ).
Dr. Maurice de Fleury. Paris: F£lix Alcan, ^diteur, 1901,
pp. 412. Price 7 f. 50.

This is an attempt to explain the leading symptoms of neurasthenia,
or “ nervous exhaustion ”—a term which the author would prefer to
adopt,—define its pathogeny, and suggest a rational treatment, which
the author has found by experience to be reliable. The importance of
eliminating such conditions as early tuberculosis, alcoholism, Bright’s
disease, cancer of the stomach, etc., before diagnosing primary neuras¬
thenia is dwelt upon; and at the outset he insists on the distinction
which exists between hysteria and neurasthenia. The first chapter
deals with fatigue, which de Fleury considers the predominant, even
essential, symptom of the disease. The Arab who first wrote this
proverb: “ It is better to be sitting than standing, better to be lying
than sitting, better to be dead than lying,” must have been neurasthenic.
The sensation of fatigue, he believes, is not subjective—it is not, like
that which accompanies hysteria, modified by suggestion—although the
results of observations with the dynamometer and ergograph are not
very convincing; but great stress is laid upon the fact that with atony
of the voluntary muscles one finds evidence of atony of involuntary
muscles, revealed by unmistakable objective signs—thus pointing to the
former being objective too. The second chapter deals with the circulatory
apparatus in neurasthenics. By the use of sphygmographs, the
apparatus of Hallion and Comte for determining the peripheral pulse,

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haemocytometers, etc., careful examination of patients suffering from
neurasthenia may be made; and that their vitality and nutrition are
impaired is shown by a lowering of blood-pressure due to weak cardiac
action, a lowering of dynamometric force, an increase in extent of the
touch areas, a diminution in the activity of reduction of the oxy-
haemoglobin, a reduction in the percentage of haemoglobin in the blood,
and apparent rarefaction of the red globules, while the co-efficient of
nitrogenous output is below normal. Many of the author’s patients
were subjected a certain number of times to this series of investigations,
which should be carried out at a fixed time of the day (in relation to
meals, etc.). As regards blood-pressure especially, the author establishes
two groups or varieties : neurasthenics with hypotension, and neuras¬
thenics with hypertension ; these cases require different treatment, and
the latter group are mostly secondary to some other condition. To
attempt to treat cases of neurasthenia without determining the blood-
pressure, the condition of the heart-muscle, the activity of reduction,
etc., is to court failure. Numerous charts are given showing how
blood-pressure, dynamometric force, the activity of reduction, etc.,
approximate to the average with improvement in the patient.

Chapter IV deals with disorders of sleep. Insomnia is very often
a phenomenon of simple cerebral mechanics to be successfully
combated by purely dynamic measures, and de Fleury generally
condemns drugs in its treatment In some cases of neurasthenia,
especially secondary cases, with high blood-pressure, etc., insomnia is
due to toxaemia,and “lavage” of the blood procures sleep; but in a
large number this assumption of intoxication as a cause of sleeplessness
is, or appeared to be, erroneous : just as a careful study of these cases
convinces us that the modem view of sleep as an intoxication of the
nervous centres, /. e . the chemical theory of sleep, will not satisfy all
instances, and one has to fall back on a mechanical explanation. The
practical determination of the blood-pressure here again is of great
practical utility, for quite a different treatment is required in cases of
neurasthenia with low tension to that referred to above (/. e, for high
tension cases). In many cases, with the use of simple physical
methods, sleep can be insured; but it is advisable at the same time, by
psychological treatment, to bring about the habit of sleep.

As the stomach is, perhaps, in neurasthenia, the first muscle which
loses its tone through insufficiency of nervous influx, digestive disorders
occupy an important place in the symptomatology of the disease, and
of these the author treats in Chapter V. In correcting them,
reliance should almost entirely be placed on suitable dieting, concerning
which wise directions are here given.

As regards the help to be obtained from the examination of the urine
he speaks with caution; the results are far from uniform. An excess of
earthy phosphates in comparison with alkaline phosphates is almost
constantly found in the urine, and an excess of uric acid and chlorides.

Chapters VIII, IX, and X deal with the mental condition in neuras¬
thenia. While it is often allied to hysteria, de Fleury draws attention
to important differences between the two diseases. Neurasthenic
phenomena are not influenced by suggestion, and in the treatment of
the associated conditions different measures are called for. The author

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concludes that the nervous phenomena of Beard’s disease (neurasthenia)
are primary; and while dyspepsia keeps them up or aggravates them, it
does not originate them. Nevertheless the mental state of the neurasthenic
does not, as in hysteria, create symptoms. The symptoms of neuras¬
thenia are not engendered by the fixed idea. There is much truth in
the definition of neurasthenia as a state of irritable enfeeblement, and
the emotional outbursts so common in the disease can be shown to be
accompanied by certain physiological phenomena and to bring about an
intellectual state of depression, /. e. the idea is secondary to the
emotion; the reverse is the case in hysteria. Moreover, the
apparently spontaneous improvements observed in the mental con¬
dition of neurasthenics are often seen to be due to the stimulating
action on the nervous centres of such external agents as light, heat, the
electrical condition of the atmosphere, altitude, etc. The frequently
remarkable effects of saline injections which the author has observed
are explained in the same way. It is very important in this connection
to find out the suitable dose required to bring about satisfactory
results.

Pages 264, etc., sum up very well the author’s conception of the
pathogeny of hysteria and neurasthenia. That he does not look upon
neurasthenia, as so many have done, as a purely subjective disorder is
evidenced by his reference to its pathological anatomy, which he con¬
siders is constituted by the various ptoses of organs with distension en
masse of the circulatory apparatus—a condition which might be pro¬
duced in an animal by the experimental suppression of tonus according
to the method of Brondgeest (section of the posterior root of mixed
nerves). Briefly put, de Fleury’s view is that neurasthenia is a disease
of the physiological tonus brought about by some cause which acts on
the nutrition of the cerebral cell, and the neurasthenic mental state is the
reflex in the mind of the low vitality of the organs, of the muscular
hypotonus, and glandular hyposecretion; it is cured by tonic medica¬
tion—especially simple mechanical excitation of one or other of the
sensory surfaces of the body. A final chapter on treatment ^of which
the two most important elements at his command are saline injections
and open air with high altitude) closes an interesting, largely original,
and suggestive work. H. J. M.

Anleitung beim Studium des Baues der nervosen Centralorgane im
gesunden und kranken Zustande [Introduction to the Study of the
Anatomy of the Central Nervous Organs in Health and Disease ].
Von Dr. Heinrich Obersteiner, K.K.O.O., Professor, Vorstand
des Neurologischen Institutes an der Universitat zu Wien. Fourth
edition, pp. 680, figs. 250. Leipzig.and Vienna: Franz Deuticke,
1901. Price 17 marks.

Professor Obersteiner’s book is so well known to British neurologists,
either in the original or through Professor Hill’s translations, and its
merits are so generally recognised, that the appearance of a new and
further enlarged edition cannot fail to be welcome to very many in this

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country. Whilst the plan of the first edition is strictly adhered to, each
section bears abundant evidence that the author has been at consider¬
able pains to incorporate in the work all that he regards as of material
importance in recent observations. The period that has elapsed since
the publication of the third edition (1895) has, however, been so extra¬
ordinarily productive that his task was certainly a most formidable one.
Although there can be few better able to judge than Professor
Obersteiner of what facts in the vast storehouse of our knowledge of
the modem normal and pathological anatomy of the central nervous
system are most deserving of being included in an introduction to the
study of the subject, many of his readers who are in a position to
criticise must feel strongly that he has at times hardly appreciated the
importance of certain recent observations and teaching. To mention
only one of many examples that might be given, in the sub-section upon
the types of morbid change that affect the nerve-fibres, there is no
adequate recognition of the fundamental distinction, so clearly drawn
by Vassale, between primary and secondary degeneration. Of the
work, taken as a whole, it should suffice to say that the high standard of
the previous editions is fully maintained. W. Ford Robertson.

Studii anatomici e sperimentali sulla Fisiopatologia della Glandola pitui-
taria (Hypophysis Cerebri) [.Anatomical and Experimental Studies
upon the Physiology and Pathology of the Pituitary Gland J. Dott.

Arnoldo Caselli. Reggio nell’ Emilia: Tipografia di Stefano
Calderini e Figlio, 1900. Pp. 228, 33 figures in text

Special interest attaches to this book from the fact that its author
died while it was being carried through the press. The circumstances
are briefly indicated by Professor Tamburini in a sympathetic preface.
From an obituary notice in the Rivista Sperimentale di Freniatria , we
further leam that Dr. Caselli, who had only reached the age of twenty-seven
at the time of his death, had devoted two years of almost continuous
labour in the Psychiatric Institute of Reggio-Emilia to the researches
embodied in this monograph, which he successfully presented as his
tesi di libera docenza in the University of Rome. Whilst these circum¬
stances will naturally stimulate interest in it, the book is quite capable
of standing upon its own intrinsic merits. It is, beyond any question, a
work of very high scientific value, even though it leaves still unsolved
many important problems regarding the physiology and pathology of
the pituitary body. It contains a record of a long series of most
brilliant experimental observations, planned, carried out, and interpreted
with conspicuous ability. The work of previous observers is fully con¬
sidered, and often very ably criticised. Successive sections deal with
the subjects of the anatomy of the hypophysis, its ontogenesis and
phylogenesis, physiology and pathology, functional relations to other
organs, morphological alterations in man, organo-therapeutics, and
excision in man. The work closes with a statement of the author’s
general conclusions. Some of the more important of these are as
follows:—The anterior lobe has many structural analogies to the

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thyroid. The posterior lobe contains no nervous elements, or at most,
only rudimentary ones. Complete abolition of the functional activity
of the hypophysis (in dogs and cats) causes, in the first instance, slowing
of respiration and acceleration of the pulse, then mental depression
and disturbance of movement, characterised by arching of the back and
spastic gait, without tonic or clonic contractions of the limbs; after¬
wards progressive cachexia sets in, and the animal dies comatose. The
cachexia is due to intoxication, and the mental depression to alterations
in the cerebral tissues brought about by this intoxication; the motor
disturbances depend upon similar lesions in the spinal cord. Extirpa¬
tion of the hypophysis gives rise to diabetes, but only through injury to
the part of the brain in its proximity. Extirpation of the hypophysis
modifies the course of the tetany of parathyroidectomy, causing the
motor disturbances to be replaced by paralysis, which is soon followed
by coma and death. In dogs deprived of their thyroid gland, extirpa¬
tion of the hypophysis accelerates the course of the cachexia without
altering its fundamental character. The hypophysis appears to be in
certain respects analogous to the thyroid, but the one organ cannot fulfil
the functions of the other. Structural alterations of the hypophysis which
cause increase in its size give rise to disturbances dependent upon
injury to the optic nerves and upon raising of the intracranial pressure.
Certain morphological alterations, consisting partially in hypertrophy of
the organ, give rise to acromegaly. Pituitary extract is applicable as a
therapeutic agent in cases of mental disease in which there is depression.

W. Ford Robertson.

Uebtr Kunst und Kiinstler [On Art and Artists ]. Von D. J. Mobius.

Mit io Abbildungen. Leipzig, 1901. Crown 8vo, pp. 296.

Price 6 s.

This is an inquiry into the nature and origin of talent or special
capacities. In a volume published a year ago Mobius has maintained
that the talent for mathematics is inborn, and is not proportional to
the other intellectual faculties, and that it is associated with a large
development of the upper part of the temples. In the work under
review Mobius endeavours to show that Gall’s organography has
been unduly neglected. He devotes the first part of his essays on
music, art, poetry, and mimicry to an exposition of Gall’s views upon
these particular talents, which he follows by critical remarks of his
own. Mobius’s advocacy will appear fresh to many readers, for the
generation of physiologists who thought that it was worth their while to
argue against phrenology has wholly passed away. It is a controversy
which we should be loth to revive. As Blumenbach said of Gall’s
system, it has much that is true, and much that is new; but the true is
not new, and the new is not true. We agree with Mobius that Gall
made an excellent classification of the mental faculties. It was
complete and exhaustive, but when he arranged the whole of his thirty-
three faculties under the outer vault of the skull, where they might be
felt as “ bumps,” so that a man’s character could be read off by feeling

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I 2 I

his head, the question arose in the mind of an anatomist: What
function is left for all the other convolutions of the brain on its inner
aspects, comprising the median surface of the hemispheres, and all the
gyri below the inferior temporal, *. e. the whole base of the cerebrum ?
Apparently the strongest point which this new advocate makes in
favour of Gall’s theory is in his chapter upon music. He shows that
this is an inborn faculty found in many animals, and present with all
men, though in very unequal proportions. The power of speech may
be lost without the loss of the musical sense or power of expression.
Mdbius tells that Gall placed the organ of music in the second frontal
convolution, and that newer experiments show that this gyrus actually
plays a part in the performance of music. In the old phrenological
busts in this country the organ of music was placed lower down. Be
this as it may, when we look for confirmation of this statement of
Mobius’s we are treated to some conflicting evidence. Bronislawski, in
a rcsumi of a thesis published last year in Bordeaux, gives out that we
can with great probability place the musical capacity in the anterior
two thirds of the first left temporal gyrus and the anterior half of the
second, and the motor centre of song is probably in the second left
frontal gyrus, and that of reading music in the left parietal. The
evidence for these surprising statements is not given; but Probst is less
confident. The localisation of the tone faculty is still in its immature
stages. It is no use citing Mann’s patient, who lost all power of
musical execution after the second right frontal and the contiguous
parts had been destroyed and softened by a cyst, for in the same page
other observations are cited in which there was aphasia, without
amusie, with the same second frontal destroyed. Sometimes the
localisation is in the left, sometimes in the right hemisphere. We,
ourselves, have come to the conclusion that the musical faculty is
exercised by both sides of the brain, but that we need not repeat here.

In the chapter upon poetry he shows upon what slender evidence he
is willing to build. Giving an engraving of a bust of Goethe, he
observes that by Gall’s system the faculty of painting is moderate,
mathematical talent very small, musical talent middling, mechanical
talent moderate, poetical sense (ideality) very strong, mimicry strong ;
but then, as Mdbius observes, that as Goethe was a very great poet, his
organ of poetry should have been much greater than that of other
poets, whereas it is not. “ In the cast of his head there is only a
moderate elevation.” In other words, through the phrenological chart
Goethe would not be recognised as great amongst other poets.

We think that Dr. Mdbius would have done more wisely had he taken
what seemed good in Gall’s works without attempting to revive the
antiquated claims of phrenology.

Mobius has made a careful and extensive study of the genealogies
and relationships of men of distinction who appear in the Biographic
Universellc and other compilations. He has arrived at some generalisa¬
tions on the characteristics and descents of men of genius of the
correctness of which he makes no doubt.

Distinguished men generally have relations who also show ability.
In art, music, architecture, and other capacities, with the exception of
poetry, the inheritance of talents comes through the father. It may be

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here observed that Mobius, far from giving way to the commonplace of
taking the woman’s side in all questions, mostly does the reverse. In
his learned chapter on the zoological and historical aspects he starts
the question why women are fonder of finery than men, while in the
lower animals the male is generally decked in gayer colours than the
female. Our author thinks it likely that in the early stages of human
life both men and women alike decorated their bodies, but that the
higher intelligence of the men prompted them sooner to give this up,
leaving the women still to indulge in the old love of adornment and
gay colours. We may observe, however, that in these primitive times,
while it was for the interest of the women to look beautiful, it was for
the interest of the men to appear strong and terrible. Mobius remarks
that the love of the beautiful is heightened by sexual feelings, but it
goes far beyond. “ All Nature strives after beauty. There is beauty in
the crystal shut up in the mine, in the forms of ice, in the aspects of
the heavens, and we can perceive this objective beauty because we have
a sense for appreciating it.”

The book is full of pregnant remarks, which excite thought and
invite discussion. The author shows great power of analysis, and a
wide culture, combined with a forcible and pleasing style.

William W. Ireland.

Dreams and their Meaning. By H. G. Hutchinson. London :

Longmans, 1901. Octavo, pp. 320.

Some books, like leaden razors, are made to sell, an# this would
appear to be the objective of Dreams and their Meaning, since no
other can be discovered after a careful perusal.

A number of dreams of falling, flying, being unclothed, of being
pursued, etc., are given without any attempt at explaining their psycho¬
logical origin or significance. The only “ meaning ” attached to dreams
is copied from an older authority, to whom Zadkiel and other almanac
prophets are indebted for their very similar interpretations.

Dreams, supposed to be illustrative of telepathic and dual personality
and of premonition, are quoted from the records of the Psychical
Research Society. All that need be said of these is that the evidence
would not satisfy anyone with any critical faculty, and that if they are
the best examples that can be put on record after years of patient and
apparently strongly massed research, they are the strongest evidence
that could be adduced against the allegations they are so boldly
asserted to prove.

La Puberti. Par A. Marro. Paris : Schleicher Fr^res, 1901. Pp. 536,
large 8vo. Price 10 f.

Attention was called to this important work when it first appeared in
Italian three years ago. In this French translation (well executed by
Dr. J. P. Medici, under the direction of Dr. A. Marie) it is brought

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within reach of a wide circle of readers. The translation is founded on
the second Italian edition, which has been considerably changed and
enlarged, some of the chapters arranged in different order, new facts
and observations added, as well as a new chapter, dealing more fully
with the special environment of women. As it stands, the work is in
its own department unrivalled—whatever dispute the reader may
have with Professor Marro at special points—as regards its useful
summaries of the work of others, the very large body of original facts
presented, and the author's subtle and profound observations and
suggestions. As Professor Magnan, who writes an introduction to this
translation, truly remarks, “ this magnificent study of puberty, abound¬
ing in curious documents, concerns not only physiologists and alienists,
but magistrates and anthropologists, while every doctor will find in it
information that will be useful to him.” Havelock Ellis.

Centralblatt fiir Anthropologies Ethnologies und Urgeschichte . VI
Jahrgang, 1901. Costenoble, Jena.

This useful and ably-conducted journal has now completed its sixth
year under the editorship of Dr. Buschan, who is well known as an
indefatigable worker in many fields of anthropology, especially those
which touch on medicine and psychiatry. The attention of our readers
was called to the Centralblatt some years ago (April, 1897), and since
then several of the more important original articles that have appeared
in it have been summarised here. While every number contains an
original article by some leading anthropologist, the chief value of the
Centralblatt is due to the excellent and concise summaries and reviews,
executed by a highly-competent staff, of articles, memoirs, and books
coming within the field of anthropology. Many interesting investiga¬
tions are thus rendered easily available, and due attention is given to
work appearing in the less known languages, Russian, Hungarian,
Bohemian, etc.

We regret to learn that the publisher of the Centralblatt finds that
the support given to the journal does not warrant him in continuing its
publication. At this juncture, however, Dr. Buschan has come to the
rescue with characteristic energy, and from the beginning of the new
year proposes to carry on the Centralblatt at his own risk. It is to be
hoped that he will be encouraged in this determination to continue a
review which has a place of its own, and which he has shown himself
so well able to conduct. Certain aspects of anthropology have a very
intimate bearing on psychology and psychiatry, and the importance of
this connection is constantly becoming more widely realised. Anthro¬
pology is duly recognised in the epitomes furnished by the Journal of
Mental Sciences but except in a journal specially devoted to the subject,
it is obviously impossible to keep fully abreast with the large amount of
anthropological work bearing on the brain and nervous system. The
Centralblatt is published every other month, and the subscription is
twelve marks; with postage, thirteen marks, twenty pfennigs. Dr.
Buschan’s address is 7, Friedrich-Carlstrasse, Stettin.

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EPITOME.

[Jan.,

Part III.—Epitome.

Progress of Psychiatry in 1901.

AMERICA.

By Dr. H. M. Bannister.

The record of American psychiatry for the past year is not an eventful
one so far as matters of interest to trans-Atlantic readers are concerned.
At the beginning of the year the subject of interest was the New York
Pathological Institute and the difficulties that involved its management.
For a number of months it has been in a state of suspended activity—
not dead but sleeping—and now appears to be about to start again on
a fresh career of usefulness. A new organisation has been planned, an
advisory board appointed, consisting of recognised authorities in their
departments, and including representatives of the related specialties of
psychology and general biology, as well as those of pathology, neurology,
and psychiatry. The gentlemen who have accepted positions on the
board are well known, and their interest in the Institute and its aims
undoubted. Their names will carry weight; Professor McKeen
Cattell holds the chair of psychology in Columbia University, Professors
Ewing and Herter represent the two great medical schools of Bellevue
and Cornell, Dr. H. A. Hern, of Albany, a well-known neurologist, Dr.
Bumpus, of the American Museum of Natural History, Drs. Pilgrim
and Macdonald, representing the State Hospitals, and Dr. Frederick
Peterson, ex officio , as commissioner of lunacy, complete the board.
These gentlemen will exercise a general oversight over the work, and
when a new working staff has been appointed, we may look for good
work, carried on under more favourable conditions than was formerly
the case. It is the intention in their reorganisation not only to carry
on original research as in the past, but to utilize the Institute for
special instruction of the members of the different asylum staffs in
psychiatry and special research work. It will be located in one of the
departments of the Manhattan Hospital until such time as a special
reception hospital for the insane can be provided.

The appointment of Dr. Peterson as head of the Lunacy Commission
appears to be one that is generally endorsed. He has shown his
quality in the part he has taken in the origination and oversight of the
Craig Colony for Epileptics, an institution that is doing excellent work,
both from an humanitarian and a scientific point of view. Dr. Peterson
is a scientific physician of acknowledged standing, but it is not, perhaps*
so generally known that, like Drs. A. W. Holmes and S. Weir Mitchell,
he is also a literary man, whose work in this line, if he continues it,
will probably give him an independent reputation apart from that
gained in medicine. Thus far it has been apparently only a recreation.

I have to report what seems to be a backward step at the Ohio
Epileptic Asylum at Gallipolis. Owing to what seems to be a political
wrangle, the merits of which are not clearly apparent to outsiders, Dr.

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1902.] PROGRESS OF PSYCHIATRY. 125

Ohlmacher, the pathologist of the institution, has been forced out of
his position, in which he has done valuable work. I have not yet
heard of any one of reputation taking his place, and since his departure
the laboratory building, with its valuable collection and equipment, has
been destroyed by fire. It is to be feared that it will be some time
before we can look for further scientific contributions from that source.

Apropos of political management of asylums, a curious, if not
edifying, instance is reported from a southern State. There, where
politics are so nearly unanimous as to make one think that there ought
to be no differences sufficient to interfere with the asylum personnel,
the directors in their unwisdom saw fit to make the rule that none
except those to the manner bom should be employed. All aliens (non¬
voters ?) were therefore warned that they could not much longer hold
their positions. They appealed to the Governor of the State, and not
receiving satisfaction, they and their sympathisers—apparently all, or
nearly all, of the attendant force—struck in a body. This brought
matters to a crisis; the Governor himself visited the asylum, and made
a personal appeal to them. According to the newspaper reports, the
obnoxious regulation was repealed, and everything was again har¬
monious. This is the first asylum strike on record here, and it is to be
hoped there may never be a similar cause for another.

The experts, who examined the assassin Czolgosz as to his mental
condition, have made their report and declared him sane. Whether or
not he had accomplices may never be known. Dr. E. C. Spitzka, in a
published review of his case, seems to think he had, and that the murder
of the President may have been plotted by men who used the
murderer as their tool. Of course his persistent denial of the participa¬
tion of anyone with him in the act does not necessarily command
credence—it is only what might have been expected if there had been a
plot and his courage had not failed. The psychology of the anarchist
of the present day is, in some respects, a problem, and it is an
unpleasantly large one in connection with a certain proportion of the
foreign-bom labour element in this country. Czolgosz himself was
hardly a native; though born in America, his associations had not been
American. It has been said that he was educated in the public
schools, but I am informed that such was not the case. It is not hard
to define insanity in a legal sense in a way that might easily be made
to include the modem anarchists ; they are certainly out of harmony
with their environment in any decently organized society, and if we
credit them with any sort of sincerity, they are the most deluded
of individuals. No one is inclined, however, to believe them
irresponsible, and the prompt conviction and execution of Czolgosz has
certainly had the full endorsement of public opinion.

A year or two ago, there was much talk about insanity in the army,
especially in the Philippines, but the facts are apparently not formidable.
Indeed, both mental and physical conditions of the American soldier
in the tropics appear to be generally good, and the troops in Porto Rico
last year made the record for health in the army annals. Much is being
said at the present time in regard to the drinking habits of the soldier,
and the “canteen” question is a living one. A year or so ago,
Congress, at the instance of the temperance workers of this country,

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EPITOME.

[Jan.,

abolished the sale ot beer and light wines, which had before been
allowed at the military posts. This has stirred up much opposition, and
the majority of the army medical corps, as well as of the line officers,
appear to be in favour of a change back to the old order, claiming
that the canteen, as formerly conducted, was more favourable to
temperance and to the better discipline of the army. Without the sale
of beer and wines under official oversight, they say that the soldiers
resort to disreputable saloons that spring up in the vicinity of the posts;
in short, that the liquor-selling in the canteen was a necessary safety-
valve for the indulgence of the appetites of the men. A few army
officers have, however, expressed themselves strongly in favour of the
law as it is, among them the commanding general, General Miles, who,
in his report just given out, offers figures to show that discipline
has not suffered, and that there are fewer desertions under the present
law than there were before. As the law has only been on trial for a
year, its repeal by the coming session of Congress would be very far
from convincing as to its demerits. The subject is not directly one of
psychiatry, but it has its bearings in that direction. As I think I may
have said before, the temperance question is a perennial one in this
country, and the agitation, though sometimes carried on by extremists,
has done much good. It is probable, as General Miles says, that the
majority, or, at least, a very strong minority, of the recruits for the
U.S. army have not been in the habit of using liquor or fermented
drinks to any extent, and there is therefore an impropriety in having
them introduced to the habit under Government auspices. It is safe
to say that, if the present law is repealed, a very powerful influence will
be exerted to re-enact it.

It seems probable that there may soon be erected some sort of
substantial memorial to Miss Dorothy Dix, whose name is so familiar in
asylum reform and other good works on both sides of the water.

It is worthy of note here that the State of Michigan has made an
appropriation for a psychopathic hospital in connection with the
medical department of the State University, thus affording an oppor¬
tunity for the special study of mental disease. It may be that this is
only the forerunner of other similar foundations in connection with
other centres of medical education, and the experience in Michigan will
be watched with interest elsewhere.

Among the deaths of prominent workers in the specialty of
psychiatry during the past year two may be particularly mentioned—
Mr. John C. Shaw of Brooklyn, and Dr. W. L. Worcester of Danvers,
Mass. Dr. Shaw was better known as a neurologist, but he was for
some years superintendent of the Flatbush Asylum, and the author of
numerous papers, etc., relating to insanity. Dr. Worcester was one of
the earnest workers in the pathology of insanity, and his death is a loss
to the profession. He was in a sense a martyr to his work, his death
having been caused by blood-poisoning from an infected finger. Beside
being an accomplished physician and pathological expert, he was,
like his brother, Dean C. Worcester, of the Governing Commission of
the Philippines, strongly interested in natural history, and, but for his
diversion into medicine, would probably have made his mark as a
naturalist He was beginning to do his best work at the time of his death.

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PROGRESS OF PSYCHIATRY.

127

BELGIUM.

By Dr. Jules Morel.

M. Lentz has dealt with the statistical and clinical study of criminal
lunatics, a subject hitherto entirely untouched in Belgium. He shows
that no serious attention has been paid to these criminal lunatics or
insane criminals, who may be classed as insane, abnormal, and vicious.
If the limits of these different classes are hard to define, criminological
science must nevertheless distinguish them, even artificially. Seeking a
criterion to characterise criminal lunatics, properly so called, M. Lentz
finds it in their pathogeny, manifest in the two elements cause and effect
But amongst these lunatics occur pretty often offenders who only become
insane in, the course of their detention. They generally pass unnoticed,
and go from the prison to the asylum.

In the twenty-five years 1875-99, 485 criminal lunatics passed
through Toumai asylum. M. Lentz has remarked a considerable pro¬
gression in their numbers, and this progression has no connection with
the general increase of insanity. During a period of twenty-two years
(1875-96) the proportion of criminal lunatics to the total insane has
varied from i*6 to 10 per thousand, giving an average of 5*5 per
thousand.

The growth of insane criminality has been thus distributed :—Offences
against morals have increased 60 per cent., vagrancy 55 per cent., rape
54 per cent, threats, etc., 40 per cent, murder 29 per cent., wounding,
assaults 15 per cent., arson 3 per cent.

The forms of mental disease in the order of their importance in
relation to crime areas follows :—Mental debility 20 8 percent., delirious
insanities 15*5 per cent., alcoholic insanities 12-5 per cent., degenerative
insanities 11*9 per cent, paretic dementia 11*8 per cent, affective
insanities 107 per cent, neuropathic insanities 9 2 per cent, acute
psychoses 5 6 per cent.

Adding together the cases of mental debility, alcoholism, and degene¬
rative insanity, it is found that 45*2 per cent., or nearly half the total,
may be regarded as hereditary, and the proportion would be consider¬
ably higher—probably over 80 per cent. —if full information were
obtainable on the point. The lunatics who commit arson, theft, and
offences against morals are almost entirely recruited amongst the
degenerates. It is impossible to follow the author through his numerous
classifications and statistical details.

A very interesting discussion took place in the Royal Academy
of Medicine of Belgium regarding the service of mental medicine in the
Belgian prisons. The late Minister of Justice, M. Lejeune, in establish¬
ing this service, referred to the alienist experts, not only the prisoners
who had attracted attention by mental disorder or by the eccentricity
of their conduct, but also all recidivists, and all prisoners convicted of
offences against morals. M. Lejeune’s successor has suppressed the
expert examination of the latter categories of offenders. MM. Heger
and Lentz vehemently condemned the abolition of this examination,
which, beyond all doubt, embraced matters of the highest importance
from an anthropological point of view. Dr. Morel not only joined in

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128

EPITOME

[Jan.

the protest of these alienists, but further proved by a series of statistical
researches, referring to over 400 recidivists whom he had personally
examined, that such examinations were of the utmost scientific value.
Dr. Morel was led to intervene in the debate by the fact that he was
engaged at the moment in preparing a paper for the Congress of Criminal
Anthropology held, this year, at Amsterdam.

In that paper, La Prophylaxie et le Traitement du crimincl Ricidiviste ,
Dr. Morel, having passed in review previous discussions of this question
in the Congresses of Criminal Anthropology, referred to his own earlier
works, and particularly to the paper published in the Journal of Mental
Science in 1894, “On the Need of Founding Special Institutions for
Degenerates.” Unfortunately, his efforts had not the practical result
desired, probably because his project was regarded as Utopian. The
figures which he now brought forward were a striking proof that the
State does not understand its mission in the prophylaxis and treatment
of the criminal. In support of his views Dr. Morel quoted several
cases, amongst them one borrowed from Prof. Pelman, of Bonn, who
traced the mischief that degeneration and alcoholism can produce in a
single family, and the cost thereof to society. A woman named Aida
Jurke, bom in 1740, and dying in the beginning of the next century,
liad 834 descendants, of whom 709 could be followed. Of these latter,
106 were bastards, 142 became beggars, 64 were otherwise dependent
on public charity, 161 were prostitutes, and 76 were criminals, 7 of them
being homicides. In seventy-five years, this single family, according to
official calculations, cost in maintenance, prison expenses, etc., a sum
of six million two hundred and fifty thousandfrancs .

The second case was borrowed from Dr. Grossman’s work, JVie
wird ein Kind zum Verbrecher. The descendants of five sisters numbered
540 persons, of whom 76 per cent were criminals, and 20 per cent .
paupers; only 4 per cent . were not burdens on society. Another
criminal woman had 623 descendants, among whom were 200 criminals,
the rest being for the most part idiots, drunkards, paupers, and
prostitutes. At the Michigan Industrial Home for Girls an inquiry into
the family history of the inmates showed that “ insanity was hereditary
in about one seventh, one third had criminal parents, and two thirds
inebriate parents.”

Dr. Morel quotes further the opinion of the leading alienists of
Germany (Nacke, Mendel, Langrenter, Sommer, Cramer, Monkemiiller)
and of Italy (Marro, Penta), and arrives at the confirmation of the
views which he put forward in 1894, and which are gaining the adhesion
of the principal jurists who are interested in criminal anthropology,
and who desire to prevent and cure crime by active measures. Already,
in 1896, Prof, von Litzt at the Munich Congress of Psychology proposed
to replace the term “ freie Willengsbestimmung” by “ normale Willengs-
bestimmung.” At the Congress of Geneva Prof, von Hamel, of the
University of Amsterdam said, “ If we wish to defend society with pure
consciences let us unceasingly devote all our efforts to reform.” The
eminent alienist of Paris, Dr. Magnan, speaking of his studies of the
degenerate, declares, “Society having its share of responsibility in
individual crime, and having only one law, that of self-preservation, is
entitled, while protecting the criminal against himself, and protecting

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PROGRESS OF PSYCHIATRY.

1902.]

129

its own interests against the criminal, to use every measure for the
prophylaxis of crime.”

A glance at Dr. Morel’s statistics shows not only that delinquency is
most frequent between the ages of eighteen and thirty years, but also
that the majority of the criminals examined by him had got little or no
primary instruction, that more than half of them were of alcoholic
parentage, that more than half were themselves addicted to alcoholic
excesses, that more than a third were the children of criminal parents,
that a quarter of them had degenerative taint, hereditary or acquired,
and, lastly, that amongst the 10 to 22 per cent who were apparently free
from hereditary taint, a large number were vitiated by injurious condi¬
tions of life (e.g. y in reformatories), diseases in childhood, such as
typhoid fever, etc.

It follows, therefore, according to Dr. Morel, that the treatment of the
degenerate, the future candidates for crime, should begin in their youth.
He formulates these conclusions:

1. As a measure of social hygiene, the authorities should supervise
backward children and children living in corrupt environments, in order
to withdraw them from the control of their parents and remove them to
healthy and honest surroundings.

2. In the case of backward or degenerate subjects who, through the
irregularity or eccentricity of their conduct, come under the notice of
the authorities, an administrative report should be made, and if
required, a medico-psychological examination, the result of which should
be communicated to the administrative and, if necessary, to the judicial
authorities.

3. In case of necessity, in the interests both of society and of the
backward and degenerate individuals themselves, they should be sent
to a medico-pedagogic institution fulfilling all the conditions which can
contribute to the regeneration of those presenting unquestionable signs
of degeneracy.

4. Parents whose children, by their conduct or intelligence, inspire
fears for the future, should have the right to ask for their committal to
a medico-pedagogic institution, or to some special asylum until they
have attained an age to be subsequently determined.

5. The motive of retaliation, being Inapplicable in the case of the
degenerate, should be replaced by the idea of reformation and education.
The penal responsibility of degenerates being suppressed, they will be
committed to the care of the State for an indefinite period.

It is obvious from Dr. Morel’s statistics that the recognition of the
right of detaining juvenile criminals until they can be regarded as
seriously qualified to fill a useful place in society, would in a few years
reduce crime to a half or even a quarter of its present amount.

DENMARK.

By Dr. A. Friis.

During the past year there has been a change in the directorship at
three of the State Asylums. Dr. Helweg at Oringe died, and Dr.
Pontoppidan at Aarhus was appointed to the University of Copen
XLVIII. 9

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EPITOME.

[Jan.,

hagen as Professor of Medical Jurisprudence and Hygiene. At Aarhus,
Dr. Pontoppidan was succeeded by Dr. Hallager, Director of the Viborg
Asylum; and Dr. Helweg by Dr. Willerup, his former medical assistant.

No steps have been taken, either by building new asylums or enlarg¬
ing old ones, to meet the demands for more accommodation, and the
directors have to refuse patients they ought to admit. It is especially
accommodation for incurable patients which is wanted, and admis¬
sions are refused by hundreds for asylum treatment of this class of
patient, the claims increasing year by year. In a former number of
this Journal (1898), I mentioned the appointment of a Commission to
inquire into the question of accommodation, and in its report it stated
that the only practicable way of dealing with the difficulty was an
enlargement of the Viborg Asylum and its adaptation for receiving
both recent and chronic cases, its present population being restricted
to the latter. With reference to this proposal, a bill was promoted
in Parliament, but did not pass. Dr. Pontoppidan, who was not a
member of the said Commission, in a paper entitled “ Considerations
on the Care of Lunatics,” amongst other reforms suggests a different
way of relieving this pressure. He maintains that the State Asylums,
except Viborg, are planned as asylums for recent cases, and therefore
ought to continue as such, and not be encumbered with incurable
patients. The latter class can be well housed in cheaper institutions
—workhouses and agricultural colonies. He advocates the boarding
out in private families, and special asylums for epileptics—the whole
to be under Government supervision. This paper was published
quite recently, and it is sure to have a great influence on the legislation
of the future. Dr. Pontoppidan lays stress on the recent cases as
claiming greater care and treatment.

This year Parliament has enacted that the maintenance of epileptics
at public expense is not to be considered as parish relief, nor is this the
case with lunatics and the feeble-minded. This will enable many to be
admitted hitherto uncared for.

As regards imbeciles, there has been no change this year. The
Keller asylums in Jutland have been finished and are in use.

At the meeting of the Danish Association of Criminalists in
Copenhagen (September, 1900), the care of criminal lunatics was
discussed. Dr. Pontoppidan read a paper on the subject from the
alienist side. He doubted very much, in a little country like Denmark,
the need for special asylums, and his views were shared by Director
Lange, Middelfart; while Dr. Geill, physician to the Copenhagen
prisons, and Director Helweg, Oringe, were of the opinion that special
establishments ought to be provided, either connected with a prison or
with an asylum. It transpired during the discussion that in all the
Danish asylums there were only about one hundred criminal lunatics
under treatment.

The year under review has been rich in psychological literature.
Dr. Friedenreich has published a text-book on psychiatry ; Dr.
Pontoppidan has brought out his experiences while medical super¬
intendent ; Dr. Tryde has written on Insanity and Guilt and the Danish
Tribunal; and Dr. Wiirtzen Personal Responsibility {Psychological and
Criminal).

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1902.] PROGRESS OF PSYCHIATRY. I 3 I

FRANCE.

By Dr. Ren£ Semelaigne.

A Woman sequestrated .—A few months ago the public papers
reported that a sane woman had been sequestrated by her family;
some days after they reported that she was a genuine lunatic, but
that insanity was the result of her long detention in a closed and dark
apartment. The true history is as follows:

The Procureur de la Republique of the town of P— was advised
that a lady, Miss Blanche M—, had been sequestrated for years.
The magistrates visited the apartment in which she had been confined,
and found that the windows were closed and locked; the smell was so
offensive that they had to retire for a time until the air had been
renewed. They found the woman quite naked in bed and covered with
every kind of vermin; under the bed were sweepings and remains of
food, such as crusts, bones, oyster-shells, etc. The patient was trans¬
ferred to the hospital, and her mother and brother were taken into
custody. The mother vehemently protested against the charge,
svrearing she was greatly attached to her daughter. A few days after
she died in prison, and her testament proved that she had been kind to
the patient. The brother alone remained to be prosecuted, but it was
not possible to charge him with having sequestrated his sister as he did
not live at home. He had remained throughout life absolutely under
maternal control. The magistrate indicted him for being an accomplice
in cruelty and assault, so he had to be tried by the Tribunal Correctionnel,
and without a jury. The case could not be gone into during the
summer because of the vacation, so Mr. M— remained for about five
months in prison, awaiting his trial. In the meantime, the newspapers
conducted a violent campaign, and raised public opinion against him;
the political passion soon interfered, for the family was Conservative.
During the trial the prisoner was daily insulted by the crowd, and
stones were thrown at the carriage which removed him from the prison
to the court of justice. All the evidence proved that he was a degenerate.
He was extremely myopic, the sense of smell was very defective, and
that of taste absent, so that he was markedly incapable of recognising
the food of which he partook. Almost incapable of managing
his own affairs throughout life, he never dared oppose his mother,
who was as obstinate as her son was deficient of will. Mrs. M—
herself was most singular in her habits, and she would never have
consented to the admission of her daughter, a perfect lunatic from
puberty, to any asylum. The window had been closed because the
patient used to walk quite naked through the apartment, and the
mother, who had bad health, and never had any ideas of cleanliness,
furnished her daughter with oysters and every kind of dish, but
allowed her to lie in filthiness. The brother very often entered his
sister’s room; there he used to sit down and read to her to
amuse her. He never saw the dreadful dirtiness of her apartment,
and never perceived its foetid smell. Mr. M— is a degenerate without
any will, without sight, taste, or smell, and accordingly he is irre¬
sponsible, and ought not to have been charged; but the judges,
following public opinion, sentenced him to four months’ imprisonment.

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EPITOME.

[Jan.,

The lawyer, the family, and friends induced him to appeal from that
sentence, and the case will be called at the Cour d Appel in November.

And as a moral of that immoral history, the newspapers which
generally censure parents and relatives for incarcerating people in mad¬
houses instead of taking care of them at home, have unanimously and
correctly declared that such a patient with such surroundings ought to
have been sent to an asylum many years ago.

Criminal Assault to secure Morphia .—Some weeks ago a chemist
was called up at night. A man came in and presented a prescription
for morphia. As the paper seemed to be rather suspicious the chemist
refused to dispense it. The man then seized a scalpel from the table
and tried to stab the chemist, but the latter rightly ejected him. The
police had been advised that several chemists had recently received a
visit from a man who always presented a prescription for morphia. The
police discovered his domicile, and when they entered the room,
they found the man and two women lying on beds pale and nearly
unable to move. Mr. N— related how he contracted his sad habit Some
years ago he was suffering from a painful illness, and a doctor induced
him to have recourse to morphia. At that time he was a merchant in
Brussels, and Mrs. L— and her daughter helped him in his trade.
His praises of the drug induced the latter to try it, and they soon
became intoxicated. Mr. N— neglected his business, his customers
fell away, and he soon came to distress. They all took refuge in
Paris, where began a life of misery and want. They were suffering from
an ungovernable impulse, /. e . 9 to obtain the desired drug by any means.
So Mr. N— visited the shops of many chemists, and lately that of
Mr. C—, whom he assaulted for the purpose of securing the refused
narcotic. An action for assault and battery is directed against him
and Mrs. L—, who is being prosecuted as an accomplice. She is very
weak and quite unable to sustain an examination. The condition of
her daughter is most serious, and she seems to be at the point of death.
Let us hope that the prisoners will be discharged as irresponsible, and
that especial care will be taken of them.

Cocainomaniac Father and Idiot Children .—Dr. Marfan reports the
case of two children, complete idiots, whose mother enjoyed good health
and was without nervous taint, but whose father had always been a sharp
and irritable man. Eight years ago, when suffering from a hypertrophic
rhinitis, he had recourse to cocaine, and soon became a slave to it.
He actually takes three grammes a day. He is very fat, and shows
various nervous disorders (hallucinations, vociferations, etc.). There
are four children. First, a girl, 13 years old, very intelligent and enjoy¬
ing good health; second, a girl, aet. 8, whose conception occurred about
two months after an operation on the nose, /. e . 9 at a time when cocaino¬
maniac habits were just beginning: she is thin, rather pale, but very
intelligent; third, a boy, aet. 6, who was conceived when poisoning had
produced its full effect, he is a complete idiot; fourth, a baby, aet. 10
months, who is a microcephalic idiot.

Parricide and Mental Degeneration .—According to Dr. Regis, of
Bordeaux, those who perpetrate a parricide are nearly all degenerate
people, and such degeneracy is principally the result of hereditary
alcoholism. One can easily find amongst them alcoholism, epilepsy.

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PROGRESS OF PSYCHIATRY.

133

and delusions of persecution, but such signs are rather accessory, and
invariably grow on a ground of primordial degeneration. The cardinal
symptoms are want of affection and impulsiveness. Orestes had been
a lunatic and a member of the family of Atrides, a race of unfortunates,
degenerates, and criminals.

Delusions resulting from Jealousy .—Dr. Victor Parant, a son of the
well-known director of the private asylum of Toulouse, made a special
study, in his inaugural thesis, of delusions of this type. They may, or
may not, be systematised. The delusions without systematisation
make their appearance in degenerate states, in neuroses (hysteria,
epilepsy, neurasthenia), in alcoholism, cocainomania, mania, melancholia,
and organic disorders of the brain. The delusions of jealousy which
appear among old people seem to be more common than one might
believe according to the published cases, and Dr. Victor Parant gives,
as a reason of the fact, that old people, when they are not dangerous,
generally remain at home, instead of being sent to an asylum ; conse¬
quently their delusional tendencies are unknown out of the family.
It is an early symptom in senile dementia. The author divides
the systematised delusions of jealousy as follows: (a) primary;
(£) secondary; (c) idiopathic. The most common variety is as
follows :—Adult people present delusional ideas primarily, and not as the
result of affective disorder. The ideas are accompanied by sensorial
disorders, the prodromata are slight and short, there is a period of
irritable depression, and the delusion makes its appearance, and it is
generally a fear of conjugal infidelity. At the beginning the patient
presents a mere anxiety, afterwards a suspicion, finally the delusion
becomes fixed. Hallucinations of hearing are most frequent; halluci¬
nations of sight are uncommon. These cases do not generally commit
suicide, but they often kill their conjoint.

Systematised delusions secondary to mania, melancholia, folie d
double forme, neuroses, and intoxication are well known. The last
variety is composed of people affected with a morbid jealousy, and who
remain their whole life presenting the type of perseeutes-perstcuteurs .
They are hereditary degenerates, with stigmata and abnormalities of
morals and of temperament. Their delusions are due to false reason¬
ing. They are considered as lucid and are found outside asylums,
although they are the worst of lunatics.

GERMANY.

By Dr. J. Bresler.

The treatment of the insane without isolation in side rooms has
received much attention in Germany (Kalmus, Zellenlose Behand-
lung; Halle, Marhold, Psychiat. IVochensch, ., No. 49, 1900; Bresler,
ibid., No. 10, 1901; Hoppe, ibid 1 , No. 30, 1901). The general con¬
clusion is that such confinement is to be avoided as much as possible,
but that it is quite the right treatment in some cases.

At the annual meeting of German alienists held at Berlin, April,
1901, several important subjects were discussed. The fatnily care of

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EPITOME.

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the insane was considered. Its adoption in several forms under the
supervision of alienists was noted. It could be used with advantage
during convalescence, and was perhaps more suitable and offered more
chances for recovery in certain cases than treatment within the wards
of an asylum. The patients boarded out can be treated from the
neighbouring asylum, and cases arising quite locally need not be
removed from home. If the patients cannot be under the supervision
of the asylum staff they should be visited by inspectors specially
trained in lunacy. Finally, its adoption would tend to dissipate some
popular notions regarding lunatics.

Heilbronner summarised the pathological changes in the nerve-cell,
which have been reported to occur in the various functional psychoses.
He concluded that there were none definite for any one mental disorder,
indeed it was impossible to distinguish a sane from an insane brain.
He dismissed the numerical valuation of nerve-cells in the same way.

An important paper was that of Professor Sommer, of Giessen, on
“ A Three Dimensional Estimation of Motor Disturbances in Nervous
and Mental Diseases.” (a) An apparatus for the graphic recording of
the disturbances of the frontalis muscle; ( b) an apparatus for the
exact measuring of pupil disturbances which can be used with either
electric, gas, or petroleum illumination; (r) an arrangement for esti¬
mating the knee-jerks, clonuses, spasms, tremors, etc. ( vide Psychiat.
Wochenseh ., No. 9, 1901).

Drs. Bleuler and Delbriick have published articles discussing the
“Relationship between Asylums and Alcoholics.” There appears to
be no doubt that the physicians and attendants of asylums who treat
cases due to excessive indulgence of alcohol should be total abstainers.
The anti-alcoholic notion has many partisans in Germany in our branch
of medical science.

We are to be much congratulated on the fact that the Government,
in May, made psychiatry a compulsory subject in the medical curri¬
culum . New rules have been enacted by the Government in Prussia
(March 26th, 1901) regarding private asylums, the mode of reception
and discharge of patients, the economic administration, the medical
service, also as regards attendants, etc. An Act has also been passed
forbidding the discharge of a dangerous lunatic until the police,
after inquiring into the domestic surroundings of the patient, have
given their permission.

HOLLAND.

By Dr. F. M. Cowan.

An important event in the year has been the meeting of an Inter¬
national Congress for Criminal Anthropology at Amsterdam. I leave
the various discussions and papers to be dealt with in another part of
this Journal. It is generally admitted that an efficient staff of attendants
and nurses is indispensable in the treatment and care of the insane.
This important point has been the subject of an exhaustive and lengthy
report in our Journal. A number of questions were drawn up and

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PROGRESS OF PSYCHIATRY.

135

sent to the medical superintendents of several asylums, and the answers
received were cast into a very interesting report in which we find a
large number of data relating to the training of attendants, their pay,
leave of absence, amusements, working hours, board and lodging, etc.
The conclusion drawn by the writer of the report is that very great
progress has been made; “ contrary to what occurred nine years ago,
the care for the insane is now everywhere entrusted to a staff well
trained for their task, or at least in receipt of thorough training for their
onerous duties.” I can hardly believe that these words of the writer
will be generally accepted. Undoubtedly great progress has been
made, but there is still room for much improvement. The maid-of-all-
work, who dons the dress of a nurse and is henceforth styled “ Sister
Sarah,” does not at the same time acquire the amount of knowledge
and training required in a nurse; you cannot make a silk purse out of
a sow’s ear, and in a large number of cases the sow’s bristles show
through the silk envelope.

Dr. Bouman published an interesting paper on insanity in twins
set. 18, who became insane almost at the same time, there being only a
few days’ difference. They were occupied as servants, their situations
being far from each other, and they were not aware of one another’s
existence. The course of the disease was as strikingly analogous as
they were alike in features. They were both discharged as cured at
about the same time.

Dr. Coenen, of Amsterdam, has studied the disturbances of cutaneous
sensibility in connection with the extent of root-zones. The author
gives an exhaustive account of a series of cases of neuritis, the
cutaneous sensibility of which was accurately investigated. Space only
allows me to give his conclusions. Making allowance for the many
difficulties besetting clinical investigation of this kind, he was
struck by the conformity between the results obtained by him and
those published by Sherrington and Bolk. He considers that Sherring¬
ton’s work on the root-zones of the monkey can only be reproduced in
man by a long series of clinical observations most accurately conducted,
and followed by very careful pathological examination after death.
He was disappointed by the results he obtained from the study of
hyperalgesic zones and by the study of crops of herpes zoster, to which
Head attaches so much importance, and which he considers such a valu¬
able adjunct to the study of these phenomena. Coenen thinks that we
are yet merely groping in the dark.

Epilepsy, a disease occupying so much attention, still remains an
enigma to physicians, and every effort to penetrate into its mysteries
deserves mention. Dr. Brouwer, in collaboration with Dr. Muskens,
has introduced three forms for recording the number of attacks, and
certain symptoms attending each fit. These forms are in use in the
asylum at the Hague, and the two physicians are very well pleased with
the results obtained.

The first form notes the number of fits, the time of occurrence,
whether a regular fit or only a giddiness occurred, the nature of the fit,
and the treatment adopted. Form number two is very elaborate. It
records (a) condition before the attack; (&) warnings (aura, etc.);
(c) onset (sudden or gradual); (d) scream ; (e) colour of face ; (f) move-

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ments of limbs; (g) rolling of bead and eyeballs; {h) course of fit
(which limb was first ssonvulsed ? how did the attack spread ?);
(*) symptoms to be observed regarding chest and abdomen ; (J) tongue-
bite or not; (k) micturition or defaecation; (/) pupillary reaction;
(m) number of respirations and pulsations; ( n ) duration of move¬
ments ; (0) symptoms after the fit (headache, giddiness, sleep, weak¬
ness in one or more limbs, etc.); (/) sensibility to pain on the skin
of the chest and hands; (q) are there psychical equivalents, and if so,
which ? The third form is intended to note the influence of drugs
and of treatment in general. The forms were produced at the
meeting of the Psychological Association at the Hague, and though
several of the members present allowed that much might be learned
by their use, others thought that a number of answers to the
questions could only be properly given by the physician, and
not by the nurses or attendants. At the Hague the latter have
apparently proved equal to the task, so the authors claim; but the
testing of sensibility to pain is a diagnostic point which, I believe,
can hardly be performed by an attendant, and the results must be
accepted with very great reserve.

In October, Dr. Ruysch resigned his office of Inspector of Lunatic
Asylums., He was succeeded by Dr. Schuurmans Stekhoven. In a
country such as ours, where the lunacy law enacts that the magistrate
and not the physician is the umpire to decide whether a patient is a
lunatic or not, and where a diagnosis formed after a long and accurate
examination may be set aside by some visiting justice, a law which
does not make it obligatory that the inspectors, or at least one of
them, should be medical men, it is highly gratifying that a physician
should have been appointed to the vacancy; and more so that he is an
alienist.

Although new asylums continue to be built, the call for more room
remains undiminished, and hardly is one opened than it is immediately
filled. The medical superintendent of the asylum at Ermelo was the
first to essay the boarding out of patients in families in the neighbour¬
hood of the asylum. The results obtained were very satisfactory, and
the system has now been adopted by Government for lunatics who are
kept by the State, and not by the parishes to which they belong.
Patients before being boarded out must have been inmates of the
asylum for a period of at least three months. Of course there is a
system of inspection : the patient is visited daily by an official of the
asylum and once a week by the physician, the day of the month and
the hour of the day being noted in a book and any remarks added.
The system has now been extended. At present the Government
and the County Council give an annual grant for every pauper lunatic
admitted into an asylum. This grant for the future can be used to
assist in defraying the maintenance of patients who are boarded out.
Such insane must have been inmates of an asylum for six months, the
inspectors must approve of the house selected, and the asylum can
board out only one tenth of its inmates, while the necessary accom¬
modation must be reserved for one tenth of those out, should it prove
necessary to send them back to the asylum.

It is a pity that this system should not be more extensively applied;

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PROGRESS OF PSYCHIATRY.

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it seems a far better plan than that of enlarging existing asylums,
several of which are already far too large. At the present moment the
board of governors of the Meerenberg Asylum are contemplating a
plan of extension. As it is, Meerenberg contains more than 1300
patients, and it is probable that the extensions will enable 300 more
to be received. It is to be, as they style it, a cite medicate, but it
will only prove of temporary benefit, since, as the population of the
province increases, so will the number of lunatics.

ITALY.

By Dr. Giulio Cesare Ferrari.

Last year, in my epitome of the work accomplished in the fields of
psychiatry and neurology, I endeavoured to give a general idea of the
geographical distribution of the more important centres of study and
work, showing their chief characteristics, their diverse tendencies, and the
nature of their publications and journals. I thought that once having
accomplished this, I would be enabled, in following years, to deal
systematically with the work done, but I feared that in doing so my
production would run the risk of being incomplete and not sufficiently
precise. I am obliged, therefore, again to follow the plan I adopted
last year, but in place of noting mere general tendencies and cha¬
racteristics, I propose to note the real progress in these branches of
science.

I start my review at the north of Italy, and progress to the south.

At Turin, the psychiatrical clinique is presided over by Lombroso, but
this year he has been largely engaged in the organisation of the Fifth
Congress of Criminal Anthropology, where his teachings first found
favour. One of his assistants, now third at the asylum at Turin,
which is directed by Marro, Dr. Marco Tr&ves has done some
interesting work—I allude to his interesting investigations regarding the
malformations of the nails in cases of periodic insanity, as significant of
great metabolic changes, and on the functional stigmata of degeneracy
in epileptics; further, he has constructed an apparatus which ensures the
constancy of thermic applications at any temperature from 5 0 C. to 8o° C.,
and maintains this temperature for any desired length of time, or varies
it with the greatest readiness when the temperatures are of wider range.
These thermic applications, which can be used internally, or better
externally, have a great future before them in the treatment of nervous
diseases, and in the field of experimental science.

Marro, this year, has been engaged on the second edition of his
clinical, anthropological, and social studies on puberty, which are now
to be published in French, and which are a veritable mine of interesting
facts and original observations. Pellizzi has continued his studies on
idiocy, trying to determine an anatomico-clinical basis for his two
great classes. By original observation he has studied the pathogenetic
conditions of cerebral diseases. Martinotti and Tirelli, with the aid of
the microphotograph, have worked on the nerve-cells of the spinal ganglia.
In the field of neuropathology there is at Turin, besides Silva and

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EPITOME.

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his pupils, Pescarolo, a clinician of great distinction, who has done
exfcellent work on the resistance of the body to electricity, on the
myopathic atrophies, and on the diagnosis of spinal diseases.

Still in the north of Italy, we find the asylum of Voghera directed by
Dr. Antonini. During the past year he has been mainly occupied
(besides his work on mental degeneracy) in combating the spread of
pellagra. To this end he founded the Rivista Pellagrogica Italiana,
so as to give unity to the study of this disease, and to influence the
governing ranks of society in their battle against this plague, which is
becoming more terrible, seeing that it is spreading to the mountainous
districts which have been hitherto free.

The younger workers, who have during the past year entered the
medical staff at the asylum of Milan at Mombello, have given good
proof of steady work. We notice, above all, the studies on Parkinson’s
disease by Pini and Gonzales, and on a case of hysterical oedema of
a segmental type. Gonzales has made observations on a case of
periodic ichthyosis of a diffuse character occurring in an imbecile. Pini,
on the other hand, has published a book on epilepsy, giving a critical
risumk on the bibliography of this disease, both ancient and modem,
and on the different methods of treatment—a most interesting work, and
which shortly will be translated into French.

At a little distance from Mombello is the beautiful asylum of
Bergamo, directed by Marzocchi, where Dr. A. Mariani applies himself
to the study of the prophylaxis of pellagra. He has also constructed
an ideal goniometer for the measuring of the facial angle.

At Brescia, Lui is publishing his notes on the technique of asylum
management, which are as admirable for their delicacy as for their
sound judgment; and with Seppilli, director of the asylum, Pianetta
and Lambranzi have published a number of clinical papers in the
Rivista di Patologia Nervosa of Professor Tanzi (Florence), and in
the Bollettino del Manicomio di Ferrara .

At Padova, Obici, assistant to Professor Belmondo, who holds the
chair of Clinical Psychiatry, has studied the influence of continued
mental work and intellectual fatigue on respiration, noting that the
respiratory activity is lowest between two and three o’clock. He is now
about to publish in the BibliotKkque international de Psychologie
experimental , a volume on writing, where he tries to give a psycho¬
logical basis to graphology. As regards clinical work, he has made
numerous observations on isotony, noting the blood-pressure in the
insane, dying, seniles, and degenerates.

Coming further south to G£nes, we find the clinique of Professor
Morselli. Buccelli has a work on The Mental State of Choreies , and
Professor Morselli is preparing a volume on The Mediums , which is
sure to excite great discussion, and also a second edition of his great
Trattate di Semiologia Psichiatria , to be followed by his important
Lessons on Anthropology.

Reggio Emilia, with its Institut Psychiatrique, directed by Tam-
burini, still offers the greatest advantages in wide fields of study.
Donaggio, by continuing his work and perfecting his methods, has
demonstrated the fact, about which no one will contest his priority, that
there exists an anastomosis between the reticula around the cell, and that

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PROGRESS OF PSYCHIATRY.

139

1902.]

in the middle of the cell. The small fibrils composing this reticula
represent the path of conduction and transmission of stimuli, and
represent the true individuality of the cell, contrary to the opinion of
Bethe. Donaggio has also done some interesting work on the syndroma
of Little. Ceni has studied the treatment of epilepsy by serothe¬
rapy. He has tried the progressive injection of the serum of
epileptics, to obtain an immunity or to increase the resistance to the
onset of fits. In eight out of ten cases he obtained an improvement
in nutrition, and a diminution in the number and in the severity of the
fits. He suspended the treatment: in three cases the attacks returned,
in three cases the improvement was maintained, and in two cases the
cure was complete after the lapse of two years. In two cases the
treatment had to be stopped owing to the occurrence of grave
symptoms. Ceni believes the good effects to be due to some principle
produced by metabolism, which is of a stimulating character and which
is found in the blood. He has discovered a new physiological
equivalent of the epileptic attack, manifested by hypothermic conditions.
With Dr. Pastrovich he has published a study on the pathogenesis
of epilepsy, which shows a specific principle of a toxic nature entirely
dissimilar to the toxines found in the blood due to organic functionising.
They have also studied the adaptation of nerve-cells to hyperactivity in
a work which is published in the Rivista Sperimentale di Freniatria, the
journal of the Institute of Reggio Emilia. Ceni is now studying
Pellagra.

Pastrovich has done some neuropathological investigations, comprised
in two cases of amyotrophic paralysis, a case of epilepsy following a
wound of the prefrontal region, and a rare case of paralysis of the
hypoglossal nerve, due to a peripheral neuritis. It is the first case
of its sort published where the origin was attributed to alcohol.
One cannot speak too highly of both the author and his work. He is
now engaged on a translation into Italian of the great treatise of
Oppenheim on nervous diseases, whose pupil he has been for a long
time.

As to myself, I have studied the genesis of systematised delusions,
trying to apply to them the theory of Lange-James on the emotions. I
have, in short, supported the primary and principal influence of the
emotional state in the development of delusions of persecution in
paranoides. In another paper, published in the Journal of Mental
Pathology , I have studied the physiological conditions associated with
periodic insanity. In addition, I have undertaken the translation of
Talks to Teachers on Psychology , of William James, whose Principles
of Psychology, translated into Italian, has been a great success.

In my laboratory of psychology in the Institute, Dr. Scappuci has
worked on the motor functions in the sane and insane, and on the
methods of examining psychologically the insane.

Not far from Reggio is the asylum of Ferrara, directed by Tambroni,
where is published a Bulletin , which is making its way in the world.
He publishes short papers by his own medical assistants, and those
of the asylum at Brescia, especially on the technique of asylum
management.

At Imola, near to Bologna, Brugia, director of the asylum, is inte-

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EPITOME.

[Jan.,

rested especially in psychopathology, and is about to publish a work
on degeneracy, illustrated by photographs. He has made some curious
observations on the periodic psychoses which are not yet published.

A centre of first rank, and yearly becoming of more importance, is
the clinique at Florence, directed by Tanzi. His lectures and the
editorship of the Traite de Psychiatric , which he has filled for some time,
and upon which he has imprinted his own remarkable originality, have
prevented him from making minor contributions. But Lugaro, without
doubt the chief cytologist in Italy, has worked with the assistants at the
clinique in the fields of pathological anatomy, experimental pathology,
and clinical psychiatry. Their papers appear frequently in the Rivista
di Patologia Speritncntale —the part dealing with current literature ex¬
celling many Centralblatter.

Rome is associated with illustrious alienists and promising students.
The university course in psychiatry is given by Professor Sciamanna,
who is assisted in the clinique by Pardo, Fabrizi, and Guidi. Pre¬
ference is given to clinical work and neuropathology.

The asylum of Rome is directed by Professor Bonfigli, who in 1898
began to give much thought to mentally defective children. He
founded a national league for the protection of this class, which was
supported by many people of note in Italy. It is showing good fruit
due to the organising spirit of its founder. He was fortunate in the
selection of Dr. Montessori, a young lady, and Dr. Montesano, two
people of great intelligence and devoted to their work, and with them he
opened a school where the masters of elementary schools were able
during eight months out of the year to attend the theoretical and
practical courses on the methods of educating backward children. The
methods were illustrated at an institute where sixty of this class of
children were collected. I regret I cannot find space to dilate further
on this meritorious work. In the asylum of Rome, besides clinical
investigations, there is much work done in the laboratory on pathological
anatomy under the direction of Mingazzini and his pupils. De Sanctis
continues his work, of which I made mention last year. A distinguished
assistant at the same asylum, Dr. Giannelli, who gives a course in
psychiatry at the University of Rome, which is free, has done some
remarkable work on the cortical centres of respiration, on microgyry,
and on bulbar paralysis, due to compression.

Professor Bianchi, Director of the Psychiatrical Clinique, of Naples,
has published the first part of his treatise on psychiatry. The main
lines of this work seem to aim at establishing an anatomo-physiological
basis in psychiatry. He speaks of the functions of the frontal lobes,
and of the evolutional regions of the human brain.

Fragnito continues his studies on the evolution of the nerve¬
cell, inclining more to the multicellular origin. Bellisari reports
three cases in which an attack of tachycardia took the place of epileptic
fits. Colucci, who is in the front ranks of Italian psychiatry, shows
how the ergographic index represents well the state of neuro-psychiatric
disequilibrium of the epileptic, and in a practical way demonstrates the re¬
education of dements. Crisafulli has done some interesting clinical w r ork.

Quite near is Aversa, whose asylum is directed by Prof. Virgilio.
He has raised the question of asylums for the criminal insane.

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In conclusion, there is at Nocera Inferiore an inter-provincial asylum
for almost the whole of southern Italy. Here we find Del Greco,
philosopher and psychologist, who has maintained the necessity of a
synthetic psychopathology contrary to pure materialism, more especially
the advanced experimentalism of official psychiatry. The insanity of
women, the moral cure of psychopathic attacks, etc., are receiving
attention.

Work of a more practical nature is being done by Angiolella and
Tomasini.

As regards Sicily, Mandalari, at Messina, has studied criminality,
and de Mondio amyotrophy.

Although perhaps out of place here, I wish to mention the
distinction cast on the Italian schools by Lombroso at the Congress
of Criminal Anthropology, held in August at Amsterdam. After
Holland, the greatest number of representatives came from Italy.

The year has been full of energy, the greatest activity being
displayed in the smaller centres of psychiatry. This was shown at the
sittings of the eleventh congress of the Society Freniatrica Italiana,
held at Ancona in September, of which Prof. Tamburini has been for
long the president.

Italian psychiatry congratulates this illustrious professor, who has
had a most distinguished career, and who in December celebrated
three anniversaries,—that of his professorship, as director of his asylum,
and as editor of the Rivista Sperimentale di Freni atria.

NORWAY.

By Dr. M. Holmboe.

Since my last report (in 1898) to this Journal no important changes
have taken place in the care and treatment of the lunatics in this
country.

At the end of the year 1900 a general census was taken, and on this
occasion the insane and the idiots were specially enumerated. The
results of this census have not as yet been elaborated and published,
and accordingly cannot be communicated here.

Since 1898 only one new asylum has been opened, viz., the private
asylum of Dr. Dedichen at Trosterud, about five kilometres east of
Kristiania. The asylum accommodates 58 patients, exclusively of the
prosperous classes, and is therefore arranged to afford greater comfort
than our State asylums, which are chiefly arranged for poor patients.
Royal authorisation for the asylum was given on September 28th this year.

The Criminal Lunatics Asylum in Trondhjem, mentioned in my last
“ Retrospect,” has been enlarged to about double its size—it can now
accommodate 30 patients.

The accommodation in the Norwegian State asylums at the present
time is—Gaustad 340, Eg 260, Rotvold 275, the Criminal Lunatics
Asylum in Trondhjem 30 ; and in the municipal and private asylums—
Kristiania 120, Oslo 40, Kristiansand 21, Bergen 240, Trondhjem 280,
Rosenbergs 175, Moellendal 73, Dr. Dedichen’s 58—total being 1714.

The new State Asylum Roenvik, at Bodoe, is completed, and will

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presumably be opened in August, 1902. It will accommodate 230 to
250 patients, thus increasing the total accommodation in the asylums
of Norway to about 1950. The municipality of Kristiania has recently
commenced the construction of a new asylum at Dikemark, in Asker,
about thirty kilometres west of the town. An estate of about 440 hectares
was some years ago purchased for this purpose. The general plan will
be a “ closed ” central building surrounded by “ open ” cottages—the
latter to be added by degrees. When completed, the asylum will
accommodate 600 patients. At present, however, only the central
blocks for male patients and the administration portions are under
construction.

The want of accommodation is more deeply felt as years go by, as
the difficulties of efficient nursing in private houses are constantly in¬
creasing. This was relatively easy in former times, when a good many
farmers, for a moderate pay, were willing to receive single lunatics.
The farmer nowadays has a higher appreciation of his home life, and
hence his unwillingness to receive such patients. Consequently in the
more prosperous and densely populated sections of the country it has
been necessary to place the lunatics, who cannot be received in the
asylums, under the care of persons making a business of boarding a
greater number of patients in rooms that are especially arranged for this
purpose. These establishments, commonly called “ colonies,” do not
always satisfy the requirements of modem nursing of such patients. It
is therefore intended to establish a more thorough inspection of these
colonies, and to promulgate more stringent rules regarding the treat¬
ment of patients so placed.

The question of erecting public boarding-houses of smaller size for
incurable lunatics at the expense of the counties (“Amter ”) has also
been raised, and one county has opened such a home for 25 to 30
patients. It is in connection with a general hospital.

The three boarding-schools for idiotic children mentioned in my last
“ Retrospect ” have now been purchased by the State, and are supported
by it. A nursing home for low-class idiots has been erected by private
charity, for the enlargement of which a considerable sum of money has
recently been collected.

Epitome of Current Literature.

1. Anthropology.

Shortness of the Hallux in Epileptics , Criminals , and Idiots [Sulla
Cortezza dell* Alluce negli Epilettici, nei Criminali, e negli Idiots],
(Arch, di Psichiat ., vol. xxii, fa sc. 4, 5, 1901.) Lombroso .

Developing an observation of Frassetto, which suggested shortness
of the hallux as an atavistic stigma in criminals, Lombroso has in-

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ANTHROPOLOGY.

1902.]

143

vestigated the relative lengths of the hallux and the second digit in
series of normal and abnormal individuals.

He obtained the following results:

Normal (Calabria and Sicily), males .

Hallux < and dig.
22 per cent.

Hallux = and dig.
36 per cent.

„ (Piedmont), males .

• 24

„ „ females

Epileptics, male (m cases)

• 36

• 289 „

„ female (159 cases)

• 295 „

Lunatics (54 cases) ....

• 19

Microcephalic idiots (10 cases)
Criminals, male (256 ^es)

• 30

• 465 „

35*4

„ female (93 cases)

• 531 »

Prostitutes (50 cases) ....

45 n

24*1

These figures satisfy the author that shortness of the hallux is a
characteristic of “ criminals ” as compared with “ honest people ” (sic);
and as the development of the hallux is more marked in the human
adult than in the foetus and in the anthropoid apes, he regards it as an
atavistic stigma. He remarks that this condition is often associated
with other atavistic characters, such as the retention of prehensile
power in the foot; in his view it is another expression of the imperfect
differentiation in form and function of the hand and foot in the criminal.

W. C. Sullivan.

Feminine and Atavistic Characters in the Pelvis in Criminals [Caratieri
femminili e atavici nei Bacini dei Criminalt], (Arch, di Psichiat . 9
vol. xxii,fasc. 4, 5, 1901.) Coscia .

The authoress has studied the characters of the pelvis in sixteen
skeletons of male criminals in Lombroso’s museum. In her paper she
gives the details of the examination in each case, with tables sum¬
marising the results for the whole series. She finds that the pelvis in
the criminal tends to approximate to the female type; and, though this
type is generally admitted to be morphologically higher than the male
type, she argues that the lack of sexual differentiation implied by this
resemblance is to be properly regarded as an atavistic character,
especially as it is in many cases associated with other peculiarities of a
distinctly prehuman kind.

The abnormal characters were found in the; following proportions:

1. Large size of pelvic outlet in three cases, or about 1 % per cent.

2. General thinness of pelvic bones, especially of iliac crest (under
15 mm.), in eight cases, or 50 per cent.

3. Diminished depth of symphysis pubis (less than 36 mm.) in six
cases, or about 36 per cent.

4. Open condition of sacral canal, incomplete in 37 per cent., and
complete in one case in which the pelvis was, moreover, of oval shape.

W. C. Sullivan.

The Influence of Sex on Anthropological Characters [Der Einfluss des
Geschlechts auf die anthropologischen Charaktere ]. (Zeit.f. Morphol.
und Anthropol., Bd. Hi, H. 3, 1901.) Pfitzner, IV.

The elaborate and important anthropological investigations made
during recent years by Prof. Pfitzner at the Anatomical Institute of

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EPITOME.

[Jan.

Strasburg are well known. The present study deals with sexual
differences in hair and eye colour, and in proportions of body and
head, difference in age being always taken into account; and, from the
care with which it has been carried out, and the large number of
subjects dealt with, the study constitutes a valuable contribution to our
knowledge of this subject. As the author himself points out, certain
sources of error exist; we are dealing with dead subjects only, in a
hospital, so that there has been 44 selection by death ” and 44 selection
by hospital; ” but even when we bear these sources of disturbance
in mind the results remain very instructive. A few of the points
brought out in this lengthy paper may here be mentioned.

The author reaches the conclusion that sexual differences are, on the
whole, very slight, being for the most part the result of the difference in
size, and he disposes of the contention of those who argue that there
are serious defects of proportion in women. Certain differences, how¬
ever, are clearly brought out; the conclusion of those who have
argued that women are darker than men is here definitely confirmed ;
it is more marked as regards the hair than the eyes; women are
darker than men by about 7 per cent, as regards the hair, by about
3 per cent, as regards the eyes. Certain anomalies occur at the two ends
of life, but after twenty men invariably prevail among the light-eyed
persons who die, and women among the dark-eyed, while those with
mixed eyes are almost fairly divided throughout. Pfitzner finds reason
to believe that the hair continues to show a tendency to darken up to
the age of forty, but eye colour remains relatively constant.

The two extremes of light-eyed and dark-eyed are found to prevail
specially among children dying at an early age, while mixed eyes are
found chiefly prevailing among those who die at an advanced age 1 this
would appear to show that mixed eyes indicate a tendency to
longevity, though the author is very careful in interpreting his data.
He refers to this point, however, in reference to the body and head: as
regards general body proportions, he finds little difference in the long-
lived as compared with the short-lived, but it is not so as regards the
circumference of the head; among the long-lived there is an increased
prevalence of large heads. Very small heads, it may be remarked,
cease to grow about the age of twenty, but large heads continue to
grow up to the age of thirty and even beyond. While circumference
of head seems to be thus related to longevity, it is not so as regards
height of head; individuals with high heads are not favoured as
regards longevity.

As regards the cephalic index, certain sexual differences were found,
but they were not considerable; the author does not, indeed, feel
convinced that they may not be the result of chance. His belief that
they are probably real is due to the fact that they occur very harmoni¬
ously : in women, the indices under eighty predominate more than in
men; in men, the indices over eighty-five are more numerous than in
women. The general result is that there are 3J per cent, more dolicho-
cephals among women, 3} per cent, more brachycephals among men.
This conclusion is not in harmony with all previous investigations, but we
always have to remember that there may be racial difference in sexual
variation; these results must only be taken as reliable for Elssass-

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NEUROLOGY.

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Lothringen. The breadth-height index of the head showed no
clearly demonstrable sexual differences, such differences as occurred
being less harmoniously arranged than in the case of the cephalic
index. The breadth-height index of the face, however (/. e. y distance
from root of nose to chin expressed in percentages of the malar
breadth), showed clear sexual differences ; the indices under ninety in
women, and the indices over ninety in men, being in decidedly larger
proportion, although the general range of the index was the same for
both sexes. Havelock Ellis.

2 . Neurology.

On the Nervous System of a Hemicephale \ Ueber das Neroensystem eines
Hemicephalen\ (Arch, f Psychiat. y Bd. xxxiv, H. 3.) Mur alt y Z.

After a retrospect of previous work on anencephalous births, Dr.
Muralt proceeds to describe the skull and brain of two of those
monstrosities. The first, a male child, born at full time, lived for two
days, during which he cried lustily, swallowed, and showed the usual
muscular motions and reflexes. His head resembled that of a cat, no
forehead, the face prognathous, the nose and lips thick, and the eyes
prominent. The head was covered with thick hair, and there was no
roof to the cranium. The rudiments of the brain were shut in by a
soft membrane. These structures are pictured in a large lithograph
sheet, and their description fills seventeen pages of the Archiv.

The second case described was a foetus of the female sex, which
measured from the head to nates no more than two inches. The brain and
spinal cord were wanting. In place of the cranium, there was a sac
filled with fluid extending down the cavity of the vertebral canal.
Twenty-seven vertebrae were counted, and eighteen spinal ganglia
attached to the nerves, the growth of which appears to have been
unaffected. The sympathetic nerves were found unaltered in the neck.

In the first case, the hemicephale, the mucous membrane of the
nostrils and the sensory organs of the skin were normal, so that we
may infer that their development goes on independently of the nervous
centres. The result of Muralt’s examination of the basal portions of
the brain in this case is far from confirming the view that the deficiency
is caused by the destruction of the hemispheres through the pressure of
hydrocephalic fluid. A microscopic examination showed that the
rudiments of the centres had their own limiting coating of epithelium.
The deficiency was owing to a failure of formative power, not to
external injuries. This failure was greatest at the head, and less at the
extremity of the trunk. Those portions of the optical apparatus which
were concerned with actual vision were formed* not out of the
epithelial layer, but out of a bladder-like process of the anterior cerebral
vesicle. In the anencephalous foetus, the anterior parts of the eye, such
as the lens or ciliary bodies, have sometimes been found wanting. In
recorded cases, with two exceptions, all the layers of the retina were
found save that of ganglionic cells and nerve-fibres. This is difficult to
explain. Jacob’s rods and cones were found intact. As a rule, in the

XLVIII. 10

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EPITOME.

[Jan.,

anencephalous foetus, the retina has been found to be well developed ;
sometimes it is thrown into folds. William W. Ireland.

On the Structure of the Brain in which the Corpus Callosum is wanting,\
and on Microgyry and Heterotopy of the Grey Matter [ Ueber den Bau
des vollstdndig balkenlosen Grosshimes sowie uber Mikrogyrie und
Heterotopie der grauen Substanz von Dr . Moriz Probst\ (Bd. xxxiv,
H. 3.) Probst> M.

Dr. Probst begins by remarking that he can only find two cases
before that described by Rokitansky, in 1858, in which the corpus
callosum was deficient, one by Reil in 1812, and one by Ward in 1846.
He apparently has overlooked the case mentioned in Solly’s book on
the brain in 1827, and another by Paget in 1846. If Dr. Probst had
lighted upon the excellent paper by Dr. Alexander Bruce, recorded in
th t Proceedings of the Royal Society of Edinburgh, vol. xv, pp. 320—341,
he would have been able greatly to add to the sixteen cases which he
has mentioned. I have myself seen an instance of complete deficiency
of the corpus callosum in the brain of a deaf woman who died in the
Stirling District Asylum. There are at least six cases (Probst only
knows of two) in which, without any mental deficiency or loss of
sensory or motor power being observed during life, the corpus callosum
was found to be entirely wanting.

The case of deficiency described by Probst was a female idiot, aet. 12
years. She had scarcely any intelligence, and never spoke or walked;
the muscles of the leg were in spastic contraction. The description of
the brain occupies thirty-eight pages of the Archiv besides three pages
explaining four sheets of lithographs. The author has made most
careful microscopic examinations of the whole brain, and has taken
much trouble to trace various tracts of nerve-fibres. There are many
anomalies and defects found in this brain, so that it would be unsafe to
base any inferences bearing upon the structure of normal brains from
these dissections. It would appear as if the connections of the different
parts of the hemispheres in this brain were kept up by what he calls the
“ Balken-langsbiindel,” the associatio fronto-occipitalis of Onufrowicz. It
occupies the place of the absent corpus callosum, under the gyrus
fomicatus and above the fornix. Its fibres, short and long, longitudinal
and transverse, were traced to the gyrus fomicatus and the frontal
lobes, also to the orbital and median gyri. Its fibres passing back¬
wards go to form the posterior wall of the lateral ventricles, and perhaps
to the tapetum. Probst objects that Onufrowicz made no microscopic
observations in his case, and throws doubt on his fronto-occipital
association bundle. The name heterotopy was given by Virchow to
masses of grey matter, of much the same microscopic structure as the
cortex, which were found irregularly scattered through the brain sub¬
stance. In Probstfs case, they were found in the convolutions, in the
centrum ovale, and in the walls of the lateral ventricles. In the central
convolutions these irregular masses were found to go along with slender¬
ness of the gyri. Heterotopy has been found associated with epileptic
dementia and microcephaly.

At the end of his paper, Dr. Probst promises a further work giving
the results of his experiments upon the association and commissural

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NEUROLOGY.

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1902.]

fibres of the brain. Though this is an important subject, we advise the
author to try and convey his meaning in shorter space. Learned
Germans too often possess the property of filling up many pages
without making their meaning clear. Papers in the Archiv especially
seem often to be selected for the same reason as Frederic William’s
Potsdam Guards, namely, for their length. William W. Ireland.

On the Restoration of the Peripheral Nerves [ Ueber die Regeneration
peripherischer Nerven]. (Arch. /. Psychiat. t Bd. xxxv, H. 3.)
Bethe.

At the meeting of German neurologists and alienist physicians in
Baden-Baden, June, 1901, Dr. Bethe, of Strasburg, explained that
during the last decade a new nerve-cell theory had come into vogue.
It was assumed that the so-called neuron was an anatomical, functional,
pathological, and developmental entity. But it had been shown by
Apathy that there is a direct and intimate connection between the
neurons through the primitive nerve-fibrillae, and Dr. Bethe himself
had demonstrated that in the carcinas manas the nervous system
performs its function without any ganglion ceils. Thus the cell cannot
be a necessary instrument in the process like the pendulum of a clock,
or the wheel of a watch. Nissl has shown that the observations of
pathologists give no sure support to the neuron theory. Further
objections may be taken from the fact that several organs are affected
after section of the nerves supplying them. In the case of degenera¬
tion of muscles and glands, it may be said that this process may be
owing to atrophy from inactivity of their functions; but degenera¬
tion of the papillae circumvallatae et foliatae of the tongue in the
rabbit has been observed to follow, in from about two to three weeks
after section of the glossopharyngeals, although the stimulus has not
ceased to be applied to these organs. From this it appears that the
pathological process goes further than the boundary of the neuron.

According to the neuron theory, the ganglion cell is the nutritive
centre of its adjuncts, and the axis cylinder of the nerve-fibre perishes
if separated from the presiding cell and it can only be renewed by out¬
growth from it. The first part of this observation is correct. When
the continuity of a nerve is destroyed the peripheral end always
degenerates ; but the second part of the sentence is incorrect. It has
been shown by Huber and Buchner that the axis cylinder is not
restored from the central end of the nerve, but from the degenerated
plasma of the substance of Schwann. By experimenting on young
dogs and rabbits Dr. Bethe has found that, when the nerve-stem is cut,
the distal end degenerates; but if the process of union be hindered
that the peripheral end will in time be fully reproduced in all its parts,
although kept separated from the central end, and thus from the
original ganglion cells. Dr. Bethe has assured himself that the
regenerated nerve-end is also physiologically restored, since it can
transmit weak electrical currents to the muscles. Dr. Bethe, after
finding the still detached nerve fully restored, made a section of it
lower down, when he found that only the most distal part degenerated,
/. e. t the part separated both from the spinal cord and from the lower
extremity was not involved in the degeneration.

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EPITOME.

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Dr. Bethe then goes on to combat the views of His, who holds that
the nerves develop peripherally from the grey matter and ganglia of
the spinal cord. Dr. Bethe, on the contrary, maintains that the fibres
of the nerves originate from cells, and that the process of development
and its completion by the appearance of the myelin goes on almost
simultaneously along the whole line. William W. Ireland.

The Exact Histological Localisation of the Visual Area of the Human
Cerebral Cortex . (Phil. Trans. B. vol. cxciii, pp. 165—222, 1900.)
Bolton , T. S.

The work, which has led to the production of this excellent mono¬
graph, has occupied the author for three years. It has finally been
brought to a conclusion at Claybury, and is one of the best pieces of
work which has yet hailed from that laboratory. Dr. Bolton has
bestowed an enormous amount of industry and care upon his work,
and it is a difficult task to do justice to it in an epitome.

The author points out that the lamination of the occipital cortex
differs from that of the cortex surrounding it by having the granular
layer divided into two by a layer of nerve-fibres (line of Gennari). The
exact distribution of this " occipital lamination ” was accurately mapped
out in six normal and pathological brains (three cases were blind).
The area occupies the body of the calcarine fissure , including anterior and
posterior annectants and extending upward to the parallel cuneal sulcus
and downwards to the collateral fissure, the posterior pari of the calcarine
fissure extending to the polar sulci surrounding its extremities, and the
inferior lip of the stem of the calcarine fissure (including the superficial
surface and lower lip of the cuneal annectant) nearly to its anterior
extremity, just posterior to which the area tails off to a sharp point.
The outline of this area is therefore roughly pear-shaped, the stem of
the pear being anterior. The area is decreased in extent, but not in
distribution, in cases of old-standing optic atrophy ; and it is decreased
in both extent and distribution in anophthalmos. Similarly the line of
Gennari is much thinner than normal in cases of old-standing optic
atrophy and of anophthalmos.

The author’s conclusions are that the area located and described in
the paper is the primary visual region of the cortex cerebri, that the
part of this area to which afferent visual impressions primarily pass is
the region of the line of Gennari, that the area can probably be
described as the cortical projection of the corresponding halves of both
retinae, and that in this projection the part above the calcarine fissure
represents the upper corresponding quadrants, and the part below the
fissure the lower quadrants of both retinae. W. H. B. Stoddart.

The Croonian Lectures on the Chemical Side of Nervous Activity.

(Lancet and Brit. Med. Journ., 1901.) Halliburton , W. D.

The first lecture dealt with the general composition of nervous
structures. Grey matter contains 80—90 per cent . of water, and 50 per
cent, of the total solids are proteid. In white matter there is less
water and less proteid, and in peripheral nerves is least water and least
proteid. The most abundant proteid is a nucleo-proteid containing

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NEUROLOGY.

149

*5 per cent . of phosphorus, but there is little of this in the white
matter. The other two proteids are globulins, one of which coagulates
at 47° C.

The other important substance in nervous tissue is protagon, which
yields on decomposition cerebrin and lecithin. Cerebrin is a glucoside,
the sugar constituent being galactose. Lecithin yields on hydrolysis a
fatty acid, glycerine, phosphoric acid, and choline (an alkaloid).

The second lecture dealt with the metabolism of nervous tissue.
The lecturer pointed out that oxygen was rapidly used up in cerebral
activity, and in support quoted HilPs experiment, in which an anaes¬
thetised animal received methylene blue by intra-venous injection, and in
which any part of the brain thrown into action by electrical stimulation
lost its blue tint owing to the formation of a reduction product. Dr.
Waller’s experiments, which appear to show that carbonic acid is formed
during the activity of a nerve, were next described, and his theory of the
nutritional relationship between axis cylinder and medullary sheath
discussed. The lecturer described experiments which appear to
militate against Dr. Waller’s theory.

Passing on to microchemical methods, Nissl granules were referred
to. Chemically they are composed of nucleo-proteid. This lecture was
concluded with a discussion on the various current theories of sleep.

The last two lectures were devoted to the subject of chemical patho¬
logy, especially in reference to hyperpyrexia, general paralysis of the
insane, and Wallerian degeneration.

It was pointed out that the cause of death in hyperpyrexia was heat
coagulation of cell globulin, since 42 0 C. (108° F.) was sufficient to
cause such coagulation if sufficiently prolonged. With regard to
general paralysis, the chief points were the presence of choline and
nucleo-proteid in the cerebro-spinal fluid, and of the former after a
succession of fits. Choline lowers the blood-pressure when injected
into the circulation of animals, but this action is reversed if the animal
be previously placed under the influence of atropine. Choline is
found in the cerebro-spinal fluid and blood of other diseases in which
there is disintegration of nervous tissue in progress.

In nerve degeneration the phosphorised fats are converted into non-
phosphorised fats, and these are subsequently absorbed. This fact
explains the Marchi and Pal reactions in degenerated nerve-tracts.

W. H. B. Stoddart.

A Preliminary Communication with Projection Drawings illustrating
the Topography of the Paraazles (.Lateral Ventricles) in their
Relations to the Surface of the Cerebrum and Cranium . (New

York Med. Journ ., Feb. 2, 1901.) Spitzka , E. A.

This is an anatomical study of two heads by the sectional method,
special attention being directed to the exact position of the lateral
ventricles. The author is one of the New York medical students.

Puncture of a distended lateral ventricle is as a rule not a very
difficult matter, but if the ventricle be undistended (as in cases where it
is desired to inject antitetanic serum), success in accurately striking it
is somewhat problematical. The lateral ventricles are normally little

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EPITOME.

150

[Jan.,

more than a potential space, since, the author tells us, they are only
capable of holding 60 c.c. between them.

A study of a larger number of heads is necessary before it can be
decided how far this work will help the operating surgeon. One
ventricle out of the four examined was greatly displaced, and it must be
determined how frequently such variations exist before the author is
able to place rules in the hands of the practical surgeon.

The work is carefully and accurately carried out, and we shall look
with interest for the final result of this research.

W. H. B. Stoddart.

The Croonian Lectures on the Degeneration of the Neuron . (Brit. Med.

Journ ., 1900.) Mott, F IV.

Lecture I.—After a brief historical summary of the growth and
conception of the neuron theory, the lecturer prefaces his observations
upon degeneration of the neuron with a short account of the minute
histology of the nervous system as revealed by modern methods.

After dealing with the significance of the Nissl body and the
phenomenon of chromatolysis at some length, the question of correlation
of function and myelination is touched upon, and the first lecture ends
with a few short remarks upon the anatomical correlation of associated
systems of neurons.

Lecture II is devoted to a consideration of the effects of injury to
the nerve upon the cells of origin, of hyperpyrexia, of experimental
anaemia, of toxic conditions of the blood and lymph, and of the
selective action of certain poisons.

The portion relating to hyperpyrexia and the effects produced upon
the nerve-cell and a consideration of the chemistry of the subject will be
found abstracted from Prof. Halliburton’s papers, and needs no further
comment here. Much space is given to a description of the minute
morbid appearances of the nerve-cells, chromatolysis, vacuolation, eta,
as a result of the action of various toxic bodies upon them, and
numerous sections were exhibited.

The relative action of various toxic agents for different parts of the
nervous system was discussed, as, for exmaple, the predilection of the
tetanus toxine for the motor cells of the fifth nerve nucleus, and the
inference drawn that the protoplasm of these various neurons might
own corresponding small differences in composition. The results of
the experiments done in producing artificial anaemia of the brain and
spinal cord were reviewed, and sections shown exhibiting the changes
produced in the nerve-cells. The practical deduction drawn was that
the transitory aphasias, monoplegias, hemiplegias, etc., of syphilitic
nervous disease were in all probability due to blocking of vessels in
which the time which elapses before anastomotic circulation is
established is too short to permit fatal changes to be set up in the cell.

Thus Ehrlich and Briezen, in 1884, showed that if the abdominal
aorta were ligatured for from a quarter to three quarters of an hour and
then the anaemia were relieved, no permanent paralysis remained, but if
the anaemia persisted for over an hour permanent paraplegia of the lower
limbs resulted.

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NEUROLOGY.

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ISI

Lecture III.—This is concerned particularly with an account of the
Marchi method of staining the degenerated fibres and its chemical
reaction to the products of degeneration.

Lecture IV.—It related largely to some toxic conditions in relation
to degeneration, and commences with a consideration of the relation*
ship of tabes and general paralysis, and goes on to deal with the
relation of structure to degeneration and the pathology of primary
degeneration of the afferent and efferent systems.

The main points of these latter lectures have already been summarised
in the Journal, and need not therefore be repeated.

On the Morbid Anatomy of Pseudo-bulbar Paralysis [Per P Anatomia
patologica della Paralisi pseudobulbare\ ( Riv . at Patol ., nerv. e
ment^fase. 9, 1901.) Guizzatti and Ugolotti.

The case, a woman set. 62, alcoholic, presented the following clinical
history:—Six years ago she had a right-sided hemiparesis, followed by a
second similar attack in two years. Three years ago she had a weakening
of the voice ending in aphonia, followed by dysarthria and dysphagia.
There were also paresis of the lower facial muscles, especially on the
right side, without atrophy, paresis of the tongue and palate. In
addition to the right-sided hemiparesis, there was latterly paresis of the
left leg.

The post-mortem revealed interstitial nephritis and a marked degree
of thickening of the arteries. In the nervous system, the cortical cells,
the nuclei of origin of the cranial nerves and their roots, the peripheral
nerves and muscles were all normal. There were numerous small
areas of softening of different dates in the cerebrum in both hemi¬
spheres, one affecting the genu of the internal capsule on the left side.
In the pons were four small areas. In the cord, a rarefaction of the
direct pyramidal tract on left side, and sclerosis of the crossed
pyramidal tracts especially on right side. The authors discuss the
various lesions that have been noted in this condition in relation to the
lesions here found, and conclude that the greater portion of the bulbar
symptoms in the case were due to a small softening in the upper part
of the pons, mesially and posteriorly. This affected both strands of motor
fibres and caused the bilateral symptoms. J. R. Gilmour.

The Phenomenon of Chromatolysis after Resection of the Pneumogastric
Nerve [Le Phenomtne de la Chromatolyse aprh la Resection du Nerf
pneumogastrique ]. (Nouv. Icon . de la Salp ., Nos. 4, 5, 6, 1900.)
Ladame , C.

The work is divided into six parts. In the first part, an account is
given of the varying results obtained by Nissl’s method of staining,
concerning the minute anatomy of the nervous cell and its lesions.
The numerous modifications of this method were tried, and Ladame
places most reliance on the method of Van Gehuchten, which he has
altered in certain details; so that, for instance, instead of washing in
water after fixation he carries his specimens into 60 per cent . alcohol
saturated with chloride of sodium ; whence, after leaving them in this
bath for a while, they are placed in 70 per cent . alcohol, also saturated

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EPITOME.

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152

with chloride of sodium. He uses, moreover, essence of cedar in
preference to chloroform as the vehicle of paraffin for embedding, in
spite of certain drawbacks. Toluidine blue is used instead of methy¬
lene blue for staining the sections, and gives a neat, intense coloration,
agreeable to the eye ; moreover it is more stable than methylene blue.

In the second part, an account is given of the minute anatomy of the
neuron, and especially of the chromatic substance which plays the
main part, at all events the visible part, in the phenomenon of chroma¬
tolysis.

In the third part, a general account is given of the fundamental
factors in chromatolysis with regard to which observers are in general
agreement—such as the disaggregation and dissolution of the chromatic
masses, the turgescence of the cellular body, the displacement of the
nucleus, etc. As chromatolysis differs in nerve-cells according to the
initial lesion of the nerve, is different in motor neurons as compared
with sensory neurons, as it varies in animals, etc., the author insists on
the importance of specifying exactly the varying conditions under which
experiments and observations are made.

In the fourth part, Ladame gives an account of his own personal
experiments and observations. Two rabbits, two dogs, and two cats
were the animals used. A detailed analysis and discussion of each
case are given, with description of the sections and numerous figures,
list of apparatus, etc.

The animals were killed with chloroform after an interval varying
from 7 to 195 days after the operation (resection of the pneumo-
gastric nerve in the neck). In order to test carefully the question
of turgescence of the cells undergoing chromatolysis—generally
mentioned by observers—lists of the measurements of the cells obtained
by means of one of Nachet’s micrometers are given in extenso.

The first experiment was upon a rabbit killed on the 7th day;
the second on a dog killed on the 22nd day ; the third on a young cat
killed on the 118th day; the fourth on an adult dog killed on the
122nd day; the fifth on an adult cat killed on the 147th day; and,
finally, the sixth on an adult rabbit killed on the 195th day.

The fifth part of the paper deals with the interpretation of the
phenomena observed, and at the end there is a brief rtsume of the
main conclusions which the author deduces from his experiments.
The following are original facts and opinions:—Chromatolysis is
characterised by the disaggregation and dissolution of the chromatic
masses and the migration of the nucleus. Turgescence is not in any
way a regular phenomenon in chromatolysis. In the dog on the
122nd day, and in the cat on the 147th day, after the resection of the
vagus, the pathological dorsal nucleus of the tenth pair shows no
diminution in the number of its elements. The dog on the *2nd and
122nd day presents chromatolysis in the ganglion corresponding to the
sound nerve, as well as in that corresponding to the resected vagus.
Vacuolisation is one of the forms of the process of cellular degenera¬
tion. H. J. Macevoy.

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PHYSIOLOGICAL PSYCHOLOGY.

1 S 3

3. Physiological Psychology.

The Development of Memory in Children [Experimented Untersuchungen
tiber die Gedachtnissentwickelungbei Schiilkindern ]. (Zeits. f Psyche
Bd. xxviiy If. 1 and 2, 1901.) Lobsien , Marx.

These experiments were made on 238 boys and 224 girls, between
the ages of 9 and 14, in the schools at Kiel. Eight different kinds of
memory were investigated, involving in each group a test of the ability
to remember in exact order nine sensory impressions (nine objects
exhibited in succession, nine figures repeated, nine names of visual
objects repeated, nine names of states of feeling, nine difficult unknown
words, etc.). Among the boys the average order of excellence reached
was as follows (in decreasing values): real things, figures, words
referring to touch, visual words, words representing sounds, actual
sounds, words referring to feelings, difficult words. In every group
(except that of objects exhibited) there was a regular improvement
with age. In regard to objects seen, sounds heard, and representations
of feeling, there was a marked improvement in memory about the
thirteenth year. The memory for figures, and for sound-words, touch-
words, and feeling-words, showed most rapid development at an earlier
age (ten to eleven years). There was no tendency to a simultaneous
development in all the groups; mental energy seemed to be con¬
centrated on one group at a time.

Girls, on the whole, showed somewhat similar development to boys,
but tended to be superior. The chief period of development for girls
was about the twelfth year. The average of total improvement in
memory was somewhat higher for girls than for boys. Between the
ages of nine and ten the relative increase of memory is greater in boys
(as 6 to 5), but at all other ages the girls are superior to the boys.
The girls are notably superior to the boys as regards figures, sounds,
and visual words.

The author elaborates his results in great detail; as many as 67
tables and curves are presented. Havelock Ellis.

Studies of Memory in the Normal , Neurasthenic and Insane [Studien
iiber die Merkfdhigkeit der Normalen, Nervenschwachen und
Geisteskranken ]. (Monats. f. Psych, und Neur. f Bd. ix, 44,

1901.) Ranschburg , P.

The author has devised a method by which the memories of
individuals may be compared to one another or to a perfect standard.
His method tests the memory for words, persons, colours, orientation,
names, and numbers.

In testing word-memory, he repeats to the subject fifteen pairs of
words—five involving an association of ideas, as house, door; mouse,
trap; steam, kettle; five arranged on the principle of co- and sub¬
ordination as—hand, finger; fish, water ; day, week ; God, Heaven ;
and five having some similarity of sound as—dog, dock; wand,
wander; pick, picture, etc. He then repeats one word of each

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EPITOME.

154

[Jan.,

couple, and gets the subject to name the other word. Marks are
awarded according to the subject's success.

The subject is then shown, out of an album containing fifty bust
portraits of equal size, the portraits of four men, four women, and
two children. He is then given the album to look through and
required to pick out the portraits which he has already seen.

As a test for colour, the subject is shown five portraits pasted on
differently coloured mounts, and is required to name the colours when
shown duplicate portraits on white mounts.

The test for orientation is as follows :—The author has a sheet of
white paper mapped out into 21 x 33=693 squares. About 150 of
these squares are blacked in without any definite arrangement. Five of
these black squares are then pointed out to the subject, who is subse¬
quently required to recognise them.

Memory for names is tested by telling the subject the names of
certain persons in the portrait album, and asking him to name them
again after an interval.

Memory for numbers is tested by such associations as 15, George
Street, September 17th, eight pence, etc.

By such methods Ranschburg tested various classes of people,
700 marks being full; schoolboys obtained 360; uneducated classes
327, highly-educated classes 462, neurasthenics 317, and general
paralytics 97. W. H. B. Stoddart.

Obsessions of Scruple [La Maladie du Scrupule ou FAboulie
dilirante\ (Revue Philosophique y April and May , 1901.) Janet ,
Pierre .

Dr. Janet is unrivalled in the delicate and elaborate psychological
analysis of hysterical and neurasthenic mental states on the borderland
of insanity. In the present paper he presents a well documented study
of classes of obsession (which would by some be classed under folie du
doufe), marked by an excess of scrupulosity, more especially an
excessively scrupulous body-consciousness or modesty, obsessions of
crime and sacrilege, and hypochondriacal tendencies. Under this head
he introduces an interesting discussion of hysterical anorexia. True
hysterical anorexia, he states, is rare, and should not be diagnosed
unless there is more or less complete suppression of hunger, and also
an exaggerated tendency to physical exercise—both these symptoms
resting on anaesthetic conditions. He then narrates the case of a young
girl, Nadia, whose symptoms had been falsely diagnosed as those of
hysterical anorexia, but were really what Janet would call an obsession
of scruple. She refused to eat, but remained hungry, sometimes very
hungry, so that she would sometimes devour greedily everything she
could put her hands on, especially in private. But eating always
causes horrible remorse. There is no suppression of hunger, nor is
there any tendency to exaggerated movement; she takes exercise, but
with an effort. Regarded superficially, the idea that animates her is the
fear of becoming fat, like her mother. But that idea is not isolated,
but really connected with a whole system of complex ideas. It is not
a mere matter of coquetry; she looks on being fat as something almost

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1902.] PHYSIOLOGICAL PSYCHOLOGY. 155

immoral, something so shameful that it would prevent her from showing
herself in public. She will not eat in the presence of others, nor can
she even bear that others should hear her eating; she feels about eating
(as she herself admits) as others feel about urinating. Nor is her
feeling of shame confined to eating; from an early age she has been
ashamed of her face, her hands, her legs, her feet, and regards them as
ugly and badly made. But deeper, perhaps, than any other idea, is the
desire to remain a little child, and be loved as a child. Such a case
Janet regards as typical of this class of obsessions, very interesting from
a clinical point of view, since they give rise to all sorts of symptoms—
anorexia, chorea, writers* cramp, incontinence of urine, impotence, etc.
Altogether they constitute a great neurosis, analogous in many respects
to hysteria, but not to be confounded with it, the distinction being im¬
portant both as regards prognosis and treatment. While such cases
might be regarded as victims of a phobia, Janet thinks it better to
regard them as primarily the victims of scruple—emphasising their
troubles of will, and the ideas which they form of these troubles—and
he regards the phobia ^s secondary. Janet considers John Bunyan as
a fine type of obsession of scruple. He believes that suggestibility
plays a very small part in such cases; they are endogenous, as he
expresses it, rather than exogenous, and their obsessions are an index
of the things that are most sacred to them.

Janet has met with as many as eighty-five cases which he would
include in the group of scrupuleux , more usually women than men, and
generally among the educated class. It will be seen, however, that the
group has many affinities with other groups, and Janet proposes to
devote a volume to its more exact study. The scrupuleux do not
really believe in their own ideas, and are ashamed of them, can only
with great difficulty be brought to speak of them clearly, and they must,
Janet believes, be distinguished, on the one hand, from the victims of
systematised delusions, and, on the other hand, from the hysterical,
whose more simple ideas have a different mechanism.

Havelock Ellis.

Vertigo \Le Vertige: Atude physio-pathologique de la Fonction <? Orien¬
tation et dEquilibre\. (Revue Philo sop hique y March and April\
1901.) Grasset,

Attention may be drawn to this elaborate and systematic study by
Professor Grasset, who is also publishing (in the Bibliothtque Scientifique
Internationale) a volume entitled Maladies de t Orientation et eTltquili-
bn. The author, who shows a wide knowledge of the work on this
subject done in other countries, considers it important to remember
that vertigo is constituted of two sensations: (a) a sensation of dis¬
placement of the body in relation to surrounding objects; (b) a
sensation of loss of equilibrium. He defines it (“ synthetically and
schematically ”) as a “subjective psychic phenomenon constituted by
the transmission to the cerebral centre of a double sensation: a false
sensation coming from the apparatus of orientation, and a sensation of
the inadequacy of the polygon (by which he means the ensemble of the
automatic centre of orientation and equilibrium) to ensure equilibrium.”

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156

EPITOME.

[Jan.,

Physiological vertigos are taken into consideration, though the study
is chiefly devoted to the pathological varieties, and the symptoms are
classed as ansesthetical, hyperaesthetical, and paraesthetica). A full
schematic table of the objective and subjective symptoms is presented.

Havelock Ellis.

Cross-education . (Studies from the Yale Psych . Lab., 1900.) Davis ,

Walter G .

In continuing his investigations into this subject, Davis has confirmed
his earlier result as to the marked influence of exercise on one side of
the body in increasing power on the unexercised side, while bringing
out many new results m matters of detail. The experiments were
made with the dynamometer and the ergograph. The influence of the
factors of length of hand, length of fore-arm, previous muscular
development, and temperament are taken into account, and the sexual
differences also noted. As regards temperament, Davis finds it most
convenient, from this point of view, to recognise three temperaments :
the nervous, the motor, and the phlegmatic. *The influence of this
factor of type is found to be very important. Persons of the nervous
type tend to be quick in muscular and mental reaction, short as regards
height, and light in weight. Persons of the phlegmatic temperament
are found to be slow in muscular and mental reaction, tall as regards
height, and heavy in weight. Persons of the motor type are in all
respects medium. There are, of course, many cases of mixed type.
On the whole, however, they require different degrees of exercise to
produce the full effects of cross-education, the phlegmatic, as a rule,
considerably more than the motor. Exercise that is too slight, or too
severe and fatiguing for the individual, will fail to produce proper
development. If the work is just right in intensity and amount the
anabolism provoked is greater than the katabolism, and there is
development of the part used. An almost endless variation of con¬
ditions would be necessary to make the adjustment of exercise suitable
to all individuals. Exercise must be prescribed per order just as a
dress must be fitted to the individual.” Davis emphasises the conclu¬
sion to which his experiments point: that the mental factor is of much
more importance than the muscular factor. Cross-education is mainly
a matter of nervous centres and nervous channels. These researches
are of considerable interest, both theoretical and practical.

It may be remarked as bearing on this question of cross-education,
that since Davis’s experiments were published, F 6 r£ (in the last volume
of the Annee Psychologique) has pointed out that with the ergograph
alternation of work with right and left hands produces reciprocal
stimulation of the homologous cerebral centres. This fact also, as
F€x€ remarks, furnishes a physiological basis to Fourier’s doctrine of
the value of variety in work. Havelock Ellis.

Correlation between Mental and Motor Ability . ( Arner. Journ . Psychol .,
vol. xii, No . 2, 1901.) Bagley , W. C.

These experiments were carried out on school children at Madison
at the suggestion of Professor Jastrow, with the object of testing the

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1902.]

PHYSIOLOGICAL PSYCHOLOGY.

I 57

results of Porter at St. Louis. Porter found a marked tendency to a
direct relation between weight and mental precocity; weight, he then
argued, stood for motor ability, and hence a child increases in mental
efficiency directly as he increases in motor ability. These conclusions
have been seriously criticised.

Bagley instituted a direct comparison between motor ability (as
tested in five respects indicating motor strength, speed, accuracy, and
steadiness) and mental ability (as judged by class standing and the
teacher's independent estimate); a decidedly inverse relation was found
between class standing aud dynamometer records. So also as regards
class standing and steadiness of voluntary movement, and as regards
class standing and accuracy of voluntary movement. The relationship
of motor rapidity and one or two other motor characters to class
standing was either less clear or indifferent. Nor, when the age factor
was eliminated, was it possible to find much direct relation between
weight and motor ability. The numbers were not sufficiently large to
be absolutely conclusive, and, moreover, the method for ascertaining
correlation was a somewhat special one, devised by Jastrow. So far as
they go, however, the results are markedly opposed to Porter’s. With
whatever individual exceptions, they show that the pupils who are best
developed physically, who are strongest and have most motor control,
are generally deficient in mental ability. There seems to be little direct
relation between mental ability as represented by reaction times and
mental ability as represented by class standing. Havelock Ellis.

Taste Sensations in the Larynx \Ueber Geschtnacksempfindungen im

Kehlkopf]. {Zeits. f PsycholBd. xxvii , H. i and 2, 1901.)

Kiesow , F. y and Hahn , R.

Verson, in 1868, discovered in the epiglottis nerve-endings, which he
regarded as essentially resembling those which Schwalbe and Lov 6 n
had then recently discovered in the tongue of man and other mammals,
and regarded as the primary organs of taste. Michelson, in 1891,
brought forward experimental evidence to show that they really were
capable of conveying sensations of taste. In the present paper Kiesow
and Hahn, after setting forth the present state of the question, describe
their own experiments, carried out at the Physiological Institute of
Turin. They tested the inner surface of the epiglottis, as well as the
interior of the larynx, with reference to reaction to the ordinary taste
stimuli—sweet, bitter, acid, salt. Only three subjects were available
for complete investigation, one of these being Kiesow himself.
Schroetter’s laryngeal sound was used in applying the test solutions,
and various precautions were adopted in order to eliminate the obvious
sources of error, while all doubtful trials were left out of account. In
all three subjects the majority of experiments revealed the existence of
sensibility on the laryngeal surface of the epiglottis to all four orders
of test substances, although the sensations were of less intensity than
when the same stimuli were applied to the tongue. All the subjects
declared that they had never experienced taste sensations at such a
depth, and were able to indicate on the external surface of the neck
the spot at which the sensations were localised. Sweet and bitter

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i 5 8

EPITOME.

[Jan.,

sensations were always easily recognised. Kiesow, however, was
unable to identify acid stimuli, which he felt as salt, possibly because
the end organs for acid in his case were lacking, and their place taken
by those reacting to salt. The experiments within the larynx, made
on Kiesow alone, also revealed the presence of taste sensations.

The authors do not discuss at length the object of this gustatory
sensibility of the larynx. They regard this question as unsolved,
though they consider that such sensibility is a survival of phylogenetic
development, maintained because standing in some relation to the
reflex mechanism. Havelock Ellis.

The Development of Voluntary Control . ( Psychol . Rev ., Sept., 1901.)

Bair, J, H.

How it is that we obtain voluntary muscular control is a problem of
great interest and importance, for it helps to explain the origin and
nature of the will. Bair has investigated the conditions and processes
by which such control is gained in the case of a particular muscle. He
selected the retrahens aurem because of its complete isolation from
other muscles, the inability of most people to contract it, the com¬
parative ease with which control can be learnt, and the definite
movements attending contraction ; moreover, this muscle is adequately
supplied with motor and sensory nerves, and there is every reason to
suppose that control over it is acquired in the same way as over any
other muscle. Of the fourteen subjects on whom the experiments
were made only two could move their ears at the beginning of the
investigation, and then only by vigorously raising the brows.

Two Marey tambours were employed throughout the experiments,
connected by a rubber tube so that the lever of one tambour would
respond to the movement of the other, and the receiving tambour was
attached to the ear, a difficult part of the experiment. An induction
coil of constant current was also employed to give the subject the idea
of the movement by means of artificial contraction of the muscle.

The experiments were made in a uniform manner, and fairly uniform
results were obtained in all cases, as is shown by the series of curves
presented in the paper. Each curve consists of four parts: (1) the
current was applied; (2) then together with the current the subject
tried to add his voluntary effort; (3) then he attempted to inhibit the
action of the current; (4) finally he tried to move the ear voluntarily,
without the help of the current. Although the idea of the movement
was again and again given by the contracting current the movement
could not be reproduced when the current was withdrawn, so that the
author cannot agree with those psychologists (Stout, Baldwin, etc.) who
think that the idea of movement is sufficient to enable us to reproduce
it; “ however much may be said in favour of man’s superior mental
qualities, * free ideas,* etc., he is nevertheless conditioned by the same
laws as the animal, and cannot learn a movement apart from its chance
function in a motor impulse.” Voluntary movement of the retrahens
only begins to show itself when the subject bites the jaws together or
vigorously raises the brows; in this way the second part of the curve
came to be notably increased and the third decreased, and the fourth

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1902.]

Physiological psychology.

iS9

stage began slowly to appear. Thus the ear was first reached by
innervating a group of muscles (also supplied by facial nerve) over
which we already possess control; it was reached by making it one in
the group, so that learning to contract a new muscle is a matter of
association with a group of muscles already in good working order.
Until a movement is effected there is no sense of innervation. It was
also noted that learning to make a voluntary movement is largely a
matter of learning to relax. This is first learnt by withdrawing
attention from the movement just effected—a voluntary attempt to relax
will merely tighten the tension. When good control over the muscle
was obtained by making it one of a group, it gradually became possible
to move it without any other muscular movement. The author
concludes that the idea of a movement is not sufficient to produce that
movement; that we get control of a muscle in a group and can then
single it out and gain independent control; and that the more closely
attention can be directed to a movement, and the more nearly the part
of the movement desired not to be made can for the moment be
forgotten, the more likely is the desired movement to be accomplished.
The rapidity with which the whole process is accomplished is entirely
proportional to the ability to concentrate attention.

Havelock Ellis.

Contribution to the Study of the Psycho-physiology of the Emotions in
Connection with a Case of Ereuthophobia [Contribution d PJifudc
de la Psycho-physiologie des Emotions a propos d'un Cas cPAreutho-
phobie ]. (Rev. de Psychiat ., No. 7, 1900.) Vaschide and

Marchand.

In the various cases of ereuthophobia (or morbid blushing) recorded,
it appears to be clear that the emotional element is preponderant; but
one point has been neglected, that is, the investigation of vaso-motor
reflexes. The study of the case here recorded throws some light on
this aspect of the question, especially as the patient, being intelligent,
ablv seconded the authors in the determination of certain points of
their experiments.

M—, a shoemaker, was aged 36 years on admission at Villejuif
Asylum. In his previous history one notes that he had syphilis at the
age of seventeen; at the age of twenty one he became a soldier
in Africa, had malaria later in Tonquin, where he stayed three
years. While there, he first suffered from the obsession of blushing ;
this idea led to a change in his character so marked that it caused his
mother to send him soon after to the asylum at Vaucluse, at the age of
twenty-eight; the obsession was not divulged by the patient, so that “ the
doctors there were ignorant of his principal complaint.” He married
when he left the asylum, two years later. His certificate on admission
to Villejuif, in 1899, stated that he was suffering from chronic
alcoholism, with a subacute exacerbation, multiple hallucinations,
ideas of persecution, transitory excitement, trembling of hands, and
cramp in the limbs. Among other signs on admission were noted
exaggeration of knee-jerks and marked exaggeration of vaso-motor
reflex. A few months after his admission, the symptoms of alcoholism

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i6o

EPITOME.

[Jan.,

had mostly disappeared; the patient was sleeping better; the trembling
of the hands persisted; the ideas of persecution were still present, but
less defined.

It was only four months after arriving at Villejuif that he made his
physician a confidant of his fixed idea—he had always concealed it,
even from his mother and his wife. Since his first attack, at the age of
twenty-two years, the obsession is always provoked by the arrival of a
stranger. Pallor seemed generally to precede the blushing; the
blushing was not always present, only when the attacks were severe.
The patient was conscious of his change of character after the onset of
the morbid blushing; he became very timid, depressed. He often has
dreams in which he imagines that he meets a stranger, and under these
conditions he feels the same phenomena as in the waking state. The
obsession never leaves him. To conceal it, he gets into the shade, or
turns his back to people, or pretends to look elsewhere. But an in¬
fallible means of avoiding blushing, he has discovered, is to drink
alcohol, especially absinthe.

The authors* experiments with the patient were undertaken with a
view to determine the relations of succession between the physiological
phenomena and the emotional disorder. The neuro-vascular reactions
were studied and registered by the graphic method. The thoracic
respiration, the circulation in the radial pulse, and that in the capillaries
of the hand were taken simultaneously or in succession. The blood-
pressure was determined by Potain’s apparatus.

The experiments consisted in introducing in the room at a certain
given moment one or more strangers, and registering the effect in
the various tracings. The authors tabulate the results obtained. A
pseudo or so-called “absinthic” condition (a psychical illusion) was
induced in the subject by giving him a draught containing paregoric
elixir, and then a comparison was established with his normal condition.
The general conclusion to which the authors are led is that the
obsession of the fear of blushing (qud emotion) is cerebral in origin.
The ideation of the subject provokes an association which, in its turn,
suggests an emotion of expectation, of anxiety or anguish, and the
neuro-vascular phenomena are in no way the source of these emotional
intellectual changes. The changes of ideas and of associations of
ideas bring about, and then only a few moments after, important
respiratory, radial, or capillary modifications. That the initial pheno¬
menon is a cerebral phenomenon, and not of neuro-vascular nature, is
shown by the fortifying influence of the absinthe, which acts not in
virtue of its alcohol, but as a suggestive stimulant. Without discussing
the theory of the emotions, they believe that the theory of Jaraes-
Lange has yet to prove, and especially to explain, the mechanism of the
neuro-vascular modifications as initial phenomena. The authors’
experiments prove that the cerebral phenomena are the initial genesis
of the somatic changes, and that on account of the momentary or
spontaneous ideation, the respiration becomes more or less lowered, as
the pulse becomes more or less accelerated. H. J. Macbvoy.

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1902.]

PHYSIOLOGICAL PSYCHOLOGY.

161

Projection of Dreams into the Waking State [Projection du Rive dans
litat de Veil/e]. (Rev. de Psychiat., No. 2, 1901.) Vaschide et
Meunier.

The notes of a case—an epileptic female suffering from complicated
delusional insanity—are given to show the preponderating influence of
dreams upon the mental life. E. V—, now set. 45 years, was brought
up as a child under unsatisfactory conditions (family quarrels, unkind
mother, etc.). She was married at the age of twenty-six, and took to
gambling. She had her first epileptic fit when thirty-one, after a
violent emotional shock (witnessing the paternal house on fire); it was
followed by disordered mind for forty-eight hours. Subsequently fits
recurred for a time every six months, always followed by short periods
of mental disorder; then they became more frequent. When thirty-
seven, after an attack, she developed hypochondriacal ideas and
delusions of persecution with auditory and sensory hallucinations, on
account of which she was sent to an asylum.

She now presents hypochondriacal ideas of negation after dreams or
delusional crises. On awakening, or after the crises are over, she
remains convinced of the reality of these ideas, although she gradually
dismisses them or forgets them. After vivid dreams, she wakes up
convinced of their reality, so that in time they gradually assume the
character of obsessions and direct her conduct by provoking im¬
pulsions. These appear during the post-epileptic state with the
characteristics observed in the “psychical equivalents” of epileptic
attacks—sudden pallor of the face, irresistibility, amnesia. After an
interval of time, it becomes practically impossible for the patient to say
whether certain ideas or hallucinations originated in a dream or in
hallucinations during the waking state.

The dream, then, has for her the vividness of an hallucination, the
hallucination the indecision or vagueness of a dream. The history of
this case sets clearly the problem of the influence of dreams on the
waking state, and especially illustrates the pathological part played by
dreams. The authors believe that the psychical substratum in the
mind—subconscious as regards our personality—is often revealed in
dreams; and that the life in the dreaming state—the subconscious
modified by the physiological rest of the night—has a far more con¬
siderable influence on the waking state than the latter has on the former
(the dreamy state). It is, perhaps, in the psychological analysis of
insomnia or in the study of sleep that we shall discover the intimate
mechanism of a large number of psychopathies. A noteworthy
observation in this case of E. V— is that she presents another perfect
psychological automatism ; her movements are admirably co-ordinated,
her gestures well defined; a state of consciousness, a strict logic
presides over the satisfaction of her desires,—in a word, the human
machine “ functions ” without any appreciable defect, better, perhaps,
than in a completely normal individual. Are we to attribute the
perfection of this automatism to the predominance of the dream over
her real life? Other important issues are raised in this interesting
study, which constitutes a plea for the careful observation and analysis
of dreams. H. J. Macevoy.

XLVIII. 11

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EPITOME.

162

[Jan.,

Materialistic Psychiatry [Materialistische Psychiatric ]. (Monats. f.

Psych, und Neur ., Bd.ix , H. 1, 1901.) Juliusburger , Otto.

Dr. Weygandt, in an article entitled “Psychology and Cerebral
Anatomy in Special Relation to Modern Phrenology,” which appeared
in Die Deutsche Medizinische Wochenschrift\ made the statement that
the only true basis for the study of psychiatry is the acceptance of the
doctrine of psycho-physical parallelism, and quotes Wundt’s definition
of this parallelism in support. Dr. Juliusburger feels it his duty to pen
a somewhat indignant and scornful reply, and points out, in the first
place, that whereas in 1863 Wundt, in his lectures, treated human and
animal psychology from a monistic point of view, it is only in later
years (1892) that he took up his dualistic standpoint of a psycho¬
physical parallelism, according to which, although with every psychical
act there is a co-existent physical phenomenon, nevertheless these two
manifestations are entirely independent of each other and have no
causal relationship. Dr. Weygandt agrees with Ebbinghaus that mind
and brain are not separable entities—the one a product of the other—
but they are an actual combination, varying only according to the
point of view from which we regard their manifestations; when viewed
from within, these phenomena are psychical, when from without,
physical.

Dr. Juliusburger confesses himself totally unable to understand this
theory, and agrees with Ziehen that it is little more than playing with
words.

The theory of localisation is now on such a firm basis that one is
compelled to apply it to every psychical phenomenon, and the fact
that many errors occur in attempts at minute localisation does not in
any way detract from the truth of the principle.

Dr. Weygandt repudiated the theory of the junction of Meynert’s
association fibres, apparently on the ground of insufficient proof. From
this Dr. Juliusburger assumes, though on what grounds this is not
clear, that Weygandt denies the theory of association altogether and
adduces examples of manifestations in the insane which, to him, are
only to be explained by an association theory.

The reply concludes with a small dissertation on the neuron and a
long quotation from Herbert Spencer on the transformation and con¬
servation of energy, neither of which appears to be relevant to Wey-
gandt’s original article.

The whole tone»of Dr. Juliusburger’s contribution rather gives the
impression that there is a considerable substratum of argumentum ad
hominem , and it is worthy of notice that the journal which printed Dr.
Weygandt’s article declined to accept Dr. Juliusburger’s reply for
publication. W. H. B. Stoddart.

The Evolution of Psychology \DEvolution de la Psychologic']. (Rev. de
Psychiat ., No. 9, 1900.) Toulouse , Ed.

The author is interested in determining in what direction the spread
of our knowledge of psychology tends ; what results seem desirable and
probable in the struggle going on in the various fields of energy which
are thrashing out its problems. For centuries introspection was

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PHYSIOLOGICAL PSYCHOLOGY.

163

1902.]

practically the only means of study employed by philosophers; then
came the experimental method. In this connection Toulouse em¬
phasises the importance in our measurements of having physically and
chemically defined standards. It is not only necessary to have a
number to express our toil measurement, it must be a number
determined by precise conditions. The difficulties under which various
workers labour are pointed out, especially that of obtaining average sub¬
jects for experiments.

In asylums for the insane we have a vast and rich field of experience,
where subjects are numerous and realise true natural experiments, so
that the psychiater is, in truth, the best armed in this struggle of ex¬
perimental psychology.

Toulouse concludes that the orientation of psychology, determined
by the actual experimental tendencies, must be towards psychiatry as
obtains in Germany. H. J. Macevoy.

The Influence of Alcohol on Handwriting [Ueber die Beeinflussung der
Schrift durch den Alkohol ]. (Psychologische Arbeiten , Bd. Hi, H. 4,
1901.) Mayer, Martin .

Previous investigations have shown—in harmony, indeed, with daily
experience—that alcohol renders more difficult the perception of
sensory impressions and the associated mental activity, while, on the
other hand, it makes voluntary operations easier. At the same time,
in apparent apposition with the latter result, alcohol has little or no
influence in increasing work done with the dynamometer or ergograph.
In order to follow out the workings of alcohol in a field where its finer
influence could be precisely traced and measured, Mayer has investi¬
gated its effects on handwriting in accordance with the exact methods of
Diehl. In one series of experiments the dose of absolute alcohol taken
was 30 grammes, in another series 60 grammes. The results are recorded
in full detail in this paper. It was found that alcohol has a slowing
influence on writing movements; in small doses the pauses are
shortened and the pressure increased; in large doses the pauses tend
more to be increased, while the pressure is decreased; there is no
recognisable influence on the way of writing. These results are
recorded in detail with the precision that the instrumental study of
handwriting now renders possible. Incidentally, Mayer introduces an
interesting discussion of the resemblance of alcoholic intoxication to
mania, which has often been pointed out. In both there is diminished
attention, a flood of ideas with tendency to sound associations, an
inclination to arrogance, and increased facility in obeying impulses.
As soon, however, as we begin to inquire into the details of psycho¬
motor activity (as may be done by reference to Gross’s study of the
precise characteristics of the handwriting in mania) profound differ¬
ences may be traced. Common to both states is the shortening of the
pauses, the release of movement becoming easier. In mania, however,
there is greater excitability, the shortening becoming more marked in
the course of writing, while in intoxication the pauses soon tend to be
increased. Movement itself is in both conditions slowed, but in mania
with very great rapidity. In mania, also, the writing is from the first

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164

EPITOME.

[Jan.,

large, and tends to become larger as writing is continued, while in
intoxication there is no change in this respect. Pressure, again, is
much more increased in mania, and rises as writing is continued. The
finer variations do not disappear as they do in intoxication, hut are
still more marked than normally, and changes in pressure occur with
undue swiftness. On the whole the phenomena of intoxication, as
evidenced by the handwriting, present a picture of increased excita¬
bility succeeded by paralysis, while in mania no symptoms of paralysis
appear at any stage in the writing process, but, instead, an increasing
excitability overcoming a preliminary tendency to inhibition of move¬
ment. Havelock Ellis.

On the Duration of the Psychic Action of Alcohol \Ueber die Dauer der
psychischen AIkoholwirkung \. (Psycho logische Arbeiten % herausgeg.

von Kraepelin, Bd. iv, H. i, 1901.) Riidin .

This paper is a further contribution to the experimental study of the
action of alcohol on mental function, which has already been the object
of several valuable researches by the Heidelberg school.

The author’s chief aim was to determine how long a single dose of
alcohol continues to influence simple psychic processes. The same
question was investigated by Fiirer (vide communication to Congress
for Prevention of Alcoholic Excess, Basle, 1896), who found that the
effect of alcohol administered over-night lasted throughout the following
day. As Fiirer’s experiments, however, were all made on a single
individual, and with very large doses of the drug, control researches
appeared desirable.

The experiments recorded in the present paper were made on three
persons for a period of eight days, and on a fourth for a period of eleven
days. The subjects were selected with due regard to similarity of age,
education, habitual abstinence from alcohol, etc., and the conditions
of the experiments were arranged on the usual lines. The alcohol was
given in the form of wine, the dose being equivalent to 90—100
grammes of absolute alcohol. It was administered half an hour before
the evening worktime of the fourth day, and in the longer investiga¬
tion a second dose was given to the subject on the evening of the
eighth day.

The experiments referred to addition of figures, learning by heart,
reaction time, and rapidity of association. The results under the last
head were analysed in the light of Aschaffenberg’s classification of
associations.

The results of the experiments are given in full detail, and are
judiciously discussed. The author summarises them in the following
conclusions:

1. The action of a large dose of alcohol on four different indi¬
viduals showed marked differences in its direction, intensity, and
duration.

2. In general, its effect was to decrease the amount of work in
addition and in learning by heart, to cause a shortening of reaction
time with increased tendency to errors (Fehlreactionen), and finally to
accelerate associations resting chiefly on speech images. In one of the

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1902.] PHYSIOLOGICAL PSYCHOLOGY. 165

individuals examined this quickening of motor associations was the only
apparent effect produced by the alcohol.

3. The action of the drug was perceptible as a rule for twelve to
twenty-four hours, sometimes, apparently, for as long as forty-eight hours.
Of the different effects the shortening of reaction time was the earliest
to disappear, being replaced by a lengthening with persistence of
“ Fehlreactionen.”

4. The susceptibility to alcohol is not dependent on want of habit;
it may be very slight after prolonged abstinence.

The conclusions as to the nature of the alcoholic influence are in
accord with those of most other observers, and appear fully warranted
by the facts, as shown in the detailed account of the experiments.

The inferences regarding the duration of this influence—the special
object of the inquiry—are perhaps more open to criticism. The
supposed effect during the day after the administration of the alcohol is
not shown, as is the case with the immediate effect of the drug, by an
absolute decrease in the amount of work done; it is apparent only in
a failure to reach the increased rate of work which would be expected
under normal conditions as a result of practice. This rate of work is
estimated by comparing the amount done on the day before the alcohol
with that on the third day after its administration, the result being
controlled by reference to the average range of variation from other
causes calculated on the figures for the entire period of the experiment.
The risk of fallacy in this method when applied to such short periods is
obviously great, and even if its substantial accuracy be admitted, the
effects which it is supposed to demonstrate in these experiments are
very slight and very inconstant. Further proof, therefore, is needed
before the author’s view on this point can be finally accepted, especially
as it is in contradiction with the results of at least one observer
(Partridge). The question is of considerable interest, for, as the author
points out, such a persistent action of alcohol would be an important
element in establishing the chronic intoxication.

The experiments showing the influence of alcohol on the different
forms of association are particularly interesting and suggestive. The
paper is altogether a very notable contribution to the scientific study of
alcohol. W. C. Sullivan.

The Action of Hunger on Psychic Processes [Ueber die Beeinflussung
geistiger Leisiungen durch Hungern ]. (Psychologische Arbeiten ,
herausgeg . von Kraepelin , 3 d. iv, H 1, 1901.) Weygandt.

In this paper the author records the results of a series of elaborate
experiments showing the condition of mental function during pro¬
longed abstinence from food. The experiments were made on six
individuals; the period of fasting generally ranged between 12 and 36
hours; in one instance it was extended to 48, and in another to
72 hours. In some of the experiments water was withheld as well as
food. The psycho-physical tests employed were those current in
Kraepelin’s laboratory, a few modifications of detail being introduced
in some of them. One new method—Griesbach’s examination of the
range of tactile sensibility—was also tried, but was found very un¬
satisfactory.

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EPITOME.

166

[Jan.,

The results of each test are given in full detail, with an exhaustive
discussion of their interpretation. A short review of the references to
the question in general and scientific literature is added.

The author terminates his remarkably able paper by the following
conclusions:

1. The psychic process undergoes a distinct change in conditions
of abstinence.

2. The action is a sharply defined one, in that certain functions are
more affected, others less, and others not at all.

3. Perception is not influenced by hunger.

4. The association of ideas is modified, the inner associations
decrease, associations by speech-images increase, sound associations
appear, association time is not changed.

5. Addition is considerably retarded.

6. Memory work in learning by heart is distinctly retarded; the
change affects only the retention, not the speech process.

7. There is a slight slowing of reaction time; mistake reactions
(“ Fehlreactionen ”) are occasionally increased.

8. The effect of practice is not perceptibly impaired during the
hunger phase.

9. Susceptibility to mental fatigue is not essentially different from
the normal.

10. Inattention and, still more, emotional irritability, are slightly
increased during hunger.

11. Abstinence from water as well as from food seems to affect the
process of association more than abstinence from food alone; otherwise
no differences appear between the two conditions.

12. The psychic changes in the phase of hunger disappear
gradually, and not suddenly, after its cessation; they are still per¬
ceptible forty-eight hours after a period of abstinence lasting two
days.

13. The action of hunger resembles the selective action of several
chemical agents, and certain mental disorders which accompany
anomalies of metabolism; it most nearly approaches, without, however,
exactly producing, the psychic changes after bodily exertion.

14. In nocturnal exhaustion experiments, the symptoms of mental
and physical fatigue seem to be associated with those due to
hunger.

15. The psychic symptoms of the so-called exhaustion psychoses do

not correspond to the changes which are produced by simple abstinence
from food. W. C. Sullivan.

The Neurosis of the End of the Century [// Nervosismo di questa Fine di
Secolo ]. (Conferenza 1899. Nel Cireolo Filologieo di Napoli -

Estratto da Flegrea.) Bianchi , L.

This address was delivered at the conference of the Philological Club
at Naples, in 1899. The author points out that the neuroses are as
old as man. He passes in review the different phases of these neuroses
through which races have come as knowledge advanced. In the early
ages as the result of a belief in a vindictive God, the neuroses assumed

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1902.] ETIOLOGY OF INSANITY. 167

a melancholic form with religious ideas. The neuroses of the Greeks
and Romans were coloured by the realism of the period. There
followed an era in which all power was given to Satan, and in conse¬
quence an ascetic mysticism resulted, with the foundation of many
religious orders, which spread all over Europe. Epidemics of hysterical
and demoniacal possession were common. A new era dawned with
greater liberty of thought and action. The author then gave statistics
pointing to the great advances made in language and education, in our
knowledge of the human body, and the laws governing it. From these
have followed the neuroses of the present time—the weariness of life,
the diffidence, the excitability, the unrest that needs always new and
more powerful stimuli, the intolerance of restriction and of discipline
that denotes a great hypertrophy of egoism which, in its most marked
development, gives us the anarchist epidemic.

This will be checked by a knowledge of the facts and laws of Nature.
Larger concessions to labour and to agriculture and more liberty for
evolution may cause anarchism to disappear, but the neuroses will
continue varied and eternal as life itself. J. R. Gilmour.

4. ^Etiology of Insanity.

On the Etiology and Morbid Anatomy of Recurrent Insanity [Zur
Aetiologie und pathologischen Anatomie des periodischen Irreseins).
(. Monats.f Psych . und Neur., Bd. viii, H. 5, 1900.) Pilcz, A .

Heredity is the most important factor in the causation of recurrent
insanity, and Dr. Pilcz quotes many distinguished authors in support
of this view. Kraepelin puts the proportion of cases of recurrent
insanity with hereditary taint at 80 per cent., while Morel regarded
folie circulaire as a manifestation of hereditary taint.

Second in importance as an aetiological factor Dr. Pilcz places
acquired disposition. By this he means traumatism and organic brain
disease. The writer insists at some length on the latter. He points
out that recurrent insanity does not, as a rule, tend to dementia.
Twenty-five cases are here noted, of which eight showed no positive
change post mortem, while the remaining seventeen showed anatomical
changes. In all the seventeen dementia had set in, while in all the
other eight there was no sign of weak-mindedness. It may therefore
be assumed that in any given case of recurrent insanity where there is
intellectual impairment, there is one or more focal cerebral lesion.
There is nothing characteristic in the position or nature of these
lesions, except that in all there is secondary glia proliferation.

No explanation is forthcoming of our inability to find cerebral
changes in those cases where there is no impairment of intellect, and
Dr. Pilcz suggests that research should be directed to anomalies of
convolution, developmental abnormalities, etc.—conditions which are
teratological rather than pathological, and which would point to faulty
development of the nervous system, giving rise to stigmata of degener¬
ation in the brain.

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i68

EPITOME.

[Jan.,

The author, in conchision, draws attention to the setiological and
symptomatic similarities between recurrent insanities, and Samt and
Krafft-Ebing have described an “epileptic circular insanity.”

W. H. B. Stoddart.

Alcoholism as a Cause of General Paralysis [ISAlcoolismo come Causa
della Paralisi generate]. (Ann. di NevrolAnno xix, fasc. 2.) Seppili.

The author, studying the aetiology in 102 cases (78 males and 24
females) of general paralysis admitted under his care to the Brescia
asylum between 1894 and 1900, found 16 cases (13 males and 3
females) in which alcoholism appeared to him to be the sole cause of
the disease. He gives in this paper a very brief resumk of the clinical
history of these cases, and of the macroscopic brain lesions noted in
ten of them. He finds that alcohol is capable of generating a true
general paralysis, and that cases of alcoholic origin do not differ in any
respect from cases of other causation. In six of his cases the disease
was of the exalted type, in one of the hypochondriacal, and in nine of
the simple demented type. The cases ran a progressive course without
remission, terminating fatally in from two to three years. The dis¬
tinctive characters which some authors assign to alcoholic general
paralysis or pseudo genectiX paralysis—generalised tremor, slightness of
speech trouble, frequency of remission, etc.—were not noted. Hallu¬
cinations and the delirium of conjugal infidelity, also said to be specially
common in such cases, were only found in one instance.

From a foot-note it appears that syphilis was traced only in twenty
cases of the whole series, and in five of these the history was doubtful.

As the author’s results are in marked contradiction with those of
most other observers, it is to be regretted that he has not given some
details of the evidence from which he inferred the causation of the
disease in his cases. W. C. Sullivan.

The Altiology of Progressive Paralysis in the German Tirol. ( Allgem .

Zeiis. f. Psych., Bd. lviii t H. 2 and 3, 1901.) jEisath, G.

From the beginning of the year 1889 to the end of 1899, 128 cases
of progressive paralysis came under observation in the German Tirol;
out of this number there were 104 men and 24 women. The
amount of insane patients during these eleven years came to 5*4 per
cent.; out-patients as well as in-patients were included in this calculation.
The age at which the disease made its appearance varied between
thirty and sixty-four.

The syphilitic nature of the disease was carefully considered, and the
cases were divided into three groups:

1. Syphilis certain in 27 per cent.

2. Syphilis uncertain in 34 per cent.

3. Syphilis absent in 39 per cent.

Other observers, such as Rieger and Sprengeler, have obtained higher
percentages in their syphilitic cases, 41*5—43*4 per cent. The
author explains the low percentage in his syphilitic cases by saying that
he only included under the heading No. 1 those patients who pre¬
sented actual signs of the disease when they were examined.

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1902.]

ETIOLOGY OF INSANITY.

169

Many observers, he adds, would include under “ syphilis certain ” cases
having a history of several miscarriages, childless marriages, suspicious
fundus changes in the eye, and a history of some venereal disease;
he, on the other hand, would class these under No. 2. Another cause
which would help to explain tfce low percentage would be the fact that
peasants in the country are very often not aware that they have had
syphilis. A third cause of the low percentage is due to the fact that
during the first few years after 1889 less notice was taken of syphilis as
being a cause of progressive paralysis; the effect of this would be to
increase the number of doubtful cases and diminish the number of certain
ones. If Berkeley-Hill’s rule were a law, that is, if two thirds of the
doubtful cases were classed among the certain ones, then the number
of paralytics due to syphilis would rise to 47*9 per cent . In all other
cases of insanity syphilis is regarded as a cause in only 1*3 per cent .
Statistics in the Tirol show that paralytic dementia follows the
spread of syphilis. It appears that the country population are free
from paralysis, and that the germ of the disease is brought from the
towns. The author states that in his cases the period of time elapsing
between the primary sore and the onset of progressive paralysis varied
from seven to twenty years.

Traumatism was regarded as a cause in eleven cases.

Alcoholism was an aetiological factor in 36*5 per cent, of the cases.

Lead was not regarded as a cause. Two cases followed the infectious
diseases malaria and typhoid, but in both the length of time was too
great between the infectious disease and the onset of paralysis to
regard the one as the cause of the other.

Mental overstrain was a cause in five cases.

Heredity played a part in 33 per cent.

The particular occupation seems to have a great influence on the
disease; thus, amongst country peasants the amount of paralysis was
•07 per mille; Artisan class, *39; business and trade in towns, 1*38 ;
military and workers in the open air, 7.

The risk of getting progressive paralysis is 142 times greater in
towns than in the country; thus during eleven years the figures showed
for the country *07 per mille, , whilst amongst the town population it
was 1 per cent.

Dr. Eisath finds that as far as the German Tirol is concerned (and
this must be regarded as chiefly a country population) sexual excesses
form the chief cause of the disease, syphilis and alcohol being included
as setiological factors. R. Carter.

The Bodily and Mental Individuality of the Woman and her Insanities
[DIndividuality somato-psichica della Donna e le sue Frenopathie\
(II Manicomio, Anno xvii , Nos, 1, 2.) Del Greco.

This thoughtful paper treats of the different characters of nervous
diseases manifested in women from those in man. It groups the
mental alienations of women into six classes, distinguished by tempera¬
ment, and profound alterations of constitution brought about by disease.
In the mental derangements of the female, observes the professor, there
is a more pervading change in the whole temperament, not only

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170

EPITOME.

[Jan.,

mental perversions, but a multiplicity of organic sensations which act
upon the entire personality, inducing states of exaltation and depression,
emotions of joy and grief, of fear and anger. These complex changes
sometimes culminate in the feeling of altered personality. The
structural differences between the male and female render the latter less
able to react upon external nature. Her frame is adapted to maternity,
conception, gestation, labour, lactation; then the renewal of the periods
induces profound changes in her organism. These functions affect even
the disposition of the bones and ligaments, the increase and diminution
of the unstriped muscular fibres, the activity of the sympathetic ganglia,
the vascularisation of organs, and the augmented cellular secretion and
enlargement of the glands. The totality of changes, so diverse and
profound, subject the feminine constitution to grave fluctuations, which
alter its relations to the outer world and affect the psychical manifesta¬
tions.

It has been observed that in the transmission of hereditary disease
from the male parent, troubles of nutrition such as gout and diabetes,
are resolved in the daughters into nervous and mental affections. The
woman is stronger than the man in nutritive powers, which react more
easily, and are the great provision of latent energy indispensable to the
function of maternity. On the other hand, the woman has less power
of action and co-ordination in the psychical and nervous functions; she
has less cerebral and neuro-muscular energy. In her, the psycho-
organic reflexes predominate, and the inhibitions of cerebral life are
weaker. Thus, in the woman, the pathological heredity attacks the
place of least resistance. The greater disposition of women to
insanity has been affirmed by Esquirol and commented upon by Marro
in his elaborate studies on the subject.*

Marro has observed that after the menopause the mental alienation of
women turns in a new direction. In the young and robust woman
insanity often takes the form of mania with perverted sensations.
After the menopause she is no longer subject to profound nutritive
oscillations ; but there occurs the danger of defective excretions of the
products of physiological changes, and she becomes liable to fall a prey
to persistent ideas of a sad complexion. She broods over past loves,
the decay of beauty, and the lost power of pleasing.

Hysteria, with its heightened suggestibility, is the exaggeration of the
emotional element so powerful in the feminine constitution.

As a mother the woman shows her noblest qualities. On the stage,
she surpasses male actors owing to her lively reproductive imagination
and quick emotional susceptibilities, while, in all the occupations which
demand original intellectual power, she falls behind the man.

The female criminal sometimes shows an utter perversion of the
moral nature so that she may even become a heartless and cruel mother.
Her perfidy is deeper than that of men, and she is skilful in tempting
men to acts of violence; if she cannot arm the hand of the assassin, she
will use poison with a more relentless cunning than that of the male
criminal. William W. Ireland.

* The work cited is A. Marro, “ La pazzia nelle donne,” “ La donna e la
degenerazione considerata dal punto di vista sociale .”—Agli Annali di Freniatria,
1892-94.

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 171

On Spiritualism and Insanity [ Ueber Spiritismus und Geistesstdrung].

(Arch. f. Psych ., Bd. xxxiv, H. 3.) Henneberg , R.

Dr. Henneberg has read deeply in the extensive literature of
spiritualism and occultism. He treats of table turning and spirit
rapping, and what he calls psychographs, in which the subject, believed
to be in a trance, writes to the dictation of the spirits of the dead. He
mentions cases in which the mental derangement resulted from being
hypnotised. Persons who practise these so-called communings with
spirits have fallen into hysterical conditions. Some of these were
previously disposed to neurosis, so that the tendency was merely
aggravated. In other instances hysteria appeared as the result of these
practices in persons previously healthy. Dr. Henneberg gives in detail
the description of eight cases in which insanity was the result of con¬
centration on spiritualistic experiments. He observes that it is the
duty of the physician to warn persons disposed to nervous diseases
against any dealings with mediums, magnetisers, and faith healers, who
work on the imagination. William W. Ireland.

5. Clinical Neurology and Psychiatry.

Autobiography of a Maniac [ Se/bst-Biographie eines Falls von Mania
Acuta]. (Arch, f Psyche Bd. xxxiv , H. 3.)

The subject of this paper who records her own experiences was a
Miss L. S—, described as a highly gifted and well-educated lady. She
was admitted to the asylum at Zurich, December 21st, 1882, being
then thirty-two years of age. There was a record of insanity in
her family. As a child, she was intelligent, imaginative, and
impressionable, unpractical, not good at arithmetic, but fond of
drawing. As she grew up, she had religious scruples and doubts,
especially about the time of confirmation. She was affected by
listlessness and melancholy. At her own request, she was sent to a
parsonage in the Pays de Vaud, where the cloud soon passed away.
When twenty-one years of age, L. S— visited Italy. Amongst her
Italian studies she read the Decameron. This book did not affect or
excite her at the time, but left much that was impure in her memory,
which had an evil effect in later days. She never read any other books
of an indelicate character. She fell in love with a man with whom she
used to study, who was nine years younger than herself. Apparently
they were engaged to be married. He became insane, which deeply
affected her. Before her own mental derangement she had a lasting
dull headache, especially at the occiput, and sometimes pains and
peculiar feelings in the head, but the attack of mania came on quite
suddenly. When admitted to the asylum, she was very much excited,
and seems to have been put under restraint and treated with the
Deckelbad (the warm bath), the head remaining uncovered through a
lid. She describes her terrors, the chain of ideas which rushed through
her mind. She recalls that she used many words to which she gave

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172

EPITOME.

[Jan.,

quite a different meaning to that they usually bear; some of them were
of provincial or of foreign origin. She did not think she was insane nor
recognise her excitement, and was surprised that people were afraid of
her. She could, however, appreciate the mental alienation of her
fellow-patients. She took great pleasure in feeding birds; she had
many hallucinations and dreams which passed into her memory as
illusions. She heard voices though she denied it. Her hallucina¬
tions or delusions were of various kinds and degrees, rising from mere
suppositions to convictions; sometimes when spectral figures appeared
to her she would guess who they were, try to identify them with real
persons; for example, she saw an elderly woman of commanding
aspect, very pale, and dressed in white robes, whom she supposed
might be Queen Elizabeth of England. In honour of this personage
she thought she saw a young horse sporting about in the sea. Looking
out at the window of her cell, she saw the figure of a little grey monkey,
of almost human expression, rising from the ground, and making signs
for her to come away with it. This she felt willing to do, and thought
that there was a kind of understanding between them. Another time,
she thought that she was in purgatory, and that her companions in the
asylum were going through penance there. She believed that she saw
Pope Leo XIII, Dante, St. Catherine of Siena, and Francis of Assisi,
and nourished the delusion that her grandmother was the original of
Gretchen in Faust , and that her family were connected with Goethe.
She thought that the currents of air which passed through the gratings
were intended as signals from persons who wished to help her, and she
stuck little things in the wire to keep up the correspondence. The
birds who flew about the windows she took as messengers of freedom.
She heard a tumult outside which she believed to be caused by
anarchists, and a hollow voice as if preaching, but so quietly that she
could not follow the words. She also heard noises like that of
machinery. She thought that her teeth had been so calcified that they
were all grown together, and expected them to be forcibly separated. A
large number of hallucinations and delusions are tabulated in a brief
form. After thirteen months 1 detention in the asylum she was discharged
cured, and although nearly twenty years have now elapsed, she has had
no return of mental derangement. William W. Ireland.

Idiocy and Athetosis [Idiotismo ed Atetosi], (II Manicomio », Anno xvit\
Nos. i, 2.) Tomasini, S.

The author describes one case of idiocy combined with athetosis, and
gives a summary of the contributions which have been made to this
subject. The number of autopsies of double athetosis is small.
The lesions found in athetosis have been mainly of a haemorrhagic
character, though a few cases of atrophy and asymmetry of the brain,
cerebellum, and bulb have been recorded. Athetosis is not in¬
frequently met with in paralytic idiocy, although it often occurs where
the intellect is not impaired. It seems needless, therefore, to treat
what is merely a symptom of cerebral or nervous irritation as a
concomitant of so profound an affection as idiocy.

William W. Ireland.

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

173

Cerebral Paralysis and Idiocy [Cerebrale Kinderldhmung und Idiotie ].

(Arch, f Psych ., Bd. xiii, xxxiv , H. 3.) Wachsmuth, H,

He has made a careful study of twenty-two cases of this malady.
Most of his material is taken from the hospital at Merxhausen, which
receives incurable insane females from the province of Hessen
and the principality of Waldeck. Out of 700 patients, there were 185
idiots, 22 of whom, /. e., about 12 per cent,, were affected with cerebral
paralysis. He deals with all the symptoms and pathology of the
affection. In such cases the paralysis and idiocy is complicated by a
variety of nervous symptoms, especially with epilepsy, which affects
at least half the patients, and helps to increase the mental deficiency.
Dr. Wachsrauth’s paper fills forty-four pages. His experience leads him
to confirm the observation of Bourneville, that epilepsy generally dis¬
appears between the fortieth and fiftieth years of life. A great part of
our cases, he observes, have already passed this age, and they have no
more epileptic attacks. In other instances a diminution of the epileptic
attacks has been observed. Many of the cases of cerebral paralysis are
regarded as being the sequel of encephalitis, sometimes caused by
infectious diseases. Wachsmuth does not consider the amount of
paralysis is a measure of the mental deficiency. This study of the
subject has induced him to divide his cases into four classes.

1. Cases in which there is a complete restitution of bodily and
mental health.

2. Cases in which there is no enduring injury to the mind but
paralysis and other bodily symptoms.

3. Cases in which mental deficiencies, but no bodily injuries
appear.

4. Cases in which there are both lasting mental and bodily de¬
rangements.

This last group comprises by far the largest number of cases. It
is true, as Dr. Wachsmuth observes, that the diagnosis of the other
groups is much more difficult. William W. Ireland.

Polyclonus in General Paralysis \Policlonie nella demenza Paralitica\
(Riv, di Patol , 9 Nerv, e Ment, 9 fasc. 6 , 1901.) Zambranzi, R,

The author describes two cases, the first, a man, set. 31, who died after
fourteen months’ illness, with well-marked symptoms of general
paralysis. Ten days before death various groups of muscles of the right
side of the body (those supplied by lower branch of facial nerve, those
of right side of tongue, external abdominal oblique, serratus magnus,
biceps cruris, flexors of forearm) were affected by clonus, irregular, with
short but distinct intervals; the clonus ceased with sleep, and had no
effect on the movement of the muscles. It continued till his death.
In the second case, a man, set. 39, the muscles of face were first affected,
and, after a short interval, the right side of body. The movements
were arythmic, irregular, and rapid, diminished by movement, in¬
creased by an emotion; they ceased in sleep. The pectorals, the
abdominal oblique (120 contractions per min.), the extensors of the
forearm, and the adductors of the thigh (150 per min.) were all affected.

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EPITOME.

[Jan.,

Athetosis, affecting right hand, on one occasion supervened. The
clonus later spread to left side of body. During the later stages of the
illness they reappeared for a third time. The author points out the
relative infrequency of the condition associated with the psychoses.
He compares at considerable length the clonus with the allied muscular
tremors in chorea in its various forms, and with the group of misclonus
associated with epilepsy with a view to establishing the seat of the
lesion. This is concluded to be in all these cases probably cortical.

J. R. Gilmour.

Psychomotor Hallucinations in General Paralysis [Hallucinations
Psycho-motrices dans la Paralysie generale\. (Arch, de Neurol .,
July , 1901.) Marie et Buvat.

The notes of three cases are given, preceded by an account of the
observations made by others on this subject—Esquirol, S^rieux.
Psychomotor hallucinations, verbal and graphic, appear to be rare in
general paralysis, although one must not lose sight of the fact that their
diagnosis in this condition is difficult, either on account of their
transient character, or on account of the dementia of the patient.

In the first case, that of a man, aet. 35 years, the patient speaks of
himself in the third person, and believes he has someone, a woman,
inside him who speaks to him and writes to him with his own hand, and
to whom he speaks. The second case is that of a man, aet. 47 years.
Associated with disorders of memory and attention he has psychomotor
hallucinations. He announces that the “don” is about to speak.
His voice alters and he speaks of himself as a stranger; this “don”
speaks with his tongue in his teeth and converses with the patient and
with those who speak to him. This condition is also revealed in the
letters which he writes. The third is that of a man, aet. 38 years. A
voice within him addresses him thus : “What are you doing, B—, in
this place ? Go home.” When questioned, he says that a woman con¬
stantly talks to him in his mouth, moves his tongue in spite of himself,
and insults him ; he closes his teeth so as not to speak, but speaks in
spite of himself. H. }. Macevoy.

The Genital Sense studied in the same Patients during the Three Stages
of General Paralysis [Du Sens genital etudie chez les mernes Malades
aux trois Periodes de la Paralysie gcnerale\ (Arch, de Neurol.
July , 1900, to July , 1901.) Marondon de Monty el.

The author has studied the condition of the genital sense in 108
general paralytics in relation to age, form of mental disorder, etc., and
draws certain interesting conclusions. He finds that, for example, the
self-satisfaction of general paralytics and their delusions of great
physical strength are not due to genital over-activity. That disorders
of the genital sense are not related to alterations of touch sensation or
of sensation to pain, as has been held by some observers. In seven
cases, especially where delusions concerning the genital organs were
prominent and spontaneously related (notes given), it appears clear
after reading the account given that the genital delusions have no
physical basis, and do not seem to be related in any way with the state
of the genital organs. Dr. de Montyel finds no relation either between

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

175

the condition of the genital sense and the subjective sensations felt in
the skin by certain general paralytics. Alcohol, of all causes, appar¬
ently is most frequently responsible for alterations in the genital sense,
more especially in the direction of increase.

As regards the important questions of prognosis and diagnosis, the
author has no doubt that in the prodromal period genital disorders by
their early appearance, their accentuation, and their special character¬
istics, may enable one to foresee or predict general paralysis some time
before its invasion. These disorders appear early, and when they
consist of alternating excitement and impotence, as is most commonly
the case, the import is clear. Persisting total impotence is important
from the point of view of diagnosis when the general health is good.

Not much help is forthcoming in this direction as regards prognosis.

The author resumes under twenty-three different headings the
conclusions which he has drawn from his researches—dealing with
male general paralytics only. H. J. Macevoy.

On Fixed Ideas \SuH idee fisse\. {Clinica Moderna , 1899.) Blanche , L .

This is a lecture on fixed ideas and obsessions. For the genesis of
these two factors are necessary, first, an excessive condition of feeling;
second, a congenital or acquired weakness of mental constitution.
The difference between them and paranoia consists in the fact that in
the case of obsessions there is no alteration of the personality. The
author divides them into (1) obsessional emotions, (2) obsessional ideas,
and (3) obsessional impulses. This is not a rigorous psychological
distinction, but it is justified by the prevalence of one of the elements
constituting each group. The emotional group may be divided into
repulsions (or phobias) and imperative desires. The phobia may
be general or for one determinate object only. Under the heading of
obsessional desires are included dipsomania and certain other drug
habits. The obsessional impulses are distinguished by their motor
content; as these become more automatic they pass into the group of
ties. Obsessional ideas have frequently a hypochondriacal basis.
They are rarely accompanied by hallucinations. As regards prognosis
there are two classes of cases, first, those in which the original psychi¬
cal weakness is hereditary or dates from early infancy; second, the
cases in which the weakness is acquired. In the first class the outlook
is very grave and amelioration only results where development and
education are very favourable. Other functions may through time
become affected, but it rarely passes into other forms of insanity.
Agitated melancholia may, however, develop. Suicide is rare, those
affected being generally undecided. The treatment is largely general.
Muscular and mental exercises are of benefit, as also outdoor work and
electricity. If neurasthenia be present it is an indication for treatment;
suggestion may also be tried. J. R. Gilmour.

Heart and Circulation in the Feeble-minded. (The Amer. Journ. Med.

Sc., June, 1901.) Taylor and Pearce.

The writers contribute, in this paper, the results of observations
made at the Pennsylvania School for Feeble-minded Children at

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EPITOME.

176

[Jan.,

Elwyn, Pa., but state that this is only a partial representation of
their work.

They were chiefly concerned with the so-called imbecile class or
backward-minded individuals, in whom a fair degree of amelioration
can be expected, and they hope yet to secure some practical results by
treatment directed towards the vascular system and its innervation.
For the idiot, they truly observe, little can be expected from any treat¬
ment other than educational and hygienic.

They believe that the nervous system of the young child suffers
from the effects of toxins in many ways not yet understood, and
suggest that the foundation of much disease, especially that affecting
the brain, is laid long before we are capable of suspecting or de¬
tecting its presence, through the agency of insidious and unknown
toxic agents. They infer that much of this damage is expended upon
the structures of the circulatory system, and think that even if we
could control the activity of the vaso-motor system alone much might
be accomplished. The alternation of exalted or depressed states
may be taken as an expression of a cytolysis of the cerebral neurones.
Again, they infer that the peculiarities of the mental phenomena
depend in some measure upon the degree of cell alteration as welt as
upon the character of the circulatory poison, and also upon the
number, condition, and situation of the neurones involved in the
process.

After some further observations on toxaemia and auto-toxaemia in
their relation to circulatory incompetence, they quote Oliver and
Wilmarth on Mongolian forms of idiocy, to the effect that the general
pathological conditions, such as club-shaped, cold, clammy extremities,
tendency to ulceration, ecchymoses, etc., bear close causal relation to
imperfect development of the entire vascular system. The patients
generally succumbed, during the colder months of the year, with gross
haemorrhagic or exudative lesions in the mucous tracts and other vital
areas. The common aetiological factor was great activity, and a final
overthrow of the nutritive centres during the earlier portion of the
antenatal existence

The subsequent part of this article consists of tabulated records of
forty male and thirty-two female cases, studied out of the total number
of 955 inmates examined, from which the authors draw the following
conclusions, e. g.> that organic vascular heart-disease is a large aetiological
factor in continuing the downward course of imbeciles; they having
found a great number of varied cardio-vascular signs, and these out of
proportion to the mental defect. Careful anthropometric studies and
observations in detail of somatic disease other than that of the nervous
system should be made in cases of mental enfeeblement. Many of the
high-grade cases can be bettered much more by attention being paid to
the therapeusis of the cardio-vascular disorders of imbeciles, also of the
insane. Scientific laboratory studies of the blood and excretions will,
no doubt, furnish valuable data in this direction in the future, admitting
the large rdle which biochemical products must play in the pathology of
many diseases. The action of certain alkaloids upon the peripheral
circulation needs careful study and experiment. The proper use of
especially directed regulated movements (imbeciles being good

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 177

imitators) is beneficial, as by improving the physique, however slightly,
the mentality will also be improved.

Care must be taken that backward children are not physically
overworked in view of their preponderating lowered physique and
liability to heart disease, but fresh air and properly directed active
employment are indicated. A. W. Wilcox.

A Study of the Insanities of Adolescence . (fourn . Nerv. and Ment. Dis. r
Aug , 1901.) Pickett.

In this article, the author studies the cases of 284 young male
patients, between fifteen and thirty years of age on admission to the
Philadelphia Hospital, having excluded all those who were plainly
imbecile, epileptic, or paretic. After alluding to the histories of
these cases, alcoholic in forty-four,—although most of these he
believes, were moderate drinkers,—he asks “ What relations have the
doctrines of degeneration with our present subject ? ” and points out
that Esquirol and Morel have observed the tendency of hereditary
insanity to appear at puberty and in adolescence, and that the latter
author more definitely states that at this period degeneration reveals
itself. A degenerate history was obtained in more than three quarters
of the author's cases. The anatomical marks of degeneracy also
were common, but unfortunately no systematic study of these was
made. Obsessions, the psychic stigmata of degeneration according to
Magnan, he believes with Regis are rather actual insanities, disorders
of the will on a basis of neurasthenia; coming and going with the state
of nervous health they are stigmata only as insanity itself is a stigma :
to serve as a real test of degeneration, a stigma must be permanent.
Only by close anatomical study on a large scale with classification of
stigmata, can degeneration obtain a useful clinical significance. He
agrees with Morel that the theory of degeneration should be kept
single and thought of mainly as related to heredity. It is important
not to confuse the two uses of the word “ degeneration,” the one being
proper to psychiatry, the other to pathological anatomy. With Jaffray
he thinks that “ to be insane, the patient must be degenerate.”

He next deals at some length with the question of classification, and
quotes Wille to the effect that there is no insanity peculiar to puberty,
but only “puberty modified” insanity. He criticises this author’s
book on the ‘ Insanities of the Puberty Age,’ saying that to regard
mania, melancholia, circular insanity, etc. (the “simple elements of
insanity,” as Magnan calls them), as fundamental, in the way that the
simple elements in chemistry are so, is right in teaching, but is wrong in
the philosophic study of psychiatry, and also Morselli’s statement that
hypochondriasis is a distinct clinical entity, and the insistence of the
Germans on acute paranoia, which, he says, clinically helps us little.
There is no boundary, he admits, between mania and paranoia, but
the prognosis in the borderland cases is that of mania or of para¬
noia according as excitement or delusion dominates the picture.
From the standpoint of prognosis, then, what are the “ puberty
modifications ” of insanity ? he asks, and replies : In the first place,
a tendency to dementia. In this connection Morel first used the ,

XLVIII. 12

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EPITOME.

[Jan.,

term dimenct prlcoce . The theory is, according to Mills, that with many
individuals the potentiality of life, mentally, is early exhausted. In the
author’s own series less than one fourth left the hospital restored, many
of these probably continuing “ psychic cripples.” On the average, two
thirds of the insane men at the Philadelphia Hospital, between fifteen
and thirty years of age become chronic dements or die of intercurrent
disease. This is an important clinical fact, and justifies, he believes, in
itself, a separate consideration of the insanities of puberty, for when
we apply clinical tests we apply the only tests that hitherto have borne
fruit in psychiatry. With Kraepelin, then, he claims special considera¬
tion for many of his cases, on the clinical ground of prognosis:
dementia precox.

He then gives three tables and a chart of eleven cases of katatonia,
seventeen of paranoia, and thirty of hebephrenia in which hopeless
dementia came on rapidly. Following Kahlbaum’s advice to “ group
by the most frequently occurring symptom ” in these cases he notes
two important ones, first, delusion ; second, catalepsy.

The author is a firm believer in katatonia, and after discussing the
symptoms of this form of insanity at some length, he proceeds to the
prognosis, agreeing with Kahlbaum that in many cases it is good. This
is contrary to the teaching of the later German writers. He believes that
at this period of life recovery is possible from mild forms of both
katatonia and paranoia. He found that persecutory delusions were
common in his cases, and formulates the theory that an adolescent will
react to such a delusion in the form of egotistic delusion, or in the
form of katatonia according as his temperament is egoistic and
assertive or soft and hysterical. He found that the paranoics were
rather older than the rest of his cases, and harmonises this fact with
his theory by assuming that age braces the hysterical temperament and
increases the assertiveness of the individual. This would explain the
frequent coincidence of katatonic and paranoic manifestations in the
same patient as noted by Kahlbaum, Kierman, Spitzka, and many
others since. He then describes the various symptoms exhibited by
this series of cases, pointing out that dementia which shows itself from
the beginning of the mental trouble is the most important, and names
this group, after Kraepelin, dementia paranoides. Hebephrenia he
looks upon as including those cases of dementia precox which are
not distinctly paranoic and not katatonic; it is a group of the
unclassified members of dementia precox.

In conclusion, the author truly remarks that, after all, it may be the
most common-sense plan to divide the insanities into the conventional
forms of mania, melancholia, etc., then to approach the subject from
a second standpoint, discussing the cases in their relation to periods of
life—childhood, puberty, adolescence, the menopause, and senility.

A. W. Wilcox.

Insanity of Adolescence \Folie de P Adolescence], (Arch, de Neurol,,
Aug,, 1900.) Boumeville and Beilin,

The notes of an interesting case are given—fully and carefully
recorded as Boumeville’s cases generally are. A. G—, a girl aet 14

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

179

years was admitted into the Fondation Vallle, March 4th, 1899. Her
family history was very bad—father, alcoholic and violent; mother,
hysterical, then insane; grandparents, neurotic, as well as several
uncles and aunts. The patient was possibly conceived when her father
was drunk, her mother being at the time liable to attacks of hysteria.
She had once convulsions limited to the face; up to the age of twelve
years she had nocturnal incontinence, and after this had attacks of depres¬
sion, of alternating crying and laughter. When her mother was placed
under care, the girl was placed in an orphan school at Les Andelys, where,
no doubt, under the influence of the separation from her mother and
religious practices she developed mystical delusions—she thought she
was Joan of Arc and had blessed visions, etc. A few days later she
came under Bourneville’s care. The mystical delusions persisted for a
few days, and after a short remission (March 9th—23rd) were followed
by a period of maniacal excitement—crying, singing, incoherent purpose¬
less movements, extravagance, dirty habits, and insomnia. The attack
lasted a week, and was followed by a remission (March 30th—
April 21st) after which she was somewhat melancholic for a while,
although free from hallucinations and mystical delusions. On May 1st
she was practically well. About a year later, menstruation appeared,
without any mental disturbance. The treatment consisted in baths and
douches, with the administration of chloral and bromides to combat
the insomnia and excitement; general exercises, occupation, etc,
afterwards. H. J. Macevoy.

Systematised Delusional Insanity from Dream to Dream [Dilire
systematise de Rived Rive], (Rev. de Psychiat., No. 4, 1901.)
Klippel and Trenaunay .

This is a case with a long chronic evolution, which shows the
narrow relations which may exist between dreams and delusions.
Whether dreaming during sleep, or apparently at times dreaming when
awake, the patient presented persistent delusions which were grafted on
or sprang from the dreams, and occasionally led to acts. O. L— was
aged 49 when he came under the authors* care, having been in the
post office for twenty-four years; he complained of pains in the lower
limbs, which exaggerated a natural limp (due to former injuries), and
pains in the head, which he referred to visions he had recently
experienced. The patient had written a long account of these
hallucinations, which revealed two dominant ideas: (1) that the
patient was God*s elect, and (2) that he was persecuted. To explain
them he referred to certain episodes which had occurred far back in
his life, and the visions seemed to be of two kinds: (a) representations
of his ordinary life; (b) supernatural. As regards these supernatural
visions, a few of these were extra-terrestrial (referring to the heavens,
to the sun, etc.), but most fa large number altogether) were terrestrial
(a rainbow descending about the patient’s head, beholding Christ on
the Crpss appearing on a newspaper he was reading, a star falling and
the moon stretching out to catch it, etc.). Hallucinations of
hearing occasionally accompanied the last-mentioned hallucination of
vision. The ideas of persecution arose in his mind at the time of
appearance of these visions; they mostly referred to his thoughts being

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EPITOME.

[Jan.,

read. The various hallucinations appear to begin in dreams, during
which he is authorised to divulge them, etc. H. J. Macevoy.

A Case of Prolonged Dream , Toxi-infcctious in Origin [ Un Cas de
Reve prolongd Origine toxi-infectieuse]. {Rev. de Psychiat., No.
6, 1900.) Klippel and Trenaunay.

The case simulates a form of alcoholism. Nightmare, dreaming pro¬
longed into the waking state, general mental confusion superadded—
these represent the degrees of infection acting on the brain, and well
illustrated in the notes of this observation.

A man, set. 41 years, was admitted into hospital on June 6th, 1899,
suffering from acute articular rheumatism. His family history qua
nervous disease was not good. At eighteen years of age, he joined the
navy, and beyond some rheumatism, his health kept fairly good during
his eight years’ sojourn in the colonies. He then took up photography,
and in this work suffered from attacks of vertigo (? from cyanide of
potassium fumes) up to the age of thirty. At this time, he had an
illness lasting three months, which left his face drawn to the left, and
details of which he completely forgot. After this, he had several
attacks of acute rheumatism.

The present attack was articular, no cardiac trouble ; it responded to
salicylate of soda. Suddenly, on June 15th, during convalescence, he,
without warning, was seized with cerebral disorder (the salicylate was
not given after June nth), he became excited in the night, confused,
had delusions that he was invited to a presidential reception, and
wanted to get out of the hospital, etc. In the morning, this mental
confusion was especially noticed on recalling events of the night, but he
was still full of delusions. This condition lasted until June 19th, it
was worse at night, and he was generally calm and less confused
in the day, although his delusions were even then easily excited by
reference to the dreams of the night before. As the mind improved, it
was especially noticed that the tongue, which at first was much furred,
became cleaner, and finally normal on the 20th, although there was
not anything especially to note concerning his other organs and
functions. All memory of the mental disorder vanished after the
attack. A few days later, the patient had a relapse of rheumatism, but
the mind kept clear. The patient was not a drinker, although the
details of this attack so strongly suggest a form of alcoholic toxaemia.

H. J. Macevoy.

The Importance of Dreams as Symptoms of Disease [La Valeur
skmeiologique du Rive]. (Rev. Scient ., No. 14, 1901, premier

semestre.) Vaschide and Pieron.

This is a continuation of a paper on dreams (see Revue Scientifique ,
March 30th, 1901), and deals especially with the dreams of epileptics.
Reference is made to Duaste’s cases, in which dreams occurred during
the epileptic seizure only (Journal de Medecine de Bordeaux , Nos.
xlviii andxlvix, 1899); but the possibility of the dream being merely an
aura must not be dismissed. Certain characteristics of epileptic dreams
are to be noted : the predominance of the colour red; certain parts of

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 181

the body especially figure: the head, the sexual organs, the chest; the
introduction of strong animals, the act of falling, etc.

Dreams are often the indication of functional disorder, but are of no
help in gauging its gravity. In certain organic affections prognostic
signs may be given by dreams. The authors give the notes of several
cases illustrating this point; in one, a vivid dream, in which the head
was squeezed in a vice, preceded the onset of meningitis; in another,
during which the throat was seized by a coachman, an acute sore throat
followed; in a third case a girl dreamt that she was knocked down by
her fiance , who pressed his knee upon her throat and filled her mouth
with filth ; four days later she developed a dangerous sore throat. The
authors believe that dreams in insanity may be of prognostic and
diagnostic value. They look forward to the publication, later on, of
observations on this subject. H. J. Macbvoy.

Case of Kleptomania and Death from Cerebral Urccmia [Observation d'un
Cas de Kleptomanie terniinepar tin Acces uremique d forme nerveuse\
(Rev. de Psychiat., No. 8, 1901.) Meunier.

On January 12th, 1901, H—, set. 40 years, was admitted to Sainte
Anne Asylum, having just escaped imprisonment, owing to Dr. Garnier’s
certificate of " mental debility, melancholia, confusion of ideas, excite¬
ment at intervals, want of appreciation of his condition, etc.” A few
days later he came under the care of Dr. Marie at Villejuif. He
became troublesome on account of his pilfering habits. On seven or
eight occasions he robbed patients of such things as books, ink-stands,
pencils, etc. When the objects were found in his pockets, he always
maintained that he was driven to steal in spite of himself. In March,
he was placed on a diet without salt—or rather with a minimum of salt—
(75 grains a day in his bread and milk); in addition, he was given
30 grains of bromide of potassium per diem. On the first day,
(March 1st) of this treatment he committed a robbery, but never after.
Moreover, his demented appearance improved somewhat, and he
became sociable with the other patients ; towards the middle of the
month he began to occupy himself. At the end of March, he was put
on ordinary diet, and the bromide of potassium suppressed, but the
kleptomania did not recur. From April 1st to June 19th, he was quiet
and well behaved, and presented nothing unusual. Suddenly, on
June 15th, he presented slight left hemiplegia on getting up in the
morning ; he got up, although dazed and complaining of severe head¬
ache; at 7 o'clock he was seized with epileptiform convulsions lasting five
minutes, followed by coma with high temperature, and ending fatally
on the third day. There was marked albuminuria. Venesection was
performed. At the autopsy large congested inflamed kidneys were
found, and hypertrophic cirrhosis of the liver. The interest of the case
is the apparent cure of the kleptomania under the influence of the
bromide and cutting oft the table salt. H. J. Macevoy.

Autosuggestive Neurasthenia [La Neurastenia autosuggestiva\. ( Riv .

Mens, di Neuropat. e Psichiat., July, 1901.) Guidi , G.

The author describes under this heading a group of cases in which
the mental disturbance is always associated with subjective psychical

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182

EPITOME.

[J an -i

facts. He divides his thirteen cases into three groups. In the first,
some illness has directed special attention to the organ afterwards
believed to be diseased. In the second, the individuals thought they
had heart disease, after having seen cases of it in others. In the third,
the psychical trauma was caused by some marked agency as death of
friends or parents. The symptoms were mild depression, confusion,
and ideas that some organ was diseased. These cases come on in
apparently healthy individuals and heredity is generally absent. They
differ from hysteria in the absence of any objective phenomena and
from phases of pathophobia in being unattended by any signs of
degeneracy. The author considers that they arise from the impression
absorbing in a morbid way the attention of the subject, and producing
the beginning of an association of ideas. J. R. Gilmour

Psycho-motor Epilepsy of Syphilitic Origin , with Consciousness of the
Epileptic Attacks, and associated with Criminal Tendencies
\Epilessia psichomotoria con coscienza degli accessi e manifestazioni
criminose e di origine sifilitica\ (Arch, di Psich., vol. xxii,fasc.
4, 5, 1901.) Lombroso , Gina.

This is a very complete clinical report of a case of some interest.
The patient, a man, aet. 68, with nothing special in his family history,
had contracted syphilis at the age of 21; twenty years later, after a
period of intense brain work, he had a sudden attack of localised frontal
headache with paresis of the right side. The paralytic symptoms
cleared up rapidly, but the patient remained subject to headache and
vertiginous attacks, and also to periodic fits of morbid anger with
impulsive violence to things and persons about him. Latterly, these
symptoms increased, and the patient's mental power declined.

Signorina Lombroso, after an exhaustive examination, arrives at a
diagnosis of epilepsy due to syphilitic arteritis with meningeal lesions.
Attention is drawn to the anti-social direction of the impulses; and the
authoress particularly emphasises the complete retention of memory
during the epileptoid attacks. W. C. Sullivan.

Epilepsy and Crime [ furistische Briefe ; III. Fallsucht und Verbrechen ].

(Allgem. osterreich. Gerichts-Zeitung, 1901.) Benedikt.

The author points out, that in relation to crime, it is necessary to
consider separately the periodic attacks and the intervallary condition
of the epileptic. Of the former he distinguishes three varieties—
(1) absences, or petit mal; (2) convulsive attacks; and (3) attacks
characterised by phases of altered consciousness—psychic epilepsy. It
is regarding the last class of epileptic phenomena—the most important
in legal medicine—that Benedikt's remarks are specially interesting.
He points out that in these epileptic dream-states the actions performed
may be very complex, and may have the appearance of deliberation;
that memory may be partially retained for events at any period of the
attack; and that the attacks may last for hours, days, or even longer.
He considers that such prolonged attacks have affinities with periodic
insanity and with dipsomania.

Apart from the fits, many epileptics present no mental abnormality,

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 183

while others are defective in intelligence and prone to criminal
impulses. In the latter, Benedikt contends, the criminal temperament
must be an extension of the same deformed brain-state which leads to
the convulsive attacks in the non-criminal epileptic. He thus, to a
certain extent, accepts Lombroso’s doctrine of the epileptic basis of
instinctive criminality.

Reference is made to two or three illustrative cases of psychic
epilepsy, but without details. The paper is rather discursive.

W. C. Sullivan.

Clinical Contributions concerning Insanity with Rigidity of Muscles
{catatonic) [Klinische Beitrdge zur Katatonie\ {Allgem. Zeits . /.
Psychiat ., Bd. Iviii , H. 2 and 3, 1901.) Schiile .

The catatonic condition has as much individual existence as any
other form of primary dementia ; it is episodic in following other morbid
psychical processes. The condition is said to be caused by a particular
form of cortico-psychical inhibition, combined with a subcortical
inhibition and excitation, particularly of the cortical centres.

Clinically, these cases do not always lead to imbecility, but pass on
to forms of monomania and stupor, which after a long time may end
in imbecility. The best known condition in which the catatonic
state is seen is in paralysis, in which the muscular system has lost its
tone, such as status catalepticus, and a form of occasional stammering,
in which the labials cannot be pronounced, alternating with inhibition
of speech, nodding movements, etc.

This want of tone in the muscles is seen in chronic monomania
and in cases of sexual excitement, particularly when associated with
masturbation, and in women in cases of metritis. The disease is met
with also in certain periodical conditions, particularly periodical mania
in imbeciles and juveniles. Recovery takes place in these cases, as
the catatonia is less severe. Another periodic type is the so-called
stupor variety met with in menstiual cases.

In subacute and chronic melancholia, the patient becomes stiff and
motionless, the features are fixed; he keeps very quiet, and repeats the
same words or sentences as the case may be. Simple movements are
made in jerks, they are much delayed and ultimately cease. The
patient is apt to stop half way whilst he is accomplishing a certain
movement; he “ strikes an attitude ” and remain so for hours, or even
days. He talks of an “ impending danger ” which prevents him from
doing anything. In these genuine melancholic cases, the patient passes
through a stage of hallucinatory stupor before the catatonic modifica¬
tion commences. The stupor diminishes during the atonic stage,
but consciousness remains dulled.

There are no certain signs which can guide our prognosis in this con¬
dition. With regard to the tension of the motor apparatus, this sym¬
ptom gives no clue to prognosis.

As a general rule the prognosis in acute cases with a moderate degree of
stupor (especially in hallucinatory stupor) is better than in chronic cases.
The prognosis in the chronic cases is better in adults than in juveniles.
A sudden return of consciousness is unfavourable. The psychical

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EPITOME.

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state must be closely observed, the more the intellect is disturbed the
graver the prognosis. As a rule, in catatonic 41 mania ” the prognosis
is good when movement is chiefly affected, and symptoms of cerebral
irritation are few, the patient being middle-aged and well nourished.
Coldness and oedema of the extremities are unfavourable signs. A
subnormal temperature is also a bad sign. The prognosis is exceed-
ingly grave when cerebral innervation occurs, as seen in paresis of
muscles of the face, pupil, or eye.

Signs of peripheral paralysis in the extremities (tibial and peroneal
nerves) is grave, and also vomiting when it occurs. The influence of
masturbation on the course of the disease is very important.

R. Carter.

6 . Pathology of Insanity.

Multiple Cystieerci of the Brain and Epilepsy [ Cisticercosi multipla
delP Cervillo ed Epilessia ]. (Riv. di Patol ., Nerv. e Ment.,fasc. 5,
1900.) Zui, A.

The patient was a lad set. 18. At six years suffered from periodic
frontal headaches and hebetude. After two years had vertigo and
“ absences.’ 1 The character changed, and he became strong and
irritable. He attempted murder at seventeen, and shortly thereafter
had the first attack of “classical” epilepsy. This was followed at
intervals by other seizures, and he died in status epilepticus. The
autopsy showed numerous cysticercus cysts in the pia, some on the
surface free, others embedded in the cortex, which tore as they were
removed. These cysts varied in size from a pin’s head to a small
hazel nut. There were a few subcortical cysts, some in the basal
ganglia and lateral ventricles. The pons, cerebellum, and cord were
free from cysts, as were also the internal organs. Cysticercosis produces
in the brain the same symptoms as other focal lesions. When
multiple, and especially when they arise in the period of development,
they may produce, instead of an epileptiform phenomenon, a true
epilepsy. J. R. Gilmour.

On the Alterations of the Central Nervous System in the Acute
Confusional Psychoses [Nuovo Contributo alia Conoscenza delle
Alterazioni del Sistema nervoso centrale nelle Psicosi acute
confusionali\ (Riv. di Patol 1 , Nerv . e Ment ., fasc. 8, 1901.)
Cauria, M.

This is the third paper by this author on the same subject. In this
case the types of alteration of the nerve-cells were two:—First, the
disintegration of the chromatic substance which, reduced to fine
granules, was scattered uniformly through the cell, rendering it homo¬
geneous ; the nucleus central and unaltered. This is the usual type
following toxines. Second, the type with central chromatolysis and
deformity, and displacement of the nucleus. This is the type following
the cutting of the axis-cylinder process. In this case, this was associated
with degeneration of the fibres of various parts of the motor tracts,

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and was probably an example of the secondary degeneration of the
nerve-cell from “reaction at a distance.” The lesion in the
pyramidal tracts of the cord stands in relation to the symptoms
presented by the patient, e, g . hypertonus, exaggeration of the tendon
reflexes, paresis of the upper limbs. The curability of such cases is
not in contradiction with the anatomical facts, as the alteration in the
nerve-cell is reparable. The primary degeneration of the fibres is
probably due to the same toxineas had produced the nerve-cell change.

J. R. Gilmour.

7. Treatment of Insanity.

A Contribution to the Statistics of the Asylum Treatment of Alcoholics
[Zur Statistik der Anstaltsbehandlung der Alkoho/islen]. ( Allg .
Zeits.f Psychiat., Bd. Iviii , H. 4, 1901.) Moeli .

This paper gives a very elaborate analysis of 742 cases of alcoholism
(males) admitted to the Lichtenberg Asylum during the six years
1 893-99. The cases are classified according to the number of
previous admissions, mode of admission (from police, from hospitals,
and voluntarily), length of interval in relapsing cases, duration of treat¬
ment, nature of symptoms, predisposition (heredity, trauma,
epilepsy, etc.), external influences (occupation, home conditions, etc.),
nature of offence in criminal cases. Further cross classifications show
the relations of these different orders of fact to one another.

In so complex a paper it is only possible to indicate a few of the
more salient points.

Of the total number of cases a shade over 40 per cent . had been
under treatment before; 7*14 per cent . had relapsed upwards of five
times. In the relapsing cases the interval between the admissions did
not appear to be materially influenced by the length of the preceding
treatment, e. g. the proportion of early relapses (within three months)
was even a little higher in those cases where the treatment had ex¬
tended over nine months than in those where it had lasted less than
three months.

Voluntary admissions were much more frequent after several
relapses.

As regards the character of the symptoms, the majority of the cases
are classed by the author under the heading of “ general mental weak¬
ness without delirium to this class he assigns 83 per cent, of the
cases with frequent relapses.

Parental alcoholism was noted as a predisposition in 47-8 per cent.
of the series, trauma in 22*1 per cent., epilepsy in 7 per cent . In
many cases several of these conditions co-existed. The influence of all
these factors—and of the traumatic factor in particular—was more
marked in the frequently recurring cases.

The statistics of delinquency showed the usual prevalence of crimes
of violence against the person.

The author is careful to point out that he does not claim any general

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186

EPITOME.

[Jan.,

validity for conclusions drawn from the study of so special and limited a
field, but he is disposed to think that the facts warrant a good deal of
scepticism as to the probable results of the asylum treatment of the
habitual drunkard. He believes that after care, involving exclusion of
the moral and material influences which make for intemperance, is
likely to be of more effect than prolonged treatment in inebriate
reformatories. W. C. Sullivan.

The Bed Treatment of Insanity [Le Traitement par le Repos au Lit en

Midecine mentale]. (Arch, de NeurolMay, 1901.) Paris, A .

Dr. Paris confirms by his testimony the value of rest in bed in the
treatment of the insane. He also points out that it does not really
raise the expense of maintenance appreciably, for if, on the one hand,
it necessitates an increase, in the staff of attendants, it obviates the cost
of the destructiveness of the maniacal patient, and the greater and
more prolonged consumption of sedative medicines, etc. Another
aspect of this question is the lessened call for surgical treatment which
rest in bed brings with it; thus the metrorrhagias, wounds, and fractures
are much less in evidence, and one accident in particular is of much
less frequent occurrence, viz. hernia.

Dr. Paris finds it necessary that the bed treatment should be
practised in separate rooms (not isolation cells) as the treatment in
dormitory is not successful. Harrington Sainsbury.

Statistical Consideration of a Series of Gyncecological Observations at the
Asylum of Ville-Evrard in 1899 [ Considerations statistiques sur le
Service d'Observations gynlcologiques de r A site public de Ville-Evrard
en 1899]. (Arch, de Neurol., Aug., 1901.) Picqul et Febvrl.

In this paper, the authors point out the frequency with which gynaeco¬
logical troubles are found associated with mental perversions, and they
insist upon the dependence in many cases of the latter upon the pelvic
mischief. According to the traditions of asylum practice in France a
pelvic examination is only performed after the consent of the relations
has been obtained. At the asylum of Ville-Evrard, with 400 to 450
beds, this consent was obtained in sixty-six cases only. Excluding, for
reasons, five of these cases, there were fo^nd gynaecological troubles in
fifty-nine out of the remaining sixty-one cases. With this enormous
proportion in view, and the frequent aetiological relationship between
this form of disease and mental aberration, the refusal of the relations
to allow the necessary examination of patients who are themselves not
able to act on their own behalf becomes a very serious matter, and the
authors ask whether society, which takes upon itself to commit a patient
to an asylum and by law to administer and protect the property of the
individual, cannot take better care of that other form of property—
health. True, in cases where symptoms are urgent we may take it
upon our own consciences and act then and there as we deem best
for the patient, but, as MM. Picqu£ and Febvrl insist, where does
urgency begin in matters medical and surgical ?

Harrington Sainsbury.

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187

Dispensary Treatment of Mental Diseases. (Amer. foum. Insanity, July,
1901.) Channing, W.

Dr. Channing pleads with much force for the wider establishment of
out-patient departments for the treatment of mental affections in con¬
nection with hospitals and dispensaries. Such departments, besides
giving treatment and instruction (a very important part of their work),
would serve as a “ repository for the troublesome, a clearing house for
doubtful cases, and a bureau of information in regard to the necessary
machinery to be made use of in committing or otherwise disposing
of patients.” Those who have had charge of our overcrowded out¬
patient rooms will appreciate to the full the need which Dr. Channing
points out, for it is absolutely impossible under present conditions to
give the mental cases which now and again present themselves as
out patients the attention they require. As it is these sufferers have to
content themselves with a dose of mistura alba or calomel, or perhaps
a dose of bromide and some hasty words of reassurance, and then the
“next patient.” Perhaps the greatest service which these mental
departments promise is in connection with defective children, some of
whom “ furnish a portion of the dullards in the schools, who are
such an injury to the advance of the average pupils. Others become
tramps or criminals. The girls often become the mothers of illegitimate
children, and so spread the circle of degeneration and defect wider and
wider.” Dr. Channing accentuates the importance of the last-mentioned
work, and in order to utilise more effectually the proposed department
he systematises in tabular form the investigation of the defective
child

The long list of mental affections which Drs. Channing and Jelly
have had under observation at the department which they have
established in connection with the Boston Dispensary, U.S.A., furnishes
sufficient evidence of the need for the department. The experience in
this country which similar departments have gained will unquestionably
enforce Dr. Channing’s advocacy. Harrington Sainsbury.

Modem Advances in the Treatment of the Insane . (Scot. Med. Surg.

Journ., Aug., 1901.) Havelock, T. G.

The advances referred to are, first, the erection of detached hospitals
at asylums and the allocation of cases on admission to the various
parts of the asylum where they can be best dealt with. Not least
among the advantages of this system is the result that, the less
interesting cases “ are not lost sight of, as they are apt to be in a
block full of recent admissions.”

Next, on the subject of bed treatment of the violent insane, we find
that Dr. Havelock is not in accord with this method, at any rate as
advocated by Continental physicians in particular, and as a routine
practice. He deprecates these restrictions of practice to “ bed-treat¬
ment ” or exercise treatment, and counsels the judicious use of all
methods available, and their individualisation.

The villa colony asylums are on their trial, he thinks, at any rate as to
their economy of working, though he has no doubt that many cases
may with great advantage be treated in detached buildings.

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EPITOME.

[Jan.,

Under new remedies we find the thyroid gland mentioned, only to be
discarded, except in the insanity of myxoedema. Among sedatives
paraldehyde is stated to be “the most valuable and safest hypnotic,”
though he finds it unavailing in the excitement of general paralysis
and in senile alcoholism. In these latter, he has recourse to chloral.
As to sulphonal and trional, Dr. Havelock gives words of warning—the
latter he finds less prone to excite haematoporphyrinuria, but not to be free
from this danger. Hyoscin he finds useful only in exceptional cases of
extreme urgency, dormiol and chloralamide of doubtful utility.

Harrington Sainsbury.

Three and a half years' Experience of Faradisation of the Head on
Scientific Principles in the Treatment of Chronic Insomnia and
Associated Neuroses, comprising a Series of Forty-six Cases. ( Glas .
Med. Journ., Aug., 1901.) Sloan, S.

This paper gives a complete record of all the cases without
exception. The results are arranged under five heads:

1. Cases in which the patient (he or she being judge) has been
cured.

2. Cases in which the improvement has been marked.

3. Cases in which the improvement has been slight.

4. Cases without appreciable result.

5. Cases in which some harm was done, though this was of a
temporary nature.

Forty-five per cent . of the cases come under heading 1 ; 32 per cent.
under 2 ; it per cent, under 3. the result being not worth the
trouble; 9 per cent, under 4; 2 per cent, under 5, though the dis¬
tress caused was for a limited time only. These results are brilliant,
and Dr. Sloan is justified in summing them up in the following
words:—“ that there is no remedial measure at present known to
the profession, other than a prolonged holiday, which will give such
immediate and more or less prolonged benefit.”

Dr. Sloan wisely refrains from any serious speculation as to how the
current produces its results, and after a short description of the ex¬
hilarating effects of the treatment which, independently of the action upon
'the sleeplessness, he has observed, he passes to his modus operatidi ’.
The stance is of 10 to 20 minutes* duration, on an average 15 minutes.
A large electrode of 15 square inches is applied to the brow, and one of
10 square inches to the nape of the neck. A current of \ to 1
milliampere is applied, and at the end of the sitting the current is
gradually reduced, and then shut off, the patient being allowed to
remain quietly sitting for a few minutes longer, this latter being an
important detail. Dr. Sloan uses a secondary coil of much greater
length than that usually employed, containing some 8000 to 9000
turns. It is evident that the employment of this treatment depends
much on attention to minute detail, the avoidance of any loose con¬
nection, etc., and for these we must refer to the original paper.

Harrington Sainsbury.

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SOCIOLOGY.

189

8 . Sociology.

Flagellatio Puerorum as an Expression of Masked Sadism in a
Sexual Invert \Ftagellatio Puerorum als Ausdruck des larvirten
Sadismus eines pcedophilen ContrarsexualenV {Allg. Zeitsch . f.
Psychiat ., Bd. Iviii , H. 4, 1901.) Von Krafft-Ebing.

The patient, set. 34, a lawyer by profession, married, with neuropathic
heredity, and having himself presented all his life symptoms of the
degenerate temperament—obsessions, labile emotional tone, tremors,etc.,
—was accused of immoral acts with boys under his care It was
proved that for many years he had shown a morbid passion for flogging
boys about the age of puberty on the bare nates, frequently offering
them bribes to get their consent to the operation. He also stroked
and pinched the buttocks, but did not at any time touch the genitals,
nor did he himself on these occasions show any signs of sexual
excitement.

The accused did not dispute the facts, but maintained that he had
acted purely from motives of pedagogic zeal, that when flogging the
boys he had no sexual thoughts, and no erection. It appeared, how¬
ever, from his own admissions, that he was of morbid sexual

disposition; his sexual impulses were feeble; he found difficulty in
normal intercourse, to which he had to stimulate himself by images of
boys, and by the desire of paternity; his rare erotic dreams were
associated with similar images.

The case was clearly one of homosexualism and sadism in a
degenerate. A further question, however, remains: May not the
patient himself have been, as he alleged he was, unconscious of the
sexual cause of his conduct ? Krafft-Ebing is disposed to think that
he probably was. His sexual hypoaesthesia would allow his inversion
to develop in the ideal direction without local genital reactions. So he
would remain ignorant of the sexual origin of his pedagogic taste, just
as the pubescent girl is unaware of the sexual source of her religious
passion. And when, later on, sadist impulses appeared, he would still
remain in this state of self-deception, since the satisfaction of these
impulses was not associated with any specifically sexual phenomena.

Such a condition must evidently modify the individual’s “ respon¬
sibility,” since it implies the absence of the sense of wrong-doing. The
question raised in this case is of wide application, for this independence
of consciousness and conduct is by no means rare, especially in the
degenerate, in whom the rdle of the unconsciousness is greater than in
the normal. Cases of the kind illustrate the disadvantages in practice
of standards of responsibility based on such metaphysical notions as
the doctrine of free-will. W. C. Sullivan.

A Plea for the Sterilisation of Women as a Means of limiting or
preventing the Reproduction of Leaver Degenerates \_Per la
Sterilizzazione della Don?ia come Mezzo per limitare o
itnpedire la Riproduzione dei Maggiormente Degenerati\ ( Bolle -
tino della Soc . Ginecol. di Napoli, 1901.) Zuccarelli.

In an address to the Gynaecological Society of Naples, the author*

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190

EPITOME.

[Jan.,

who is apparently a thorough-going optimist, urges the desirability of
accelerating human progress to perfection by a system of artificial
selection involving the sterilisation of the degenerate. He thinks it
preferable that women should be the victims of this system, and he
exhorts his gynaecological hearers to devise new and safer operations to
this end. W. C. Sullivan.

On Reform of the Lunacy Law [furistische Briefe ; VI. Zur Reform
der Irrengesetzgebung\. (Allgem. osterreich . Gerichts-Zeitung, 1901.)
Benedikt.

The author considers that the present time is favourable for bringing
the provisions of the criminal and civil law into better accord with
modern views of insanity. He touches on most of the aspects of
lunacy legislation, and suggests various reforms in principle and
procedure. He particularly emphasises the need of fuller recognition
by the law of the pathological element in the criminal nature; the
practical corollary of this admission should be the establishment of
asylums for criminal lunatics, and of other special institutions inter¬
mediate between the prison and the asylum for degenerates and weak-
minded criminals.

With regard to the general question of the relation of society to the
lunatic, the author thinks that the law might define those mental con¬
ditions which are to be reckoned as distinctly insane, and which may
be considered sufficient grounds for committal to an asylum. On this
point Dr. Benedikt has the courage of his convictions, and does not
recoil from the attempt to enumerate these conditions. His list in¬
cludes : (1) hallucinations ; (2) illusions ; (3) states of excitement with
actions dependent on hallucinations and illusions; (4) mania;
(5) simple melancholia ; (6) melancholia with delusions; (7) confusion
(Verwirrtheit) ; and (8) dementia. The law should impose on medical
men the duty of notifying cases of insanity (as defined in this list) to
the proper authorities, who can then decide the further steps—-com¬
mittal to an asylum, home treatment, etc.,—which may be desirable in
the individual instance.

Inebriety, sexual perversions, and similar conditions Benedikt would
have expressively recognised in law as distinct from insanity; the in¬
dividuals presenting these vicious tendencies should not be deemed
irresponsible, but should be subjected to a modified penal discipline in
special institutions. W. C. Sullivan.

The Total Abstinence Question [Zur Abstinenzfrage], ( Wien . med .

Presse , No. 14, 1901.) Benedikt.

Dr. Benedikt has been moved to wrath by the recent progress of the
theory, especially current in the experimental school of psychologists,
that even small doses of alcohol act injuriously on mental function.
Anticipating that this heresy would be supported by the Vienna Anti-
alcoholist Congress, he has accordingly confided to the columns of the
Wiener medizinische Presse , with a perhaps excessive candour, his
opinion of the doctrine and its advocates. The latter are, in the
professor's view, for the most part a lot of “ young-lady-like idealists, 1 ’

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SOCIOLOGY.

191

“ altruistic hypochrondriacs,” “ sophists,” and so on. Dr. Benedikt
confines himself to the use of these energetic epithets and to the
rhetorical invocation of universal practice in regard of alcohol; he does
not meet the theory which he denounces by criticism either of the ex¬
periments on which it is based or of the interpretation which has been
placed upon these experiments. W. C. Sullivan.

An International Swindler [La Truffatrice intronazionale\ ( Riv.
Mens, di Psich . Forense , Anno 1, 1899.) Bianchi y L.

This is a medico-legal report on the condition of a lady arrested for
repeated acts of fraud and theft. Her history is of interest. During
the past twenty years she has been under treatment in Camberwell and
Banstead Asylums in this country, in three asylums in America, and in
many on the Continent. She was of good family (with a marked pre¬
disposition to phthisis and nervous disease) and highly educated. She
was the authoress of two novels of the decadent type, which caused
some talk when they were published in 1892. The chief diffi¬
culty in deciding the question of her responsibility arose from the
largely negative results of her examination. The reports sent from the
different institutions were vague and unsatisfactory, and no definite
diagnosis had evidently been possible. Morphinism, hallucinations of
hearing, and tendency to suicide were facts, however, stated in different
reports. From the history and the great variety of the symptoms of her
different illnesses, Professor Bianchi came to the conclusion that her
condition had an hysterical basis, and that she was not responsible.
This finding was accepted by the Tribunal. Subsequent symptoms
also confirmed this diagnosis. J. R. Gilmour.

On the Isolation of Tubercular Patients in Asylums for the Insane
[Sur Pisolement des Tuberculetix dans les Asiles dAlilnis\ (Rev.
de Psychiat ., No. 1, 1901.) Marie .

This is an extract from a communication made at the Congress of
Psychiatry, 1900, in collaboration with Dr. Toulouse. It is important,
in the first place, that candidates for the post of attendants in asylums
should be carefully selected before being engaged, and attendants
properly treated (isolated, etc.) when suffering from phthisis. Dis¬
infection of infected rooms, and avoidance of overwork among them
should be attended to. A special asylum sanatorium for tubercular
patients should be erected. At Villejuif this is already realised.
Attention is called to the mortality statistics of the asylum in the
department of the Seine. Out of a total of 1017 deaths there were
170 from pulmonary affections (including forty-five cases of phthisis,
eleven of haemoptysis, and thirty-three of chronic bronchitis). Some
reference is made to information obtained from Great Britain, Italy,
and Germany on this question of tuberculosis in the insane.

H. J. Macevoy.

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EPITOME.

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9. Asylum Reports.

Some English County Asylums.

Demn .—The Committee report four times in each year to the
County Council, which we believe to be an uncommon practice. Yet
in addition to this they desire to be brought into still closer relation to
the parent body.

The Committee are of opinion that they should be more closely associated with
the office of the Clerk of the Council, and have, as all the other committees, the
advantage of the clerk at their meetings. Such an arrangement would tend to
facilitate the business and render unnecessary the constant reference of one office
to the other, and they hope the County Council will sanction such an alteration.

They also

recommend the Council to approve of the third proposal of the Select Committee,

“ that county councils should have power conferred upon them to provide separate
accommodation for imbeciles and epileptics.”

We see no reason against committees and county councils taking
such powers, but as we have said before, though in individual instances
some good may arise, it is not probable that any such benefit will be
found by its general application as some authorities seem to think.

A proportion of 26 general paralytics in hi male admissions is
enormous, especially when it is remembered that the chief seaport in
the county has its own asylum.

Gloucestershire .—This county is one that shows no increase in
occurring insanity.

The subjoined is from the Commissioners' report and is noteworthy:

We may say that a general air of contentment reigned. No one was turbulent,
very few noisy, and we attribute much of the quietude to be due to the fact that
the Committee regularly visit the wards and listen to the patients’ complaints.

Dr. Cradock makes a close study of American legislation for the
limitation of insanity. He reproduces the following from a Minnesota
project of law:

The Bill provides that no man or woman who is epileptic, imbecile, feeble¬
minded, or afflicted with chronic insanity shall intermarry within the State when
the woman is under the age of forty-five years. Any person who, not being an
epileptic, marries an imbecile or one afflicted with chronic insanity, or who
knowingly violates this provision, shall, upon conviction, be punished by a fine of
not more than $1000 (^200), or by imprisonment in the State prison for not more
than five years, or by both such fine and imprisonment.

It would be interesting to know on what grounds an epileptic is thus
favoured.

We are getting on. It is stated that at a Colorado medical meeting
a doctor proposed that parents should be allowed to arrange the painless
destruction of their imbecile children. Commenting on this the
Medical Journal (of that ilk?) appears to have said (possibly in
sarcasm):

The proposed law is too wishy-washy: the children should be killed whether

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193

their parents consent or not, and the latter also had better be put out of the way
lest they procreate other children of feeble intellect 1

It is well that full development of the idea should be put before those
who hope to limit insanity by Act of Parliament.

Hereford .—The old, old story from the Commissioners’ report!

The staff of attendants gives for day duty one for every eight and a half male
and one for every eight female patients.

Numerically this is a sufficient staff, but we regret to say that the duration of the
service is most unsatisfactory, no less than 58 per cent, of the men, for instance,
having been less than one year in the asylum service.

This, coupled with the fact that there have been since our colleagues’ visit,
several instances of roughness towards and neglect of patients, points to the
necessity of measures being taken to secure and retain the services of competent
and suitable attendants.

The scale of wages for the attendants of the first class on both sides is too low,
especially having regard to the fact (which we mention with regret) that no prospect
of a pension is held out on retirement.

Another cause that militates against the duration of the service of the staff is
the lack of cottage accommodation for married attendants.

And from Dr. Morrison’s report:

But the duration of service among the male attendants is highly unsatisfactory.
The majority of the class of men we have had in recent years to select for
appointments have left much to be desired for their fitness, while many who have
shown aptitude for the work have left either to revert to their previous trades,
enter the Poor Law service with its prospect of pension, or to take up private
nursing, all of which appear to offer a better remunerative opening to steady well-
trained men than service in the asylum. Your Committee will need to provide
means and ways to retain the services of this class of men, which at present we
seem unable to do.

Northumberland .—It is odd reading that a coroner should stir the
Committee up to provide an Isolation Hospital. But the occurrence
of a second case of erysipelas in one ward prompted a jury to express
a not unnatural surprise that there is no means of isolating infectious
disease in this asylum. The procedure bore immediate fruit.

Dr. McDowall states that while free expert advice in mental trouble,
though offered, was not accepted when given at the asylum, the
institution of an out-patient department for such cases at the Royal
Infirmary, Newcastle, has been accompanied by marked success. He
attends once a week.

Somerset and Bath ( Wells ).—We deeply regret to have to mention
the sad death of Dr. Law Wade. The facts of his death and his claims
to a feeling remembrance of his services and life on the part of the
Association have been appropriately dealt with elsewhere. It is
noteworthy that this his last report shows for the year such satisfactory
ratios as 51*4 of recoveries and 8 9 of deaths. In relation to the latter
it may be pointed out that while influenza and its complications carried
off none of the 32 males who died, no less than 18 out of the 42 female
deaths were attributed to this fell disease.

That Dr. Wade possessed one essential element of success in
managing an asylum—the securing the esteem of the subordinate sta ff—
XLVIII. 1 3

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EPITOME.

194

[Jan.,

is made evident by the subjoined extract from the Commissioners*
report:

The staff of attendants is sufficiently strong, and they seem of a respectable
class. No fewer than 60 per cent, of the men and 30 per cent, of the women have
lived for many years in the asylum service, whilst the number of men under one
year’s service would be reduced by one half had it not been for the calling out of
the Reserves.

Suffolk .—We commend to notice Dr. Whitwell’s method of showing
statistical facts by chromatic plans. On one sheet the additions, sub¬
tractions, and remainders of patients at the end of each year are thus
contrasted. A second sheet brings before the eye in a forcible manner
a division of patients, union by union, into five classes—acute recover¬
able cases, those who are chronic but must be detained, those who are
chronic but might be treated elsewhere, those who are chronic but
whose removal would mean expensive increase in staff, imbeciles and
idiots. As Dr. Whitwell remarks, the table shows the population of
the asylum in terms of the money value of its elements to the com¬
munity.

The following pregnant table shows from this year’s admissions the tendency of
cases to recover or otherwise in relation to the period at which they come under
treatment:

Percentage of
recoveries.

. 90 per cent.

• 73 »

. 20 „

The admission of a child of 5 years old suffering from mild im¬
becility suggests that the ordinary Poor Law arrangements in Suffolk
have not attained a very high level of efficiency.

West Riding. —The wages and hours of service are under the con¬
sideration of the committees on the representation of the staff.

At Menston a new Homestead has been built and taken into use. It
accommodates 40 farm patients, with 4 attendants. It is found to be
very useful.

At Wakefield the Acute Hospital has been opened, and so far has
been found to answer its purpose admirably. Stanley Hall has been
purchased and adapted for the reception of imbecile and idiot lads
suitable for the treatment to be provided there. A specially trained
attendant and his wife from the Royal Albert Asylum have been engaged
as chief attendant and schoolmistress. Further development of the
principle of segregation in this asylum consists of new epileptic
blocks and two cottage homes.

Patients who came under treatment
before termination of the
1 st month after inception
and

6 th „ „

12th

Some Scottish District Asylums.

Glasgow , Gartloch. —This report is the last which Dr. Oswald will
issue. His translation to Gartnavel, on which we congratulate him,
will be dealt with in another part of the Journal. Though it is only the
fourth report of the asylum, it tells of a proposed increase of 240 beds

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ASYLUM REPORTS.

l 95

1902 .]

in the shape of separate villa pavilions for chronic cases. Dr. Oswald has
carried out the training of attendants to the full, and has added
practical and theoretical instruction in sick cookery and massage by
competent teachers from Glasgow. We notice, with regret, that several
important tables of statistics are omitted. Those dealing with past
history (Nos. 2, 3, and 4) do not appear. The admissions were more
than 50 per cent, of the average residence.

Govan , Hawkhead. —The Visiting Commissioners both speak highly
of the work of the hospital section of the asylum, and, indeed, of the
whole of it. Mention is made of the efficacy of rest in bed for several
days after admission. We are sure that in suitable cases experience
will confirm the teachings of Dr. Rayner at Hanwell on this point some
years ago. Dr. Watson can show the satisfactory ratio of 48 per cent, of
admissions, excluding transfers. We find no table showing the form of
insanity on admission. This is a regrettable omission. Nearly 20
per cent, of the deaths were attributed to general paralysis, which,
indeed, formed the prominent factor in causation of death.

Lanark , Hartwood. —We sincerely regret to read in various parts of
the report mention of Dr. Campbell Clark's severe indisposition. For
some months he was absent on leave, and his duties were taken over
by his senior assistant, Dr. Kerr, and performed by him to the
expressed satisfaction of the Committee, Commissioners, and Dr.
Clark. In this asylum, too, the statistical tables do not include any
dealing with the history of the place. We look to these institutions,
with so many progressive ideas and practices tending to increase
recoveries, to justify evolution by results, and of such results a
complete record should be kept from the commencement. For the
past year we find, by working out the figures for ourselves, that the
recovery ratio is so satisfactory as 55 per cent.Q)

Lanark and Govan , Kirklands. —There is much truth in the
following remarks of Dr. Skeen :

Most of these recoveries have been good—cases which, with fair chances given
both by themselves and their surroundings, ought to do perfectly well in the world.
Unfortunately there is perhaps nothing so hard in the life of a person who has
been confinea in an asylum for the insane, especially if for any lengthened period
—say over the twelve months—as the going out again into the world. Such a
person, unless backed up and assisted by friends, is naturally very diffident; and
without friends, and feeling his own position, unable to explain his absence from
the world for a lengthened period in a manner satisfactory to a would-be employer
(for a residence in an asylum does not as a rule form a recommendation when
applying for work), such a person is very apt to become despondent and still more
uncertain of himself; and such cases, even if, in fact more so, their insanity has
been due to their own misconduct, are apt to fall back.

Of course a beneficial and not uncommon method of giving such
help is for the patient to be sent out on trial for a time with an
allowance from the asylum.

Roxburgh ,, etc., Melrose. —Serious overcrowding on the male side is
the prominent feature in the report, and it is proposed to build fresh
accommodation for 60 men. This is to take the shape of a hospital

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196

NOTES AND NEWS.

[Jan.,

similar to that which successfully dealt with the surplus female
population. Dr. Carlyle Johnston roundly but very properly tells his
committee that “the male patients do not, in fact, receive that
consideration, that quality of care and treatment, which their friends
and guardians have a right to expect.”

(*) Since the above was written announcement has been made of Dr. Clark’s
much regretted passing away.

Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

The General Meeting was held in London at the Rooms of the Association,
11, Chandos Street, Cavendish Square, W., on Thursday, November 21st, 1901,
at 3 p.m. Dr. Blandford presided.

Present— Members: Drs. G. F. Blandford, C. Mercier, H. A. Benham, H. H.
Newington, T. B. Hyslop, H. Rayner, H. T. S. Aveline, C. H. Bond, G. S. Elliot,

P. W. Macdonald, C. H. Hitchcock, A. Boycott, H. A. Kidd, E. B. Whitcombe,
W. D. Moore, S. R. Macphail, D. Fleck, W. Kingdon, H. E. Haynes, A. Turner,

J. R. Whitwell, L. French, E. Daunt, W. S. Kay, S. Edgerley, W. C. Sullivan,

K. C. Stewart, J. C. Johnstone, E. D. O'Neill, F. O’Mara, C. Clapham, F. Edridge-
Green, S. J. Gilfillan, C. Caldecott, F. H. Edwards, H. N. Cappe, G. H. Savage,

G. E. Shuttleworth, J. Chambers, T. O. Wood, F. R. P. Taylor, H. G. Hill,

H. C. MacBryan, H. N. Kershaw, H. Corner, B. Pierce, R. H. Steen, R. N. Paton,

Q. T. Ewart, R. Pugh, D. Bower, R. J. Stilwell, W. Rawes, W. Douglas, T. S.
Adair, A. Miller, J. Baker, J. B. Spence, and Robert Jones.

Visitors: Sir T. Lauder Brunton, Dr. T. Brunton Blaikie, Messrs. H. Barnell,

A. H. Bostock, G. L. Craik, Louis French, Alfred Nutt, J. Danvers Power,
W. A. Stansfield, A. Wallace, and Hugh H. Weir.

The Hon. Secretary read a telegram which he had received from the President,
Dr. Oscar Woods, regretting his inability to be present at the meeting.

Dr. Mercier proposed that, owing to the absence of Dr. Woods, the senior
ex-President, Dr. Blandford, be asked to take the chair.

This was seconded by Dr. Rayner, and carried unanimously.

Apologies for non-attendance were received from Dr. Urquhart, Dr. Lloyd
Andriezen, and Dr. Wiglesworth.

The Chairman said he thought the meeting would agree that the minutes
might be taken as read, in order to economise time, as they had already appeared
in the Journal. Agreed.

The following candidates were elected as ordinary members:—Barnett, Horatio,
M.B., B.C.Cantab., M.R.C.S., L.R.C.P.Lond., Medical Superintendent, Stretton
House, Church Stretton, Salop (proposed by Theo. B. Hyslop, Maurice Craig,
and W. H. B. Stoddart); Barwell, Francis B., M.R.C.S.Eng., L.R.C.P.Lond.,
Assistant Medical Officer, Darenth Asylum, Dartford, Kent (proposed by F. R. P.
Taylor, E. H. Beresford, and Robert Jones); Cleland, William Lennox, M.B.,

B. Ch.Edin., Park Side, South Australia (proposed by J. Murray Lindsay, C. Mercier,
and A. R. Urquhart); Cooper, K. D., M.R.C.S.Eng., Assistant Medical Officer,
The Lawn, Lincoln (proposed by A. P. Russell, H. Hayes Newington, and A. R.
Urquhart); French, Louis Alexander, M.R.C.S., L.R.C..P., Bethlem Royal Hos¬
pital, Lambeth, London, S.E. (proposed by Theo. B. Hyslop, Maurice Craig, and
W. H. B. Stoddart); Harding, William, M.D., M.R.C.P.Lond., Medical Super¬
intendent, Northampton County Asylum, Berry Wood, Northampton (proposed

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NOTES AND NEWS.

197

1902.]

by Robert Jones, H. Hayes Newington, and C. T. Ewart); Munn, Patrick James,
M.B., C.M.Edin., Assistant Medical Officer, Three Counties Asylum, near Hitchin,
Herts (proposed by S. E. de Lisle, David Bower, and Horace E. Haynes); Ogilvy,
David, B.A., M.B., B.Ch., M.D.Dub., L.M., Assistant Medical Officer, Ban stead
Asylum, Sutton, Surrey (proposed by T. Claye Shaw, D. Johnstone Jones, and
Ernest C. Lambert); Starkey, William, M.B., B.Ch., B.A.O.Roy.Univ.Irel.,
Assistant Medical Officer, Down District Asylum, Downpatrick, Ireland (proposed
by M. J. Nolan, Conolly Norman, and Arthur Finegan).

Pensions for Irish Asylums Officials.

Dr. E. D. O’Neill, of the District Asylum, Limerick, said that before reading
the resolution which stood in his name he wished to briefly explain to the members
how the matter came to be brought up that day. At the annual meeting in Cork
he read a paper on theipension question, in which he put forward definite views.
But, unfortunately, through an oversight, he omitted to have a resolution proposed
at that meeting giving effect to the conclusions in his paper. Accordingly, at
very great personal inconvenience, he was present at this general meeting to
rectify that omission by asking the members of the Association to unanimously
pass the resolution he was about to propose. There was nothing of a contentious
character in the proposition, and he felt sure it would be unanimously adopted.
He had originally hoped to include in the proposition the three countries of the
kingdom, because he regarded the question as of an international character, one
which affected all asylum officials in England, Scotland, and Ireland. He thought
the members should make a determined and united effort to push forward the
question ; otherwise he feared that when some of the members of the Association
came to look for that superannuation to which they were entitled, they would find
themselves grievously disappointed. A resolution framed on the same lines had
already been proposed on behalf of English asylum officials. It might reasonably
be asked, How did that resolution crop up at that meeting P Should it not have
been submitted to the Irish Division ? The only reasons he had for not bringing
it before the Irish Division was that there would not be a meeting until next
April, and he was anxious to have the approval of the Council of the Association,
and that the resolution should be ratified at a general meeting. The resolution
was as follows:

“ Resolved, that the Medico-Psychological Association of Great Britain and
Ireland earnestly desires to call the attention of Government to the great injustice
inflicted on Irish asylum officials by the wording of the clause of the existing Act
of Parliament dealing with the question of superannuation. It regrets that the
Government did not avail themselves of the opportunity afforded by recent
legislation to make more secure the provision for old age in the asylum service.
The Association respectfully urges on the Government an alteration of the said
clause by the introduction of the word *shall ’ instead of * may.’ It points out
that all other services have a fixed scale of pension, and every official knows,
when he is entering, what he will be entitled to on retirement; whereas asylum
officials are left entirely to the discretion of their committees, from whom there is
no appeal. Resolved, that a copy of the foregoing resolution be forwarded to the
Rt. Hon. George Wyndham, M.P., Chief Secretary for Ireland.”

Dr. Hayes Newington said he had much pleasure in seconding the resolution.
As Chairman of the Parliamentary Committee of the Association, on behalf of
England he could say that the question had been before that Committee for many
years past—at least ten or twelve,—and the Committee thought they were
gradually making headway. They were extremely glad to get the help of Ireland
nowadays, and no doubt the Irish members of the Association would be able to
bring pressure to bear upon their own members of Parliament, as the members of
the Association in England had endeavoured to do. The question of justice to
asylum attendants was very much like a heap of stones by the road-side, at which
horses which were not accustomed to heaps of stones were apt to shy. At first it
was found that all committees and members of Parliament, when the question was
put before them, put it on one side as a thing not to be considered; but they
were now beginning to give it more attention, and more promises of support were
forthcoming. As Ur. O’Neill had said, it would be a great help for them all if

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198

NOTES AND NEWS.

[Jan.,

they could secure the assistance of Ireland; and then when England had been
successful also, possibly Scotland would be able to get a similar measure of
justice.

The resolution was put and carried unanimously.

Sir Thomas Lauder Brunton, M.D., F.R.S., K.R.C.P., Physician to St.
Bartholomew’s Hospital, read a paper entitled “ Fairies, Apparitions, Visions, and
Hallucinations.” This paper and the discussion thereon will be published in the
April number of the Journal.

Dr. William C. Sullivan (of H.M. Prison, Pentonville) read a paper
entitled “ Crime and General Paralysis ” (see page 28).

Members afterwards dined together at the Cafi Royal, Regent Street.

Council Meeting.

A Council Meeting was held at 2 p.m. on the same day.

Present: Drs. Rayner (Acting President), H. Hayes Newington (Treasurer), J.
B. Spence, P. W. MacDonald, T. S. Adair, Theo. B. Hyslop, L. A. Weatherly, G.
S. Elliot, C. H. Bond, C. A. Mercier, H. A. Benham (Registrar), C. H. Hitchcock,
A. N. Boycott, A. Miller, H. Gardiner Hill, H. A. Kidd, R. Percy Smith. H. T. S.
Aveline, and Robert Jones (Hon. Sec.).

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division was held by the courtesy
of Dr. Moore at the Holloway Sanatorium, Virginia Water, on October 16th,
1901.

Among those present were Drs. Fletcher Beach, Moore, Andriezen, Gardiner
Hill, Chambers, A. S. Newington, Miller, Lindsay, Hyslop, Edridge-Green,
Haynes, J. W. Evans, Cole, Aa&le de Steiger, R. C. Despard, Haslett, Fielding,
Cecil Osburne, Forsyth, Fee, P. Campbell, Taylor, Stanley-Elliott, Noott, F. H.
Edwards, Tinker, Roots, Bower, J. R. Hill, Corner, Shuttleworth, Harper,
Patterson, Gayton, Outterson Wood, Worth, Kidd, and Boycott (Hon. Sec.).

After luncheon a meeting of the Divisional Committee was held. During the
morning and afternoon the members inspected the buildings and grounds, and at
3 p.m. the general meeting of the Division took place, Dr. Fletcher Beach being
voted to the chair.

The minutes of the last meeting were read and confirmed.

The Hon. Secretary read a letter from G. Harold Urmson, Esq., Commissioner
in Lunacy, thanking the Division for their vote of sympathy on the occasion of his
recent accident.

An invitation from Dr. Barton to hold the Spring Meeting of the Division at
the Surrey County Asylum, Brookwood, in April* 1902, was unanimously accepted.

Dr. Ad£le de Steiger read a paper on “ Two Cases of Lipoma of the Brain ”
(see page 64).

The Burden of Lunacy.

Dr. Andriezen gave a discourse upon the question, “ The Burden of Lunacy,
can it be mitigated ? ”

In his opening remarks he stated that appeared from the returns of the Com¬
missioners in Lunacy that there were 1300 more lunatics last year than the year
before, but the base-line from which the Commissioners made their computation
was not, in his opinion, a reliable one. They took their census upon one
day only—January 1st in each year. Now the population of asylums on that
particular date might be largely reduced on the one hand, or largely increased on
the other hand, by the conditions of the winter. The onlv proper and accurate
way of getting a reliable basis was by taking a daily or weekly census for the whole
year and striking an average. He had, for his purpose, taken the average
number of lunatics resident in asylums as giving a census which afforded the
nearest possible approach to accuracy. He should deal with the average number
resident in all institutions, except those for imbeciles or idiots whose numbers

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NOTES AND NEWS.

199

1902.]

would be found on inquiry to remain very nearly constant (their recovery and
death rates were veiy nearly constant), so that they could be put aside and
thus eliminate the question of idiocy. The average numbers resident in all
lunatic institutions—idiot establishments excepted—were as follow, intervals of
three years being selected so as not to make the statistics too numerous:—In 1891
the average number was 62,909; 1894, 68,569; 1897, 75,817 ; 1900, 82,122. They
would see that the ratio of increase every three years was much more rapid than
the increase of the population of the country. That was the first point to be
definitely grasped. Taking the population census of 1891 and that of the present
year, together with the Registrar-General's returns for the intermediate years, he
had carefully tabulated and compared them with the average numbers of the insane
population, and had found the same conclusion borne out by the data. That the
insane population had increased with greater velocity than the sane was further
shown in the chart published by the London Asylums Committee, which, doubtless,
many of them had seen. The chart was instructive because it put the results
graphically, by means of curves. (These the speaker illustrated on the blackboard.)
With this chart the Asylums Committee published the population figures also for
the districts under their charge. A growing increase in the proportion of the
lunatics to the rest of the population was apparent for the period of twelve years
comprised in the chart. The fact could be represented in another way by taking
the ratio of lunatics to the general population of England and Wales. In 1890
there was one lunatic to 336 of the general population. He had very carefully
drawn, by means of a millimetre scale, a curve (illustrated) showing the gradations
of the ratios up to the present date. It indicated that the increase was fairly
constant—no violent oscillations,—and he considered this itself was a priori
evidence that lunacy was an increasing quantity. In 1900 the ratio was one to 300
of the population, and if the curve were to be extended, on the assumption of the
same rate of increase being maintained, in 1910 the ratio would be one to 260.
This was a state of affairs by no means pleasant to contemplate. There was a
steady increase of the insane population, and at a rather greater velocity than the
increase of the general population. Now as to the question of cost. The
problem was so large as regarded England and Wales that he had thought it wise
to limit himself to the five large county asylums of London, which were typical of
the rest of the country. The original cost of the five asylums—the cost of the
buildings as distinguished from the cost of the land—was as follows:—Hanwell,
£103,000; Cane Hill, £237,000; Banstead, £288,000; Colney Hatch, £226,000;
and Claybury (which illustrated the increased cost of building materials in recent
times), .£484,000. There were other items of cost, such as the cost of original
sites, of land {subsequently purchased, and the cost of alterations and repairs.
These brought up the figures to the following amounts:—Hanwell, £420,000; Cane
Hill, £392,000; Banstead, £414,000; Colney Hatch, £452,000; and Claybury,
£527,000. The London Asylums Committee, in their report just published,
stated that the cost of labour, materials, etc., was increasing, and therefore they
had decided to increase the charge for maintenance of patients. That came into
force on the 1st July last, and he thought the increase was about a shilling per
head per week. So there seemed no prospect of the cost diminishing, but the
contrary, and added to the increasing prevalence of lunacy was the increasing
cost of the patients’ maintenance. These facts sufficiently showed the burden of
lunacy. To most of them, no doubt, it had occurred that there ought to be some
means of reducing this burden; and when public opinion had become sufficiently
enlightened the question would probably be brought forward in Parliament and
referred to a Royal Commission. As to the question of mitigation perhaps some
of the means he was going to suggest might appear to be trivial, but he thought
that taken altogether the sum total would be regarded as important. In
the early part of last century the number of cases that came to the asylums from lead
poisoning were considerable, but legislation in regard to the lead industry had ope¬
rated so effectively that now there were few cases of insanity from this cause. So, in
regard to puerperal insanity of septic origin, this had diminished since the adoption
of antiseptic methods in midwifery. He believed it was in the Boston Journal
that he saw it stated that Dr. Jelly, Collector of Records for thirty years, had clearly
proved this. He admitted the numbers concerned were small, but the facts showed
that with the adoption of antiseptic methods the effects could be restricted. In

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200

NOTES AND NEWS.

[Jan.,

referring, however, to alcohol, he thought he need not apologise for any smallness of
the numbers involved. Dr. Percy Smith, in his presidential address to the members
of the British Medical Association two years ago, drew particular attention to
alcohol as the cause of much insanity. Dr. Clouston, in his report for last year,
stated that an undue amount of mental disease in males admitted to Morningside
Asylum was caused by the excessive use of alcoholic stimulants, which accounted
for a quarter of the whole number of cases, and drink was assigned by him as
either the sole or a contributory cause in one third of the admissions of males
alone. Dr. Andriezen next referred to syphilis as a cause of insanity, and he again
quoted observations which set down syphilis as an aetiological factor in idiocy and
insanity, and classed it with alcoholism as a preventable cause. There were in
asylums a considerable number of children whose derangement was of syphilitic
origin. Syphilis produced all sorts of brain diseases. Many cases of epilepsy
were of syphilitic origin, and there was really, he thought, rather a larger percentage
of cases m asylums than was usually believed for which syphilis was responsible.
Regarding syphilis as a disease which might be prevented, various propositions
had been made, and Dr. Percy Smith, in his presidential address, had alluded to the
subject. In Norway and Finland they had made the disease a notifiable one, but
he supposed that in this country we were not yet nearly ripe enough for such
legislation, so that the prospect of dealing with syphilis by law was remote.
Referring briefly to phthisis, Dr. Andriezen said it was matter for congratulation
that the general public had at last awakened to the fact that phthisis was a
dangerous disease. There were a number of people confined in lunatic asylums in
consequence of mental diseases caused by this malady. The marriage of imbeciles,
epileptics, and persons who had had one or more attacks of insanity might well be a
subject for legislation, which could do much to lighten the burden of insanity
springing from this cause. At present, however, there was no prospect of it,
and the only thing that Association could do was to educate public opinion, and so
pave the way for legislation in future. Dr. Andriezen also maintained that
unrestricted pauper alien immigration was one of the causes of the steady increase
year by year of the burden of lunacy, and was another of those causes which
legislation could do much to prevent. He was glad to see that an organised body
of members of Parliament and others, under the presidency of Sir Howard Vincent,
was now working to bring about legislative action in this matter at an early date.
Lastly, there was the classification of patients on what he should call the medical
and economical basis. During the last few years this had been attracting increasing
attention. Chronic, incurable, and fairly harmless patients need not be housed, fed,
and clothed very much in the same way as other lunatics. It was an unnecessanr
procedure, and the pecuniary burden of lunacy might be lessened by a well-
considered scheme. The Commissioners in Lunacy had emphasised this idea,
and had issued a circular stating that where buildings were required in future for
large numbers of chronic patients the cost must be kept within certain limits, or
sanction would be refused. Dr. Andriezen, in conclusion, suggestedthe introduction
of an industrial colony system, under which the weak-minded might be housed,
and, at the same time, found useful employment. This would be much better, he
said, than their being at large propagating their species to the detriment and cost
of the community.

Dr. Fletcher Beach remarked that the amount of alcoholism depended largely
upon the prosperity of the country. When times were good they had more of it
than when times were bad. With regard to syphilis, he was present at a discussion
where it was urged that a large amount of insanity was due to this cause, but a
majority of those present thought that syphilis was not the sole cause. His own
opinion was that if all the cases attributed to syphilis were analysed not more than
5 per cent. £ould be definitely traced to that cause. However, he was not so sanguine
that they would be able to reduce that cause for some time to come. It took a long
time to convince the lay mind of anything of a scientific nature. He was very
glad to endorse what Dr. Andriezen had said in regard to pauper immigration.

Dr. Hyslop said that Dr. Andriezen’s discourse was to a large extent a reply to
many questions he had been asked by lay friends regarding the alarming increase
of insanity. The question was really a most important one. Forty years ago the
Commissioners reported that the proportion of lunatics was only one to 500 of the
population. As it had now got to one to 300, it seemed as if in another forty years

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1902.]

there would not be sufficient sane people left to manage the asylums. He believed
there was one cause of the increase of insanity which Dr. Andriezen had not
mentioned, and it arose from the struggle for existence in these days, the turning of
night into day. In the metropolis many cases came from districts like Fleet Street.
He considered that alcoholism was responsible for even more than had been stated.
They had to remember not only the cases directly caused by alcohol, but the many
attributed to specific conditions which had really been mainly due to alcohol.
Then as to syphilis. A great injury was done to the country when the Contagious
Diseases Act was repealed.

Dr. Andriezen, in reply, said he agreed entirely with Dr. Hyslop in regard to
the Contagious Diseases Act. He noticed that two or three American states,
Minnesota being one of them, had made laws within the last month or two to
prevent the marriage of weak-minded people, epileptics, etc. He admitted that it
was one of the unfortunate effects of progress and civilisation that we lived at too
high pressure.

After the discussion on the papers a hearty vote of thanks to Dr. Moore for
inviting the Division to meet at Virginia Water and for his hospitality was unani¬
mously carried, as was also a vote of thanks to the Chairman.

The members were afterwards hospitably entertained by Dr. Moore at dinner.

SOUTH-WESTERN DIVISION.

The Autumn Meeting was held in the Board Room of the Royal Mineral
Water Hospital, Bath, on Tuesday, October 22nd, by kind permission of the
Governors.

Dr. Goodall was voted to the chair.

Present: Drs. Weatherly, Baker, Blachford, Benham, Rorie, Deas, Morton,
Bullen, Millar, MacBryan, Aveline, MacDonald (Hon. Sec.), and Monckton, as
visitor.

The Honorary Secretary announced letters of apology from Dr. Oscar Woods,
Dr. Morrison, Dr. Mumby, Dr. Soutar, and Dr. Noott.

The minutes having been read and signed, the names of two candidates were
submitted for election, viz. Glasgow, John George, L.R.C.P.Lond., M.R.C.S.,
A.M.O. Portsmouth Asylum (Proposers: B. H. Mumby. P. W. MacDonald, and
G. A. Rorie) ; Findlay, John, M.B., B.Ch., A.M.O. Dorchester Asylum (Proposers :
P. W. MacDonald, G. A. Rorie, and J. Chambers) ; and were unanimously
elected.

The Next Meeting.

The Hon. Sec. reported an invitation from Dr. Aveline to hold the Spring
Meeting at the Catford Asylum, near Taunton, and moved that it be accepted
with thanks. This was cordially agreed to.

The Late Dr. Law Wade.

The Hon. Sec. said that as this was the first time they had met since the death
of the late Dr. Law Wade, of Wells, he felt sure they all wished to express their
sense of regret and loss at his untimely and unexpected death. Dr. Wade had
always taken a great interest in the Division. He was not cut off after his full term
of years, but in the prime of life, full of energy and full of work, and he felt it
was an extremely sad thing, not only for those more immediately concerned, but
for those who knew him and worked with him. He would formally move that an
expression of their regret be conveyed to his sorrowing widow.

Dr. Lionel A. Weatherly seconded the motion, and, speaking as an old friend
of Dr. Wade’s, he said that they would all miss him very much for his geniality.
His energy in his work was unbounded, and they all valued his able help. The
resolution was adopted.

Dr. John Baker read a paper entitled “Female Criminal Lunatics” (see page
* 3 )-

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202 NOTES AND NEWS. [Jan.,

Dr. J. V. B LAChFORD read a paper entitled “ Degeneration of the Optic
Thalami ” (see page 58).

Dr. P. W. MacDonald read a paper entitled “ Note on the Prefrontal Lobes and
the Localisation of Mental Functions ” (see page 9).

On the motion of Dr. Benham, seconded by Dr. Deas, a vote of thanks was
accorded to the Governors of the Hospital for the use of the Board Room.

The members dined afterwards at Messrs. Fortt’s restaurant.

NORTHERN AND MIDLAND DIVISION.

A meeting of the members of the Northern and Midland Division of the Medico-
Psychological Association was held at Bootham Asylum, York, on Wednesday,
October 30th, 1901.

Members present: Drs. Adair, Blair, Clapham, Ewan, Gill, Grove, Gramshaw,
Hearder, Hingston, Hitchcock, Holmes, Kershaw, Legge, Macleod, Macphail,
Mackenzie, Merson, Miller, Middlemass, Pope, Powell, Tighe. Visitor: Dr. T.
Anderson.

Dr. Clapham having been voted to the chair, Dr. Hitchcock (Hon. Sec.) read
the minutes of the preceding meeting, which were approved.

In connection with the nomination of members by the Northern and Midland
Division for vacancies on the Council of the Association, the following resolution
was, on the motion of Dr. Macphail, seconded by Dr. Powell, unanimously
adopted:

" That this Division desires to record its dissatisfaction that on two occasions
its nomination and recommendation of members to the Council for vacancies
arising from the retirement of members representing the Northern and Midland
Division had not been accepted.”

It was further resolved that a copy of the foregoing resolution should be sent to
the General Secretary, with a request that he should bring it before the Council of
the Association at their next meeting.

On the invitation of Dr. Gill, it was resolved that the next meeting of the
Division should be held at Shaftesbury House, Formby, on Wednesday, April 16th,
1902.

Bureau of Information.

Dr. Miller (Hatton Asylum) presented his report on the progress made in the
establishment of a bureau of information on matters of asylum administration. The
report was as follows :

At a meeting of our Branch at Leicester in April last, I briefly opened a dis¬
cussion on the desirability of forming a bureau of information in connection with
asylum management. My remarks were followed by a discussion in which all
members present, I think, took part, and while not feeling very sure of my ground
I still thought that the meeting was sufficiently in sympathy with my project to
justify my going further.

Following on the report of our proceedings in the Journal, the question
appeared to claim the attention of other members of our Association, who seemed
to think that some good might accrue from the formation of a bureau on the lines
suggested by me.

At the meeting of the Council of the Association, held at Cork, a resolution was
unanimously passed in favour of my proposal, and I was asked to proceed with
the work. As I was anxious, if possible, to start on a firm footing, I postponed
the carrying out of the instruction conveyed in the minute of the Council for the
following reason:

There are some eighty county and borough asylums, and about the same number
of hospitals and licensed houses in the country. Now, unless I could make sure of
the support of, at all events, a large proportion of the superintendents of these
institutions, it would be a useless waste of time going on with the work, as the
information I should have at my disposal would be only of a very incomplete
character.

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203

I therefore decided to send a circular letter to all the superintendents of public
institutions for the care of lunatics and lay my scheme briefly before them in the
hope that they would think fit to give me their support. The editors of the
Journal communicated with me on the subject, approving of the idea, and giving
it their practical help. I therefore sent them the proof of the circular for their
perusal, and feeling that as the members of this Branch were kind enough to listen
to my original plea, it would only be my bare duty to present the circular to them
for discussion prior to having it printed, I will therefore, with your permission,
read it.

[This circular, in a slightly altered form, is printed on page 207.]

As to the class of information sought for I have only to call to your mind the
many circulars which you receive during the course of twelve months, all of which
you reply to (or possibly you don’t), at all events you rarely hear any more from
the person who sends the query to you. A few months after you receive another
query of a practically similar nature, until you naturally begin to think these
queries more or less of a nuisance. Under the plan 1 suggest you would only be
asked to reply once on any subject in one year, and you would receive a list for
correction at regular intervals of, say, twelve months; any alteration from the
previous reply would be noted at the bureau, so that up-to-date information would
after a time be obtainable at short notice by anyone seeking it. I am sure that to
many of us an arrangement of this description would be eminently useful. I have
had to seek information by this means, rather preferring to take the collected
opinion of my fellow superintendents than consult some of the books on the subject
containing information by no means always reliable and generally more or less
antiquated. In conclusion, 1 would like to add that I am entirely in your hands;
if the venture is to succeed it will only do so by aid of your support and co-opera¬
tion.

The Chairman said that Dr. Miller brought the matter forward at Leicester, and
they very much approved of it. He was kind enough to offer to take it in hand for
a year and see what he could make of it. He (the Chairman) thought that that
meeting would approve of it, and that it was worthy their consideration. If worked
out in the way Dr. Miller pointed out, it would be of infinite use to individuals and
the Association generally.

Dr. Powell said that they must all feel very much obliged to Dr. Miller for the
work that he had done in that direction. It was a new question, and he felt that
it was a thing that was, at any rate, worth trying. They should encourage Dr.
Miller to go on with the work and accept the circular as a Division. The circular
was a reasonable one, and he moved that the meeting should support what had
been done.

Dr. Ewan seconded this motion, and it was, after the discussion of various
details, carried unanimously.

The Photographing of Insane Patients.

Dr. Powell then opened a discussion on “ The Photographing of Insane Patients:
is it Detrimental to Them ? ” He said that he believed most asylums had adopted
the system of photographing patients on admission, that is, as many as could be
got to sit still. It occurred to him that this was done somewhat indiscriminately,
and done too much as a routine without considering whether it gave pain to the
patients or not. He argued that the pain would be very considerable in cases of
sensitive melancholia. He recollected seeing two women coming away from the
room in perfect misery, and it seemed to him that the process had given them pain.
Delusional patients were very suspicious, and they, too, would object. These cases,
perhaps sensible in other ways, would feel their residence in an asylum acutely, and
would be glad to forget it. They would look on the fact of having been photo¬
graphed as a permanent record of their residence in an asylum, and they would
rather not have it. They did not get acute cases in the case-books unless they
were snapshotted, and they did not do that, To illustrate a case completely they
should photograph the patient on discharge as well as on admission. He should
not hesitate for one moment to commend the system of photographing patients
and illustrating the cases in the case-books, but he should recommend that it be
not done as a routine process. He would ask the medical officers to discriminate,

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and if the photographing gave the patients pain he would not have it done. He
only brought the matter up in that cursory way to hear what other members of the
Division had to say about it.

The Chairman said that the subject was a very interesting one. There might,
he thought, be processes of photographing patients without their knowing
anything about it. They would then get a much truer likeness with regard to the
complaint.

Dr. Gill said it was a question whether there was any advantage to science in
photographing all patients. He agreed that if it was to be done it should be
done in a very secret way, and the photograph destroyed after the patient left.

Dr. Macphail thought that if any of the patients could give a good reason why
they should not be photographed they should have the right to do so. He did not
think the custom was abused very much.

Dr. Pope said that he had never seen any objection to it, and the case-books
were kept under control. It seemed to him that the Lunacy Commissioners
looked for it, for they made in their reports such entries as “ No photography
done,” “ No photograph room provided.” He agreed with Dr. Powell that the
system should be safeguarded. Snapshotting and enlarging could easily be done.
In large asylums it was a great advantage to have photographs as a means of
identification.

Dr. Adair said that he had had a good deal of experience in photographing
patients, for he had five or six hundred admissions per year and they photo*
graphed all they could. If there was any case, however, which they thought was
not fit or would not be advantageous to the patient it was not done. In any case
where a patient objected they did not take the photograph, but he must say that
the cases were very rare where the patients objected. As to the question of
privacy they took the history of all the cases, some of which were not too credit¬
able to the patients, and it was as bad to keep thai H as it was to keep the
photographs.

Dr. Miller said that he had snapshotted several patients during the past
fifteen years and it had not been objected to until the previous week. He con¬
tended that photography was very useful in tracing escaped patients.

Dr. Hitchcock spoke of the undesirability of photographing patients. He did
not think that anyone had a right to photograph insane patients, and he had felt
very strongly on the subject since some years ago he was shown in the collection of
an amateur photographer photographs of patients suffering from acute mania.
The only argument in favour of photographing the patients was that of identification
of large numbers in large pauper asylums, and that criminal lunatics might be so
identified.

Dr. Powell said, in reply, that he was struck by the fact that Dr. Gill and Dr.
Hitchcock, who had to do with better-class patients, should have expressed
opinions against the system, and he considered that pauper patients should receive
equal consideration. He would not say that as scientific men they had no right
to photograph for the treatment of disease. It was a good thing that patients
should be consulted regarding their wishes in the matter. Still, if a delicate,
sensitive melancholiac were appealed to he could not say no, although he might
feel that he would prefer to not be photographed. With regard to identity he had
never had a case in his twenty-one years’ experience.

A vote of thanks to the Chairman closed the meeting.

Previous to the business meeting the members had luncheon in the asylum and
were taken round the building ana grounds by the medical officers. In the evening
members and friends to the number of twenty-one had dinner at the Station Hotel,
York.

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205

RECENT MEDICO-LEGAL CASES.

Reported by Dr. Mercier.

[The Editors request that members will oblige by sending full newspaper reports
of all cases of interest as published by the local press at the time of the assizes.]

Rex v. Pritchard.

Charles Legg Pritchard, 24, painter, was indicted for sending to Sir Edward
Bradford a letter threatening to kill and murder Francis Hanks. Hanks was a
chief inspector in the service of the North Metropolitan Tramway Company.
Prisoner had for some time past busied himself in watching the North Metropolitan
Tramways, and had persuaded himself that there had been cruelty to the horses
and overloading of the cars, and he had for some time been sending letters of
complaint not only to the officers of the Company but to the police. On August
12th he wrote to Sir Edward Bradford to the effect that he had received no
assistance from the police, and that in consequence of the violent behaviour of
certain persons towards him, he had taken a revolver with him, and should not
hesitate to use it. A police officer called upon the prisoner and cautioned him.
On September 2nd the prisoner wrote another letter to Sir Edward Bradford in
which he threatened to shoot Hanks. The prisoner was arrested upon a warrant
and struggled violently with the police, trying to get his hand to his pocket, in
which was found a loaded revolver. The police proved the facts, and declared that
there was no foundation for the statement that there had been cruelty to the horses.
Dr. Scott, medical officer to Holloway Gaol, was of opinion that the prisoner was of
unsound mind at the time he wrote the letter, and that he did not know the nature
or quality of his act, or that he was doing wrong; also that the prisoner was at
present of unsound mind. Guilty, but insane.—Central Criminal Court, October
23rd, Mr. Justice Bigham.— Times, October 24th.

That the prisoner was insane there seems to be no doubt, but the interest of the
case lies in the very unusual form that the insanity took. It seems to have been a
case of paranoia, but the delusion of persecution was unique in this respect: that
the persecution was directed, not against the person himself, but against the horses
of the tramway company. So far as I am aware, no such case has been recorded
before.

The terms in which Dr. Scott was allowed to give his evidence should be noted.
In this and in the following cases he stated his opinion in the very terms which
have often been prohibited, and attention is again drawn to the freedom with
which the medical witnesses are now allowed to prove insanity in this way, and
to the great latitude that is given them in courts of justice.

Rex v. Holmes.

Harriet Holmes, 46, married woman, was indicted for the murder of her two
children. It was the common case of a woman in a fit of depression murdering
her children. The facts being proved, Dr. Scott gave his opinion that the
prisoner was of unsound mind at the time she killed the children so as not to be
responsible for her actions. Guilty, but insane.— Central Criminal Court, October
23rd, Mr. Justice Bigham.— Times, October 24th.

Rex v. Richardson •

John Thomas Richardson, 41, salesman, was indicted for the murder of his son,
set. 2 years. Prisoner murdered the child by punishing him with excessive
violence for some childish indiscretion. He struggled violently with the police on
being arrested, and when charged he said : “ Me kill the child! I love my baby.
Wilful murder ! you must be mad. I thought the baby had a nerve, so I bit it
through the mouth and on the top of the head, and I thought it would doit good.”
The prisoner had been very strange in his manner some time previously. He was
extremely fond of the child. Dr. Scott gave his opinion that the prisoner was

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insane at the time he committed the act, and did not know its nature and quality.
Guilty, but insane.—Central Criminal Court, October 23rd, Mr. Justice Bigham.
— Times, October 24th.

Rex v. Neville.

Alice Neville, 37, was indicted for wounding George Neville, her husband, with
intent, etc.

The husband, on his return from work, noticed that the prisoner was very strange
in manner, and that the bed had not been made. He asked her to pull herself
together and make the bed, and he sat down to read while she did so, and went to
sleep. He awoke to find her standing in front of him with a knife. He was
bleeding from a wound in the throat. The prisoner attempted to cut her own
throat, inflicting a serious wound upon it. She had been in a melancholy and
depressed condition for some time. Dr. Scott said that he should say that the
prisoner did not know what she was doing when she committed the act. Guilty,
but insane.—Central Criminal Court, October 23rd, Mr. Justice Bigham.— Times,
October 24th.

This series of cases illustrates very well the present practice in trials in which
the plea of lunacy is raised on good grounds. The judge allows ample latitude to
the medical witness, who is, in fact, called by the prosecution. The following
case shows a different practice :

Rex v. McKenna.

Patrick McKenna, 53, joiner, was indicted for the murder of his wife. The
accused seems to have been jealous of his wife, without cause, as he subsequently
admitted. He was drunk on the day of the murder, was refused money by his
wife, and then accused her of unfaithfulness and threatened her. Twice he went
away, and twice he returned. On the second occasion he took her by the shoulders,
and taking a carving knife off the table said, “ I will cut your throat.” She took
the knife from him, but a second time he seized it, and plunged it into her neck.
She died soon afterwards. On the way to the police station he said, “ I went to
the house without premeditation and without malice. It is horrible. She threw
the knife on the table and said, * If you want to do it, do it.’ It was done in a
minute. She was launched into eternity unprepared. She has gone to hell if there
is such a place.” Mr. Sutton, for the prosecution, said that he purposed to call two
medical witnesses to give evidence as to the state of the prisoner’s mind, in view of
a possible defence on the ground of insanity in the prisoner’s family. The judge
said he did not see that this evidence could be heard. Everybody was presumed to
be sane until they were found out to be otherwise. He did not know of any other
circuit in which it was the custom to take the course proposed by Mr. Sutton. Mr.
Sutton said that his reason for proposing to call the evidence was that on one
occasion Mr. Justice Hawkins made some very severe comments because that
course had not been adopted after allegations of insanity had been made before the
magistrate. The judge said it was not a question of custom, but one of evidence,
and what a learned judge might have thought right to be done in one particular case
was no reason for doing anything contrary to the rules of evidence. The plea of
insanity was not raised in defence, and the efforts of counsel were limited to an
endeavour, which was not successful, to reduce the crime to manslaughter. Guilty,
sentenced to death.—Manchester Assizes, November 13th, Mr. Justice Bucknill.—
Manchester Guardian, November 14th.

It is manifest that in this case there was no sufficient evidence of insanity
to enable the plea to be raised’with any chance of success, or it would have been
raised in defence. It must be remembered that the evidence gained by the prosecu¬
tion from medical examination of the prisoner in gaol is placed at the service of the
defence, and if it was not utilised by the defence it must have been because it was
not of any value; in other words, it went to establish the sanity, not the insanity,
of the prisoner.

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207

BUREAU OF INFORMATION.

We have received the following circular which Dr. Miller has addressed to the
Medical Superintendents of Asylums in England and Wales.

Warwick County Lunatic Asylum,

Hatton, near Warwick ;

November 12 th, 1901.

Dear Sir,—At the April meeting of the North and Midland Division of the Medico-
Psychological Association I introduced the subject of the desirability of forming a
bureau of information regarding asylum administration.

At the last meeting of the Council in July, a motion was unanimously carried to
the effect that I should proceed with the work. Before going further I think it
desirable that I should explain the nature of my scheme, and obtain the vote of my
fellow superintendents as to whether they are willing to assist me in the matter, as
it would be impossible to carry out my object without the assistance of, at all events,
a very large proportion of my fellow workers.

The object of the Bureau would be—

1. To receive the original query from any superintendent desiring information.

а. To send out the queries to all asylums.

3. To receive the replies and tabulate the answers in the manner prescribed in
the original query.

4. To send the replies to the questioners and to those who have responded to

the query.

5. To preserve and publish, if desirable, for circulation among the members these
replies, keep them up to date by annual corrections, and to forward a copy to each

contributor.

б. A subscription of 10 s. 6d. to be charged for the first year, the accounts to be
audited by the Association auditors, and the question of future subscription to be
considered by the members of the Bureau.

Are you willing to assist me by allowing your queries to pass through my hands

on the understanding that—

1. You receive a statement showing the result of your query tabulated to your
wishes;

2. That a copy of such tabulated statement be sent to all from whom replies are

received;

And that all information in the Bureau be at your service when required ?

Believe me, yours faithfully,

ALFRED MILLER.

‘HANDBOOK FOR NURSES AND ATTENDANTS.’

We are requested to state that as the 15,000 copies of the Handbook which have
been printed up to the present date are almost sold out, the further issue of 5000
copies has been sanctioned by the Council. It is considered undesirable to intro¬
duce at the present moment any such alterations as would necessarily constitute
the re-issue of a new edition, since such a step would, to a certain extent, put out
of date the many thousand copies now in use. It is felt that the time has not yet
come for a thorough revision. Nevertheless the Council considered that some
instructions for the prevention of the spread of consumption in asylums might well
be added, and a sub-committee (Drs. Spence and Weatherly) was requested to
draw them up. They will be printed on a separate sheet and can be readily
pasted on the inside of the covers of the book. These will be supplied gratis with
the re-issue, and to bring up the existing copies to the same level of usefulness it
has been arranged that copies in the same form will be supplied by the publishers
(Messrs. Baillifcre and Co., 8, Henrietta Street, Covent Garden) on receipt of a
stamped and addressed wrapper. It is suggested that medical superintendents
should cause such application to be made in respect of all the copies now in use at
their respective asylums.

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We also understand that the re-issue will contain the altered regulations for
training and examination which have been passed by the Association since the
first issue of the present edition.

RESIGNATION OF DR. YELLOWLEES.

The resignation of Dr. Yellowlees as Physician Superintendent of the Glasgow
Royal Asylum has not been altogether unexpected by those who were aware of
his recent illness and the grave affection of his eyesight; but still it will be difficult
to imagine Gartnavel without him, so identified has the work of his later years
become with the fame of that beneficent institution. We understand, however,
that Dr. Yellowlees does not intend to seek release from the practice of his pro¬
fession or the work of teaching, and we may hope to see him at our meetings
as enthusiastic and as helpful as ever. We have also good reason to hope that
he will place on record the impressions and recollections of his long experience of
asylum life, and can assure him of a hearty welcome to any book he may produce,
promising as it would a variety of incidents and reflections on things new and old.

Dr. Yellowlees took his degree in Edinburgh in 1857, and was then associated
with Sir W. T. Gairdner and Professor Spence in their hospital work. In the
following year he was appointed to a junior post at Morningside under the late
Dr. Skae, his colleagues having been Sir John Sibbald and Professor John
Young. General practice in Yorkshire engaged his attention for two years.
After that valuable experience he returned to Morningside, whence he was
appointed Medical Superintendent of the Glamorgan County Asylum in 1863.
On the resignation of the late Dr. Macintosh, Dr. Yellowlees was appointed to
Gartnavel in 1874. At that time there was a debt of £ 10,000 on the institution, a
debt which has been converted into a surplus of ^30,000 as the result of his skil¬
ful management. Many changes have been recorded in the administration of
Gartnavel during the twenty-seven years which have elapsed since Dr. Yellowlees’
appointment. Gartnavel is now devoted to private patients only, and the numbers
exceed those of any other similar institution in the country. The charitable action
of the asylum is deserving of all praise. A new dining hall, the reconstruction of
wards, the introduction of electric lighting, and the reorganisation of the whole
institution form the basis of a long history of successful management.

Honours have been paid to Dr. Yellowlees in recognition of his worth and
ability. He served as President of the Faculty of Physicians and Surgeons from
1892 to 1894, as President of the Medico-Psychological Association in 1890, as
President of the Psychological Section of the British Medical Association in 1885.
The University of Glasgow, where he has been Lecturer on Insanity since 1880,
conferred on him the degree of LL.D., and various foreign societies for the
study of psychiatry have included him among their honorary members.

Dr. Yellowlees has thus had the widest relations with his professional brethren
and the public, and we hope that his views and reviews will be given to the world
at no distant date.

He retires on the handsome pension of ^1200 per annum, with the best wishes
of the directors of the Glasgow Royal Asylum. Confident in Dr. Oswald’s ability
to maintain the high level of efficiency to which Gartnavel has been brought, Dr.
Yellowlees may now devote himself to work of a less harassing nature, and we are
assured that our readers will join with us in hoping that he will yet see many and
useful days.

OBITUARY.

Henry Sutherland.

Dr. Henry Sutherland, whose death on November 19th last we are grieved
to record, was a greatly esteemed and long-standing member of our Association.

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1902 .]

He was the second of six sons of the late Dr. Alexander John Sutherland, and
grandson of the late Dr. Alexander Robert Sutherland. Both his grandfather
and father held the office of Physician to St. Luke’s Hospital for the Insane. Dr.
Henry Sutherland was bom in 1841. He took the M.A. and M.B. degrees of the
University of Oxford in 1869. In 1870 he became a Member of the Royal College
of Physicians of London, and in 1872 M.D.Oxon.

He received his medical education at St. George's Hospital, London, and at
Addenbrooke’s Hospital, Cambridge. Devoting himself to the study of mental
diseases, he had his early training at Bethlem Royal Hospital and at the West
Riding County Asylum at Wakefield. After leaving Wakefield he returned to
London, and he was soon appointed Lecturer on Insanity at the Westminster
Hospital Medical School, and a Physician to the St. George’s (Hanover Square)
Dispensary. He became actively engaged in professional work as an alienist, and
he was Visiting Physician to Otto House and to Newlands House.

He was a Fellow of the Royal Medical and Chirurgical, Obstetric, and Medical
Societies, and a member of the Medico-Psychological Association, and of the
Pathological, Clinical, Neurological, and West London Medico - Chirurgical
Societies.

He was the author of A Directory of Justices in Lunacy , and of articles on
44 Feeding (forcible) of the Insane,” “ Menstruation and Insanity,” “ Cases on the
Borderland of Insanity,” “On Arachnoid Cysts,” “The Histology of the Blood in
the Insane,” and on a number of other subjects of much practical interest.

Dr. Sutherland won for himself the affection and esteem of his colleagues and
patients, and he will long be mourned by a wide circle of friends.

Archibald Campbell Clark.

The members of the Association will learn with deep regret of the death of Dr.
Campbell Clark, which occurred at Hartwood House, Lanarkshire, on November
28th, 1901. Belonging to Lochgilphead, Argyllshire, Dr. Clark in early life, before
he turned his attention to medical study, was connected for a time with the lay staff
of the district asylum there, and in this way he had the opportunity of viewing
asylum work from an unusual standpoint. It made a deep impression on him ; and
in subsequent life he showed much sympathy with the lay staff in their work, and a
large-hearted capacity of understanding and dealing with their difficulties. His
experience at Lochgilphead led him to select the medical profession, with the
object of devoting himself to asylum practice; and with characteristic pluck and
perseverance he carried out his purpose in spite of obstacles of worldly circumstance
which would have proved insurmountable to many men. He graduated at Edin¬
burgh University in 1878, and immediately afterwards became Assistant Medical
Officer in the Roxburgh District Asylum, Melrose, under Dr. Grierson. After a
few months’ service there he joined the staff of the Royal Edinburgh Asylum as
Assistant Physician under Dr. Clouston. Promotion to independent work came to
him very quickly by his appointment in 1880 to the Medical Superintendentship
of the asylum at Bothwell, near Glasgow. At that time the lunacy affairs of
Lanarkshire were in an unsettled and indeterminate state, and it was recognised
that the existing asylum accommodation was altogether insufficient. The remark¬
able success with which the small institution at Bothwell was made for several
years to meet the wants of a large and very populous district until permanent
arrangements could be made, was due entirely to Dr. Clark’s energy and ability.
The estate of Hartwood had been purchased with the intention of bunding there an
asylum sufficient for the requirements of the whole county. Subsequently it was
thought better to make separate provision for the two large urban parishes of
Glasgow, and Hartwood then became the site of the new asylum for the county of
Lanark, exclusive of Glasgow. Dr. Clark had a very important part in drawing
up the plans of the new institution, and when the buildings were ready for occupa¬
tion he went there from Bothwell as Medical Superintendent, which post he still
held at the time of his illness and death. In some respects the plans of Hartwood
followed lines which were new in asylum construction, and Dr. Clark’s practical
knowledge was justified bv the result, as in his hands the asylum quickly obtained
a very high reputation for efficiency and successful administration. Very soon
after entering on the duties of superintendentship Dr. Clark began to devote attention
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210

NOTES AND NEWS.

[Jan.,

to the special training of attendants and nurses in asylum work, and it was mainly
on his initiative that the Scottish Division took up the question of providing more
systematic instruction for them. He acted as convener of the first committee
appointed for that purpose, and wrote one section of the Handbook for Attendants ,
which has since been enlarged and adopted by the Association as its authorised
text-book for the examination for the certificate of proficiency in nursing and
attendance on the insane. He found time also for original investigations in the
more strictly medical portion of his work, and made valuable contributions to the
journals, his papers on puerperal insanity being especially noteworthy. He like¬
wise filled the post of Mackintosh Lecturer on Psychological Medicine in St.
Mungo’s College, Glasgow, and published a Clinical Manual of Mental Diseases.
During the last two years the state of his health Jiad caused much anxiety, and for
a time he had to give up work entirely and go to the South of England to recruit.
He rallied somewhat, but his health was never good again, and the end has come
all too soon to an active life. He was twice married, and leaves a widow and
family, with whom much sympathy is felt in their loss. To know Dr. Clark in
private life was to recognise his broad-minded sympathies, his great consideration
for others, and his thorough goodness of heart. By his death the Association,
and particularly the Scottish Division, loses a most valued member, and one who
was foremost in working for the advancement of everything connected with our
special department of medicine.

RESIGNATION OF THE REGISTRAR.

Every member of our Association will regret to hear that Dr. Benham has felt
it necessary to place his resignation in the hands of the President. His health
has been unsatisfactory of late, and he has been obliged to apply for a long leave
of absence Dr. Beveridge Spence has kindly consented to carry on the work
until more permanent arrangements can be made. The Association is deeply
indebted to these gentlemen for all the laborious work which they have done in
the office of Registrar. We hope that Dr. Benham will return to his post with
renewed health and vigour.

NOTICES BY THE REGISTRAR.

Examination for the Nursing Certificate.

One hundred and twenty-seven candidates applied for admission to the November
examination for this certificate. Of this number eighty-nine were successful, thirty-
three failed to satisfy the examiners, and five withdrew. The following is a list of
the successful candidates:

Derby County Asylum, Mickleover. —Males: George Davidson Anthony, Walter
Thomas Smith, Henry Yates. Female: Agnes Campbell.

Kent County Asylum, Maidstone. —Males: William Albert Bradford, Percy
Hubbard, Clement Newman, John Moore Richards, Jesse George Stanford, John
Woodsell. Females: Lucy Flora Hayter, Nellie Reeves, Emily Spurgeon.

London County Asylum, Bexley. —Males: William Benger, Arnold Carryer,
William Henry Carver, Frederick Montague Jeffery, Edward Mitchell, James
Robbens. Females : Margaret Hassell, Alice Holland.

Somerset and Bath County Asylum, Cotford, Taunton.— Males: William John
Homer, Philip Pook. Females: Ellen Locke, Alice Miller, Lily Tuck.

Warwick County Asylum, Hatton. —Females : Rose Anna Boyle, Clara Chance.
Mary Jemima Harvey, Elizabeth Mason, Henrietta Elizabeth Steadman.

Joint Counties Asylum, Carmarthen .—Males: Thomas Evans, Arthur Fishpool.
Females: Theodosia Davies, Mary Ann Griffiths, Lillian Margaret Jeffreys, Mary

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1902 .]

NOTES AND NEWS.

21 I

Hannah Lloyd, Agnes Margaretta Poyntz, Winifred Wintour, Florence Agnes
Wood, Elizabeth Morgan.

Peckham House Asylum, London .—Males: Edward Ablitt, Rudland Bere.
Females: Edith Emily Baxter, Alexandra Emily Hill, Elizabeth Lewis, Margaret
Christina Simpson.

The Retreat , York. —Females: Susan Emily Clark, Isabella Annie Hearder, Ethel
Mary McKew.

Prestwick Asylum, Manchester. —Male: William Rowarth Stubbins.

SCOTLAND.

District Asylum, Inverness. —Male: Donald MacDonald.

James Murray's Royal Asylum, Perth. —Males : John Cameron, Donald
McLeish. Female: Christina Mustard Ford.

Kirklands Asylum, Bothwell. —Males: George Bryce, James Saunders Lubanski.

Roxburgh District, Melrose. —Female: Jane Clubb.

Royal Asylum, Edinburgh. —Females : Margaret Copinger, Bessie Marwick,
Robina Milne, Elizabeth Porter, Agnes Thorburn Purves, Hannah Elizabeth
Robertson, Margaret Jane Sinclair, Annie Winkle.

IRELAND.

District Asylum, Londonderry. —Male: John O’Donnell. Female: Catherine
McDevitte.

District Asylum, Omagh. —Males: Peter Kelly, Johp McConkey. Females:
Isabella Armstrong, Susan Boyle, Mary Anne Martin, Ellen McCullagh, Minnie
McCreery, Mary Anne McEnhill, Kate Mullan, Mary Stewart.

St. Patrick’s Hospital, Dublin. —Male: Patrick Cleary. Females : Kate Camp¬
bell, Alice Sherry.

SOUTH AFRICA.

Valkenberg Asylum .—Females : Kate O'Reilly, Violet Ulrich, Kate Walker.
Robben Island Asylum. —Males: John Lineker, Walter Frederick Rigley.
Females: Florence Maud Bernott, Katherine Moore, Elizabeth Gerber.

The following is a list of the questions which appeared on the paper:

1. Describe the mechanism of respiration. State what changes take place in the
blood and in the air during respiration.

2. What are muscles ? What are the different kinds of muscles ? Of what uses
are they and how do they act ? Give the names of some of the principal muscles.

3. How would you arrest bleeding from (1) an artery r (2) a vein—say in the leg ?

4. What are—(1) fomentations? (2) stupes? (3) inhalations? (4) gargles?

5. What dangers are sick people exposed to by change of temperature in sick
wards?

6. What do you understand by the “insane ear” ? What other name is used
for it ? In what cases does it occur and how is it caused ?

7. Describe fully what is meant by a “ draw-sheet." What are its uses ? How
do you change it when a patient is still in bed ?

8. What are the principal points upon which the medical officers at their visits
may require information from you regarding sick patients who may be placed
under your care ?

9. What precautions would you take in preparing a bath for a patient ?

10. What is meant by “ impulsiveness ” ? What are the chief morbid impulses
to be watched for in insane patients, and in what cases are they most likely to
occur ?

Next Examination for Nursing Certificate.

The next examination will be held on Monday, May 5th, 1902, and candidates
are earnestly requested to send in their schedules, duly filled up, to the Registrar

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212

NOTES AND NEWS.

[Jan.,

of the Association not later than Monday, April 7th, 1902, as that will be the last
day upon which, under the rules, applications for examination can be received.

Note .—As the names of some of the persons to whom the Nursing Certificate has
been granted have been removed from the register, employers are requested to refer
to the Registrar in order to ascertain if a particular name is still on the roll of the
Association. In all inquiries the number of the certificate should be given.

Examination for the Professional Certificate.

The next examination for the Certificate in Psychological Medicine will be held
in July, 1902.

The examination for the Gaskell Prize will take place at Bethlem Hospital,
London, in the same month, and the examiners are authorised to award a second
prize in this competition should one of the candidates attain such a standard as
would justify them in doing so. Due notice of the exact dates will appear in the
medical papers.

For further particulars respecting the various examinations of the Association
apply to the Registrar, Dr. Spence, Burntwood Asylum, near Lichfield.

Prize Dissertation.

Although the subjects for the essay in competition for the Bronze Medal and
Prize of the Association are not limited to the following, in accordance with
custom the President suggests—

1. On the advantage of providing hospitals in asylums for acute mental cases.

2. Causation of colitis in asylums, and how it can be prevented.

3. State care of the insane.

The Manuscript Prize Dissertation and every accompanying drawing and pre¬
paration will become the property of the Association, to be published in the Journal
at the discretion of the editors. The dissertation, for the Association Medal and
Prize of Ten Guineas, must be delivered to the Registrar, Dr. Spence, Burnt-
wood Asylum, near Lichfield, before May 30th, 1902, from whom all particulars may
be obtained.

By the rules of the Association the Medal and Prize are awarded to the author
(if the dissertation be of sufficient merit) being an assistant medical officer of any
lunatic asylum (public or private) or of any lunatic hospital in the United Kingdom.
The author need not necessarily be a member of the Medico-Psychological Asso¬
ciation.

THE CRAIG COLONY PRIZE FbR ORIGINAL RESEARCH IN

EPILEPSY.

Dr. Frederick Peterson, of New York City, offers a prize of $200.00 for the best
original unpublished contribution to the pathology and treatment of epilepsy.
Originality is the main condition. All manuscript should be submitted in
English. The prize is open to universal competition. "Each essay must be
accompanied by a sealed envelope, containing the name and address of the author
and bearing upon the outside a motto or device, which is to be inscribed also upon
the essay. All papers received will be submitted to a committee, consisting of three
members of the New York Neurological Society, and the award will be made
upon its recommendation at the annual meeting of the Board of Managers of the
Craig Colony, October 14th, 1902.

Manuscripts should be sent to Dr. Frederick Peterson, 4, West Fiftieth Street,
New York City, on or before September 30th, 1902. The successful essay becomes
the property of the Craig Colony, and will be published in its medical reports.

NOTICES OF MEETINGS.

General Meeting .—The next General Meeting will be held, through the kind¬
ness and courtesy of Dr. Mould, at the Royal Hospital, Cheadle, on February 14th,
1901.

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1902.] NOTES AND NEWS. 213

Northern and Midland Division. —The Spring Meeting will be held on
Wednesday, April 16th, 1902, at Shaftesbury House, Formby, Liverpool.

South-Eastern Division. —The Spring Meeting will be held at the Surrey County
Asylum, Brookwood, in April, 1902.

South-Western Division. —The Spring Meeting will be held at the Cotford
Asylum, near Taunton, in April, 1902.

Scottish Division. —The Spring Meeting will be held at the Central Hotel,
Glasgow, on March 28th, 1902.

Irish Division. —The next Meeting will be held at the Royal College of Physi¬
cians, Dublin, in April, 1902.

AFTER-CARE ASSOCIATION.

The Archbishop of Canterbury will preside at the Annual Meeting of the After-
Care Association, to be held at Lambeth Palace Library, on February 8th, 1902, at
3 P-m-

APPOINTMENTS.

Blair, Robert, M.D.GIasg., appointed Consulting Physician to Woodilee Asylum,
Lenzie.

Beresford, Edwin H., M.R.C.S.Eng., L.R.C.P.Lond., appointed Medical Super¬
intendent of the New Metropolitan Asylum, Tooting Bee.

Dobson, Nurgamt Austin, M.B., appointed Assistant Medical Officer to the
Bracebridge Asylum, near Lincoln.

Donaldson, William Ireland, M.D.Dublin, appointed Medical Superintendent to
the London County Asylum, The Manor, Epsom.

Eades, A. L, L.R.C.P. and S.I., appointed Senior Assistant Medical Officer at
the County Asylum, Winwick.

Hunt, Thomas, M.R.C.S.Eng., L.R.C.P.Edin., appointed Resident Medical
Officer, St. George’s Retreat, Burgess Hill.

Johnston, George A., M.B., Ch.B.Aberd., appointed Assistant Medical Officer
at the Royal Asylum, Montrose.

Kerr, Neil T., M.B.Edin., appointed Medical Superintendent of the Lanark
District Asylum, Hartwood.

Marr, Hamilton, C., M.D.GIasg., appointed Medical Superintendent, Woodilee
Asylum, Lenzie.

Oswald, Landel, R., M.B.Glasg., appointed Physician Superintendent to the
Royal Asylum, Gartnavel, Glasgow.

Parker, Wm. A., M.B.Glasg., appointed Medical Superintendent of Gartloch
Asylum, Glasgow.

Perceval, F., M.R.C.S.Eng,, L.R.C.P.Lond., appointed Medical Superintendent
of Prestwich Asylum.

XLVIII.

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THE

JOURNAL OF MENTAL SCIENCE

[<Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland 1 ]

No. 201 [To."T] APRIL, 1902. VOL. XLVIII.

Part I.—Original Articles.

The Treatment of Incipient Mental Disorder and its
Clinical Teaching in the Wards of General Hospitals .
By Sir John Sibbald, M.D., etcC 1 )

I have to thank the Council of the Society for their
kindness in appointing a day for the discussion of the question
which is the subject of the following paper. The paper has
been written at the suggestion of my friends Dr. Clouston and
Dr. John Macpherson ; but it is right to say, as they have left
me a free hand in dealing with the subject, that they are not
to be held responsible for the opinions it contains.

Our chief object is to elicit the views of the meeting in
regard to what we deem an important deject in the present
arrangements for the treatment of mental disease and for
giving clinical instruction in regard to it; and I am to indicate
that, in our opinion, this defect might be best remedied by the
establishment of wards in the Royal Infirmary for the treat¬
ment of incipient and transitory mental disorders. I therefore
propose to show that, from the point of view of public charity,
the establishment of such wards is desirable ; and I hope also
to make it clear both that the present opportunities for clinical
instruction in insanity are singularly inadequate, and that the
wards we propose would furnish the means of making such
instruction efficient and complete.

It is proper to put on record that the raising of the question

XLVIII. 16

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216 treatment of incipient mental DISORDER, [April,

at present is entirely due to my friend Dr. John Macpherson,
one of His Majesty’s Commissioners in Lunacy, who con¬
tributed a valuable article on the subject to the Scotsman of
July 4th last ; and if, as I hope, the present discussion takes
effect in the establishment of the wards we desire, it is to him
that our gratitude will be due. It is not, however, a new
question. In the original plan of the Royal Infirmary a large
portion of the under floor was appropriated to patients suffering
from mental derangement, so that the question of providing for
such cases within the institution dates back to, at the latest,
the year 1738 ; but the question was not discussed in its
present form till the middle of the nineteenth century, before
which time neither the importance of hospital treatment for the
early stages of insanity nor the necessity for any clinical
teaching in insanity can be said to have been recognised.
Even so late as the year 1870, as I showed in an article in the
Journal of Mental Science (January, 1871), neither in this
country nor on the Continent was provision for the clinical
teaching of insanity in the medical schools anything but
exceptional. The first who effectually awakened an interest in
the subject was Griesinger, who, for some years previous to his
appointment in 1865 as Professor of Nervous and Mental
Diseases in the University of Berlin, had insisted on the im¬
portance of providing efficiently for such teaching in every
medical school, and who induced the authorities of the Royal
Charity (the great general hospital at Berlin) to provide for
clinical teaching, both in neuropathy and psychopathy, by
giving him wards illustrative of each of these subjects. My
own active interest in the subject began in 1866, when I
translated the opening lecture of Griesinger’s first course
(Journal of Mental Science , January, 1867). In 1867 I
attended several of Griesinger’s lectures in Berlin ; and
in that and subsequent years advocated, when opportunity
offered, the establishment in this country of wards somewhat
similar to those at Berlin.(*) But I felt, in common with many
others, that the most important requirement in those days was
to obtain the recognition of instruction in insanity in any shape
as a compulsory part of a medical curriculum—a recognition only
recently obtained in Scotland, and one for which, I understand,
we are largely indebted to the advocacy of Sir Arthur Mitchell,
when a member of the late Scottish Universities Commission.

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1902.]

BY SIR JOHN SIBBALD.

217

The importance of teaching insanity, and of illustrating the
teaching clinically, gradually, indeed, became more and more
felt, until now there is teaching, both systematic and clinical,
in connection with every medical school. The clinical teaching
is, however, always given in asylums, and that this is an
imperfect arrangement was early recognised. The late
Professor Laycock recognised this so clearly that he sug¬
gested, in 1869, that the managers of the Royal Infirmary
should set apart wards to serve both for the treatment of
mental disease and for the clinical instruction in insanity of
medical students. Sir Arthur Mitchell also advocated the
establishment of such wards in his Morison Lectures in 1871,
and so far succeeded in the advocacy that plans were prepared
for such wards among the original plans for the buildings of
the present Royal Infirmary. Sir John Batty Tuke, though
he afterwards supported a proposal that a special hospital for
the treatment of mental disease and for its teaching should be
established in London, said in an article in the Nineteenth
Century for April, 1889, that the “ideal arrangement for
teaching is a department for the treatment of insanity in
connection with general hospitals.” The importance of hospital
treatment for the treatment of the early stages of mental
disorder has also been recognised in the interest of the patients,
independent of the question of clinical instruction. The most
conspicuous instance of this within my knowledge is the wards
for the treatment of incipient mental disorder that Dr. Carswell
induced the Glasgow Parish Council to establish in connection
with their poorhouse hospital, and which have been in operation
for more than twelve years. Though these wards have not, as
far as I am aware, been made to serve the purpose of clinical
instruction, Dr. Carswell has shown their usefulness in providing
curative treatment for patients whose malady has not reached
the stage which makes relegation to an asylum necessary.

Other illustrations might be given of the way in which
the question now raised has occupied the minds of those inte¬
rested in the treatment of the insane and in the efficiency of
medical teaching, but sufficient has been said to show that
the matter has been long under consideration.

Little need be said to show that the wards we propose
would be useful from the charitable point of view, patients in
the early stages of mental disorder being at present almost

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218 treatment of incipient mental DISORDER, [April,

entirely neglected. If hospital treatment is desired for any of
these unfortunate sufferers, the only direction in which we can
look is either to general hospitals or to lunatic asylums; but
the desired help cannot be obtained there, for cases of mental
disorder are, as a rule, excluded from general hospitals, and the
cases we have in view have not arrived at the stage which
makes relegation to an asylum either necessary or justifiable.
It is certain, therefore, that a considerable number of patients
are thus allowed to fall into incurable insanity who might
have been, and indeed ought to have been, saved from that
fate.

A few words may be said as to the way in which these
cases of commencing mental disease have come to be unpro¬
vided with hospital treatment. I need scarcely say that it is
not in any sense the result of premeditated neglect. It has
arisen, indeed, in an indirect way, from the exceptional care
that the Legislature has taken to provide efficient hospital
treatment for the insane poor as a whole, they being the most
numerous of the few special classes of patients for whom
hospital accommodation is provided compulsorily by the rate¬
payer. This accommodation, as every one knows, is given in
the institutions called lunatic asylums ; but the Legislature has
judged it necessary so to hedge round with statutory precau¬
tions the admission of patients to these institutions, and there
are such impediments in the way of their admission, due to
social considerations, that it is not until mental disorder has
taken indubitable hold of a patient, and not even then in many
cases, that the asylum can be resorted to. The statutory
precautions (at least as regards all patients except those called
“ voluntary patients,” who are necessarily a very small class)
prevent the admission to an asylum in Scotland of every
person for whom medical certificates, according to a prescribed
form, and a sheriffs order cannot be obtained ; and similar
precautions exist in England and Ireland.

The impediment arising from social considerations is
perhaps the most important of all. It is always with great
reluctance, and only as a last resort, that a patient is placed in
an asylum. So far as this reluctance is justifiable, and so
far as it has much practical effect, it rests on the fact that a
person who has once been an inmate of an asylum is regarded,
though often quite erroneously, as unreliable for sound judg-

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1902.]

BY SIR JOHN SIBBALD.

219

ment and prudent conduct, and is henceforth seriously handi¬
capped in the battle of life. For these two reasons, then—the
legal and the social,—there is a large number of the persons
suffering from mental disorder and requiring hospital treatment
who are prevented from being treated in asylums at the stage
of the disorder when treatment is not only most needed but
also most likely to be effective in promoting recovery. As I
have already indicated, this exclusion from asylums, means as
regards these patients their exclusion from hospital treatment
of any kind ; and I do not think it requires much argument to
show that in Edinburgh such treatment can only be obtained
by the establishment of special wards in the Royal Infirmary.
It is evident that the requirements of the case would not be
met by the creation of any institution into which only persons
suffering from mental disorder would be received. Such an
institution would be shunned on account of the social injury
resulting from residence there ; and treatment in the infirmary
would be free from such disadvantages. The introduction of
the proposed wards into the infirmary would also be an act of
the highest philanthropy, as tending to obliterate the line of
demarcation which has too long been drawn between patients
suffering from what are called bodily diseases and patients
suffering from what are called mental diseases, or, to state it
more correctly, between those whose bodily illness has affected
their minds and those whose bodily illness has left the mind
in its normal condition. It might reasonably be expected also, if
it were understood by the public that special attention was given
in the infirmary to ailments in which the mind is disturbed,
that there might be established in connection with the proposed
wards a useful “ out-patient ” department, somewhat similar to
that conducted by Dr. J. Batty Tuke, jun., in connection with
the Edinburgh New Town Dispensary, in which patients suffer¬
ing from mental failure or exhaustion, or any of the mental
troubles which result from unsoundness of health, might receive
trustworthy and helpful advice and assistance. There is an
out-patient department for mental ailments in successful opera¬
tion under Dr. Rayner at St. Thomas's Hospital in London ;
and a similar department established by Dr. Bevan Lewis in
connection with the West Riding Asylum at Wakefield has also
been found of very great use, notwithstanding its association
with an ordinary asylum. It might certainly be expected that

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2 20 TREATMENT OF INCIPIENT MENTAL DISORDER, [April,

such a department would be more resorted to by patients if it
were connected with the Royal Infirmary than if it were con¬
nected with an institution devoted solely to the treatment of
mental disease ; and it is with great satisfaction that I am able
to say that all these gentlemen view with keen sympathy and
approval the idea of conjoining such a department with
psychiatric wards in a general hospital.

It is important, in considering the introduction of wards
such as we propose into the infirmary, to recognise that they
need not differ appreciably from the ordinary wards of a general
hospital. The question cannot be fully discussed on the present
occasion ; but I hope in a few words to indicate broadly the
grounds on which I express this opinion.

It must, of course, be borne in mind that it is not proposed
that patients should be kept in the wards for long periods ;
neither is it proposed that the wards should be places for the
compulsory detention of patients. The limitation of the period
of residence is important, for this reason among others : that it
helps to emphasise the fact that the wards are not intended for
the treatment of confirmed cases. For my own part, I should be
satisfied with a period of residence of not more than six
weeks. Before the end of that time, if death or recovery had
not taken place, it would in most cases have become evident
that removal to an asylum was inevitable. The restriction as to
compulsory detention would exclude such patients as, if they are
to be interfered with at all, can only be dealt with under the
statutory provisions which regulate the admission of patients to
asylums.

In any discussion of the arrangements of the wards it is also
necessary to keep in view the trend of medical opinion as to
the treatment of mental disorder in its early stages ; and there
can be no doubt that this opinion has been steadily moving
more and more towards the adoption of methods more closely
resembling those resorted to in the treatment of bodily disease.
The main indications of treatment, especially for the incipient
and transient phases of mental disorder—whether characterised
by melancholic depression, maniacal excitement, mental con¬
fusion, or stupor,—are to obtain repose, to induce cessation of
effort, both mental and bodily, and to restore the nutritive
processes to healthy action. In the great majority of cases
these results are best attained by medical treatment on ordi-

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1902.]

BY SIR JOHN SIBBALD.

221

nary therapeutic principles, by rest in bed, by continuous
nursing, and, in certain cases, by a discriminative application
of hydrotherapy. In recent years the conviction has been
growing that treatment on the lines of that associated with
the name of Weir Mitchell, which has been found so efficient
in dealing with other neurasthenic conditions, is equally appli¬
cable to the early stages of mental disorder. It is not, of
course, to be regarded as a panacea ; but there is good reason
to regard it as an essential element in the treatment which is
most likely to benefit the great majority of such cases. Active
exercise and occupation are no doubt invaluable in the treat¬
ment of many cases of mental disorder; but their chief use is
either in cases which have not reached the stage when hospital
treatment is desirable, or in cases which have passed that
stage and have become suitable for treatment in an asylum.
Recent experience has shown also that many of the benefits
formerly supposed to be obtainable only by voluntary exercise
can be better obtained by massage and similar expedients
included in the Weir Mitchell method. This method, gene¬
rally known among alienists as “ bed treatment,” has for many
years been growing steadily in favour, chiefly under the influence
at first of Guislain, of Ghent, who strongly insisted on its value
in the treatment of melancholia, and more recently of Ludwig
Meyer, of Gottingen, who advocated its more general use ; and
its efficiency is now widely recognised among asylum physicians
in this country.

The practical conclusion which, I think, we are justified in
drawing from these considerations is that such asylum adjuncts
as workshops, exercise gardens, cricket fields, and other
arrangements not usually found in general hospitals would be
unnecessary in connection with the proposed wards.

But we cannot omit from consideration, when discussing the
arrangements of the wards, the improved system of nursing,
the so-called “continuous nursing,” which has developed pari
passu with the bed treatment. One of the results of this
development has been to modify and, in the minds of many,
to revolutionise our ideas of the structural requirements for the
treatment of active mental disease. It is chiefly owing to the
adoption of this system that seclusion rooms and single
rooms of all kinds, which were formerly regarded as indispens¬
able for the treatment of a large number of asylum inmates,

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2 22 TREATMENT OF INCIPIENT MENTAL DISORDER, [April,

especially the excited and restless, are coming to be used
only in a few exceptional cases. With very few exceptions it
is now found that cases of acute insanity, even the excited and
noisy patients, may be more efficiently treated in associated
dormitories than in single rooms.

Another recent development has brought wards for mental
diseases more into line with ordinary hospital wards than they
formerly were. This is the introduction of nursing by women
into the male wards of asylums. In regard to this I shall
content myself with a reference to the example of the wards
for mental diseases in the general hospital at Copenhagen,
where the nursing staff is almost entirely female, and to the
position of the matter in the Stirling District Asylum. In
that asylum the chief officer on the male side under the
medical staff is a lady superintendent. Out of a total of 350
male patients, 11 5, or nearly a third, are, during the daytime,
entirely under the care of female nurses ; and this third includes
the great majority of the male patients suffering from acute
forms of mental disorder. Sixty-seven of the male patients
are at present under the care of female nurses both night and
day. I have already indicated that hydrotherapy is useful in some
early cases. To provide for this, however, it would only be
necessary that a suitably fitted bath-room should be attached
to the wards ; and in regard to the importance of this treatment,
I may refer you to a valuable article on the subject by
Professor Kraepelin, of Heidelberg, in the Centralblatt fiir
Nervenheilkunde und Psychiatrie for December last.

In estimating the value of the kind of treatment I have so
imperfectly sketched, it is of great importance to keep in view
that it tends in every way to foster a feeling among the
patients that they are from first to last regarded as suffering
from illness which requires medical aid, and that the treatment
is such as will suggest to their minds that everything that is
done has for its object the promotion of their welfare.

It will require very few words to indicate the nature of the
defects which exist in the present arrangements for clinical
teaching. You may well believe that they do not rest upon
anything for which the eminent lecturers are responsible who
conduct the teaching for Edinburgh University or for the
Royal Colleges School; and neither are they defects which
are peculiar to the Edinburgh School. One of them is

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BY SIR JOHN SIBBALD.

223

that the teaching is given at too great a distance from the
rest of the work of the students. For Edinburgh the clinical
instruction is given at Morningside and Larbert Asylums,
whose remoteness prevents the students from availing them¬
selves of the teaching, except to a very limited extent. To
make the teaching really efficient, it must be given in the
immediate neighbourhood of the school, and this has been so
fully recognised in Germany that since the year 1866 special
buildings called clinical asylums have been erected in the
immediate neighbourhood of sixteen of the German universi¬
ties to fulfil this requirement. At the other four universities
the defect did not exist, as there were either wards for mental
diseases in the general hospitals connected with the universities,
or there were asylums in close proximity, so that every university
has now its psychiatrical clinique close to the medical school.

The requirement that the clinical teaching of mental disease
should be provided in the immediate neighbourhood of the
medical school is thus fully met by the German universities.
I do not wish it to be understood, however, that I recommend
the example of Germany as one to be followed in every
detail. It is probable that the difference in the requirements
of the lunacy laws in Great Britain from those of similar
enactments in Germany would render an exact imitation im¬
possible ; but independently of that consideration, I think, from
what I have seen of the German arrangements, that they are in
several cases open to the objection that they are too suggestive
of the ordinary asylum. In these instances they do not form
part of the same building, or group of buildings, as the
general hospital; and they are really small asylums, although
intended only for the treatment of recent insanity or of recent
insanity and allied nervous disorders. They are looked upon
by the general public as asylums; and though Professor
Meschede, of Konigsberg, says that patients come more readily
to them than to ordinary asylums, the fear of being socially
damaged by residence there not only exists but has a seriously
deterrent effect. They fail, therefore, to provide to any great
extent for the special class of incipient and early cases
which we desire to benefit. It may prevent misunderstanding
if I point out that the “ hospital in London with a visiting
medical staff for the curative treatment of pauper lunatics and
for the study of insanity,” which was proposed in 1890 by

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2 24 TREATMENT OF INCIPIENT MENTAL DISORDER, [April,

Mr. Brudenell Carter’s Committee of the London County
Council, would have been very similar in character to the
German clinical asylums, and would, from the point of view of
the present paper, have had similar defects. Its being intended
for the treatment of patients certified to require detention in
an asylum would also have made it differ essentially from the
proposed wards. The examples within my knowledge which
come nearest to an ideal arrangement seem to me to be the
new wards for nervous and mental diseases in the Royal Charity
at Berlin, and similar wards in the Communal Hospital at
Copenhagen. I have not seen either of these buildings ; but I
am glad to be able to take the following details in regard to the
Copenhagen wards from the description given by Dr. Urquhart,
of Perth (Journal of Mental Science , January, 1897, p. 201).
In this general hospital, containing 900 beds, which is in the
immediate neighbourhood of the university, there are two
pavilions under Dr. Pontoppidan, each containing about sixty
beds, one for mental diseases and the other for other nervous
diseases ; and both are available for clinical teaching. At the
time of Dr. Urquhart’s visit the nursing of the male patients
had for eight years been almost entirely done by women, one male
attendant being attached to each of the two male wards. The
male attendants are subordinate to the female nurses, and are
not engaged in what is strictly speaking nurses’ work. During
the eight years only one patient had been found impossible
for female nursing. The average length of residence of the
patients is about three months.

The other serious defect in the present clinical teaching
is more important than mere distance. The great majority
of medical students are destined to be general practitioners,
and it is therefore of the first importance that in all clinical
instruction they should be made familiar with the diagnosis
and treatment of those phases of disease which fall to be
treated by the general practitioner. But the only clinical
teaching of mental disease that exists at present is given in
lunatic asylums ; and consequently the only patients whom the
students see are those whom the general practitioner is not
called upon to treat.

It must be kept in mind that it is in the initial stage of
mental disorder, before it has reached the stage when relega¬
tion of a patient to an asylum would be resorted to, that it is

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BY SIR JOHN SIBBALD.

225

of most importance that medical treatment should be careful
and skilful, because it is then that it can be most effective.
It is then that under careful guidance the patient may most
hopefully be placed in circumstances that will allow the restora¬
tive forces of his constitution to regain control, that toxic pro¬
cesses may best be checked, and that the exhausted brain-
cells may be stayed in their progress towards disorganisation.
It is true of mental diseases, more perhaps than of any other
class of diseases, that the earliest stages are those in which both
teachers and students can best obtain much of the information
necessary for the study of the nature and the causation of the
malady; and it is consequently of special importance that
students should have an opportunity of seeing such cases as
early as possible.

I feel sure, also, that our knowledge of the real nature and
the best treatment of mental disease would be greatly advanced
if there were more ample opportunity for the careful observa¬
tion and study of its early phases ip hospitals, and more
especially in hospitals associated with medical schools. The
study of disease in all its relations would have made compara¬
tively little progress during the past century without the light
derived from the systematic observation which can only be
effectively carried out in hospitals ; and it is scarcely question¬
able that most of that systematic observation has been
originated and carried on under the stimulus due to the
association of the treatment of disease with its teaching. I
think it is a matter of common experience that the patients
whose curative treatment receives the most careful and capable
attention are those whose good fortune it has been to be treated
in wards where teaching is practised, and that it is the physicians
and surgeons engaged in teaching who have chiefly contributed
to our knowledge of the nature and the treatment of disease.
I think it only reasonable, therefore, to expect that the observa¬
tion of the early stages of mental disease in clinical wards would
contribute notably to advance our knowledge.

I do not wish it to be understood that I am of opinion that
no useful clinical teaching is to be obtained in asylums.
On the contrary, I think that cases of recent insanity may be
seen in asylums from which lessons of great value to the
ordinary medical student can be drawn, and that it is only in
asylums that the medical student can see certain forms of

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226 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

mental disease which he should see if he is to have clinical
teaching in its most complete form. I should therefore be
glad, where an asylum is within convenient reach, that the
opportunities of instruction which it affords should not be
neglected. The point I wish chiefly to emphasise is that under
present arrangements an important part of the instruction that
the ordinary medical student should receive is omitted. He
receives no direct clinical teaching as to the treatment of the
incipient and the transitory phases of mental disease in their
earliest stage, that is, before they have passed out of the
hands of the general practitioner. It is in the treatment of
these phases of mental disease that he will in after life find
himself in presence of one of his most serious responsibilities,
and it is only by the establishment of such wards as we pro¬
pose that he can be duly equipped for the discharge of these
responsibilities. I desire to press as strongly as I can that the
need for these wards is urgent. In establishing them I think
that provision would be made both for the treatment of a class
of patients now exceptionally neglected, and for making prac¬
titioners of medicine better prepared for a most important part
of their work ; and I believe that a step would thus be taken
which would redound to the credit of Edinburgh.

(*) A paper read at a special meeting of the Edinburgh Medico-Chirurgical
Society on Wednesday, February 19th, 1902.—(*) See Journal of Mental
Science, July, 1868, p. 253.

Hallucinations and Allied Mental Phenomena . By Sir

Lauder Brunton, M.D., F.R.S.O

“ The wicked flea !'—Everybody knows the “ wicked flea,” for
it is no respecter of persons. It makes its home in the palace
of the prince, the hovel of the savage, and the tent of
the Arab. The devotions of many a worshipper are destroyed
by the Pulex *tabemaculi , or church flea, which makes up by
its voracity on Sundays for enforced abstinence on other days
of the week ; and one of the wonders narrated by travellers is
that on camping in the desert they have found this wicked little
creature waiting for them, ready to bite, although apparently its
progenitors from time immemorial could hardly have had an
opportunity of gratifying their taste for blood. When in Rome

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BY SIR LAUDER BRUNTON.

227

one summer, fleas were abundant in the hotel where I was
staying. I used to walk barefooted about my room every
morning, and soon a prick on the instep would warn me that a
flea was there. I looked down, saw a little black speck, put a
wet finger upon it, and after a little rub would transfer it to a
basin of water. The sensation of something solid between the
finger and thumb and the transference of the black speck from
my instep to the water convinced me of the presence of the
flea, for I had the threefold evidence (1) of common sensation,
(2) of sight, and (3) of muscular sense all combining to prove
the actual existence of the flea. At other times during the day
I had the evidence of sensation to indicate to me that fleas
were again biting, and I felt quite convinced by sensation alone
that such was the case, for although I could not corroborate
the evidence of sensation either by sight or by muscular sense,
yet it was not contradicted by these senses. But sometimes I
have felt upon my hand a sensation exactly similar to the bite
of a flea, and yet, as the hand has been on my writing-table
within full vision, and no object whatever was to be seen on the
hand, I have discarded the evidence of sensation in favour of
that afforded by sight, and come to the conclusion that no flea
either was or had been upon my hand. Had it not been for
the sensation of sight, however, and had the hand been hidden
from my view, I should have confidently believed that it had
been bitten, trusting to the evidence of sensation, which, though
unconfirmed by sight or muscular sense, was not contradicted
by these senses.

“ The wicked flee when no man pursueth ”—I have pur¬
posely chosen this common illustration ; firstly, because it is
familiar to the experience of every one ; and secondly, because
it was suggested to me by the phrase “ the wicked flee when
no man pursueth, 1 ”(*) a phrase descriptive of violent exertion
combined almost certainly with the painful emotion of great
terror without any objective cause. The terror and the flight
are both due simply to a belief in the presence of pursuers
when such pursuers do not exist in reality, but only in
imagination.

Effects of imagination .—The degree of vividness with which
the supposed pursuit is present to the imagination of the
pursued may vary within wide limits. He may simply believe
that he is pursued without his senses giving him any evidence

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2 28 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

of the fact, but sometimes the mental excitement may be so
great that it is transferred to the organs of sense, and he may
actually believe that he hears their footsteps and distinguishes
voices, or even that he sees the pursuers themselves in the
distance. After outrunning and escaping from his imaginary
pursuers he would, in such an instance as this, give a graphic
account of how he had seen and heard them,—an account
which, relying on his senses of sight and hearing, he would
believe to be true, though in reality it was perfectly false.

Credulity and scepticism .—In primitive communities the atti¬
tude of men’s minds tends towards credulity. They are ready
not only to accept the evidence of their own sensations, but
also the statements of others, even when their own sensations
fail to afford evidence of the existence of the things which
others declare they have seen or heard. They are inclined to
attribute blindness or deafness to themselves rather than falsity
of vision or hearing to another. In more civilised countries,
however, excessive credulity is checked by scepticism. State¬
ments made by an individual which are in contradiction to the
sensations or ideas of the majority are disbelieved, and
scepticism is, indeed, frequently carried to excess, and state¬
ments of fact are scouted as untruths. A good example of
this is the complete incredulity with which Du Chaillu’s state¬
ment of the existence of gorillas was met, until its truth
was proved by the actual production of skeletons and skins of
the gorilla.

Positive and negative evidence .—Until this was done the
evidence in favour of the existence of a gorilla was the same
as that of the existence of fairies, in so far as it depended
upon individual testimony. It differed in this respect, how¬
ever, that Du Chaillu had checked the evidence of sight by
other senses ; and although this evidence was not confirmed,
yet it was not actually disproved by the evidence of others,
who, although present, had not seen the animals he described.
The existence of fairies, on the other hand, rests on the
evidence of people who had seen and heard them, and
sometimes been touched by them, but whose evidence as to any¬
thing objective was disproved by that of their neighbours, who
saw, heard, and felt nothing at the moment when the fairies
were alleged to have been present.

Definitions .( 8 )—Before proceeding further to discuss the

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evidence of our senses, it may be well to state the meaning
which I attach to some words which will be sure to come into
the discussion. By hallucination I understand a sensation
perceived by the individual without any objective cause ; by
illusion, a wrong perception excited by some external cause.
By vision I understand an hallucination or illusion of the
sense of sight ; by apparition I understand a vision respecting
some particular individual known to the observer.

Usually it is the action of stimuli on the peripheral ends of
sensory nerves that excites sensations, but similar sensations
may be produced by irritation of the large nerve-trunks into
which the peripheral branches unite in their passage upward to
the brain, or of the nerve-centres in the brain itself, although
the peripheral branches have received no stimulation whatever.
Yet under such circumstances sensation is usually referred by
the individual to that part of the body to which the peripheral
branches of the nerve are distributed, and from which sensory
impulses would ordinarily be received. Thus when the trunk
of the ulnar nerve, usually known as the “ funny bone,” is
either twitched or struck at the elbow the sensation is chiefly
referred to the fingers, to which the peripheral branches of* the
ulnar nerve are distributed, although no irritation has been
applied either to the fingers themselves or to the peripheral
branches of the ulnar nerve in them. In the same way, after
a leg has been amputated a man very often complains of pains
in his toes at change of weather. The reason is that the end
of the nerve in the stump becomes liable to irritation from
atmospheric changes, and this irritation is referred to the toes
in the same way as the sensation caused by a twitch or blow
on the “funny bone” is referred to the fingers. Similarly,
irritation of the cerebrum, or brain proper, may produce
sensations of pain, of feeling, of sight, or of hearing, although
the peripheral nerves and nerve-trunks, which would ordinarily
create such sensations, have not been stimulated at all. In
this way impressions of sight or of sound, of touch or of pain,
may be excited in the nerve-centres, and they are referred by
the individual to the periphery just in the same way as
excitement of nerve-trunks. In this way a person supposes
himself to be conscious of impressions made upon his senses
from without, although such impressions are due entirely
to changes in his own nervous system.

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230 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

Perception of sensations .—All physiologists are now agreed
that the perception of sensations occurs in the cerebrum, or
brain proper. Those changes in the cerebral cells which are
correlated with the perception of sensations are usually
originated by impressions made upon the peripheral organs of
sense—the eye, the ear, the nose, the tongue, or the skin, etc.
The peripheral organs of sense, again, are affected by external
objects, and it is from the impressions thus made upon them
and transmitted from the sense organs, through the nerves, to
the brain that we form our ideas regarding external objects.
It is evident that the correctness of these ideas will depend
upon the perfection with which (i) the organs of sense,
(2) the transmitting nerves, and (3) the brain-cells perform
their functions, and that imperfection in any one of these
structures may lead the individual to form erroneous notions
regarding the external world.

Eyes and ears in different people .—I believe that people
generally do not make sufficient allowance for differences
between their neighbours' eyes or ears and their own.

In a most interesting lecture delivered several years ago at
the Royal Institution, Liebreich pointed out that the peculiar
character of Turner's later pictures was due to an alteration in
his eye which caused him to see points as perpendicular lines
—a condition which is easy to imitate by looking at lights
with the eyes almost but not completely shut. He showed also
that the purple tones in Mulready's later works were due to a
yellowness in the painter's vision which caused him to use too
much blue in the endeavour to obtain the correct colours in his
pictures.

For my own part, I confess that at one time it never occurred
to me that certain so-called impressionist pictures, with large
blotches of colour and vague outlines, might actually represent
what the painter himself saw, because all the objects that I saw
had sharp and distinct outlines—so distinct, indeed, as to dis¬
tract my attention from the colour of the objects. But since I
have become to a certain extent presbyopic and wear glasses,
I find that by using lenses that are too strong for my eyes the
outlines of objects become blurred, but at the same time their
colour becomes much more distinct and impressive, my atten¬
tion being no longer directed away from it by the outlines. I
am therefore inclined to think that the so-called impressionist

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BY SIR LAUDER BRUNTON,

231

pictures may not be due to a simple desire on the part of the
painters to put down on canvas something that neither they
nor anybody else have ever seen, but may really be due to
defective vision on their part, so that they deserve pity instead
of scorn.

Acuteness and range of sight and hearing ,—A greater range
of colour-vision allows some people to see things to which
others are quite blind. For example, I know that others see
in a fire on a winter’s evening lovely blue and violet flames,
while I myself see nothing but red and yellow; and to those
who are able to hear the note of a bat the air of a summer’s
eve may be full of shrill shrieks, while to others there will be
perfect silence. Extreme acuteness of hearing may give to
some people what seems to be almost a prophetic power denied
to others, as is shown by the following incident.

My friend Professor H. C. Wood, of Philadelphia, told me
that when out hunting he found his senses were, as a rule,
quite as acute as those of any of his companions, whether they
were Red Indians or white men. On one trip, however, he
had with him an Indian hunter whose acuteness of hearing
seemed almost preternatural. On one occasion this Indian
said : "Two men and a woman are crossing the lake, and will
be here in about half an hour.” Wood asked him how he
knew. He said by the splash of the paddles and the sound of
their voices. The distance was so great that Wood thought at
first it was mere fancy on the Indian’s part, but the appearance
of the travellers at the time the Indian mentioned showed that
he was quite correct. In the same way the sense of smell may
be pretematurally acute, and one lady told me that she was
able to recognise coats belonging to different people by the
smell. The extreme delicacy of touch attained by some people
is little short of miraculous, and it is said that some of them
can even distinguish the colours of stuffs and substances other¬
wise alike.

Divining rod .—Some people also seem to have a peculiar
power of appreciating moisture, though they themselves cannot
tell by what sense they do so. These people appear to have
the power of discovering water, even at a considerable distance
under the surface. The use of the divining rod is usually a
subject of ridicule ; but for my own part I quite believe in it,
because I have known people who possess the power, and

XLVIII. 17

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232 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

although I have not actually seen them exercise it I have not
the least doubt that their statements regarding it are true. It
seems to me not improbable that they are enabled to perceive
the presence of water through some vague sensation occurring
in the joints or fibrous tissues when water is near, and this
gives rise to slight involuntary movements, whereby the rod
in their hand moves. I have been led to think this by the case
of an old lady, one of my patients, which seems to supply the
clue to the mode of action of the divining rod. She was very
rheumatic and suffered much pain in her joints, especially at
change of weather or in any damp place. So great was her
sensibility to damp that she told me she could tell if she were
driving over a bridge or near water even when her eyes were
closed. In fact, she said, " Wherever you would see fog on a
summer’s morning when the sun is just rising, I should feel it
if I were driving over that place at midday.” The divining
rod itself I regard as a mere indicator of involuntary muscular
action magnifying slight movements, in the same way as
the lever of the sphygmograph magnifies the lever of the
pulse.

In his poem on Signs of Rain , Edward Jenner, the dis¬
coverer of vaccination, has the lines—

Hark how the chairs and tables crack!

Old Betty’s joints are on the rack.

The cracking of chairs and tables, of course, is due to the
absorption of moisture by the dry wood, and its consequent
swelling, so that a strain is put on the joints of the various
pieces composing the table. The cause of the pains in old
Betty’s joints is less evident, but probably both they and the
divining rod are phenomena more complicated, yet of the same
kind as the cracking of the tables, the turning up of the
under sides of leaves from swelling of the petioles, and the
appearance of a man instead of a woman before rain in the
old-fashioned weather-glass, where the string suspending the
little figures twisted or untwisted according to the amount of
moisture in the air.

Indeed, I think it is quite possible that an ordinary galvano¬
meter needle suspended by a thin thread of twisted silk
impregnated with calcium chloride or some other hygroscopic
material might serve as a “ dowser ” in the absence of any

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BY SIR LAUDER BRUNTON.

1902.]

233

man or woman possessing the nervous sensitiveness necessary
to move the divining rod in the usual way.

Failure of the divining rod ’—In his Curious Myths of the
Middle Ages , Baring-Gould tells the story of a man who
traced murderers from the scene of their crime for a long dis¬
tance by means of the divining rod. He was brought to Paris,
and his failure to track people there led to his being utterly
disregarded ; but if we read the whole story, and in place of
putting in the words “ man ” and “ rod ” we use “ bloodhound ”
and “ nose,” every one will say that the story is perfectly natural,
and no one would wonder much that a bloodhound who could
follow a track in the country might fail to find it in crowded
streets. There seems, in fact, to be nothing more extraordinary
or incredible in one man finding water by the divining rod
while another cannot, than there is in the well-known facts that
a camel becomes conscious of the vicinity of water long before
a man, or that some people can hear high notes inaudible to
others, as anyone can test for himself by means of a Galton’s
whistle.

Causes of Alterations in the Keenness of the

Senses.

Peripheral changes, —Keenness of the senses may be increased
or diminished by local alterations either in the nervous centres
or the peripheral sense organs. As an example of the latter we
may take the application of strychnine to the eye, which is said
to increase the keenness of sight, while the sense of hearing
may be gradually diminished by blocking of the auditory
meatus by wax or the Eustachian tube by mucus, whilst
the effect of cocaine in abolishing common sensation is
now universally known. Excessive keenness of the senses
may be due to changes in the brain ; and in one case which
I knew of inflammation of the brain, the sense of hearing
during the illness became so extraordinarily acute as to
remind one of the Indian hunter whom I have just mentioned.
Every one knows the appearance of flashes of light which
occur if the eye is struck in the dark, and the lovely peacock’s
feather which can be seen if one gently presses on the eyeball,
especially from its nasal side. We thus see that some people,
through the natural acuteness of their senses, recognise objec-

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234 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

tive conditions such as the blue flame of carbonic oxide, the
screeching of a bat, or the presence of moisture of which other
people are quite unconscious, while on the other hand buzzing
or ringing in the ears, flashes of light, or visual appearances may
occur from changes in the organs of sense without any corre¬
sponding external object.

Cerebral conditions .—But the perception of impressions
transmitted to the brain from the organs of sense depends
much on the condition of the brain itself. Many impressions
pass unheeded, for in walking through a crowded street we
see numbers of people of whose presence we are conscious
only so far as to avoid collisions, and whom we do not re¬
member. Yet it is possible that many of these impressions of
which we appear to be quite unconscious, and of which we
have no recollection, may yet have imprinted themselves in
some way upon the nerve-centres, and of these we may possibly
again become conscious under other circumstances. Every one
knows the powerful influence of smell in recalling scenes and
persons—so much so, indeed, as occasionally to make one feel
as if one were living a second time. Twenty years ago I
suffered from malarial fever very severely and was obliged to
go abroad. My wife and I took passage on a P. and O. boat.
The passage to Gibraltar was very rough and the weather in
the Bay of Biscay very stormy, so that my wife was unable to
eat anything on the whole passage, and subsisted chiefly on
limes and dry biscuits. From Gibraltar we went to Tangiers,
and the passage there was also exceedingly bad. Some years
afterwards my wife, in going out of the dining-room, just as we
had risen from dinner, suddenly said, “ I do not know what is
the matter with me—I feel quite ill, just as if I were going to
be sea-sick.” She was unable to perceive any cause for this
sudden feeling, but from where I was sitting I could see that
she had just passed some Tangerine oranges, which were on a
side table in a position where she was unlikely to notice them.
She was not conscious of the smell, but she was conscious of
the associated ideas of Tangiers and sea-sickness. In the same
way the sense of hearing may give rise to associated ideas
without the sounds rising into consciousness. Several years
ago I was one night dressing for dinner on the second floor of
my house, and all at once, without any reason for it that I
could perceive, I began to think of a man whom I had seen

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BY SIR LAUDER BRUNTON.

235

two or three years before, although there was nothing
apparently to recall him to my memory at that particular
moment. On going down to my study on the ground-floor
I found this very man there. I have very little doubt that I
had dimly heard his voice, and this recalled him to me, although
I was not conscious of hearing anything. I believe, however,
that a dog would have been definitely conscious of his presence,
whereas I had only a vague suggestion of it. Some people
have an extraordinary memory for sounds or voices, just as
others have for faces, and in them the recurrence of a sound
may occasion a definite sensation instead of a vague impression.
Some time ago one of the nursing sisters in St. Bartholomew's
Hospital heard a peculiar footstep on the stair outside her
ward, and said, "If he were in the hospital I would say that
was So-and-so's footstep," mentioning the name of a patient
who had been under treatment in her ward more than ten
years before. It turned out afterwards that this patient had
returned to the hospital, and it was really his footsteps she
had heard. Such exact recollection is, however, rare, and I
believe it is vague suggestions, caused by the sounds of footsteps
or voices of approaching people, that give rise to the prover¬
bial appearance of people who are being spoken about. A
curious example of a sensation, apparently unfelt at the time,
being afterwards recalled, occurred in the case of a friend
of mine. He had a tooth extracted under nitrous oxide, and
during the extraction made movements as if conscious of pain,
but on awaking from the anaesthetic he had no remembrance
of any painful sensation. Next night, however, he dreamed
the whole thing over again, and felt the pain of extraction in
his dream. The perceptive centres have been well compared
to a palimpsest, in which the various writings have been
washed out again and again, but the last writing may blur in
one place, or render legible in another, the remnants of the
words previously written there. It is extraordinary how the
impressions of our senses are modified by our ideas. Every
one knows how the glowing coals in the fireplace on a winter's
night take all sorts of forms and faces; and one sees the
influence of ideas constantly in medical students who are
learning auscultation, who hear, on listening to the chest of a
patient, what they think ought to be there, and not the sounds
which are actually there. I well remember an instance of this

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236 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

sort occurring in my own case in regard to colour. The late
William Black, the novelist, and I were watching the Falls of
Niagara together. Black, who had a wonderful eye for colour,
asked me what was the colour of the body of water before it began
to fall over the cliff. Looking at it I said, “ It is dark bottle-
green,” a colour which I had seen in water before. “ No,”
replied Black, “ it is livid purple.” At first I thought that he
was mistaken, but on looking carefully I found that he was
quite correct, and that in giving my answer I had disregarded
the evidence of my senses in favour of a preconceived idea.
Every one knows the story of the practical joker who collected
a crowd at Charing Cross, and by the simple means of
suggestion got many people to believe that the stone lion
which formerly stood over Northumberland House actually
wagged its tail. I have heard it said, though I do not know
with what truth, that one of the extraordinary juggling tricks
shown in India depends upon suggestion for its success. A
man erects a pole, and up this pole a boy seems to climb to
the very top, and then to disappear. Yet a camera, while it
shows the pole, does not show a boy climbing upon it at all.
The vision of the boy climbing and ultimately disappearing is
said to be entirely subjective on the part of the beholders, and
no boy has been climbing at all. In this case a suggestion
conveyed from the sense of hearing has awakened in the brain
a visual sensation.

Thought-transference .—In some experiments that I made
some years ago on thought-transference I noted a similar con¬
dition, in which a stimulus which would ordinarily have
awakened one sense was actually perceived through another
sense. When seated, together with my wife, in a very quiet
country cottage, she opened a volume of the Psychical Society's
Transactions and looked at a page of diagrams. She put her
hand upon mine while she looked at this, and I quite felt that
her hand moved very slowly on mine, but I was quite unable
to make out by the sense of touch what the movement was.
On closing my eyes, however, a spectrum rose before me very
like what one sees when one closes one's eyes after looking at
an incandescent lamp. The spectrum that I saw was of a
triangle enclosed in a circle (Fig. 3). I drew this, and on
comparing it with the figures at which my wife was looking,
I found the triangle I saw was almost identical with one

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1902.]

BY SIR LAUDER BRUNTON.

237

on her book (Fig. 1), but while she was looking at it
her attention had strayed to the next page on which
was a line enfolding itself so that part of it formed a
circle (Fig. 2). These two figures had combined themselves
in the spectrum that I saw, and which, no doubt, had been
excited in my visual centres by the movement of her hand
upon mine unconsciously drawing the figures she saw. The

Fig. 1.

Fig. 2.

Diagram looked at in
a book.

Diagram to which the gaze wandered
from Fig. i.

stimulus thus produced had probably passed up the nerves to
the centre for touch in my brain, but had there excited only a
vague feeling, while in the centre for sight it had raised a
definite perception. In the same way I found that an impres¬
sion might pass from the sense of hearing to that of sight.
Sitting a few feet off, I closed my eyes while my wife drew on

Fig. 3.

the floor some simple patterns copied from the book already
mentioned. One of them was a circle with a single stroke
passing outwards from the centre (Fig. 4), and this I re¬
produced almost exactly, with the exception that, instead
of making one stroke from the centre, I drew a bundle
of rays (Fig. 5). It is very easy to make out whether
a person is drawing a triangle, a square, or a circle on

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238 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

the back of one's hand with a point if the figure be
large enough, but as the figure gets smaller and smaller it
becomes impossible to define it by the sense of touch, and then
the sense of sight appears to take up the work and produce the
spectra I have described ; but there is a limit even to this, and
if the drawings or movements on the back of the hand are very
small the spectra become indefinite and unlike those at which
the draughtsman is looking. I once tried to repeat this
experiment of visualising spectra through touch with my friend
the late Mr. George Romanes, but the movements of his hand
upon mine, although distinguishable as movements, were so
slight and so limited that I could not make out what he was
drawing, either through the sense of touch or of sight.

Fig. 4. Fig. 5.

Diagram drawn on the floor
with the foot.

Spectrum seen after hearing diagram,
Fig. 4, drawn on floor.

It is quite possible that the tactile sense in some persons
may be much keener than in me, and that tactile sensations
too slight to be perceived by them through the brain centre
for touch may be perceived as spectra when they are blind¬
folded in a way that seems almost miraculous to others. A
case which appears to be of this kind has been recorded by
Dr. Davey.( s ) In these experiments the visual sense was
excited through the sense of hearing, and I only saw the
spectra when my eyes were shut.

Visions — voluntary .—It is possible for some people with their
eyes shut, and by a vigorous effort of will, to call up some
familiar face or scene; very rarely, however, can this be done
with the eyes open. The late Professor Guy, of King's

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BY SIR LAUDER BRUNTON.

1902.]

239

College, stated that he possessed the power in his youth, and
that Goethe possessed it during the whole of his life.( 4 )

Involuntary .—Tesla, the famous electrician, was further
troubled by a strange affection of the eye, causing the rising of
images so persistent that they marred the vision of real
objects, and disturbed his mind. Whenever an object was
named to him, its image would appear at once so vividly
before his eyes that he often believed it real. This illusion
caused him such discomfort that he tried his best to break it,
but did not succeed until he was twelve years old. Then, for
a time, he was able to banish the images, but they have since
returned, though less persistently. His later observations have
convinced him that these images are really the recalling of
former visual impressions, consciously or unconsciously re¬
ceived^ 5 )

Suggested visions .—In Miss Kingsley’s work on West
Africa she mentions a very curious way the natives have of
killing some one they dislike. The assailant “ throws his
face” at the victim, by some process which Miss Kingsley
does not describe. The consequence is that the unhappy
victim sees the face wherever he turns, and by-and-by either
commits suicide or dies of exhaustion. This seems to be a
process of suggestion, the effect of which upon the visual
centre of the brain is so powerful that the suggested object is
constantly present. In this case the suggestion made by
another causes an object already seen to reappear, and in all
probability the powerful effect of this suggestion is due to
the low development of the higher cerebral centres in the
negro.

Closely associated with the African practice of throwing the
face and with hypnotic suggestion is, I think, the Italian
superstition of the “evil eye.” Its Italian name, “Jattura,”
su £g ests “ Gettare incanti,” “ to cast enchantment,” and if this
derivation be correct it would correspond closely to the African
term of “throwing the face.” It is certainly much more
dreaded by the nervous and impressionable races of Southern
Europe than amongst the more impassive inhabitants of
northern climes.

Hypnotic visions .—But in the most civilised races temporary
inaction of the higher centres may render the individual sus¬
ceptible to suggestion to such an extent that he will completely

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240 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

disregard the impression of his own senses and act only upon
the suggestions made to him. Thus in an hypnotic stance, in
which I had not the slightest doubt of the bona fides both of
the subject and of the operator, I have seen a man avoid
obstacles where there were none, try to sit down on a chair
which was not there, drink mustard and water with the greatest
gusto, and spit out pure water as if it had been a most filthy con¬
coction. These are some of the very commonest effects of
suggestion, and there are many others more complicated and
more interesting, but I need not further dwell upon them.

One of the most common ways of producing an hypnotic
condition is to stare intently at some luminous object, prefer¬
ably held above the level of the eyes. But intense concentra¬
tion of vision, even on an object which is not luminous, is
sufficient to produce this state, and the monks of the Monastery
of Mount Athos are said to have thrown themselves into a
condition of trance, in which they supposed themselves to be
conducted to heaven, by each man persistently staring at his
umbilicus. By steadily staring into the fire some people are
able to bring on a dreamy condition, in which their fancy seems
to be freer from the trammels of sense than at other times, and
persistent staring at a crucifix may not improbably have led
to the visions of many religious enthusiasts, as well as to
the curious feeling of levitation or floating in the air which
many of them have experienced.

Hypnotism is not a condition which occurs only in man ; it
can be produced also in animals. The old experiment in
parlour magic of hypnotising a fowl by pressing its beak
gently to the ground, and drawing a chalk line straight
onwards from the point of the beak, succeeds easily and
perfectly, even in a crowded lecture room, as I have
many times proved. Langley succeeded in hypnotising
young crocodiles, and Preyer hypnotised frogs so completely
that they sat still until they dried up to mummies, al¬
though there was no obvious reason why they should not
move as they liked* The hypnotic condition is, I think,
probably due to two or more nervous currents acting in
opposite directions, and its probable mechanism may become
to some extent intelligible from the old illustration of a
donkey dying of hunger between two bundles of hay so
equally attractive that it could not turn towards one bundle

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1902.] BY SIR LAUDER BRUNTON. 241

for a bite on account of the equal and opposite attraction of
the other bundle drawing it in a different direction.

Hypnotism is, I think, to be classed with many other
phenomena under the head of “ Inhibition,” but these I have
discussed at length elsewhere, and it would take too long to
enter into them now.( 6 )

One of the most interesting phenomena of hypnotism is
that of deferred suggestion, in which, during the hypnotic
sleep, the operator suggests to the subject that Jiours, days,
or even months afterwards he shall do something at a certain
time.

Premonition .—Closely allied to this is one form of pre¬
monition. An intimate friend of my own, who at that time
was Surveyor-General of Canada, told me that on one occasion
he had a premonition that some misfortune would befall him
unless he was at a certain place on a certain day. He left his
occupation, and travelled 200 miles across the prairie to arrive
at the place which he had in his mind. On his arrival he
found that his premonition was perfectly correct, and that mis¬
fortune would have befallen him had he not been there. He
did not tell me what the misfortune was, and naturally I did
not ask him. It appears to me that this somewhat unusual
phenomenon is but an exceptional form of a very ordinary
occurrence. Very many people have the power of sleeping
perfectly soundly, and yet awaking at an unusually early hour
to catch a train. During all the hours of sleep, however deep
it may seem to be, some part of the brain appears to remain
awake and to keep a record of the passage of time. Before
going to sleep the individual has before him the data (a) that
his train will start at a certain hour, and that (< b ) unless he
awakes in good time to reach the station ( c ) the train will
start without him. In my friend's case I think he must have
had unconsciously before him, when he started on his tour
over the prairies, certain data which would work out a definite
result in a given time if he were not there to prevent it.
During both the time of sleeping and waking these data were
present to his mind, and as the problem approached solution
he felt that he must needs go to prevent the result from being
worked out.

Some of the forewarnings that occur in dreams are, I think,
of a similar kind. The poet says, “ For morning dreams

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242 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

presage approaching fate, And morning dreams as poets tell
are true.” Now the dreams that occur in the morning on
awaking are usually more or less closely associated with the
thoughts that occupied the mind on going to sleep. In my
own case, I find that if I am awakened in the middle of the
night from a deep sleep, any dream that occurs at the moment
of awaking has a starting-point in some occurrence several
days back.

Rain areas and pain areas .—Other premonitions may, I
think, be due to atmospheric conditions. For example,
my wife on one occasion was induced to travel back from

Fig. 6.

France to Ireland by a very strong impression that her
mother needed her/*'and to the great astonishment of her
friends she arrived at home and found that it was so. I
am inclined to regard this as a phenomenon of the same
character as the occurrence of neuralgic pains at or about the
same time in places far apart, in men who have suffered from
gunshot wounds. During the American War, Weir Mitchell
took a particular interest in gunshot wounds, and after the war
was over his patients were distributed throughout the States.
He was interested to find that on one day he would get a
batch of letters complaining of their wounds from patients in
the Far West, and a day or two after from others in the middle

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1902.]

BY SIR LAUDER BRUNTON.

243

of the States, and a little later from those in the east. On
comparing these complaints with the meteorological records, he
found that a wave of rain and a wave of pain were travelling
across the States at the same time. These areas were concentric,
but the rain area was much smaller than the pain area. All
those in the rain area who felt their wounds troubling them
saw that the weather was disturbed, and were satisfied as to the
cause of pain ; but those in the pain area saw no reason for the
pains they were suffering, although they were in reality due to
the same meteorological causes as those in the rain area.( 7 )
The radius of the pain area was no less than 1 50 miles greater
than that of the rain area, and that of the rain area from the
storm centre was 550 to 600 miles. I am inclined to think
that my wife’s action was probably caused by some meteoro¬
logical change which had previously been associated in her
mind with some ailment in her mother requiring her care. The
same meteorological condition had probably occasioned in the
mother the need for care, and in the daughter the sensation of
being needed. The meteorological condition here had had an
effect in recalling sensations similar to that of the sense of
smell to which I have already alluded.

Brain waves .—All the phenomena that I have described seem
fairly easy of explanation, but there is a certain residue which is
difficult or impossible to explain by ordinary causes. For in¬
stance, I have known the case of a lady who dreamed during the
Crimean War that her son, who was before Sebastopol, was
injured in the right foot. Some months afterwards an officer
in his regiment came back to England and told her that her
son was injured in the left foot. “No,” said she, "it was in
the right foot; ” and it turned out that she, who only knew of
it from her dream, was right, and the officer who came to bring
the news was wrong. Many such phenomena may be regarded
as mere coincidences, but I think they cannot all be dismissed
in this way, and the discovery of wireless telegraphy seems to
render it quite possible that the brains of different people may
occasionally be so en rapport that they act together like the
transmitter and receiver in Marconi’s system. This theory was
first propounded under the title of “ brain waves ” by Mr. James
Knowles in a letter to the Spectator of January 30th, 1869,
and the prevision showed in this letter is so remarkable that I
think it worth while to quote a large extract from it:

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Google

244 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

Let it be granted that whensoever any action takes place in the brain,
a chemical change of its substance takes place also; or, in other words,
an atonic movement occurs ; for all chemical change involves—perhaps
consists in—a change in the relative positions of the constituent par¬
ticles of the substances changed.

[An electric manifestation is the likeliest outcome of any such
chemical change, whatever other manifestations may also occur.]

Let it be also granted that there is, diffused throughout all known
space, and permeating the interspaces of all bodies, solid, fluid, or
gaseous, an universal impalpable elastic “ ether,” or material medium of
surpassing and inconceivable tenuity.

[The undulations of this imponderable ether, if not of substances
submerged in it, may probably prove to be light, magnetism, heat, etc.]

But if these two assumptions be granted—and the present condition
of discovery seems to warrant them—should it not follow that no brain
action can take place without creating a wave or undulation (whether
electric or otherwise) in the ether; for the movement of any solid
particle submerged in any such medium must create a wave ?

If so, we should have as one result of brain action an undulation
or wave in the circumambient, all-embracing ether—we should have
what I will call brain waves proceeding from every brain when in
action.

Each acting, thinking brain would then become a centre of undula¬
tions transmitted from it in all directions through space. Such
undulations would vary in character and intensity in accordance with
the varying nature and force of brain actions, e. g. the thoughts of love
or hate, of life or death, of murder or rescue, of consent or refusal,
would each have its corresponding tone or intensity of brain action, and
consequently of brain wave (just as each passion has its corresponding
tone of voice).

Why might not such undulations, when meeting with and falling upon
duly sensitive substances, as if upon the sensitised paper of the photo¬
grapher, produce impressions, dim portraits of thoughts, as undulations
of light produce portraits of objects ?

The sound-wave passes on through myriads of bodies, and among a
million makes but one thing shake, or sound to it; a sympathy of
structure makes it sensitive, and it alone. A voice or tone may pass
unnoticed by ten thousand ears, but strike and vibrate one into a
madness of recollection.

In the same way the brain wave of Damon passing through space,
producing no perceptible effect, meets somewhere with the sensitised
and sympathetic brain of Pythias, falls upon it, and thrills it with a
familiar movement The brain of Pythias is affected as by a tone, a
perfume, a colour with which he has been used to associate his friend,
he knows not how or why; but Damon comes into his thoughts, and
the things concerning him by association live again. If the last brain
waves of life be frequently intensest—convulsive in their energy, as the
fire-fly’s dying flash is its brightest, and as oftentimes the “ lightning
before death ” would seem to show—we may, perhaps, seem to see how
it is that apparitions at the hour of death are far more numerous and
clear than any other ghost stories.

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1902.] BY SIR LAUDER BRUNTON. 245

He narrates the story told to Mr. Robert Browning, who said
that—

when he was in Florence, some years since, an Italian nobleman (a
Count Ginnasi, of Ravenna) visiting at Florence, was brought to his
house, without previous introduction, by an intimate friend. The Count
professed to have great mesmeric or clairvoyant faculties, and declared,
in reply to Mr. Browning’s avowed scepticism, that he would undertake
to convince him somehow or other of his powers. He then asked Mr.
Browning whether he had anything about him then and there which he
could hand to him, and which was in any way a relic or memento.
This, Mr. Browning thought, was perhaps because he habitually wore
no sort of trinket or ornament, not even a watchguard, and might,
therefore, turn out to be a safe challenge. But it so happened that,
by a curious accident, he was then wearing under his coat sleeves some
gold wrist studs to his shirt, which he had quite recently taken into use,
in the absence (by mistake of a sempstress) of his ordinary wrist
buttons. He had never before worn them in Florence or elsewhere,
and had found them in some old drawer where they had lain forgotten
for years. One of these gold studs he took out and handed to the
Count, who held it in his hand awhile, looking earnestly in Mr.
Browning’s face, and then said, as if much impressed, " C & qualche
cosa che mi grida neir orecchio, ‘Uccisione! uccisione!*” (“There
is something here which cries out in my ear, * Murder ! murder ! * ”)

And truly (says Mr. Browning) those very studs were taken from the
dead body of a great-uncle of mine, who was violently killed on his
estate in St. Kitt’s, nearly eighty years ago. These, with a gold watch
and other personal objects of value, were produced in a court of justice
as proof that robbery had not been the purpose of the slaughter, which
was effected by his own slaves. They were then transmitted to my
grandfather, who had his initials engraved on them, and wore them all
his life. They were taken out of the nightgown in which he died, and
given to me, not my father. I may add that I tried to get Count
Ginnasi to use his clairvoyance on this termination of ownership also;
and that he nearly hit upon something like the fact, mentioning a bed
in a room ; but he failed in attempting to describe the room—situation
of the bed with respect to the windows and door. The occurrence of
my great-uncle’s murder was known only to myself of all men in
Florence, as certainly was also my possession of the studs.

In general, thought is communicated from one man to
another by the muscular movements which originate speech,
alter facial expression, produce gestures or writings, and not
unfrequently the unconscious thought conveyed by facial ex¬
pression belies the statement made by the lips. In Mr.
Browning’s case it seems possible that Count Ginnasi could read
in the unconscious expression of Mr. Browning’s face some¬
thing which led him to suspect some horror connected with the

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246 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

wrist studs. At the same time it seems possible that changes
in Mr. Browning’s brain may have been communicated directly,
as in Marconi’s apparatus, to the brain of Count Ginnasi
without the intermediation of facial expression on the one
hand, and of sight on the other.

Hallucinations .—Some of the various apparitions or appear¬
ances of friends, deceased or otherwise, which have been recorded
upon fairly good authority may be regarded as phenomena
belonging to the same class as wireless telegraphy, though in
others the object seen may be due to self-suggestion. I think it
probable that in both these conditions there may be no definite
lesion, either of the brain or of the eye, such as might be dis¬
covered by the naked eye or microscopical observation, but in
other cases I think some lesion probably occurs either in the
eye itself or the cerebral centres. Mr. Tatham Thompson has
recorded a most interesting case of a lady who came to him
because she saw the head and horns of a goat constantly
before her.( 8 ) On measuring her field of vision with a perimeter
he found that there was a blind spot corresponding to the
figure she had described, and this was due to the bursting of a
blood-vessel in the eye, and consequent injury to the retina
(PI. I). Other cases of hallucinations of vision may be due to
choroiditis, *. e. inflammation of one of the membranes lining
the interior of the eyeball. I think it very likely that this
disease may be the cause of the hallucinations observed by Dr.
Head in cases of herpes zoster ophthalmicus , a form of shingles
involving the eye, and which is accompanied by a severe
irritation in some of the nerves going to the eye.( 9 ) Dr. Head
found that out of eleven cases of this disease five had been
subjects of typical hallucinations. One saw “a large white
face at the bottom of the bed,” one a “ corpse; ” two saw
figures standing beside the bed, “ misty as if wrapped in a
cloak ; ” and one, even whilst walking the room at night on
account of the pain, frequently saw a shadow without a face or
limbs standing in the room. The well-known case of the
German bookseller Nicolai or that of Mrs. A—, recorded by
Sir David Brewster, and quoted by Huxley in his Eleynentary
Physiology , as well as many others,( 10 ) may have been due
either to haemorrhage or inflammation in the interior of
the eye.

Causation of visions : organic causes .—But in the latter case

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JOURNAL OF MENTAL SCIENCE, APRIL, 1902.—Plate I.

Fig. 1. — Scotoma having the shape of a goat’s head. (After Tatham Thomson.)

Fig. 2.—Retinal haemorrhage giving rise to the scotoma shown in the previous
figure, the lower of the two branches being limited by a vein.

To illustrate Sir Lauder Brunton’s paper.

Adlard & Snn, fmf>.

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1902.]

BY SIR LAUDER BRUNTON.

247

there were hallucinations both of hearing and sight, as the
lady several times heard voices speaking to her, while at others
she saw her husband, a cat, a corpse, and deceased friends.
The occurrence of these phenomena suggests irritation in the
centres for hearing and sight, and it seems to me possible that
they may have been due to small atheromatous particles, which,
becoming detached from the walls of the blood-vessels, and
carried to these centres by the current of blood, have plugged
some small vessels in the brain, and thus given rise to localised
irritation. But there are certain drugs which will also cause
hallucinations of sight and hearing without producing any
organic change. Amongst these are cannabis indica, quinine,
and salicylate of soda. A most vivid account has been given
by Dumas in his Count of Monte Cristo of the visions produced
by cannabis indica, but others have failed to get a similar
result, and I have no personal experience of it myself.
Quinine, as every one knows, often gives rise to the sound of
bells in the ears, and salicylate of soda does the same. Quinine
rarely or never gives rise to visions, but salicylate of soda does
so in many people when they have their eyes shut, and in a
few when they have their eyes open. In the case of an old
gentleman who was taking salicylate of soda, both his friends
and I were much alarmed by the patient describing processions
of people all round his bed, when, with the exception of a
single attendant, no one was in the room. At first I thought
that the patient was delirious, but I found that the pulse was
quiet, the temperature normal, or rather subnormal, and I
therefore concluded that the visions were probably due to
irritation of the visual centre by the salicylate, of a similar
nature to that which so frequently occurs in the auditory centre.
The correctness of this hypothesis was proved, I think, by the
fact that a very short time after the salicylate was left off the
visions disappeared. I think it not unlikely that irritation may
be caused also by commencing inflammation, which may ulti¬
mately lead to epilepsy and mental aberration. I once met with
a curious case in J. S—, a student at St. Bartholomew's Hospital.
He came to me one day in a state of great agitation, and told
me his story. About ten days previously he had gone from
the hospital to his rooms in Middleton Square. On entering
the door he saw some one dressed in a brown coat sitting on
an arm-chair with his feet in the fender. He did not recognise
XLVIII. 1 8

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248 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

the figure, and he said, “ Who are you ? ” thinking it was one of
his fellow-students. The figure gave no answer, but shrugged
his shoulders ; so J. S— thought it was only a fellow-student,
and repeated the question. On getting no answer he said,
“ You may just as well speak; ” but instead of going
to the figure he went aside and threw off his great-coat.
The figure remained perfectly quiet until he went up to it, but
on putting his hand on the figure’s shoulder it entirely dis¬
appeared. He was naturally very much alarmed, but went
about his work at the hospital as usual. The night before I
saw him he had again gone to his lodgings, and seen the figure
as before, but instead of going up to it he simply gave a loud
shriek, and fell down unconscious. My diagnosis was that he
had had an epileptic seizure with a visual aura. On the first
occasion he had had the aura only without the attack, but on
the second he had had both the aura and the seizure. I gave
him some bromide and tried to quiet his mind, but in a few days
after I was sent for to see him again, and then I found that
he was in a state of wild delirium, and was seeing processions
of people going round and round his bed. He was taken to
the hospital for a short time, but not recovering, he was trans¬
ferred to an asylum, Here he remained for some time, and
then he seemed to get well. He returned to his studies, but
did not qualify, and then went to India. From that time
onwards he seemed to be unable to get on with any one. He
thought himself that he was irritable, but he managed to get a
place as librarian, and the last I heard of him, about six years
ago, was that he was still in it. The story of poor J. S—
reminds one very strongly of the German stories of the
Waldmadchen, where a hunter or woodsman goes out in the
forest, sees a vision, usually of a woman, whom he sometimes
follows to some enchanted land, and then by-and-by finds
himself back in the wood where he was, and, rising from a
state of apparent unconsciousness, finds his way home; but the
neighbours observe he is never quite the same man afterwards
—exactly as happened to poor J. S—.

The relationship of epilepsy to visions raises the interesting
question of how far the so-called “ seers,” “ prophets,” and “ medi¬
cine men ” actually beheld visions, and how far they were able
to bring them on by the antics or privations which they regard
as a necessary preliminary to the exercise of their powers*

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BY SIR LAUDER BRUNTON.

249

Many years ago I sa^a performance of “howling dervishes,”
and while shouting continuously “ Allah ! Allah ! ” they waved
their heads up and down and moved their bodies up and down,
and left their hair flying about while they described a vertical
figure of eight (8), and this went on for some time, until one man
fell down in an epileptic fit. This exhibition threw a curious
light upon the story of Samson, which had been to me, as it is
to most children, of the utmost interest. This story is now by
many critics discredited and looked upon as a solar myth, but
to me it is a most vivid description of a man in whom great
natural physical strength was extraordinarily exaggerated
during periods of abnormal mental excitement. This excite¬
ment usually came on only in consequence of some external
stimulus. When a lion roared against him, he sprung at it and
killed it by tearing its jaws apart. When the Philistines
shouted against him, he seized the jawbone of an ass—the first
thing that came handy—and slew therewith a thousand men.
His hair had never been cut from the time of his birth, and in
it lay his strength. When the treacherous Delilah shaved his
head and delivered him into the hands of the Philistines, he
became weak as other men. Till I saw the performance of the
“ howling dervishes ” I could not understand what Samson
meant by saying, “ I will go out as at other times before, and
shake myself” (Judges xvi, 20). After seeing the per¬
formance, it seemed to me not unlikely that Samson was
in the habit of bringing on the fit of excitement by shaking
himself like a dervish, and the mass of hair which he
possessed would tend to increase his excitement, and when
the hair was shaven off the mere shaking had no effect.
If this view be correct, the statement “ Howbeit the hair of
his head began to grow again after he was shaven ” (Judges
xvi, 22), acquires a new interest, for with its growth his super¬
natural strength appears to have returned, so that when he
bowed himself between the pillars of the temple of Dagon he
overturned them, and slew at his death more than he had ever
slain in his life. I do not know that I should have connected
Samson’s supernatural strength with the dervish performance
had it not been that several weeks before I saw it I had
walked up the hill which is before Hebron. The hill is very
steep, the day was very hot, and I could not help thinking
what a foolish man Samson was to take the gates away from

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250 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

the city of Gaza, to carry them away inland for fourteen hours
and right up to the top of a steep hill, when he might quite
easily have thrown them into some ravine where they would
be quite as useless to the Philistines as on the top of the hill.
This act appeared to me to be more like that of an epileptic,
who runs straight on without either knowing or caring where
he is going, than that of a sensible man ; and the greater part
of Samson’s acts were rather exhibitions of blind fury than of
the wisdom of a judge. Samson’s achievements recall those of
the Scandinavian hero Berserker, who entered into the battle
with nothing on but his “ bare sark ” or shirt only, but in a state
of fury which seemed to serve him in place of armour. This
fury was no doubt imitated by many of his followers, so that
his name has now become attached to it as an adjective. How
it was brought on I do not know, but it seems closely allied in
its nature to that which the Malays induce by hasheesh before
they run amok.

Migraine .—Many authorities regard epilepsy and one-sided
headache, or migraine, as closely associated conditions ;( n ) and
epilepsy is supposed by some to depend upon a spasmodic
contraction of some of the blood-vessels in the brain. Du Bois
Reymond, who suffered much from migraine himself, ascribed
it to spasmodic contraction of the blood-vessels in his head, for
he found in his own case that during the attack his temporal
artery (vide Figs. 7—9) became tense and hard like a bit of
whipcord, and the pupil of the corresponding eye dilated as if
the sympathetic nerve in the neck had been stimulated.
Others, again, have held, also on the ground of personal experi¬
ence, that the blood-vessels were widely dilated. Observations
that I have made on my own head show that both these ideas
are right, for I find that the condition is really one of peripheral
contraction and approximal dilatation ; i. e. those parts of an
artery which are nearest the heart expand widely, whilst those
which are farthest away contract tightly. The carotid artery
dilates widely and throbs violently, but the temporal artery is
usually contracted as in Du Bois Reymond’s case. Some¬
times, however, the dilatation extends even to the temporal
artery, so that it is dilated and throbbing while the headache
is just as severe as when it is contracted and hard. On such
occasions, if I pass my finger far enough along the artery, I
always find a spot where the contraction begins, and usually

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1902 .]

BY SIR LAUDER BRUNTON.

251

the branch (vide Fig. 8) which ascends up the frontal bone
feels like a bit of piano wire under the finger, while the artery

Fig. 7. Fig. 8,

Diagram of arteries during migraine,
showing dilatation of the carotid
and spasmodic contractions of the
temporal arteries.

as it crosses the temple is soft, dilated, and pulsating. Occa¬
sionally the vascular condition at the temples seems suddenly

Fig. 9.

Diagram of arteries during migraine, showing dilatation of the
carotid and temporal arteries, and spasmodic contraction of an
ascending frontal branch of the anterior temporal artery.

to become normal, and the pain is transferred to the back of
the head, and —what is sometimes more extraordinary—the

Diagram of the carotid, temporal,
and occipital arteries in the
normal state.

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252 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

pain may leave the head altogether quite suddenly and com¬
mence in the abdomen, or vice versd. There is evidently a
close connection between the abdomen and the head, and one
of the comrfionest terminations of migraine is violent vomiting.
The pain of migraine is frequently accompanied by other
phenomena, which are readily explicable on the hypothesis
that those branches of the carotid artery which pass to the
interior of the skull are affected in the same way as those
which pass to its outside. If the terminal branches of the
temporo-sphenoidal artery (PI. II, fig. i) become contracted like
a bit of piano wire, as the one which runs up my forehead does
during a headache, the nutrition of the centre for sight in the
brain must necessarily be impaired, and if the spasm should
extend farther down the artery to 5, the centres for hearing,
taste, and smell will also suffer (PI. II, fig. 2). I think it is prob¬
able that such impairment is the cause of the indistinct vision of
the hemiopia, /. e . blindness to all objects on one side of the
body, either to right or left, even of complete blindness, and of
the zigzags which occur either before or during an attack of
migraine. The senses of taste and smell are less frequently
affected, but I have one case in which the patient has neither
taste nor smell during the attack of headache, and after it is
over both taste and smell return quite suddenly. In this
patient there is no disturbance of vision, nor is there any
aphasia during the attack. In other cases one finds aphasia
to a greater or less extent present during the attack, and
passing off when it is over.

To some the idea may seem far-fetched, but I am inclined
to believe that the fairies which many people declared that
they saw were nothing more than the coloured zigzags of
migraine modified by imagination, and in some cases, perhaps,
accompanied by, and to some extent occasioned by, an
abnormal condition of one or other eye. It is quite extra¬
ordinary to notice in the stories of fairies how often the “ seer ”
was struck blind of one or other eye, and after this his power
of seeing fairies disappeared. When I was a small child, my
aunt’s maid told me that she had seen fairies when she was a
little girl living in Earlston, the home of Thomas the Rhymer,
and the centre of fairyland. She was standing one morning
at the door of her house, when she saw a troop of small people
dressed in green coming up the street. She called to her

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JOURNAL OF MENTAL SCIENCE, APRIL, 1902.—Plate II.

Fig 1.—Distribution of the arteries in the brain. (After Ross.)

To illustrate Sir Lauder Brunton’s paper.

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Adlard & Son, Imp.

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JOURNAL OF MENTAL SCIENCE, APRIL, 1902.—Plate III.

Fig. 1. —Dante and Virgil watching Paola da Malatesta and Francesca
di Rimini in the procession of spirits. (From Dord’s Inferno, by kind per¬
mission of Messrs. Cassell and Co., Ltd.)

Fig. 2. —Procession of spirits taking the form of a D. (From D
by kind permission or Messrs. Cassell and Co., Ltd.)

(From Dore's Panic!iso,

. permission
To illustrate Sir Lauder Brunton’s paper.

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dtilard & Sen, hup.

1902 .]

BY SIR LAUDER BRUNTON.

253

father and mother to look at them, but neither of them could
see anything. A few years ago I got her to give me a written
description of this occurrence, and I took it with me to a
meeting of the British Medical Association at Portsmouth,
where I read a paper on “ Headaches.” Since then I have laid
it aside so carefully that I cannot find it, and consequently
am unable to quote it verbatim. In his address at the British
Association, Professor Rhys said that he considered the stories
of fairies to be founded upon the existence of a small degene¬
rate race. It is with the utmost diffidence that I dissent from
so great an authority, but it seems to me that whilst the
stories of brownies, i. e . the small supernatural household
drudges of farmhouses in Scotland, may very well depend
upon the existence of a few remnants of a degraded and
degenerate race, yet some stories of the fairies belong to an
entirely different class, although in others the character is
mixed. In Scotland the fairies and the brownies are entirely
different beings, but in Wales and Ireland they seem less
sharply differentiated. It is noticeable that visions of the
fairies, or little green folk, are very generally accompanied
by jingling of bells, and this I regard as stimulation of
the nerve-centres for hearing coincidently with that of the
visual centres. The relation of the appearance of fairies and
that of the Waldmadchen to epileptic states is, I think, indi¬
cated by the person who saw the fairies, like the man who
saw the Waldmadchen, being carried off for a time, which
seemed to him years, into some supernatural country, on his
return from which he found himself exactly at the spot whence
he had gone. It is, moreover, just between sleeping and
waking condition that epilepsy so frequently occurs, and as
Scott says:

’Twas between the dawning and the day,

When the fairy king hath power,

That I fell down in sinful fray,

And ’twixt life and death was snatched away
To the joyless elfin bower.

It may be incidentally remarked that Gustave Dora's pictures
of long lines of people, as, for example, in his picture of Paola
da Malatesta and Francesca de Rimini in his Inferno , have a
striking similarity in form to the (cf Plate III, figs, i and 2, with
Plate IV) zigzags seen in sick headache ; whilst Dante himself

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254

HALLUCINATIONS AND ALLIED PHENOMENA, [April,

appears to have seen something of this kind, for in his Paradiso ,
canto xviii, lines 70-72, he says, “ So, within the lights the
saintly creatures flying, sang, and made now D, now I, now L,
figured in the air.” Sick headaches are, perhaps, more frequent
amongst highly sensitive members of civilised communities,
but it is probable that they have existed at all times and
amongst all peoples, and wherever they have been present
they may have led to visions. Numerous examples have been
found of skulls belonging to the Stone Age in which large
holes have been bored with stone implements, and the
patient has not only recovered, but has lived for a long
time after the operation. This is shown by the edges of the
bone not being sharp or rough, as they would be for some time
after the operation, but smooth and bevelled by slow absorp¬
tion after the wound had healed.( 12 ) Some authorities have
supposed that these openings in the skull have been made for
purposes of priestcraft, and that the priests, by pressing hard
on the brain through the opening in the skull, were able to
induce epileptic fits in the patient, and then announce that he
Weis possessed by a spirit, and in a fit condition to give
oracular responses. It is possible that the openings in the
skulls may have subserved this purpose, but to any sufferer
from sick headache the first idea that suggests itself is that the
holes were made at the request of the sufferers in order to
“ let the headache out,” for when the pain of headache
becomes almost unbearably severe, an instinctive desire some¬
times arises either to strike the place violently in the hope of
relieving the pain, or to wish that some operation could be
done to remove the pain ; and some of the South Sea Islanders
actually make a hole in the skull for this purpose.( 18 )

Perhaps the hallucinations that are of the most practical im¬
portance are those of hearing, where patients are told by voices
inaudible to others that they must do certain things, some¬
times of the most gruesome nature, and their obedience to
such voices may lead them to commit the most horrible crimes.
In the case of the inmates of a lunatic asylum, the dangers
which might arise from any such hallucinations of hearing can
be carefully guarded against ; but when persons, otherwise
apparently perfectly sane, are subject to them, the risk which
they may cause is considerable. Sometimes such hallucinations
of hearing may be beneficial instead of harmful, the individual

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JOURNAL OP MENTAL SCIENCE, APRIL, 1902. Plate IV.

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Google

Visual appearance which sometimes precedes a sick headache.
After Hubert Airy.

To illustrate Sir Lauder Brttnton’s paper.

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BY SIR LAUDER BRUNTON.

255

1902 .]

being told to do eertain things which are right and proper. In
some cases such hallucinations appear to have had the most
wide-reaching effect—as, for example, in the case of Mohammed,
who began dating his mission as the “ prophet of God ” from a
vision of an angel who spoke to him and announced his
prophetic mission. The attack in which this occurred appears
to have been curious, because it began with a flood of light
succeeded by unconsciousness, after which the vision was seen.
It occurred in the night, so that no one was able to say whether
the vision was accompanied by any convulsion ; but he was liable
to attacks of definite epilepsy, so that his biographer says that
“ he would be seized with a violent trembling, followed by a
kind of swoon, or rather convulsion, during which perspiration
streamed from his forehead in the coldest weather, he would lie
with his eyes closed, foaming at the mouth and bellowing like
a camel.” It is curious to speculate what the fate of the world
might have been if bromide of potassium had been known in
the days of Mohammed, for the free use of this substance
might not only have checked his fits, but removed the visions
by which they were accompanied. In sick headache, as in
epilepsy, bromide of potassium is very useful. I find that a
combination of it with salicylate of soda is more useful still,
and forms a very efficient remedy both for the prevention and
arrest of the migraine. Numerous other drugs, such as caffeine
antipyrine, phenacetine, arrest headaches. All the mental
faculties are no doubt greatly modified by the condition of the
intestines, and everybody knows that headaches are apt to be
produced by constipation ; while an attack of migraine may
often be warded off by a blue pill and a black draught.

All the phenomena I have been describing of the most part
are of a morbid nature. It is quite true that some of
the most remarkable men in the world’s history have been
epileptics, but I do not think that Julius Caesar, Napoleon, or
Mohammed were great because they were epileptics. As a
rule, epilepsy tends to destroy mental power rather than to
increase it, and the curious lethargy which Napoleon exhibited
at the Battle of Leipzig, and which there led to his defeat and
consequent ruin, is probably rather to be ascribed to his
epileptic tendency than to the indigestible bun which is said to
have led to the disaster. Julius Caesar and Napoleon were
great men, not because of their epilepsy, but in spite of it;

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256 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

and the visions of Mohammed alone would not have given him
his extraordinary power over his countrymen and over the
then known world had it not been that they were backed up
by extraordinary mental power and energy in the intervals
between his fits. It is only since the main part of this
paper was written that I have become aware that the views
I have expressed regarding Samson and Mohammed are
considered by some not only irreligious in themselves but
calculated to wound the religious feelings of others. Nothing
could be further from my intention. The part played in
the history of the nations or in the history of the world by
these two men is altogether unaffected by the question
whether they were subject to nervous disease or not. The
point in question is simply how the great Ruler of All has
been pleased to produce certain effects, and no more concerns
the question of His rulership than a discussion as to
whether the Koran was written on the blade-bones of a sheep
or on the finest vellum, or whether the Marseillaise was written
with a steel or quill pen. Instead of such an investigation
being frreligious, it seems to me that research is clearly indicated
as a duty by the words in Psalm cxi, 2, “ The works of the
Lord are great, sought out of all them that have pleasure
therein.”

(*) Read at the General Meeting of the Medico-Psychological Association, No¬
vember 21st 1901.—( 2 ) For definitions, vide Baldwin’s Dictionary of Philosophy and
Psychology . Macmillan*. New York and London, 1901.—(*) Davey, “Transference
of Special Sense,” Journal of Physiological Medicine and Mental Pathology ,
vol. vii, part 1.—( 4 ) Hooper’s Physician’s Vade Mecum , 7th edit., p. 115. Edited
by Wm. Augustus Guy and John Harley. London, 1864.—(*) Munsey’s Maga¬
zine , Nov., 1901, p. 216.—(®) “ Inhibition, Central and Peripheral,” ‘West Riding
Asylum Reports,’ Nature, xxvii, 1883, PP* 419-422, 436-439, 467-468, 485-487.—
( 7 ) Weir Mitchell, “The Relations of Pain to Weather,” Anter. Joum. of Med.
Sci., April, 1877.—(•) Tatham Thompson.—(•) H. Head, Goulstonian Lecture for
1901. Brain , part iii (1901), p. 352. Macmillan: London and New York.—
( 10 ) E. H. Clarke, Visions : a Study of False Sight. Houghton, Osgood, and Co.:
Boston, 1878.—( n ) Vide especially Hughlings Jackson, Lancet , Aug. 14, 1875, etc.
—( ls ) Lucas Championni&re, Htude historique et clinique sur la Trepanation du
Crdne : la Trepanation guidie par les Localisations cbihrales, p. 2. Paris, 1878.—
(**) Lucas-Championni^re, op. cit ., p. 6.

Discussion

At the General Meeting, London, November 21st, 1901.

Dr. Savage said that he had looked forward with a great deal of interest to the
paper, but he feared he had regarded it from a different standpoint. It was rather
a rude shock to him to have to look upon fairies as the outcome of epileptic or
migrainous hallucinations. He still rather liked to regard them, not quite from
this sensory point of view, but from the standpoint of a combination of this view

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BY SIR LAUDER BRUNTON.

257

1902 .]

with his own wishes and feelings. What Sir Lauder Brunton had said about the
limitation of one’s senses he regarded as all-important. He thought of what Sir
Samuel Wilks used to say when going through the wards of Bethlem Hospital:—
“ How do you know that these hallucinated people are not speaking the truth, and
that it is not due to your ignorance that you deny that there are voices and visions ? ”
He thought the explanation given by Sir Lauder Brunton of some of the telepathic
experiences mentioned was altogether satisfactory. It seemed to him, Dr. Savage,
that there were certain men who moved in harmony with certain others, and in
certain relationships. The epileptic conditions, and conditions of the organs of
sense one could not help admitting, but that they were at the foundation of all the
observed phenomena he was disinclined at present to believe. There were certain
other relations, one of which Sir Lauder Brunton spoke of, namely, unconscious
keeping or marking of time. Most people possessed that power, but some more
than others. There were one or two conditions which he was surprised Sir Lauder
Brunton had not spoken of as being origins of those fancies, e.g. dream conditions.
One was constantly encountering people who would narrate what might be fairy
tales. They might choose to call them delusions, or to say they were halluci¬
nations, but they were graphic descriptions of what these people had seen. They
had been dream conditions, and there was an interesting connection with epileptic
dream states, in which similar impressions were produced.

Coming to hallucinations, Dr. Savage said he could not help thinking of 1 AEsop’s
Fables.’ He had been in the habit of telling students that he had never yet come
across an ^Esop’s fable which he had not seen represented in the wards of the
hospital. Another cause of many of those fairy tales, very important from the
mental standpoint, was the receptivity of the undeveloped mind, the tendency to
explain. He often thought of what Sir William Gull said many years ago, “ It is
the wise man that investigates, it is the savage that explains.” It was the state of
mind which was ready to explain. The rain-maker and the rain-explainer came
long before the meteorologist; so also the myth-maker came long before the man
who recognised hallucinations of one kind and another. The environment and the
constitution of individuals and the catastrophies of Nature had given rise to fairy
tales.

He could only add that the subject which had been brought forward by Sir
Lauder Brunton was one of extreme interest; and it was possible in the time at
their disposal to touch on only a few of the many sides it presented.

Dr. Mercier said that he never remembered a more interesting paper being
read before any society. The extraordinary way in which Sir Lauder Brunton
had suggested explanations for inexplicable things was most interesting. He
agreed with Professor Clifford Allbutt as to the impermissibility, in the eyes of
science, of appealing to the supernatural until all possible explanations from the
natural had been exhausted. Sir Lauder Brunton had shown, not, perhaps, in
every case satisfactorily, that there was a possible explanation, according to the
known laws of physical nature, of those occurrences which seemed to us occult,
mysterious, and inexplicable. That was a service which he thought science could
not over-estimate. There would always remain and always must remain, a
region in which we must fail to explain, and in which we must fail to bring
phenomena under known laws, i. e. laws of uniform sequence. But so long as we
were in this world our task was to reduce that region as much as possible, and it
was because Sir Lauder Brunton had enabled them to see the way in which a very
large portion of that region might be reclaimed from the unfathomable sea of the
inexplicable that his discourse was so very valuable to the members of the
Society.

Mr. Alfred Nutt said that it was exceedingly interesting to him, as a member
of the Folk-lore Society for twenty years, and as, he trusted, a scientific student
of all the phenomena which were grouped together under the heading of folk-lore,,
to find a man of science also engaged in investigating those phenomena, who had
undoubtedly succeeded in throwing a great deal of light upon them. The
members of the Folk-lore Society were accustomed to approach those phe¬
nomena from the historical rather than from the psychological side, and he
thought that was the tendency of the majority of the students of folk-lore, but
it was a tendency against which he had always, both by word and, as far as
possible, in his own investigations, endeavoured to protest. He would

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258 HALLUCINATIONS AND ALLIED PHENOMENA, [April,

have been glad if Sir Lauder Brunton had paid a little more attention to
what might be termed the collective hallucinations rather than the individual ones,
because it was really the collectivity or grouping of those hallucinations which
gave them their interest. The fact that those hallucinations were found practically
all over the world and at all periods of history was one of great importance, and
the great problem with students of folk-lore had always been to determine why it
was that those phenomena were alike. Why was it that the Babylonian priest,
whose words could be traced back nearly five thousand years, the Finnish
enchanter, the wise man of Ireland or of the Scottish peasantry, the “ medicine-man ”
of the Red Indian, and the wizard in South Africa employed almost entirely the
same methods to produce the same results, and not only employed the same
methods, but did, to a very large extent, arrive at the same results ? If he might
venture to make a suggestion, he would ask Sir Lauder Brunton to specially
investigate hallucinations from that point of view, and in any explanation of
hallucinations to recollect it was not the hallucination of an individual being, e.g.
the lady whose retina had a defect which caused her to see a goat. That may
have been the explanation, but why was it that nearly the whole world over the
particular supernatural power, being, or evil thing so frequently assumed the form
of a goat ? It did so in antiquity, it did so throughout the mediaeval ages, and it
did so still in the minds of the peasantry, who were subject to those ideas. It was
impossible that any such cause as was suggested—and probably rightly suggested
in the case of that lady—was valid throughout. There must be some other law at
work, and that law, to a great extent, was the “ law of convention.” It was
wonderful when once an idea had been set in circulation how it contrived to
dominate the perceptions of mankind. A man would see a thing because someone
else had seen it in the same way, and he unconsciously expected that it was so.
One might also mention the divining rod, to which Sir Lauder Brunton had
referred. The curious fact was not that some people were capable of detecting
water underground, which he could quite understand, but why were they only
capable of detecting water with the rod in their hand ? Many of the “ dowsers ” were
conscientious men, and the majority believed that there was some mysterious
capability in the rod, and unless they had a rod of a particular form, and made of
special wood, they could not detect the water. Those men would fail when going
over the land without a rod, but when the rod was put into their hands they would
find water. The curious point was why a Somersetshire or Irish half-educated
peasant, who had no book knowledge of those things, should almost instinctively
resort to the same practices and the same means that his divining forbears resorted
to a thousand years ago. In reality it would be found that there had been a
tradition which had been handed down completely independent of the usual modes
and vehicles of culture, independent of the school, or the schoolmaster, or the
priest, or the doctor, and one could find very often the peasantry still in possession
of such a tradition, which was really almost as old as the world.

Finally, he said he would like to enter one word of protest, lest some gentlemen
in the room, who were not quite familiar with those studies, might think it was
held among folk-lorists generally, against the conclusion that there was a historic
basis for a belief in the fairy world. He believed that the historical realistic element
rested on the very smallest grounds. The fairy belief could not be explained by
certain historical conditions which obtained in these isles, because a belief in
fairies was prevalent all over the world,—amongst the tall races, among the short
races, the dark races, and the fair races, and in ail stages and conditions of culture.
Though that belief might plausibly be explained on an hypothesis about the races
inhabiting these islands, that hypothesis could not apply when they were found in
Polynesia or amongst the Indians of America. As a matter of fact, the ancient
belief in these islands was not that the fairies were a small race. The oldest
accounts we possessed of fairy tales were found in ancient Irish literature, and
there the fairies were beings of the same shape and stature as men, only more
beautiful and more magnificent than ordinary men. The fairy queen who carried
off Thomas Godiva was shown as in every way having the same stature as ordinary
women. He would ask his hearers, as men of science, to believe it was possible to
study subjects which seemed so little susceptible of scientific study as fairies in a
truly scientific spirit. They, in the Folk-lore Society, had been trying to do it, and
he believed that they had succeeded in throwing light on a considerable number of

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BY SIR LAUDER BRUNTON.

1902 .]

259

those questions. Personally, he thanked Sir Lauder Brunton heartily for a most
enjoyable afternoon.

Dr. Robert Jones said the truth probably lay between the two extremes.
The historical record had been touched upon, and, on the other hand, was the
view that fairies were nothing but the results of headaches, practically delirious
nonsense, according to Sir Lauder Brunton. The untutored mind and children in
all ages had a strong regard for the great forces of Nature; the sea, great water¬
falls and whirlpools had a personification allotted to them, and it was pretty to see
these exemplified among children. In one’s own nursery one had seen the children
playing at horses and trains, and at anything, indeed, which possessed power. He
had very little to say on the fairy aspect of the question ; they who were members
of that Society were more experienced with the hallucinatory aspect. Sir Lauder
Brunton had referred to the fact that hallucinations were often connected with the
association of ideas, in support of which he quoted the incident referring to the
lemons and oranges. The experience of those whose work lay in asylums
led them to endorse what Sir Lauder stated. For instance, he, Dr. Jones, had
never yet come across a deaf mute who had hallucinations of hearing. Hallucina¬
tions could not be a new creation. He had also a number of blind persons under
care, and among those who were congenitally blind he had never found one with
hallucinations of sight. It was also interesting that these abnormal features had
relation to the psychopathic tendency, as in the case of the student referred to by
Sir Lauder. One found that if there were an hallucination it was often connected
with a psychopathic history. Those of us who dwelt in asylums were living with
people whose friends and relations were also more or less affected. On visiting
days in asylums one knew almost instinctively which friends belonged to particular
patients; they had the same mental condition, the same sympathies; they often
denied their friends’ delusions, and not infrequently shared them. He had read a
good many folk-lore books, and expected to hear that afternoon more about the
ideal and spiritual aspect than Sir Lauder Brunton had given in his material and
scientific explanation. The fact that the ancient Greeks personified the brute
forces of Nature was to be seen in the Elgin marbles in the British Museum, as
exemplified in the amazons and centaurs of the metopes. As men became able to
satisfy themselves in regard to the apparently supernatural, and the laws of Nature,
such as gravity, etc., became more understood, these things disappeared, and a
natural and satisfactory explanation was arrived at. It was very picturesque to feel,
when wandering through the woods, that there were lovely nymphs of the groves
and fairies of the brooks, mountains, and grassy meadows. In Vortigern’s Valley,
in North Wales, where he went a few months back, a place which was almost shut
in from all outside habitation, with a bay opening into the sea and an almost
precipitous background of rocks, when coming up a winding path one called out,
the echo—a Nature spirit—was at once thrown back. In the unlettered and
untutored time of man, what was more reasonable than the belief that it was one’s
friends who answered from the spirit world P It was a picturesque conception, but
it could not now be accepted. This reference to spiritual beings as the cause of
Nature led up to what was called medical mysticism. The age of exorcising the
maniac had gone by with us, but it had not yet passed away in the East. Recently
some of those present had been members of a committee for establishing a hospital
for the insane in Lebanon, and they had it on the word of Mr. Waldmeyer that
the treatment of the insane and the epileptic in that country was repulsively cruel
and inhuman. The poor victim was taken to a cave, and was beaten until, after
writhing in pain, he passed into a slumber, the result of pure exhaustion, but which
the priests attributed to expulsion of the evil spirit. In that medical mysticism,
which is the assumption of an a priori immaterial force, being, or power called
Life, and a deduction from this, which cannot be verified, that a spirit is able by
its own order or thought to subdue external realities, and that mind acts upon
matter from the outside, it is concluded that some influence, some occult power,
does act upon the human organism. We know how fear paralyses, and how certain
other states of emotion might influence the circulatory, digestive, and other systems,
hence the possibility of curing disease by a mode of thought is suggested. It was
a satisfaction to feel that at the present day we were more enlightened than our
remote ancestors, and more able to understand the laws governing the great forces
in Nature, such as those of gravity, heat, growth, and decay, and that the idea of

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260 hallucinations and allied phenomena. [April,

spirits, good or bad, had disappeared in the light of modem research and know¬
ledge, of which Sir Lauder Brunton was so exemplary and so brilliant an exponent.

Sir Lauder Brunton, in reply, said he had to thank the President and all
who were present for their kindness in listening to an address which he felt had
been too long. On account of this feeling he had shortened it a good deal,
otherwise he would have taken up some of the questions which Mr. Nutt had
raised. He was glad to find that Dr. Savage and Dr. Mercier agreed with him in
thinking that however much could be explained by ordinary laws, there was still
something which could not yet be so explained. No doubt they would gradually
increase the boundaries of the known, but there was still a very considerable
residue which to us was unknown. Examples of that were very numerous, and
more especially those examples which would come under the head of second sight
or prevision. There were a number of those which he was absolutely unable to
explain, or to get the very slightest idea as to how they came about. They might
hope that by-and-by those would be explained. Mr. Nutt had asked why the
same methods had been employed all over the world, and with the same results.
He, Sir Lauder Brunton, supposed one reason was that headaches and mental
disturbance could be brought on by the same methods all over the world. He
believed that primitive men were subject to headaches just as we are now. It was
true there was no direct evidence of that fact, but those who had suffered from
migraine knew that there was an awful pain about the temporal region, and one
sometimes thought, 1 do wish I could let this headache out.” In the skulls
which had been discovered belonging to the Stone Age, some had a hole in the
temporal region. The men of that time had evidently drilled their heads with
stone implements, and the patients had recovered, because the edges of the hole
were completely smoothed off, showing that the scalp had healed over, and the
bone had undergone gradual absorption. He believed that those men had a scar
there, not because the priests of that age knew anything about the Rolandic area,
or because they were able, by pressure on the proper spot, to bring on the fits, but
because the poor creatures had a pain in their head, and had a hole drilled to let
that pain out. And if one assumed that those men had headaches, he thought it
Was very likely that they had visions also. If they had “sick headaches,” they
probably had the visions which preceded sick headaches, because their eyes were
built upon the same plan as ours. And although in many of them there might be
no subretinal haemorrhage, yet they were liable to inflammation of nerves, just as
we were ; and they might also get, either from exposure to cold or from injury,
inflammation of the Gasserian ganglion. They might also get inflammation in
the choroid, and then they would 'see visions, just like Dr. Tatham Thompson’s
patient did, who saw visions because of choroiditis. Or, like Dr. Head’s case,
those men might have had inflammation of the Gasserian ganglion. He fancied
that was the reason people saw the same kind of visions the whole world over.
The retinal vessels, he supposed, were arranged in primitive man in much the same
way as in civilized races, and that the same formation of the retinal vessels,
which limited the scotoma in Dr. Thompson’s case, and gave it the form of a goat,
might have occurred in the ancient Greeks and in other races. No doubt cases of
collective hallucinations were exceedingly interesting. In his paper he had
mentioned one of those juggling feats which were shown in India, where a man
exhibited a pole up which a boy appeared to climb, and when the boy had
climbed to the top he disappeared into empty air. It was said that when a
photograph was attempted to be taken of the boy he was never there. But the
juggler had suggested to the people that he was there, and they were convinced
that they saw the boy, though he was not there. Those collective hallucinations
were of the same type as that of the man who went to Trafalgar Square and
looked on the old lion jand said “Its tail wags;” others looked and replied,
“Yes, it wags;” but, of course, it did not. Those collective hallucinations and
the influence they had exerted in the world’s history was one of the most
interesting problems that anyone could tackle. But it was very difficult, and he
had neither the time nor the ability to attempt it. He would be very glad if
someone would take up the history of Peter the Hermit, and the history of
Savonarola, and set out how much of their influence was due to hypnotic
suggestion. By that means an enormous service to history would be accomplished.
He granted that, as Dr. Robert Jones had said, the truth probably lay between the

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THE CARE OF THE INSANE.

26l

1902.]

two extremes. He had tried to present one side of the subject, and there would
be many to put the other side. Perhaps they would put it so strongly that he
would not be able to resist the evidences brought against him. He again thanked
all most heartily for the interest shown in his address.

Hospital Ideals in the Care of the Insane: a Statement of
Certain Methods in Use at the Stirling District
Asylum , Larbert. By George M. Robertson, M.B.,
F.R.C.P.Edin., Medical Superintendent.

Preliminary.

Before giving a description of the particular methods of
caring for the insane in use here, to which attention is to be
drawn, I consider a statement of the general principles under¬
lying these methods a necessary preliminary, in order to place
the reader in touch, if not in sympathy, with my motives, and
to enlighten him as to my objects.

The dominating principle is the desire to make the asylum
a medical institution, worked on the same medical principles
and with the same nursing ideals as our great general
hospitals, which are acknowledged to be the most perfect result
of modern humanitarianism and medical science.

To give full effect to this dominating principle , there are
not only many things to be done in our asylums, but much to
be undone, for asylum treatment of the insane, to its great
misfortune, has a 44 past.” No doubt its most repulsive
horrors—chains, cruel violence, and systematic neglect,—have
gone, never more to return, but much of the past is not dead ;
traditional ideas of dealing with the insane still exist, handed
down from one generation to another, and the acceptance of
the modem principles of non-restraint, humanity, and medical
ideals in the treatment of the insane by the medical officers,
and the best class of attendants and nurses, has not abolished
traditional practices among the general mass of asylum officials.
We have assumed too readily that the mass was leavened with
these ideas, the pinch of which we never, but they constantly,
feel; we have flattered ourselves much too soon that by
our efforts the insane had become emancipated.

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262

THE CARE OF THE INSANE,

[April,

Prison Features and Defective Care at Night.

The asylum, only yesterday as time goes, traced its origin
to the old Tolbooth, and neither in its construction nor in its
administration has it yet emancipated itself from the prison
and from prison life. The practice of building numerous
cells, which we have recently re-christened with the more
pleasant name of “ single rooms,” is directly adopted from its
prison prototype. The practice of confining patients in these
cells by day, which is steadily being abolished, and by night,
which is in process of reduction, is also a relic of this origin.
If, however, we are to live up to the hospital ideal I have laid
down, we must determine to reduce compulsory incarceration,
by night as well as by day, to the same extent as mechanical
restraint has been reduced in asylums, that is, practically
abolished, and only used in most exceptional cases. Instead of
a lock and key and shuttered cell, we must adopt the strictly
medical methods of continuous personal supervision at night
by employing one or more nurses or attendants in all cases
showing active symptoms. If insanity be a disease, it must be
treated in a medical spirit, and it must be treated at night not
by incarceration, but by personal supervision, and with as
efficient supervision as by day. It is, then, a first necessity
to increase the night staff in asylums. In the past the want
of this staff has interfered most materially with the welfare
of our patients, and as compared with hospitals we are, with
respect to night supervision and treatment, most shamefully
behindhand. The “abuse of single rooms” resulting from
this, to which Dr. Elkins in particular has directed attention,
can only in this manner be abolished, a reform in asylum
administration which, in my deliberate opinion, ranks in
importance with those associated with the names of Pinel,
Tuke, and Connolly.

Roughness.

There are, however, other practices in asylums, also inherited
from the past, which are more difficult to eradicate. That
violence is habitually practised towards the insane in asylums
we all know is certainly not the case, though the fact that brutal

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1902.] BY G. M. ROBERTSON, F.R.C.P.EDIN. 263 .

assaults are occasionally committed cannot be denied in the
face of the evidence that exists. But short of this, my infor¬
mation and experience have convinced me that a great deal of
unnecessary force or roughness, not amounting to actual
violence, is employed. This only rarely culminates in a really
grave assault, which then proves a blessing in disguise, as it is
difficult to hide traces of it from the medical authorities, and
an example is frequently made of the offender. I do not
altogether blame • attendants for this immediate recourse to
forceful methods, because they come to the asylum ignorant of
the management of the insane, and inherit the traditions of the
evil past to which I have alluded. They are, perhaps, not even
consciously severe or harsh, as they themselves have been
accustomed all their lives to give and receive knocks, but that
it is a failing, especially of male attendants, and causes more
anxiety than any other, will be admitted by every one. If
physical violence be absent from the female side, rough¬
ness of speech and behaviour towards patients is present
on both sides, and patients, instead of being coaxed and led,
are only too frequently driven and ordered about. This is a
very important point, for it is my belief, after the clearest
demonstration, that the greater part of the excitement, violence,
and troublesomeness of patients is artificially created and
continued, and I have not only seen this artificial excitement
produced, but I have seen it eliminated. We all recognise a
phase among epileptics in which the patient is exceedingly
irritable, and has to be most tactfully manipulated. In many
other cases of insanity there exists a similar though not so
aggravated condition, in which the patient is not really so
much excited as excitable, and it is then possible, by irritating
conduct or an exciting environment, to keep up the symptoms
of excitement, which not only is injurious to the patient but
adds greatly and unnecessarily to the work and anxieties of the
nurses and attendants. The practical point, however, for us
with our medical ideals is this: that those in charge of our
insane patients should possess a maximum of sympathy,
gentleness, and patience, that the patients should be even
more kindly treated than if sane, just as a labouring man in
hospital is treated with as much consideration as if he were a
prince, and with an attention he never received when well. In
my opinion the most satisfactory method that has yet been
xlviii. 19

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264 . THE CARE OF THE INSANE, [April,

devised for attaining these objects on the male side is the
employment of female nurses, and the extent to which they
may be employed and their usefulness have exceeded all
anticipations. On the female side, the appointment of a
number of assistant matrons to supervise the nurses and to do
duty within the wards and among the patients appears to meet
the difficulties. These assistant matrons should be well paid
and well treated, and enjoy considerable prestige and authority,
and, in my opinion, suitable candidates for these posts can be
selected from the ranks of the great army of trained hospital
nurses.

Unreliable Supervision of Staff and Non-reporting of Offences.

If anyone doubt the truth of the previous statements because
he seldom or never receives reports of roughness, let me
enlighten him why it is that the charge nurse or attendant, who
for eleven hours out of twelve is the responsibleofficial present,
so seldom reports one of his or her subordinates for roughness
or even violence towards patients. Not many months ago I
asked an excellent and kind attendant, who, on being promoted
elsewhere, was leaving me next day, to tell me honestly if,
during the many years he had been in the asylum, he had seen
attendants abusing patients, and his immediate reply was
“ Many a time,” and he added, “ Many a time have I interfered
and prevented them from abusing them too.” I then asked
him how many he had reported, and he replied he had never
done it. He said, “ I could not do it for the other attendants.
Just consider my position, doctor; I would not have had the
life of a dog with them had I done it.” This confession is not
an exceptional one, nor, to my certain knowledge, does it refer
to a state of matters existing in one asylum alone. Superin¬
tendents have overlooked this failing of human nature, which
has been fully recognised by our Army officers, that it is next
to impossible for a charge attendant or nurse to maintain strict
discipline, particularly in the sense of reporting his or her sub¬
ordinates, if when on duty or off duty he or she be regarded
as a social equal and treated in a familiar and friendly way by
subordinates. In the Army, if a man be selected from the
ranks for a non-commissioned post, he is informed that he must
cut himself off from all previous friendships among the private

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1902.]

BY G. M. ROBERTSON, F.R.C.P.EDIN.

265

soldiers, and if, for example, a new corporal be seen by an
officer coming out of a public house with a private, he would,
on his return to barracks, be placed under arrest and be repri¬
manded. Under these conditions authority is maintained, and
the offences of subordinates are reported ; under the conditions
usually existing in asylums, it is a wrench far too great to
expect of human nature for a senior attendant to report one
of his intimate friends. Moreover, not only is it contrary to
human nature, but it is against traditional practice and public
opinion, and should a man or woman be so mean as to go against
his order, he would be ostracised by his fellows. Not only is
this prohibitory power exercised over attendants and nurses,
but by questionable means over patients as well, and frequently
the only evidence available is either that of a dement, who is
too stupid to be terrorised or to give a clear statement, or of a
patient with an animus against the attendants, and whose word,
therefore, cannot be implicitly trusted. That irregularities go
on in asylums which are never reported, and that it is next to
impossible under present arrangements to bring these clearly
home to the offenders, there is ample evidence, which I might
detail were it not superfluous to do so.

The remedy is hard to find; it is possible that the higher
ideals of duty that are steadily advancing over the asylums
of the country may in time effect the desired changes, as has
already taken place in our large general hospitals, but in the
meantime the constant presence in the wards of responsible
officials, such as the assistant matrons already mentioned,
appears the most direct remedy.

Men as Sick Nurses .

If any evidence were needed in addition to the defective
care of the insane at night to indicate how far behind that of
general hospitals medical practice in asylums is, the fact that in
almost all asylums the sick and the infirm on the male side
are nursed by men would demonstrate it sufficiently. If we
are to be influenced by the highest medical ideals, it is neces¬
sary that these defects should be remedied, and as woman has
proved herself to be instinctively peculiarly fitted for nursing
duties and attendance on the helpless, and as women of refine¬
ment have not hestitated to perform the meanest offices of a

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266

THE CARE OF THE INSANE,

[April,

nurse among adult men, there is no real obstacle to the
employment of women in the male sick and infirm wards.
And, as a matter of course, if sick-nursing by women is
desirable by day, it is just as necessary and desirable by night.
Every credit is due to the male attendants in the hospitals and
sick wards who have in the past performed duties which were
unnatural and irksome to them, but for the sake of their
patients, no one, least of all themselves, will object to see all
sick, aged, and infirm men ministered to and nursed by women
under the direction of trained hospital nurses. The last par¬
ticular, a trained hospital nurse, is, I consider, absolutely neces¬
sary if we aim at high ideals, and the hospital of a large
asylum without a certificated nurse at its head is as retrograde
an arrangement as would be that of the asylum with a layman
as the superintendent of it.

The Personnel ’

Finally, in bringing an asylum into line with a good general
hospital, it is impossible to overlook the class of women that
enter the latter as nurses, and were the average personnel of
asylums similar, possibly some of the defects I have mentioned
would not exist. No one can have a higher opinion of a good
asylum nurse than I have, and I have known not a few, and I
consider the qualifications of mind, of heart, and of body
needed for an asylum nurse infinitely greater than for a
hospital nurse, just as disease of the mind is more complex
than disease of the body, and, when acute, includes the latter.
When it is considered that a good mental nurse must be
healthy of mind and healthy of body, intelligent and active ;
that she must be sympathetic and conscientious, able to con¬
trol herself with firmness and others with kindness; that she
must be submissive to orders yet ready to act on emergency;
and when it is considered that her duties are often irksome
and trying, it must be admitted that any woman of whom
it can be said that she is a good asylum nurse has thereby
extensive testimony borne to her excellence as a member of
society. Yet she receives less appreciation from the public than
a hospital nurse, or than she deserves. It must be admitted,
however, that while the standard of hospital nursing is high,
that of asylums, though rapidly improving, is below the

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1902.] BY G. M. ROBERTSON F.R.C.P.EDIN. 267

medical ideal. There is no doubt that improvement is taking
place, and I have found no means of raising the ideals and the
ambitions of asylum nurses, of increasing their self-respect, and
of improving the quality of their work equal to that of
employing hospital nurses to work in the wards among them.
It has directly inspired several to complete their training in
hospitals, and I consider the double training absolutely
necessary for a skilled mental nurse, and for the higher posts
in an asylum. The treatment and the nursing of insanity is
merely a particular branch of the great stem of general
medicine; it involves not a superficial, but a most exact
knowledge of general disease, and one can no more be a
skilled mental physician without studying general medicine
than a skilled mental nurse without studying general nursing.
A great deal of general nursing may be “ picked up ” in an
asylum, but this can never take the place of a regular training
in a large general hospital, though the lectures and examina¬
tions for the Certificates for Proficiency in Mental Nursing
have done incalculable good in their own way. I believe that the
employment of hospital nurses in asylums will go a long way
to carrying out the dominating principle I have mentioned, that
of approximating the asylum to the general hospital, not only
as regards the methods employed and the quality of the work
done, but as regards the personnel of the staff, by familiarising
the class of women who go to hospitals with the idea of going
to asylums as well.

The introductory portion of this paper being now concluded,
I pass on to describe the special features of the care of the
insane in this asylum, which are intended to remedy the
defects described, and which enable the hospital ideals to be
carried out.

Night Nursing.

Increase of Staff and a Night Superintendent; Continuous
Supervision in Dormitories ; Abolition of Solitary Confine -
inent (the Single Room System).

The obvious principle underlying the treatment of the
insane at night is that the supervision and care exercised over

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268

THE CARE OF THE INSANE,

[April,

them should not then deteriorate or cease, as frequently
happens at present, but, allowing for the altered circum¬
stances, should be as efficient as that by day, which at
present is fairly satisfactory. All those patients who, owing
to the existence of the active signs of insanity, need personal
supervision by day, also need it at night, and among these are
included the excited, the noisy, the irritable, the dirty, the
dangerous, the suicidal, the sick, the infirm, and all epileptics.
Owing to the fact that the vast majority of patients sleep, and
that no administrative or domestic work is done at night, the
staff does not need to be anything like so large as that by day.
The night staff in this asylum, containing 690 patients, and
250 admissions annually, numbers twenty, and is one third of
the day staff, and the proportion to the patients is as one to
thirty-five nearly. With this staff the principle laid down is
carried out, that of giving as efficient care and supervision to
the patients by night as they receive by day. No patient is
allowed to be noisy, untidy, destructive, or dirty, if personal
attention by nurses can prevent it; all insane habits are
checked at night in the same manner as is done in asylums
by day; and excited patients are under the continuous
personal supervision of nurses or attendants, as is usually the
case in all asylums by day. Of course night brings its own
responsibilities. By day, the nurse strives to occupy the
patient, attends to the amount of food taken, etc.; by night,
in addition to the more general duties, there is the special duty
of inducing, if possible, the patient to sleep, if he or she be
sleepless.

It is the experience in hospitals, as well as in asylums
for the poor, that immediate personal supervision by day is
only possible, having regard to economy, when a consider¬
able number of patients are gathered together in one ward
or room, the proper size of which varies with the class of
patients to be attended to, and in this ward one nurse or a
certain number of nurses can supervise a certain number of
patients. It would be impossible to do so with the same
staff were every patient in a different room. By night, of
course, the very same condition holds good ; it would be
impossible to supervise patients, except with an enormous staff,
if all occupied separate rooms, so it is necessary, if patients are
to be efficiently supervised at night, that this must be done in

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1902.] BY G. M. ROBERTSON, F.R.C.P.EDIN. 269

associated dormitories. Dormitories at night merely take the
place of day rooms by day ; the patients are classified in them
according to their symptoms and the amount of supervision
they require, on principles, not the same, but analogous to those
by day, and night nurses are placed in charge instead of day
nurses, the duties they perform being practically similar. Now,
those who have not tried this system of night supervision, who
continue to lock up noisy, excited, and troublesome cases in
solitary confinement in single rooms, according to the tradi¬
tional asylum practice, may state that at night there is one
condition that modifies the whole situation, and that is the
necessity for peace and quietness, that the sleep of many may
not be disturbed by the noise and excitement of one, and that
to fulfil this important condition it is necessary to weed out all
disturbing elements and place them apart in single rooms. To
such I would say that the real reason why in the past patients
were locked up in single rooms was the fact that the night
staff was inadequate to deal with them in any other way,
and I would point out that Dr. Elkins has demonstrated that
the remedy usually adopted for dealing with noisy and excited
patients perpetuates and intensifies instead of cures the trouble
they seek to relieve. Nothing is worse for most of these cases
than solitary confinement without personal supervision, and
continuous supervision and personal control by a full and alert
staff at night will enormously reduce noisiness, if not abolish it
altogether. The experience of Dr. Elkins has been confirmed
by Dr. Middlemass, Dr. John Macpherson, Dr. Keay, Dr. Marr,
and myself.

With regard to the admission dormitory, though the
more efficient supervision there tends to reduce noise, it
must be admitted by all of us that this dormitory, owing to
recent acute cases, occasionally tends to become noisy. To
overcome this difficulty, and that other patients should not
suffer, I have opened, when necessary, as at present on the
female side, an “ extra admission dormitory,” and have placed
here the three or four cases inclined to be noisy and trouble¬
some under the charge of two nurses ; I have also occasionally
to place a noisy case under the charge of a special nurse in a
single room. With these precautions the admission dormi¬
tories are now habitually very quiet. Dr. Clouston, who, in
this matter, may be accepted as an unprejudiced witness,

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270

THE CARE OF THE INSANE,

[April,

visited at night the worst class of patients in this asylum, and
found patients who had been for years noisy and violent under
the old single room system, quiet and asleep, and the dormitory
system of supervision working in a thoroughly satisfactory
manner^ 1 )

Even, however, if there were more noise and excite¬
ment, which there is not, and even if patients had greater
difficulty in sleeping, which is not the case, the system is one
to be adopted solely for the reason that, if loyally carried
out, it abolishes the “ abuse of single rooms.” I do not wish
to express myself too strongly on this subject, for fear of
wounding the feelings of those who still use single rooms at
night for locking up patients who, instead of solitary confine¬
ment, need much more the constant attention of a nurse. I
would state, therefore, that the rooted abhorrence and aversion
I have to the use of mechanical restraint is not greater than
that I have for the use of incarceration in single rooms, for
the former abuse was abolished nearly two generations ago,
whereas I have seen the injurious and degrading effects on
the patients of the latter as well as its demoralising effects on
the staff. It would be foolish to assert that neither should ever
be used, but I assert as my deliberate conviction that it is not
only better treatment, but a mere act of justice to the insane,
that solitary confinement should be used with as great hesita¬
tion as mechanical restraint, that is to say, practically abolished
as a regular method of so-called “ medical treatment,” arid
only reserved for the most urgent cases. Incarceration in single
rooms is not used at all in this asylum, and the door of every
single room is left standing open at night. The patients
occupying them are all sensible, clean, and trustworthy patients,
and if for greater privacy they desire the door shut, a handle
to open the door is placed inside; the rooms also are all in
process of being furnished as bedrooms, with pictures, dressing
tables, mirrors, etc. Two years ago in Glasgow at the Divisional
Meeting I stated that in my opinion if an asylum were sup¬
plied with one sixteenth of its accommodation as single rooms
it would prove ample, and that with a proper night staff it
could be managed perfectly well with one thirty-second, or

(*) Dr. Clouston, who was present at the reading of the paper, was appealed to
in order that he might corroborate these facts, and I am indebted to him for the
frank and even generous statement he made (see page 282).

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271

three per 100. My views were then received with incredulity,
but that they were not Utopian in character these more recent
results fully confirm. Thus, two years ago, so much was solitary
confinement of all troublesome cases considered an integral
part of the management of the insane, that no one would have
believed such an event as its practical abolition within the
realms of possibility, just as in Connolly’s day most asylum
officials declared the abolition of mechanical restraint an
utter impossibility. Yet both have been effected.

Sometimes the explanation is offered, when methods are in
use in one asylum that apparently fail in another, that the
patients in certain districts are more amenable to authority than
those in others. It is possible this is occasionally true, so it
must be borne in mind that the district this asylum supplies
accommodation for contains some of the most vicious, drunken,
and criminal areas in all Scotland, with a large proportion of
miners, ironworkers, riveters, and dock labourers, so that with
patients coming from an agricultural district similar results
should be easier to obtain. I must not omit in dealing with this
point to refer to the treatment by day of all acute and excited
cases in bed, according to the principles of Dr. Magnan, Dr.
Whitcombe, Sir J. Batty Tuke, and others. This is, on
the whole, a better principle of treatment for these cases, and
much safer than the older method in more general use, and it
conforms more closely to the general hospital methods and to
medical feelings. It is surprising how quickly acute cases get
over the tendency of struggling to get out of bed ; and the use of
“ alitment ” or treatment in bed by day renders the supervision
of these cases in bed in dormitories at night a comparatively
easy matter—much easier than it would otherwise be. To
those who consider that “ alitment ” by day and dormitory
supervision at night present insuperable difficulties, I refer them
to the results obtained by Dr. Magnan, which must carry con¬
viction to every open mind. He admits into the Asylum of
Ste. Anne, which is the distributing centre for all the asylums of
Paris, over 3000 recent cases yearly. All these cases, if acute,
are treated in bed in dormitories under supervision, and he
never uses seclusion in single rooms by day or by night on
account of acute excitement. There is only one other objection
to this system that I am aware of, namely, that drugging by
sedatives is increased, but with regard to this the facts do not

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272 THE CARE OF THE INSANE, [April,

bear out the contention. It is difficult to establish a normal
standard of the use of sedatives. Dr. Elkins gives the sta¬
tistics of his practice with dormitory supervision, and it is very
low. I also believe my practice to be below the average,
though I believe in the therapeutic value of sedatives, and as
the amount used is now strictly noted, my statistics will also
be available. In any case the objection that an increase in
the habitual use of sedatives is necessary may be ignored, once
the system is in full operation, as the evidence, such as it is,
points if anything the other way.

With regard to the details of the system adopted here, I
may state that every dormitory in the asylum, with the excep¬
tion of three on each side, containing together thirty-four
patients, is under the supervision of a nurse or attendant, and
seven dormitories have two nurses or attendants in each.
Those dormitories in which there are no nurses, like all the
single rooms, have their doors open, and so every patient in the
asylum can go directly to a nurse or an attendant, and none are
in solitary or associated confinement. Nearly a half of the
patients are under constant observation, and more than three
fourths are under almost constant observation, for the time
now spent in visiting the single rooms, during which some
patients lose their supervision, is short compared with the past
practice, for it is a mere walk round, as all the wet, dirty, and
restless cases are in the dormitories. I may mention that
there are four double dormitories in the asylum with folding
doors, each holding eighty beds, which are occupied by quiet
working patients, and their great size—perhaps too great—
renders night supervision of this large number easy.

To keep this system working in perfect order, there is a
night superintendent, as in a general hospital, who inspects the
whole asylum four times each night. She is a trained hospital
nurse, who receives £52 a year, and to give her high prestige and
authority in the asylum she is treated as an important official,
and dines with the matrons. She takes rank as an assistant
matron, and receives her orders every night from the matrons
and assistant doctor of each side, and reports to them next
morning ; she is not independent of the matrons, as stated
by Dr. Keay in a recent paper.( 8 ) During the night, however,
she is the responsible official, is acting matron, in fact, and,
except in extreme emergency, no changes are made, no

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273

draughts are given, and the doctors are not disturbed, without
consulting her. Her principal duty is to see that the staff
is awake, attentive, and doing its duty to the patients, and that
there are no irregularities. Her experience of the slipshod
discipline and the elementary character of a great part of
asylum night nursing would be both entertaining and profitable
to detail, but she merely confirms the statements made on these
points by Dr. Elkins and Dr. Keay. The old night staff had
grown so accustomed to getting rid of patients into single
rooms whenever they became troublesome and required atten¬
tion, that it took badly at first to the increased work entailed
by the adoption of hospital methods. This system as here
described has been in operation for more than a year ; it has
worked smoothly and satisfactorily, and it has been a source of
the greatest comfort to myself to feel that a capable and
really reliable official was on duty during the hours of darkness.

The Male Side.

Employment of Female Nurses and of a Matron .

The special features of the administration of the male side
of this asylum, to which I desire to direct your attention, are
the large number of female nurses engaged in looking after
male patients, and the fact that the head of this department
is a trained hospital nurse, instead of a head attendant, as is
usually the case. The employment of female nurses to attend
to those suffering from acute bodily illness, and from the
malnutrition accompanying many forms of acute mental
disease, brings the treatment of the insane sick into line with
that of the sick in our general hospitals. There is for this
class of cases a ward in our hospital with twelve beds and
twelve side rooms, and it is managed by four nurses during
the day, and by two nurses at night. The matron of the
male department, who has no duties to perform in the kitchen
or laundry, can give, on that account, great personal super¬
vision to the sick ward, and as she is a trained hospital nurse,
the management of the ward, the nursing of the sick, and
the training of the nurses, quite conform to that of a similar
ward in a general hospital. The difficulties that arise are
solved on similar principles. For example, if a suicidal patient
at night wishes to attend to the calls of nature, it would be

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exceedingly unpleasant for the nurse to accompany him to the
w.c.; but this is not necessary, for the solution of the diffi¬
culty that at once occurs to a hospital nurse is to make him
use a night stool and place screens around him. Another class
of patients who are on a similar footing to the sick are the
paralysed, the aged, and the infirm, and these are nursed in a
special infirm ward containing twenty-three beds, with twelve
side rooms, by a staff of four nurses by day, supervised by an
assistant matron, who is also a trained hospital nurse, and by a
staff of two nurses at night The nursing in these wards is
infinitely better than could be done by men, and the immediate
supervision of trained hospital nurses brings it up to the
highest possible level. In addition to these cases, who are
more or less on the sick list, fifty other cases not confined to
bed, including imbeciles, epileptics, and dements, who are
unable to walk round the grounds, and who need considerable
attention, are, with a sprinkling of workers and parole patients,
under the charge of four more nurses, working under the super¬
vision of the assistant matron already referred to. Lastly,
besides those cases immediately under the personal charge of
female nurses, the assistant matron has immediate access
through an open door to the ward containing the chronic
excited cases, and the matron gives personal supervision to
the acute admissions and the suicidal cases, which, in addition
to the sick, are treated in the hospital in an open day room.
During the day, out of a total staff of thirty, there are alto¬
gether thirteen female nurses on the male side, and the head
of the male side is likewise a woman. At night, out of a staff
of ten on the male side, four are nurses, and the night super¬
intendent is a woman, a trained hospital nurse. Out of forty-
two persons engaged by night and by day in the care and
supervision of the male patients in this asylum, nineteen, or
practically one half, are women, three being trained hospital
nurses.

Now, what are the advantages and disadvantages of this
system ? In the first place, it is certain that the sick and
infirm are well nursed ; bedsores are almost abolished, and
the expenditure on cotton wool and methylated spirits has
gone up proportionately ; it is also quite obvious to those
who have noted the transition, that those imbecile and feeble
folk who have to be fed and cleaned and kept tidy receive

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1902.] BY G. M. ROBERTSON, F.R.C.P.EDIN.

27s

greater attention than formerly, for this is work that comes
naturally to women, but is most irksome to men ; lastly, the
treatment accorded to over ioo patients, a third of the total
number, and these consisting of all the most trying patients
in the asylum, excluding the very excited, being in the hands
of women, is of a gentle and persuasive character. The newly
admitted acute and the chronic excited patients are under the
charge of men, but are also indirectly under the influence of
women, and even this limited supervision has greatly affected
the conduct of the attendants towards these patients, and
tended to the use of less force than formerly. The treat¬
ment of all the patients, therefore, who give cause for anxiety
in asylums is beneficially affected by the presence of women,
and it has to be noted that the only class of male patients
not closely supervised by women are the quiet working
patients, numbering about 180, who all live in a separate
block, of whom nearly a half are on parole, and many of whom
are well able to look after themselves in any surroundings.

That women should be able to do so much and so well in
an asylum has surprised all who have watched the system
grow. An intermediate stage between the present and the old
system was a period when the male side was under the charge
of a married couple, Mr. and Mrs. Macrae, now superintendent
and matron of Haddington Asylum. They were able to
initiate changes and to effect such improvements in the manners
and habits of the patients, as have greatly facilitated the
employment of nurses and the gradual extension of the system
to its present maximum limits and hospital character. I
have known it said by some that the male side of their
asylums could never be managed by women, and one has come
to regard this as a delicate compliment on the orderliness of
this asylum, seeing that there is no difficulty here. It has also
been insinuated that the male side of an asylum was not the
proper sphere for women; but as it was said forty years ago
that no respectable woman would be a nurse in a general
hospital for adults, especially in the wards for adult men, one
can obtain comfort from the thought that the former opinion
is possibly no more true than the latter was. The men are
very easily managed by the nurses, and the nurses, such as
know both sides, say they prefer it to the female side, and the
assistant matrons, who in rotation work on both sides of the

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asylum, say that there is no doubt whatever that the male side
is much easier to manage than the female. It undoubtedly
gives satisfaction to the female relations of patients, and no
argument is more powerful in allaying the anxieties of a
mother or wife as to roughness than the existence of female
nurses. Although the system has been in operation for over
two years, I have no accident to record, no assault to describe,
no scandal to report.

I have now one or two observations to record which may
prove of value to others, (a) In the first place, the thin edge of
the system, the employment of two or three women to assist
in a male hospital, though of some, is not of great nursing
value. Women will not perform many acts necessary in sick
nursing in the presence of sane persons of the opposite sex,
but will quite readily do them if left entirely to them¬
selves. Such women then cannot do much nursing, but
engage themselves almost entirely in the kitchen and scullery
or in doing housemaid’s work. To introduce effective nursing
the place, large or small, must be handed over entirely to women.

(b) If nurses are employed by day in sick wards they should
also be employed at night, and, of course, never singly. . Not
only is the work improved by this arrangement, but otherwise,
the men and the women will not report to one another much
of what they should, when they go off and on duty respectively.

(c) Nurses will perform all the operations needed in nursing
if the sick or feeble person be confined to bed, but they object
to attend to men inclined to soil themselves, if they are up and
walking about with their clothes on. If it is not considered
necessary to keep such persons in bed, they must go to a w.c.,
where they can be attended to in certain respects by a male
attendant, especially charged with the care of these cases.

( d) Nurses cannot be expected to remain in dormitories
when a number of demented patients are undressing them¬
selves, or when they are getting up, though when dressed these
patients may be placed under their charge by day. Atten¬
dants are needed for supervision at these times, and must
therefore be drawn from other parts of the asylum.

(e) Bathing must be done by male attendants.

(/) Lastly, it is necessary to have in the dormitories a large
number of folding screens, as in hospitals, so that the utmost
decency be maintained. That the system may shipwreck on

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1902.] BY G. M. ROBERTSON, F.R.C.P.EDIN. 277

many a rock such as this there is no doubt, unless care be
taken, but that, on the other hand, it can prove a complete
success, Miss Wise’s administration of the male side of this
institution clearly proves.

In carrying out the medical ideals I have advocated, I pre¬
sume it is unnecessary to refer to the great advantage accruing
from the fact that the head of the male side is a trained
hospital nurse. As an indication of the high estimation in
which she is held in the nursing world, I may state that
she was second in the recent appointment of matron to the
Royal Sick Children’s Hospital in Edinburgh. I mention
this fact as a guarantee of the class of woman who can hold
such a post as matron of the male side of an asylum and as an
index of the quality of the nursing on the male side. She also
holds the Nursing Certificate, and has had considerable asylum
experience. She has been treated with uniform courtesy and
deference by the male staff; her orders have been respected,
and no appointment I have ever made has produced less
jealousy or ill-feeling. While the good resulting from this
appointment to an immeasurable degree outweighs the evil, it
is well to face up certain drawbacks. It is (a) impossible for
the matron of the male department to be present at the weekly
bath ; (< b ) it is impossible for her to be present when the patients
are just going to bed or just getting up ; (r) a good male
head attendant can be in closer touch with his men, and in¬
fluence them for good, more especially in their hours off duty.
These difficulties might be got over to some extent by appoint¬
ing a male assistant, as was done here at first, but that plan
has now been superseded, and the charge attendants are held
responsible for their respective wards. It is true that all their
other work is closely supervised, while these points referred to
are left to fhe occasional inspection of the medical officers alone.
This may be considered a weakness in the system, but it is
not one that wrecks a scheme presenting so many other
advantages.

Female Side.

The System of Assistant Matrons .

The principal feature of the day nursing on the female side
of this asylum is the employment of hospital nurses as

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278

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[April,

assistant matrons, who are placed in charge of the various
wards. Judging by their expressed opinions and practice, the
majority of the medical superintendents in Scotland consider it
to be to the advantage of asylum nursing to have a matron
who is a trained hospital nurse. While coinciding with this
view, I consider it to be of infinitely greater advantage and
importance to have those in charge of our female wards trained
hospital nurses, for while the duties of a matron must be
mainly administrative, those of a nurse in charge of wards are
almost entirely connected with the patients and their welfare.
It has been said by some that hospital nurses never get into
asylum ways, but my experience—which, I believe, has not
been surpassed by any other person—has been quite the
contrary. I have been simply astounded at the rapidity with
which they make themselves at home and mistresses of their
wards. In so far, however, as asylum ways run contrary to
the tone, or short of the medical ideals of a hospital, the state¬
ment may be true, and it is an excellent reason for introducing
them. I have stated that the inherited traditions of the past
lie like an incubus on the present management of the insane.
We must break with this past, and no method of breaking with
it is better than that of employing as responsible head of a ward,
a trained nurse with pure hospital ideals, who insists on the
work being done in conformity with her principles. My whole
object, as those who have followed me must see, is to bring
asylum practice into line with that of general hospitals, and if
the hospital nurses I employ do not take to certain asylum
ways, but, on the other hand, introduce hospital ways, my
object is in process of being attained. Of course, it is obvious
that hospital nurses come to an asylum absolutely ignorant of
much special knowledge that is essential for the management
of the insane. They must for a short time be carefully
supervised and coached by the matron and the medical
officers, but if there are other hospital nurses in the asylum,
they learn their special duties from one another very
quickly and without any trouble. In order to get full
benefit from this infusion of fresh blood, it is an important
point to encourage these nurses to ask questions and to
offer original suggestions. The remarks of an intelligent
observer with an open mind are always interesting, and occa¬
sionally their ideas contain suggestions of the utmost value.

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1902.] BY G. M. ROBERTSON, F.R.C.P.EDIN. 279

I consider my indebtedness to the nurses I have trained to be
very great indeed. It has been said that the ordinary asylum
nurses object to having these hospital nurses, who do not know
a tithe of what they do, placed over their heads; but if dis¬
cretion be used in their introduction actual experience does not
confirm this. The hospital nurses I have appointed as
assistant matrons have all been able women, who have been
most carefully selected, and they are usually older than the
average asylum nurse. These facts, in conjunction with the
prestige attaching to a hospital training, have at once given
them great authority and have commanded respect. The fact
that they are treated differently, dine at a separate table, are
called assistant matrons, and also openly aspire to and obtain
asylum matronships elsewhere, places them beyond competi¬
tion ; and the asylum nurses are, therefore, not jealous of their
authority, whereas when one of themselves is placed in
authority there is always some jealousy and ill-feeling created.
It increases their pride in their work to have the assistant
matron working at the same duties as themselves, and it has
directly inspired many of them with the idea of completing
their training in a hospital. An indication, perhaps of great
value, as to its popularity, has been the fact that there have
been fewer changes among the nurses since the system was
introduced.

An impression has gone abroad that the assistant matrons
interfere with the pay and promotion of the ordinary asylum
nurses, but this is not so. Nurses get their annual increments
of pay, their pay for special duties, and their pay for promotion,
as formerly, and they get promoted into charge nurses as
formerly. The assistant matron's appointment is a new
creation, additional to all the others in the ward, and to say
that it interfered with the pay and promotion of the
ordinary nurses would be as legitimate as to say that
the appointment of a lieutenant to a company interfered
with the pay and promotion of the rank and file. It interferes
with the nurses to this extent only, that whereas the matron
formerly merely passed through the ward, she now leaves a
deputy to be always present to see her orders carried out, to
prevent roughness, to report misdemeanours, and to set a high
ideal of work and duty. It is possible, human nature being
what it is, that an old charge nurse would object to the

XLVIII. 20

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280

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[April,

presence of this deputy matron, and would call her supervision
interference; but recognising this point, I have always waited
till the old charge left before I introduced the new assistant
matron, and the new charge nurse has always signalised her
promotion by being exceedingly pleasant all round.

It is well to be considerate of the vested interests of the
staff, but there is a more important consideration than this,
and that is the interests of the patients, a point which most
critics of this system appear to overlook. I am convinced that
by the employment of this system of assistant matrons most
of the evils I have mentioned in the introduction of this paper,
as they exist on the female side, tend to disappear. To
disperse these evils two agents were needed on the female
side : first, a higher ideal of work , and this is now supplied by
the hospital trained nurse, who is a tangible example within
the wards ; in the second place, reliable supervision . In the
past the charge nurse was supreme, but as she was one of
themselves she had deficient authority over the asylum nurses,
and perhaps sympathised with them. The result was poor dis¬
cipline, and offences, even serious ones, were seldom reported.

Under the system of assistant matrons responsible for the
wards, and working in them, more and better work is done,
and misdemeanours, which have as a consequence become much
fewer, are loyally reported. I may state, in conclusion, that
there are three assistant matrons on the female side, and one
on the male side, and the night superintendent also ranks as
one. There are thus five assistant matrons in this asylum, all
certificated hospital nurses. They are all engaged at £40 per
annum for a period of two years, during which time they take
the Nursing Certificate, and are trained in every ward, and in
all the duties of asylum management. They all aspire to
become asylum matrons, and judging by the success of five
predecessors, they should all obtain the object of their desires
in course of time.

Conclusion.

In concluding this paper I am conscious that much ex¬
pressed in it will jar upon the feelings of many who are greatly
my seniors, and for whom I have respect and reverence. It is
inevitable, from the nature of the subject, that this must be
so, however guardedly my observations and opinions are

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1902.]

BY G. M. ROBERTSON, F.R.C.P.EDIN.

28l

expressed, for it criticises hallowed traditions and shakes fixed
beliefs. To have one’s formed habits and established ways of
thought thus upset, or if not actually upset at least disturbed,
is not a pleasing experience. I am quite ready to admit,
however, that I may be wrong in the methods I have adopted
to overcome difficulties, but I submit that they are an
honest and a carefully thought out effort to rectify the evils
that exist. I admit that it may be by other methods that
these evils will finally be overcome, and I am prepared to
adopt any method that offers a hope of amelioration. I,
however, assert that the evils I point out are not imaginary,
but are very real, and my observations are supported by
many friends who do not agree with all the remedies I have
adopted. If the reader, therefore, discovers defects in any
new departure I have adopted, let him temper his criticism
with a consideration of the means he himself is prepared to
adopt to remedy the existing deficiencies of asylum treatment.

The ideal I have set is a simple and a tangible one, that of
treating the insane in an asylum strictly according to hos¬
pital and purely medical methods. It is not a new one, the
idea is constantly on our lips. Some years ago Sir James
Crichton Browne and others proposed to build a new asylum
for the insane in London, and to start it from the beginning
on purely hospital lines ; it is at present proposed to open
wards in the Royal Infirmary of Edinburgh for the treat¬
ment of incipient and transient forms of insanity. It has
been my object, by the methods I have described, to abolish,
as far as possible, features peculiar to asylums, and shown to
be injurious or unnecessary, to elevate the standard of nursing
and duty to that of the general hospital, and to make an
asylum for the insane in reality a hospital for the treatment
of a special disease run on hospital lines under the supervision
of fully trained hospital nurses. The more nearly this object
is attained the less difference will there be between an asylum
and a general hospital, and the more nearly will the asylum
and the care of the insane be to a state of ideal perfection, for,
as I have already said, the great general hospital is the most
perfect embodiment of the practical efforts of humanitarianism
and medical science at present known to us.

(*) I desire here to express in other respects my concurrence in theoiy and in
actual practice with the principles laid down by Dr. Keay.

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Discussion

At the Scottish Divisional Meeting at Larbert, 29th November, 1901.

Dr. Clouston said that, as he had been called upon, he had very great
pleasure in expressing their indebtedness to Dr. Robertson for having asked
them to come there, and for having taken the trouble to describe in his paper the
system in operation in that asylum. He was quite certain that none of them
were too old to learn, and that any man who devoted himself so enthusiastically
to the advance of asylum work as Dr. Robertson had done, and resolutely made
an attempt to get over its weak points, would have their support. He thought
that when a man came before his brethren and described the results of what he
had done, and introduced a new system, whether they agreed or did not agree
absolutely with him, it was quite certain that they would be all the better for
having heard the paper. In regard to the paper, one might say that, in the
first place, it would be a poor compliment to Dr. Robertson if they were
simply laudatory, and said that it was all very good, that they agreed with
all they had heard, and not make any criticism. He thought it would
be also far from complimentary if they did not ask him sotne questions.
The key-note Dr. Robertson had struck was that, as they now nursed sick¬
ness in general hospitals by the best methods, the insane should have the
benefit 0? the same methods. One of the results of the new system had
been that they had developed an extraordinarily perfect hospital administration,
and that we saw crowding into hospitals some of the most educated women
and the best brains of the female sex to nurse the sick. Dr. Robertson had said,
“ Let us imitate this system, and let us carry out the same thing in our hospitals.”
He thought that in regard to these principles they were absolutely at one, and that
they should certainly carry them out in hospitals for the insane. He thought,
however, that Dr. Robertson had passed over certain of the obvious differences
between the symptoms of the insane man and those of the sane man suffering
from pneumonia or typhoid fever. Taking, for instance, the putting of patients
to bed, they knew perfectly well that many insane people did not require to be
put to bed for the same reasons that a pneumonic patient required to be put to bed.
The sick man in the hospital must go to bed ; his sickness absolutely requires it.
The sickness of the insane man presupposes no such thing, and they all knew
that in a vast number of these cases the higher brain was evolving an amount of
morbid energy which found an outlet in walking and talking, and in various
other ways of that kind. They naturally asked if it was not contrary to the
ordinary instincts of reasonableness and physiology to put all these patients to
bed. How was that morbid energy to find a safe and a physiological outlet?
He did not agree with Magnan’s routine treatment; and he had heard that there
was often a perfect pandemonium in his wards. It was a perfect scandal seeing
patients running about in a half-naked condition, and pretending to be kept in
bed when they were not in bed. He was quoting from a man who saw it lately.
He believed that a considerable number of their patients should be put to bed,
a larger number than was so treated formerly, but he drew the line in certain cases,
and he said that it was bad physiology and bad therapeutics to bottle up motor
energising in all cases. Passing to the question of the employment of women in
male wards, they all knew that women had unquestionably the instincts of nursing
to a greater degree than the male sex, and on that point he was inclined to
agree to a very large extent with Dr. Robertson; yet they must not shut their
eyes to the fact that men ruled men best, and women governed women best as a
general rule, and that questions of danger and decency came in and had to be
provided against. He would say there, and with great pleasure, that he had
spent part of the night going about the wards of the asylum in which they were
met along with Dr. Robertson, and he was impressed deeply with the quietude
and with the practical success of the system which he saw in operation. They
had lately transferred a number of their patients from Morningside, because they
had not room for them. They were taken chiefly from the chronic cases. Dr.
Robertson had the bad luck to get one or two of the worst patients in Morningside.
He was beyond measure astonished and exceedingly pleased to find a woman

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who, when in Morningside, was a homicidal dangerous inmate, and a most
objectionable woman, and when there never slept out of a single room, lying
calmly and sweetly asleep in one of these big observatory dormitories. He
thought that Dr. Robertson had carried out the system more perfectly than even
Dr. Elkins, and he had carried it out in a way to benefit his patients in a very
high degree. In regard to the employment of women in the male side of the
house, he* thought that was all a question of degree. He said they had all done
more or less what Dr. Robertson had done, but he had done it in a much more
systematic way than most of them had done. He would point out, however,
that under the name of hospital nursing Dr. Robertson was establishing a very
aristocratic system. He knew that they would all like that every nurse and
every attendant should be a conscientious, kindly, refined, duty-doing, and duty-
loving person. He thought that they had all been trying to secure such a staff.
Dr. Robertson takes a woman from a general hospital, a person of superior social
standard, and puts her in charge of every ward. He asked if Dr. Robertson
would tell him whether that added to the self-respect of the ordinary asylum
nurses or not. He would point out to Dr. Robertson that he was running the
risk of having the head of the ward highly qualified and doing her best, but with
all the other nurses in a position that was disheartening and even lowering. Dr.
Robertson had said that this was no practical objection, and he was extremely
glad to hear it; but for himself he would rather raise and train his old nurses as
a principle than put a hospital nurse over each ward. His ideal was not Dr.
Robertson’s ideal in that matter. The nursing in a general hospital and that in
an asylum differed in many ways, and he often found first-rate hospital nurses
most incompetent in consultation practice. Looking to the future, he would
rather go in for the idea of raising all asylum nurses up to a high level. Taking
a hospital nurse and putting her in that position did not eliminate her original
sin ; she was still a woman, and it was to be presumed she had all the evils and
good qualities of womankind. They must keep in mind the large number of
persons they needed for their service, and that in those circumstances it was better
to pick the best of a numerous class than have to take the second-best of a less
numerous one. Dr. Robertson had made an appeal to him personally, and he
would make an appeal to Dr. Robertson and ask him whether the women’s
hospital at Morningside could have been conducted better in anyone way than Mrs.
Findlay had conducted it for the last twenty-eight years. He therefore thought
that they might get what Dr. Robertson wishes to attain without going about it
in the way that he does. He would much prefer to place in charge of many of his
wards women of the right sort promoted from the ranks. Let them send the
fittest of their present nurses for a short hospital training, and let them get into
their hospitals some fully trained general nurses, so as to combine the strong
points of both systems. He could not sit down without expressing his sense of
the great benefit he had derived from hearing Dr. Robertson’s paper and seeing
his results. An enthusiast will make any system work, and by experiment
and by running risks their department had in the past benefited incalculably.
Dr. Robertson had perhaps put on his colours a little too vividly, but he was
well aware that faults in asylum administration did exist. He was not there to
deny that, and he thought that every man who endeavoured earnestly and
honestly as Dr. Robertson had done to diminish these faults was doing a great
service to the insane, and for that they owed him gratitude and admiration.
(Hear, hear, and applause.)

Dr. Yellowlebs thought that the world owed a great deal to its enthusiasts,
and that it was well that some enthusiasts had so much wisdom in their enthusiasm
as Dr. Robertson’s paper had shown. He agreed with much of what he had said,
but some things he would be disposed to question. Dr. Robertson had first of all
condemned single rooms with an emphasis which was quite unreasonable. He
thought that a single room was more frequently a privilege to a good patient than
a place of confinement for a bad one. He knew that a vast majority of his single
rooms were so regarded. Of course, single rooms could be abused, but he was
astonished to hear them condemned as Dr. Robertson had condemned them when
he said that he regarded the use of a single room in the same light as he regarded
mechanical restraint. He thought that was going over the line and quite unreason¬
able. He knew that there were many patients who were certainly quieter and

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better when they were in single rooms than when they were in dormitories. Cer¬
tain patients had the feeling that they were annoyed and tormented in a dormitory,
and he thought that they should have single rooms, and should not be made to
sleep where they were uncomfortable. He did not think that Dr. Robertson should
glorify himself so much on the fact that he never put a patient in a single room.
He scarcely knew what to speak about next, as the paper touched on so many
questions. He quite recognised the need for improved nursing, but he thought
that Dr. Robertson’s remarks on present-day nursing were unjustly severe, though
he had softened them towards the end. They all knew that some of their attend¬
ants were black sheep, but it was unfair to condemn them all as nurses, and to
take women in their places, as if women had the monopoly of humanity and kind¬
ness. He thought that was going much too far. As to the value of women nurses
in certain male wards there was no question. He adopted that system in Gla¬
morgan, and regretted that he had not been able to use it in Gartnavel.

As to the treatment of maniacal cases by rest in bed, or by abundant exercise,
he thought there were both classes of cases, and it would not do to make an
absolute rule. He had of late years used the bed treatment much more than in
former days, and he thought that on the whole a great proportion of the patients
were better for being in bed in the early stages than if allowed to run about and
exhaust themselves by needless expenditure of nerve energy. All depended on
the wisdom of selecting the right treatment in the right case.

He said that he must emphasise what Dr. Clouston had said about the idea
which seemed to have taken possession of Dr. Robertson, that the mere fact of
41 hospital training ” creates the very superior female officers whom he values so
much. He had no such reverence for mere hospital training as Dr. Robertson
had. It was not the fact of hospital training which secured successful nursing
here; it was the fact that Dr. Robertson took infinite care in selecting good women
who did their duty admirably when hospital trained, and would have done it still
better if asylum trained. It was all nonsense to suppose that the mere hospital
training did it. He knew a good many hospital nurses to whom he could not
entrust a patient at all. Hospital nurses and asylum nurses were entirely different.
The hospital nurse must strictly obey orders and be observant, careful, and kind ;
the asylum nurse must be all this and much more : she must control the violent, and
calm the excited, and cheer the depressed; her conduct and conversation are
potent for good or ill to her patient, and she may at any moment have to cope
with emergencies demanding the utmost care and judgment. This is far better and
higher work than ordinary sick nursing, and gives greatly superior training,
though it may well be supplemented afterwards by some training in the nursing of
bodily illness. (Applause.)

Dr. Rorie said that he had nothing to add to what had fallen from Dr.
Clouston and Dr. Yellowlees as to how much they were indebted to Dr. Robert¬
son for his paper. Referring to the use of single rooms in the treatment of
violent patients, he said that during the last twelve years he had not had any
cases of seclusion of patients during the day. He had a very strong feeling that
the seclusion of these patients had a marked effect in demoralising the condition
of the patients and in prolonging the state of excitement. He said that he had
these acute maniacal cases treated in the dormitories, and he found that the asso¬
ciation with other patients and the supervision entailed shortened the period of
excitement. With regard to the question of night supervision, he had changed
that also to a very considerable extent. On the female side, where there are
about 240 patients, he had seven night nurses, and there had been a very marked
improvement in the reduction of the number of cases that required to have
separate rooms for themselves during the night. He said that he had no expe¬
rience of female nurses on the male side of the house, but from what he had
heard and what he had seen elsewhere he was satisfied that the introduction of
that system was bound to have a very efficient result. He thought that the ideal
standard which they should set before them in the treatment of the insane was
that which existed for the treatment of bodily diseases in the best general hos¬
pitals. He found that the system of putting newly admitted patients for a week
or ten days to bed had a beneficial effect in regard to their future progress.

Dr. Marr referred to the satisfactory results which had been obtained at
Lenzie by adopting the plan of keeping the noisy patients in an associated dormi-

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tory at night. His experience had caused him to form the opinion that it was
desirable to appoint a nurse, who had been trained in a general hospital, to act as
supervisor of the night nurses. He approved of treating all patients, on admis¬
sion, in bed, and certain patients, particularly cases of acute melancholia, benefited
by resting in bed for a considerable time.

Sir John Sibbald, who was presiding, said that, in his opinion, no more
interesting subject had been brought before this Association. He quite agreed
with Dr. Clouston and Dr. Yellowlees in their appreciation of the valuable
results which should accrue from the efforts of an enthusiast imbued with Dr.
Robertson’s ideas. He said that he was strongly inclined to hold the view that
Dr. Robertson was right, and that they would all come to think very much in
that direction if they had not done so already.

Dr. Keay said that he would like to express to Dr. Robertson thanks for his
paper, which he thought was a most valuable one. Without going into details he
would say that they were all agreed about the necessity for giving up locking our
noisy and troublesome patients in single rooms during the night. He thought
there was no need to discuss that. As to the value of female nurses on the male
side he could speak from their experience at Inverness during the past three and
a half years, during which time their male sick wards and their male admission
wards had been entirely under the charge of women. He thought that Dr.
Robertson had mentioned, in regard to that matter, a very important point, and
that was that they should be entirely under the charge of women, and that male
attendants should have nothing to do with them. When he opened the new
wards on the male side and proposed to put women in charge of them his idea was
to put a trained hospital nurse with asylum experience in charge of each sick ward,
and give her male attendants to work under her as orderlies; but here he met with
opposition at once. The nurses objected to having male attendants to assist
them, and explained the reason to him. There were many duties which a nurse
had to attend to in the case of insane men that she would not do assisted by or in
the presence of male attendants, and she was auite willing to undertake all the
duties simply with the help of women. He took the advice and placed the wards
entirely under the care of women, and the thing had gone on for over three years
without any difficulty at all. He thought that Dr. Robertson was right in a great
deal of what he said about the faults of attendants. That was a matter in which
he was afraid they had been slack. He thought that it was not of much use to
increase the night staff by putting on a great many more night nurses and night
attendants if they did not have these nurses and attendants properly looked after.
He thought that was the difficulty, and they might appoint head night nurses and
head night attendants from their asylum staff without, after all, obtaining proper
supervision and efficiency. He found that one attendant or nurse would not
report another. On the contrary, they shielded one another, even though the
patients suffered. He thought that what they wanted in charge of the night staff
was what Dr. Robertson called a night matron to supervise the whole night staff
of the asylum. He thought that nothing else than that would be successful, for
the male as well as for the female wards. There was one matter on which he
must say that he did not quite agree with Dr. Robertson, and that was his plan of
having hospital-trained women without asylum experience as assistant matrons to
have charge of wards. What was to become of their asylum nurses and attendants
if that was carried out fully P There was nothing before them ; they had no pro¬
motion to look forward to. They would simply remain ordinary asylum nurses
and attendants, and had nothing to hope for beyond that. He did not see why
asylum nurses and attendants, if they were of the right material to begin with, and
if they were properly trained, should not be capable of doing all that was required.
He did not see any advantage in having hospital-trained women in charge of the
ordinary chronic asylum wards. He would again thank Dr. Robertson for the
most instructive paper that he had given.

Dr. Bruce thought that this was one of the most interesting papers that they
had had at these sectional meetings for many a year. He only wished that in the
sectional meetings in the future they would have papers as interesting. He said
that the time was very short now, and that he must confine his remarks largely to
criticism of points on which they did not agree. From the small experience that
he had had he thought that Dr. Robertson was right in most of his details. In

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the nursing of sick people, even where there were noisy cases, the proper person to
have charge of these people was a woman. He thought it was not a man’s duty
to be in the sick room. The majority of the men abhorred the work and did not
do it properly. Until they had their hospital wards in charge of nurses he did
not think they would have any satisfaction in working them. When he went to
the asylum at Murthly there were four nurses in charge of the men’s sick ward
and hospital, and they discharged their duties admirably. Men who were trouble¬
some and dangerous in charge of male attendants when taken and looked after by
women often became quite quiet and did everything they were told. With
regard to night duty he thought also that Dr. Robertson had probably struck a
fairly sound note. He did not know whether he would have a woman in charge
of the night staff. He thought it would be a very good method, but there were
certain difficulties in his way at Murthly. He had gone on many occasions round
the wards, and he could not tell how many night attendants he had found asleep
on duty. If he found them asleep on duty once he could not tell how many times
they had been asleep before that and never reported. He found on one occasion
three men asleep on duty out of a night staff of four men. The only man who
was awake—and he presumed he could not sleep—was the man who visited the
wards. He believed that some one in a better social status was absolutely
necessary for the night supervision of asylums. There were two points upon
which he did not agree with Dr. Robertson. First, that three single rooms per
hundred patients was sufficient. He would go a good deal further than that, and
say one to ten was the proper proportion. The other point which he thought
Dr. Robertson was off the line was when he put hospital nurses in charge of his
nurses. He had had a year’s experience of that, and he had cleared out the
hospital nurses and put a good matron in charge of the whole house, and he had
never had any bother since. He found when he cleared these hospital nurses out
that the junior nurses were very ignorant. He understood that the hospital
nurses were to teach the asylum nurses certain nursing duties, but he found that
they did not do so. Those who were directly under the hospital nurses had
picked up what they did know by simply watching very carefully, and he asked
them individually how much they had learned from Miss So-and-so. They said
that they were not taught anything, and from the examination he made he was
perfectly certain that they were not benefited by the system. The truth was that
the hospital nurse gained her knowledge by a considerable amount of trouble, and
she did not care to pass that knowledge on to some one else for nothing. Since
they got rid of the hospital nurses two of the junior nurses had developed
sufficiently to be made charges. He did not know a better nurse than the girl
who was in charge of the hospital now. She showed no signs of being a good
nurse under the hospital nurse system. He really thought that on that point if
they wanted to advance they would have to improve the asylum nurses as a
whole.

Dr. Carlyle Johnstone said that they all agreed with Dr. Robertson in the
main. He did not think that there was anything revolutionary in the principles
which he advocated. They had been working on the same lines for the last two
or three generations, though some of them, owing to structural conditions or
other difficulties, were still unable to carry out their views in full detail. There
were many interesting minor points in the paper, but, after all, these were not of
vital importance. They need not quarrel over the question of “ hospital ’’
nurses, for that was merely a question of names. What they all believed in was
that the attendants on the insane should be nurses in the best and widest sense of
the term. An asylum attendant was much the better for being a hospital-trained
nurse, but a hospital-trained nurse was of little use in an asylum until she under¬
stood the special requirements of the insane and possessed the necessary qualifica¬
tions for dealing with them. As to the question of single room versus dormitory,
he did not think that there was any special virtue in a dormitory or any special
vice in a single room. The essential thing was that the patient should receive
the care and treatment which was suitable to his particular requirements. Some¬
times this could be best attained in a single room and sometimes in a dormitory.
No doubt all of them had been guilty of the abuse of single rooms, and they had
most of them found out that they did not require nearly so many of these rooms
as had once been considered necessary; but it appeared to him that there might

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1902.]

also be an abuse of the dormitory, and that it was both unreasonable and cruel to
insist on all cases being treated in associated dormitories. Seclusion, that was to
say placing the patient in a room apart from others, was not merely a justifiable
means of treatment, but a very proper and necessary one in many cases. One
did not need to be a doctor to appreciate the truth of this. As Hezekiah in his
sickness turned his face toward the wall, so it had, from all time, been the natural
desire of those who were distressed or troubled in mind to find a refuge in
solitude from the importunities of their fellows. Dr. Robertson might say that
these poor sufferers did not know what was good for them, but he imagined that
Dr. Robertson himself would prefer single room treatment to dormitory treatment
in his own case. With reference to Dr. Robertson’s practice of putting a “ hos¬
pital ” nurse in a ward as a sort of supervisor over the charge nurse, he feared
that this would lead to difficulties, and that it was not calculated to raise the
standard and the efficiency of the under nurses. At the same time he quite
approved of having a certain proportion of hospital-trained nurses in charge of
certain large sections of the institution, provided, as he had said, that these
hospital nurses were given a thorough training in the special requirements of the
insane, without which they were likely to be more ornamental than useful. He
wished to repeat, what he had urged in season and out of season, that one of
their most important duties as guardians of the interests of the insane was the
systematic practical training of their staffs, and this not merely by lecturing and
exhortation, but by the continual methodical demonstration and practice of
everything that was embraced within the general nurse’s handicraft, so that from
the humblest “ attendant ” to the most superior ** hospital nurse,” it should be
apparent to every member of the staff that they were all engaged in nursing sick
folk. He felt bound to add that the description which Dr. Robertson had given
of the ill-treatment of the insane under somewhat old-fashioned conditions was,
in his opinion, an exaggerated one, and he must say that if abuses existed such as
had been described, then he should be more inclined to lay the blame on the
superintendent than on the attendant; and he would suggest that, if these abuses
were to be removed, a more revolutionary change was called for than the mere
introduction of hospital nurses.

Dr. Turnbull agreed in the main with what had been said by the other
members. In regard to the nursing of asylum male patients suffering from
bodily infirmity or sickness by female nurses, he thought they were now all
agreed that it is a very desirable step and a perfectly practicable one. In Fife
they had passed through the same experience which Dr. Robertson and Dr. Keay
had referred to. Structural peculiarity in the buildings had made it impossible
to introduce female nursing on the male side as early as he would have liked, but
when a new hospital block was erected advantage was taken of it to place the
male sick room in the centre of the building, where it could be easily reached from
the female side. He had at first intended to have one or more male attendants
also in the sick room, but the nurses, while willing and anxious to do the work,
had a strong feeling against undertaking it in association with attendants. He
had, therefore, made the experiment of putting the sick room entirely under
female charge, and in his opinion it had proved an unqualified success, good both
for the patients and for the staff. He had been struck with the very small
proportion of cases requiring sick-room treatment that had to be kept out on
account of the female nurses being there. Often they were free altogether for
long periods from any case of that kind, and even over a series of years he had
found that the proportion of such patients was certainly not more than 5 per
cent. In the Fife asylum the senile cases were generally placed in the sick-room,
and in asylums where the population was so large as to require separate wards for
senile and sick cases he thought there would be no serious difficulty in placing the
senile ward as well as the sick room under female charge, as Dr. Robertson had
done in Larbert asylum. In regard to dormitory observation at night he agreed
with Dr. Robertson as to its great value, but thought that certain details should
be kept in view. Like all of them he had felt that patients placed in single
rooms were apt to be neglected and to fall into bad habits, and about ten years
ago he introduced an observation dormitory for chronic cases with a nurse on
duty in it all night, and a number of cases that had formerly been constantly in
single rooms were placed in it. He remembered well the difficulty he had in

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[April,

persuading some of the older officials that such a step was possible; but the
dormitory had been kept in regular use, and the patients much improved thereby.
In the observation dormitory for recent admissions it should be kept in mind that
sometimes one troublesome patient would interfere with the sleep of all the others
in the room, and the mere fact that nurses were there and were necessarily moving
about at times seemed to have to some extent a disturbing effect on certain
patients. At any rate he had several times noticed that convalescent patients
were very grateful when they were removed from the observation dormitory, and
passed on to a room or dormitory in which there was not the same amount of
movement going on at night. He believed that the practical value of dormitories
lay entirely in the fact that supervision of a large number of patients was more
conveniently carried out and more likely to be kept up steadily there, but thought
that certain other requirements were better met by single rooms, and that the
latter were properly adopted if the supervision of patients in them was still kept
up to the desired standard. For instance, there is a distinct class of patients who
are unduly irascible and quarrelsome, who (as it were) respond too actively and in
a morbid way under ordinary sources of irritation. He thought that these cases,
both for their own sakes and for the sake of the other patients, were distinctly
better when placed in single rooms, and by making suitable arrangements it was
quite possible to have them in rooms by themselves, and still to keep up all the
supervision that is desirable.

Dr. Farquharson said that he had come there to learn something about the
methods of Scottish asylums. He had listened with great interest and a good deal
of profit to Dr. Robertson’s excellent paper, and also to the very valuable
discussion which had followed it. He agreed with many of the points mentioned
by Dr. Robertson, and so many of the speakers had gone over them in turn that
there was very little left for him to say. The asylum of which he had charge was
a building of not very recent date, and, owing to its construction, was not
altogether adapted for putting female nurses in charge of the male sick wards,
but it certainly seemed to him a very proper thing to do if the circumstances
permitted of it. He hoped that in course of time he would be able to do it.
With regard to the question of keeping patients in seclusion, he might say that
during the three years he had been a superintendent it had very rarely been
necessary to seclude a patient in the daytime. At night they had certainly a very
large number of single rooms occupied, but the majority of these rooms were
really a privilege for the better conducted patients. A few of them were used for
troublesome cases, but the majority of such cases were kept under observation in
dormitories where there were nurses all night.

Dr. Robertson said he had to thank them very much for the manner in which
they had received his paper, and also for the criticism that had been offered. He
had great pleasure in receiving them that day in the Stirling District Asylum,
and he thanked them for coming in such numbers, there being representatives
present from most of the asylums in Scotland. As had been pointed out by
others, he thought there was probably not very much difference between his point
of view and that of some of the speakers who, however, had criticised the details
of the paper. The details were quite a matter of secondary consideration, and it
was important that on broad principles they were more or less at one. Owing to
the short time at his disposal there were only two points that he could refer to.
One was the question of the assistant matrons. He could see perfectly well that
the feeling of the meeting was against the employment of hospital nurses on the
female side, and he deplored this greatly from his desire to see improvement
taking place in asylum nursing. Some thought that it created a class, and in
that way had a tendency to lower the status of the ordinary asylum nurse. He
might say that his aim, object, and intention in the introduction of these nurses
was to benefit the insane and to improve the position of the asylum nurse. He
had no intention whatever of lowering them. He was, moreover, perfectly certain
that the system had elevated the ideals of the nurses, and it had increased their
self-respect to have working beside them nurses who had completed their hospital
training. In no respect had he found, after five years’ experience, that it had
acted disadvantageously. Others had said that it would stop all promotion, but
it does not; there is absolutely no change from what took place in the past. The
only appointment that was probably more definitely kept back from them was the

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1902.] NIGHT NURSING, ETC., IN ASYLUMS.

appointment of matron. He would like to know how many medical super¬
intendents present had appointed matrons from the ordinary asylum staff. He
doubted if in recent years there were more than one or two who had ever done so,
therefore no appointment had been kept away from the asylum nurses by his
system. It had encouraged them to nobler efforts and to complete their training
in general hospitals, and as a matter of fact a number of nurses who had come in
contact with these hospital nurses had, after obtaining their nursing certificate,
gone and completed their training in the general hospitals. He had no doubt
that some of these would come back to the asylums to fill the higher posts. He
simply made these statements to prove that his idea in appointing these assistant
matrons was to improve asylum nursing and to raise the position of the present
asylum nurse, and he believed that the results justified his actions.

In the second place, with regard to the use of single rooms, he had demonstrated
that the confinement of patients in them at night was no longer a necessity in
asylums, however advisable it might be in exceptional cases. He had stated that
3 per cent, of single rooms was ample to meet the requirements of all these
exceptional cases, though the existence of a much larger percentage was of value
as bedrooms for privileged quiet cases, and for the treatment of special diseases
as erysipelas and consumption. He quite agreed with Dr. Johnstone as to the
benefit certain cases received from the quiet seclusion of a single room, but if
these cases needed supervision a special nurse should be present, and he was
ouite opposed to the practice prevailing at present of locking up the patient.
The system of locking up patients in seclusion was liable to great,abuses, and he
had found it almost impossible to check these abuses except by totally abolishing
the system. On one occasion, many years ago, after acting, as he thought, with
great care, he had ordered a girl suffering from adolescent mania to be confined
in the padded room. She was kept there for several days, as every day, during
his visit, he received graphic accounts from the nurses of her violence and excite¬
ment, till one nurse came to him secretly, and informed him that the reports he
was receiving of the frightful violence of the patient were quite untrue. Here
was a patient under this system of seclusion suffering unfair and most improper
treatment under his eyes, and, but for an accident, it would not have been dis¬
covered. He would not deny that locking up patients in solitary confinement, as
defended by Dr. Yellowlees, had not occasional advantages—at one time superin¬
tendents pied strenuously for the retention of even mechanical restraint and
strait waistcoats on account of their usefulness,—but any systems such as these,
liable to gross abuse, were better abolished, and it was absolutely certain, from
his results, that solitary confinement, especially at night, was greatly abused at
the present time. To save the nurses trouble and the asylum expense, patients
were being systematically locked up at night who should be under the constant
supervision of nurses. He had very gratefully to thank Dr. Clouston for the
statement he had made with regard to the system of night nursing. It would go
very far towards establishing the system, and extending the belief in its merits,
which, however, appear to be now recognised in Scotland.

The employment of women on the male side had met with their expressed or
tacit approval, and he would not delay them by referring to it. He was sorry that
his remarks had prolonged the discussion, as the time at their disposal was so
insufficient.

Some further Remarks upon Night Nursing and Super¬
vision in Asylums . By Frank Ashby Elkins, M.D.,
Medical Superintendent, Metropolitan Asylum, Leavesden.

A PAPER upon the subject of “Night Nursing and Super¬
vision in Asylums,” by Dr. Middlemass and the writer, was

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NIGHT NURSING, ETC, IN ASYLUMS,

[April,

read at the Annual Meeting of this Association in 1899, in
which the practices pursued and the results obtained at the
Sunderland Asylum during a period of four years were fully
dealt with, and it was advocated—

1. That the night arrangements in asylums be closely
approximated to those which exist in general hospitals.

2. That all acute, noisy, dirty, and destructive patients be
placed at night in dormitories under constant supervision, and
be removed only when it is evident that they have ceased to
require such special care.

It is not claimed that what was attempted and done at
Sunderland Asylum was any new departure in asylum manage¬
ment, for it was known that in the minds of asylum medical
officers there was dissatisfaction with the nursing and super¬
vision of the insane at night, and it was also known that in a
number of asylums the advantages of having a larger night
staff were realised, and in some cases acted upon.

Dr. Middlemass will say what further there is to be said
respecting Sunderland Asylum, whilst it is proposed in this
paper to raise points for discussion in describing the night
nursing and supervising arrangements at the Metropolitan
Asylum, Leavesden, where all the patients, without exception,
sleep under constant night supervision.

It is not advocated that in every asylum there ought to be
continuous supervision and nursing of every patient during the
night. That is a matter to be settled by the medical super¬
intendents of the respective asylums, and largely depends, it is
presumed, upon the class of patients housed, and the kind of
sleeping accommodation provided.

Leavesden is believed to be the only public asylum where a
nurse is placed at night in charge of every ward and dormitory,
but this is considered both justifiable and necessary under the
circumstances now to be described.

The metropolis supplies Leavesden Asylum with the most
miscellaneous collection of human wreckage which, it is
probable, has ever been accumulated in an asylum.

No patient under sixteen years of age is admitted, so that
no children are found in the wards, and patients dangerous to
themselves or others are not supposed to be admitted, although,
during the two years 1900 and 1901, thirty-five such cases
were transferred to the London City and London County

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1902.] BY FRANK ASHBY ELKINS, M.D. 291

Asylums, the Leavesden staff not being sufficiently numerous
to deal with suicidal and dangerous patients.

The bodily state of the admissions is shown in the following
table, which deals with the two years 1900 and 1901 :

In good bodily health and condition

Total.

In average bodily health and condition .

In indifferent bodily health and condition

In weak bodily health ....

l60

In very weak bodily health and exhausted

condition .....

159 163 322

The weak and very weak include all patients suffering from
physical disease, including epilepsy. It is rare to admit a man
or woman capable of doing any work, and many of those
admitted can only be treated in an infirmary ward.

The workhouses of London and their lunatic wards send
numbers of restless, broken-down senile cases, many epileptics,
general paralytic men and women who have not exhibited the
classical symptoms of the disease, and are therefore not readily
diagnosed by the workhouse medical officers, demented
drunkards in an exhausted state after years of drinking,
imbeciles and idiots of all kinds, cases of circular insanity and
recurrent mania, paralytic and other nervous cases, patients
with advanced bodily disease and some mental symptoms
superadded, crippled and deformed people with minds full of
suspicions, cranks and delusional cases, odd cases which cannot
be included, without an act of mental reservation, in any of the
tables prepared by the wisdom of this Association, and a small
proportion of possibly curable cases, among which may be
mentioned some alcoholic cases, some climacteric cases, and
some other cases of mania, melancholia, and stupor. The
London City and London County Asylums send some of their
dements and oddest patients, certifying them incurable, harm¬
less, and suitable for Leavesden.

Out of a population of 1780 patients, about 350 are suffer¬
ing from tuberculosis, whilst 400 more are in the infirmary
wards, making a total sick of about 750, whilst many more
aged and feeble are in the ordinary wards. There are nearly

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292 NIGHT NURSING, ETC., IN ASYLUMS, [April,

400 epileptic patients in the asylum, some of whom are
treated in the infirmary wards and some in the ordinary wards.

Such, then, is the character of the population which has to
be dealt with at Leavesden.

Turning now to the sleeping accommodation provided, the
following table supplies the information :

No. of ward.

Character of ward.

Single

rooms.

No. of
patients.

F. I.

Ordinary infirmary .

F. Ia.

Tubercular infirmary

F. lb.

ii ii

M. II.

Ordinary infirmary .

M. II a.

Tubercular infirmary

M. II b.

»» » •

F. III.

Admission ward

F. Ill a.

Ordinary infirmary .

F. Ill b.

» »

M. IV.

Admission ward

. 0

M. IV a.

Ordinary infirmary .

M. IV b.

»> »

. O

F. Va.

Dormitory

F. Vb.

» •

M. VI a.

» • •

M. VI b.

>» •

F. Vila.

>» • •

F. VII b.

»> • •

M. Villa.

>» •

M. VIII b.

F. IX a.

a •

F. IX b.

M. Xa.

it • •

M. X b.

F. XI a.

Tubercular dormitory

F. XI b.

a a •

M. XII a.

a a

M. XII b.

n a

F. XV a.

Dormitory

F. XV b.

a • •

1780

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1902.]

BY FRANK ASHBY ELKINS, M.D.

293

Besides the attendant or nurse in charge, there is at least
one other sleeping within call in a room off the ward or
dormitory.

It must be explained that until recently the population
numbered 2000, but on account of the high prevalence of
tuberculosis, and the necessity of giving a greater amount of air
space per head, especially to those affected with tubercular
disease, the Asylums Committee of the Metropolitan Board
reduced the accommodation provided to 1780 beds, the
advanced tubercular cases having 100 square feet of floor space
by day and by night, the incipient tubercular cases having 60
square feet of floor space by night and 30 square feet of floor
space by day, the ordinary infirm and sick cases having 850
cubic feet by day and night, and ordinary cases having 500
cubic feet by night and 300 cubic feet by day. The above
figures are not ideal by any means, but economic and tother
considerations had to be thought of in apportioning the amount
of air space to be given to each patient.

It may be said at once that dormitories and infirmary wards
to accommodate such large numbers are a mistake, because of
the difficulty of supervising and nursing each individual in them,
but experience teaches that an asylum containing only small
dormitories, small infirmary wards, and numerous single rooms,
is equally a mistake for rate-paid patients, because proper
* supervision and nursing, both by day and by night, can only be
obtained at great expense, by means of a very large staff.
These remarks, of course, do not apply to asylums for the
reception of private patients.

As to the number of patients that can be looked after at
night by one nurse, it is suggested that in a ward for acute,
feeble, and sick patients, the limit should be placed at twenty-
five, whilst in a dormitory for quiet patients, requiring raising
on account of their habits or attention during a fit, the number
might be about forty or fifty.

At Leavesden Asylum there are but thirty single rooms,
some of which are padded, and all of which open off the wards,
the doors being left open at night to facilitate inspection by
the night attendants. They may be regarded as privilege
rooms, because they are occupied by trusted patients, many of
whom help in the work of the ward. Some years ago these
rooms, in common with similar rooms in some other asylums.

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[April

were inhabited at night by restless, noisy, troublesome, dirty,
and destructive patients. Under such circumstances no real
efforts could be made to find out the causes of the restlessness,
sleeplessness, and noisiness ; and all these and other bad habits
became confirmed, instead of any attempts being made towards
amelioration or cure ; no efforts could be made to cure destruc¬
tive habits, and it came to be regarded as necessary for such
patients to tear up a certain amount of bed and body clothing
every night; no efforts could be put forth to cure wet and dirty
habits, and in the morning urine and faeces were smeared all
over the floor and bespattered the walls, whilst the odour of the
rooms occupied by such patients was inexpressibly nasty. No
efforts worth mentioning were made to nurse and care for the
single room patient during the night, and under such circum¬
stances it was little wonder that he generally became worse
mentally and bodily. The evil did not stop with the unfortu¬
nate victim, for often, by his shouts and by thumping at the
door and shutters of his room, he kept many of the patients in
the adjoining wards awake all night

Nocturnal seclusion may occasionally be a necessity, as day
seclusion sometimes is ; but it is urged that this method of
treatment, like mechanical restraint, should be used most
sparingly, and only on medical order. Nocturnal seclusion is,
of course, justifiable in the case of homicidal patients, and
perhaps in a few other rare instances, but even in these cases
most careful arrangements should be made for their comfort,
supervision, and nursing during the night. The more experi¬
ence one has of proper night nursing, the less necessity there is
found for nocturnal seclusion, and at Leavesden Asylum during
the last three years not a single patient has needed to be
secluded on the male side, whilst on the female side, during
the last two years, since the system described above has been
in operation, only one homicidal patient has been so secluded.
Experience, too, has taught that whilst among the newly
admitted there is little or no difficulty in nursing them in a
dormitory at night, yet among those long accustomed to be
secluded at night it takes a considerable time and much
patient nursing before confirmed habits of noisiness, dirtiness,
and destructiveness can be corrected, and such patients are
very apt to relapse from time to time into their former evil
ways.

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1902.]

BY FRANK ASHBY ELKINS, M.D.

29s

In general hospitals there are side rooms off the wards with
one, two, or three beds in each for cases of meningitis, apoplexy,
and the like, where extra nursing and attention are needed by
day and by night. This arrangement might very well be
copied in asylums, some side rooms being attached to the
infirmary wards. When, as would usually happen, the side
room was only used by ordinary patients, then the door would
be left open, and the nurse stationed in the ward would be able
to give the room a general supervision ; but when the room
was used for the purpose for which it was built, then a special
nurse would be placed in charge, and the door communicating
with the ward, if necessary, shut. This, it is suggested, is a
suitable arrangement in the case of specially suicidal patients,
restless, feeble, senile patients, troublesome general paralytics,
the dying, and other cases which readily occur to one's mind.

It is suggested that if modem asylums had followed the
type of Leavesden Asylum, reducing the size of the wards, and
adding side rooms to the infirmary wards, the Commissioners
in Lunacy would not have needed to comment upon the great
and hardly justifiable expense entailed in the erection and
administration of new asylums for rate-paid patients.

The night staff at Leavesden numbers thirty-five officials.
On the female side there is one head night nurse, who is the
supervising officer ; one charge night nurse, who usually acts as
an ordinary night nurse, but when the head night nurse is on
leave, takes over that official's duty; and seventeen ordinary
night nurses. On the male side, the staff includes one head
night attendant, one charge night attendant, and fourteen
ordinary night attendants. As there are thirty infirmary
wards and dormitories in the asylum, each under super¬
vision, it will be seen that one attendant and two nurses
act as reliefs. Occasionally, owing to sick or emergency
leave of the night staff, or owing to the necessity of closely
watching suicidal or other special cases, it is necessary
to draw upon the day staff for further help. Exclusive of the
supervising officers, the proportion of night staff to patients is
about one to fifty-four, and this, it will be seen, is not an ex¬
travagant proportion.

As to the books kept by the night staff, a description of
what is done on the male side will suffice, as on both sides
similar books are kept, except that on the male side the

XLVIII. 21

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296 NIGHT NURSING, ETC., IN ASYLUMS, [April,

records are printed on blue paper, whilst on the female side
white paper is used. The following are the printed headings
in each ordinary night attendant's book :

No. of patients sleeping in ward.

Date.

No. of ward.

Wet and dirty. —Here are given the names of those actually
wet and dirty during the night

List of soiled linen , etc. —Verified and signed in the morning
by the charge day attendant

Having fits. —Names ; numbers of fits.

Restless and noisy. —Names.

Sick and requiring special attention .—Names.

Sleeping in single rooms. —Names.

Temperature.

Having stimulants. —With amount given.

Temperature of ward. —Taken twice during the night.

Complaints as to heating of ward.

Other matters requiring special reports , such as deaths , acci¬
dents, officers ’ visits , wet mattresses , reports of special cases, etc.

In the morning the head night attendant examines each
night attendant's book, to see that it is properly kept, and then
initials it.

In order that there may be continuity of treatment, the
charge day attendant reads the night report every morning,
and when, in the evening, the charge day attendant hands over
his patients, together with the medicines and extras required
during the night, he fills up a simple book of four columns :

Requiring medicine and extras. —Names.

Newly admitted. —Names.

Requiring special attention. —Names.

Remarks.

Bearing in mind that the head night attendant is a super¬
vising officer, his night report is made as simple as possible, so
that his time may not be unnecessarily taken up by bookkeeping*
He reports only the important events to be found recorded,
and all unimportant details can be sought for, if required,
in the ordinary night attendant’s book. The head night
attendant's book, when open, presents two sides, one almost
blank, and giving him a very free discretion, headed Special
observations , and the other having the following headings :

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BY FRANK ASHBY ELKINS, M.D.

297

The time when each round of visits was started. —As a rule,
he pays five visits to the infirmary wards and four to the
ordinary wards during the night, in no particular order, and
the times of these visits are also recorded in the ordinary night
attendant’s book.

Temperatures of the wards.

No. of patients wet and dirty in each ward .

No. of wet and dirty articles in each ward.

No. of patients having fits.

Officers visiting the wards.

Patients taking medicine and stimulants.

He also has to answer in writing two questions every
morning :

Have the duties of the night attendants been satisfactorily
performed ?

Have any omissions in the checking occurred , and why ?

These books are very simple, answer their purpose well, and
are easily kept, although a description of them on paper
makes them seem somewhat complicated.

If we except a general but real supervision on the part of
the medical superintendent, the assistant medical officers, the
matron, and the other chief officers, upon whom does good
night nursing and supervision depend ? It mainly depends
on having a really trustworthy supervising officer, who can be
depended upon to report without fear and favour, who can be
relied upon to act wisely in emergency, and who has training
in mental and bodily sick nursing. Such an officer, occupying
a position of real trust and responsibility, should have generous
remuneration, an assured position, and comfortable quarters.
Dr. Robertson, of Stirling District Asylum, and Dr. Keay, of
Inverness District Asylum, advocate that the supervising
officer should be a hospital trained nurse. In the Asylum
News, a periodical so ably conducted by Dr. Shuttleworth, and
which, it is pleasant to note, is now accorded a welcome in
most asylums, appears an interesting paper on “ Asylum
Nursing,” read last year at the International Congress of
Nurses, held at Buffalo, U.S.A., and contributed by Mrs. P. C.
Chapman, formerly successively matron of Leavesden and of
Claybury Asylums. In this paper Mrs. Chapman argues, with
great force, that the hospital trained nurse cannot regard her¬
self as having had a complete training for her profession as a

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298 NIGHT NURSING, ETC, IN ASYLUMS, [April,

general nurse unless she has had some experience in mental
nursing, and equally it is insisted that the asylum nurse should
go through a course of training on the general lines of a hospital
nurse. These views are certainly correct, for when, in 1899,
an epidemic of enteric fever, enteritis, and pneumonia occurred
at Leavesden Asylum, and eighteen hospital trained nurses
were temporarily placed upon the staff, it was possible to
observe the effects of a lack of training in mental nursing.
The experience showed that the average hospital trained
nurse was not so expert in preventing bedsores in the insane
sick as the asylum trained nurse, and, as might be expected,
she was not so tactful and efficient in the management of the
insane sick. Failing to manage her patient properly, she was
very apt to fly to such extreme remedies as restraint and
seclusion, and would like to have tied the patient in bed when
he was restless, or put him into a single room if he were a
little noisy. There was also a tendency to run away if the
patient talked a little nonsense, and if, as unfortunately
sometimes happened, the patient was not very decent in his
manner or conversation, some hospital trained nurses were
apt to be thrown into a panic. These observations, however,
prove what might be expected : that the hospital trained nurse
must get proper training in mental nursing before she can be
considered thoroughly competent and reliable enough to nurse
the insane sick. It is suggested that the best head night
nurses and attendants are those who have had asylum expe¬
rience, and have been trained on hospital lines.

The efforts of the head night attendant should be seconded
by observant and trained night attendants, and in order to
keep such it is pleaded that their status and pay should be
that of charge attendants, instead of ranking them with
ordinary attendants, as is done at most asylums. It is better
to allow all the male night attendants to live outside the
asylum, giving an allowance in lieu of board, lodging, and
washing, as is done at Leavesden, where shortly there are to
be erected twenty-two cottages for the married attendants, a
class which ought to be encouraged to stay. It is unfair, too,
to expect the night nurses to sleep in the asylum within ear¬
shot of noise of all kinds, and it is pleasant to announce that
a nurses* home will shortly be erected at Leavesden for all
the night, and a portion of the female day staff.

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BY FRANK ASHBY ELKINS, M.D.

299

And now, in order to raise a point for discussion, a thorny
subject is touched upon : the nursing of sick and infirm male
patients by female nurses. The subject has been so fully
dealt with by others that no attempt will be made to advance
the arguments for and against the introduction of female
nurses into male sick and infirm wards, but it is prophesied
that before long, in most asylums, the male sick and infirm
patients will be nursed by female nurses. At Leavesden
Asylum the principle has already been in part adopted, for a
superintendent nurse, who holds both the nursing certificate of
this Association and a hospital certificate, is in charge of the
nursing of the six male infirmary wards during the daytime. For
various reasons nothing further has as yet been done. One
reason is, that as the Metropolitan Board are about to open a large
asylum at Tooting Bee especially for the reception of the sick
and infirm, it is suggested that this class of patient is likely to
largely decrease at Leavesden. In this belief all do not share,
and it is still to be feared that Tooting Bee Asylum will
quickly be filled with a helpless and hopeless population,
leaving Leavesden in much the same state as before, although
a temporary relief may be experienced. If, as is believed,
Tooting Bee Asylum is to be managed on hospital lines, there
may, and it is trusted will be, an example of what can be
done in this direction, and Leavesden, if these views be correct,
will, it is hoped, soon follow in the wake by having female
nurses in the male infirmary and sick wards. Every one agrees
that there are certain sick and infirm male cases which cannot
be nursed by women, but those who have really tried the
experiment soon find how very exceptional these cases are.
It is contended that the advantage of female nursing for the
large majority of male sick and infirm patients is conclusively
proved; and at Leavesden there would not be the least
hesitation in placing female nurses in charge, both by day and
by night, with a feeling of confidence that the very best was
being done for the patients concerned.

It may be remarked that a mixture of male and female
nurses in a ward is not advocated.

There does not seem to be any authentic record as to who
first suggested the use of the " tell-tale ” clock, but the circum¬
stances surrounding its introduction and early history may
easily be imagined. Given an untrustworthy person sent on

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[April,

duty where little or no supervision of him was possible, the
problem to be solved was: By what means could it be proved
that he really was or was not on duty during the hours and at
the times expected of him ? For answer came the introduction
of the “ tell-tale ” clock, at first, no doubt, a simple mechanism,
but gradually increasing in complexity as means were dis¬
covered to circumvent its records, until at last was evolved
that highly ingenious contrivance at present in use, whose
records, however, may still be rendered void by those who set
themselves to the task, because the human mind is more
subtle than any instrument.

In every asylum which boasts a past, many stories have
been handed down of the misdoings of the notoriously un¬
reliable night watch, the forerunner of the asylum night nurse.
The duty of the night watch was to stay as much as possible
near those patients most in need of watching, to visit the other
patients at intervals, not to absent himself from the sphere of
his labours, and under no circumstances to go to sleep. He
also did certain other duties, but mainly his function was to
watch, and not to nurse the patients committed to his care.
It may be imagined how the medical officers then in charge of
asylums welcomed a contrivance of the nature of a “ tell-tale ”
clock as some sort of check upon such an official ; but it is
difficult to understand why universally in English asylums,
where there are, or ought to be, competent night nurses and
attendants, and above all a trustworthy supervising officer,
such instruments should still be insisted upon as necessary.

Dr. Keay, in a recent paper, writes: “ It is hard to see what
information can be obtained from the record of a ‘ tell-tale ’
clock further than that an attendant was in a certain place in
the asylum at a certain hour, and that when there he devoted
a certain amount of attention to the clock. Without further
information showing what attention he gave to the patients, I
do not know that the knowledge regarding his movements is
of any particular value. He may cuff the ears of a restless
patient, but the * tell-tale * clock looking on is reticent on the
subject. ‘Tell-tale’ clocks are a bad substitute for effective
supervision of the night staff. Let us have this effective
supervision, and such contrivances will disappear as being out
of date, and no longer required.” At Leavesden, where the
“ tell-tale ” clocks were already placed, they are still in use, but

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BY FRANK ASHBY ELKINS, M.D.

301

as every ward door has glass panels, as the nurses and
attendants placed in charge of the wards are regarded as
trustworthy, and are kept occupied by their nursing duties,
and as, moreover, there are reliable supervising officers, it was
not thought necessary to make additions to the “tell-tale”
clocks when the night staff was recently increased.

It is not proposed in this paper to take up at any length
the treatment from the medical and nursing points of view of
those troublesome symptoms of mental disease, most noticeable
during the night, such as noisiness, restlessness, violence,
excitement, destructiveness, wet and dirty habits, and sleep¬
lessness. The subject is large enough for a separate paper,
and is ripe for full discussion in connection with the question
of night nursing and supervision of the insane. Each indi¬
vidual case of noisiness, restlessness, violence, excitement,
destructiveness, wet and dirty habits, and sleeplessness should
be considered individually and on its own merits. It may be
objected that it is a matter of only treating symptoms, but
nevertheless it is advisable to approach all such cases in the
same way as one approaches a case of pneumonia or a case of
tuberculosis of the lungs,—with the intention of using every
possible means for the amelioration or cure of the condition.
It goes without saying, that in all such cases a most careful
physical examination should be made, the treatment of the
bodily state being all-important No one, for instance, will
deny that loaded bowels and dyspepsia are accountable for
many of the bad symptoms mentioned above. A real interest
in the case and steady determined effort will work wonders.
Every aspect of the case should be studied, even the history of
the case before admission being found useful, for in at least
one case, that of a middle-aged man, who was constantly noisy
at night, it was found that he had been a night-worker and a
day-sleeper nearly all his life. A consideration, too, of the diet
is very important, for every medical officer of an asylum is
acquainted with the senile maniac who suffers from boulimia,
sleeps after all his meals, and keeps every one awake at night
in his ward unless he is brought under proper medical and
nursing treatment. The importance of recording early
symptoms, and thus having the chance of warding off attacks,
cannot “be too much insisted upon, and the night nurses should
be specially instructed to be on the watch for certain symptoms

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[April,

which vary in different patients. Every night nurse should be
taught all the known nursing artifices for inducing sleep,
because if a patient can be made to sleep a great many acute
symptoms are obviated. Wet and dirty habits, except in cases
of paralysis and other actual diseases, can nearly all be cured
if proper means be taken. A noisy patient moved from one
ward to another under the care of a different nurse often ceases
to be troublesome. A wet day, when patients cannot get out
of doors, results in a restless night for some, and no one denies
that exercise and fresh air are the best of soporific agents.
Since paths have been made round the asylum estate at
Leavesden the patients have been quieter at night. The
importance of tubercular patients living as much as possible in
the open air is now insisted upon by all medical men, and as
the tubercular insane include many patients suffering from
delusions of suspicion and unseen agency, and liable to excite¬
ment, the result of belief in these delusions, the necessity of
having shelters, as at Leavesden, in the gardens used by such
patients so that they may be out of doors almost regardless
of the weather, is self-evident. Such shelters, it is claimed,
amongst other good effects, diminish excitement and increase
the sleep of insane patients.

What, it may be asked, are the advantages which have
accrued at Leavesden by this larger amount of night nursing
and supervision ?

The dangers from such unlooked-for, but not altogether
rare occurrences as fires, unexpected fits, apoplexies, and other
sudden illnesses, suicides in patients not regarded as suicidal,
assaults, and even homicides are minimised. Compared with
their former state, the quietude of the wards and dormitories is
a constant marvel, even to those officers accustomed to visit
them. Of course there are noisy patients at times in the
dormitories and sick rooms or it would not be an asylum for
the insane, but the condition of affairs may be described as
similar to that of a sleepy village, whose quietude is occasion¬
ally disturbed by the brawls of a midnight reveller, whose
doings afford a topic of conversation for the next day. In the
same number of the Journal of Mental Science which contains
the paper by Dr. Middlemass and the writer upon “ Night
Nursing and Supervision in Asylums,” there is also a criticism,
and the opinion is expressed that “ the unreasoning mania of

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BY FRANK ASHBY ELKINS, M.D.

303

epilepsy, the monotonous verbigeration of the idiot, the long-
winded orations of the general paralytic, even the stertorous
breathing of the apoplectic, are surely out of place in dormi¬
tories where some poor soul may be struggling for sleep and
sanity.” At Leavesden the “ poor soul ” could retire to rest in
nearly every one of the thirty wards and dormitories almost
sure of not being disturbed during the night, and at Sunder¬
land Asylum the careful statistics of Dr. Middlemass prove the
comparative quietude of properly supervised wards. At
Leavesden there is a large number of epileptics, and it is
claimed that the night nursing, combined with medical treat¬
ment and proper day nursing, has reduced the number of cases
of unreasoning mania of epilepsy, whilst it is urged that if such
a case do occur, nocturnal seclusion is the worst treatment that
can be adopted. At Leavesden there are a considerable
number of idiots and imbeciles, and some of them are noisy at
night occasionally, but there has been no experience of idiots
who occupy their nights in monotonous verbigeration, and keep
their fellow-patients awake night after night, yet it is not
doubted that such cases can be produced by long-continued
neglect. During an experience extending over seven years at
Sunderland and Leavesden, it has never been necessary to
place a general paralytic in day or night seclusion, and it must
be remembered that at Sunderland general paralysis is so
common that for a time, at least, every fifth admission suffered
from the disease. A side room and a special nurse should
certainly be the prescription for the critic’s last example—the
apoplectic. Here, again, it is necessary to repeat what was
written in 1899 : “ We readily and without reserve grant that
the system is not a specific warranted to be applicable to and
to cure every case without exception ; but, on the other hand,
we would emphatically state that the cases to which it is not
applicable are altogether exceptional.”

Another good result has been that the wet and dirty patients
have been largely reformed, many becoming quite clean who
formerly wetted and dirtied their beds every night. This
aspect of the subject was so fully dealt with in the previous
paper that it is proposed to present only a table of results
obtained at Leavesden, which, bearing in mind the class housed,
is considered most satisfactory :

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304

NIGHT NURSING, ETC., IN ASYLUMS,

[April,

1900.

1901.

Males.

Females.

Males.

Females.

Average number of faulty patients per
night during the year ....

1849

I 3‘05

Average number of dirty articles per night
during the year.

6496

1x284

46* 16

Total number of soiled mattresses both
day and night during the year

When a mattress is found to be wetted or soiled, a special
inquiry is held as to the cause, and as to whether the nursing
is to blame. It may be interesting to record the results of
these inquiries during the year 1901. In sixteen cases the
waterproof sheets were waterproof only in name, for liquids
passed through them ; in seventeen cases the nurses forgot to
place the sheet under the patient; in seven cases patients
became dirty in habits who had hitherto been clean, and there
were no waterproof sheets on their beds ; in two cases in¬
experienced nurses were unable to manage patients, and wet
mattresses resulted ; in two cases the waterproof sheet became
disarranged ; in one case a patient, objecting to the waterproof
sheet on the bed, removed it without being seen, and afterwards
soiled her mattress ; in one case diarrhoea in a quiet patient
was the cause; and in the last case a patient deliberately
emptied his chamber utensil into his bed on recovering from a
fit.

With the exception of those of confirmed bad habits,
destructive patients no longer constantly tear up their bed and
body clothes at night, although a certain amount of destruction
still takes place.

Both at Sunderland and at Leavesden, besides the betterment
of the patients 1 state at night, it is maintained that the good
nights now generally enjoyed by the worst patients have
secured for them better general health, an amelioration of their
mental condition, and, what is very important for them and
others, quieter days. Patients who are subject to attacks of
sleeplessness can be specially watched and treated, and it is
not doubted that attacks of noisiness, excitement, and violence

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1902.]

BY FRANK ASHBY ELKINS, M.D.

305

can be warded off by the observation of early symptoms.
Sleeping draughts are rarely given, and then only for definite
medical reasons, and the Sunderland statistics show how very few
draughts are given or needed in properly supervised wards. It
is certainly bad practice to give sleeping draughts to patients
in single rooms, in order that others lying in adjoining wards
shall get sleep.

In conclusion it may be objected that what is possible with
the Leavesden patients is impossible with the patients at other
asylums, and one can only plead an opposite opinion as the
result of fourteen years’ experience among very different classes
of the insane in widely separated parts of the country.

The opinions now ventured are the outcome of experience,
not only at Leavesden, but at Greenock, Edinburgh, and
Sunderland.

Discussion

At the General Meeting at Cheadle, February 14th, 1902.

Dr. Middlemass said that the experiences he gave in the paper read about
three years ago, to which Dr. Elkins had referred, had been fully confirmed since
then. He had seen no reason to modify those statements, and the same system
was still in force in Sunderland. So far as he had been able to gather from the
criticism of his paper there was no question but that the treatment they advocated
with regard to wet, dirty, and destructive patients was a satisfactory one. The
only point upon which there was a great difference of opinion was with regard to
the dormitory treatment of noisy patients, and this, he fancied, would always be a
matter regarding which there would be opposing views. He thought that the
more they endeavoured to treat patients on the lines indicated the less noisiness
would occur. Of course they were quite ready to acknowledge there were ex¬
ceptional cases, where, in spite of the nursing and attendance at night, patients
were noisy; but he thought if they persevered with the treatment of such patients
in an open dormitory, they would in the end succeed in getting them to be as quiet
as their neighbours. He had said there were exceptional cases, and he had one or
two patients whom he had tried in an open dormitory, and he had found it
necessary occasionally to place them in a single room at night. Occasionally they
were better in a single room. After some time he tried them in a dormitory again,
and, as a rule, found they were quiet there. He thought they should persevere
with that plan, and should not be discouraged by exceptional cases. But if they
wanted their night nursing to be a success on the lines laid down they must pay a
good deal of attention to it. Something more was necessary than to simply give
instructions to the chief night attendants. Personally, he made a point of
constantly visiting the dormitories, of going through them three or four nights
every week, and seeing for himself how things were, noting all the cases that were
noisy, endeavouring to discover, if he could, the reason for this condition, and
trying, as far as possible, to combat it.

Dr. George Robertson sent the following contribution, which was read in his
absence:

It gives me great pleasure to accede to Dr. Elkins’ request to add to his paper a
short statement of my experience and of my opinions of the system of night
nursing of the insane which he advocates.

It is now some years since Dr. Elkins, then Medical Superintendent of the
Sunderland Asylum, opened my eyes to the gross abuses connected with the use
of single rooms at night, and to the success with which most of those patients

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306

NIGHT NURSING, ETC., IN ASYLUMS,

[April,

whom we had got into the habit of calling “ single room patients ” had been
treated by him in dormitories under supervision. That some of the most trouble¬
some and disgusting manifestations of insanity took place in single rooms at night
was, of course, obvious to me and every one else; but I had come to accept these
results as inevitable in the course of insanity in all large asylums. My conscience
was, however, touched by Dr. Elkins’ statements and results, and I decided at once
to devote my attention to the habits of those “single room cases.” The most
obvious change in methods that the new treatment involved was the placing of the
patients in associated dormitories instead of in single rooms, and so the old and
new methods of treatment were familiarly described as the “ single room system ”
and the “dormitory system.” These names led on the part of opponents to a
magnification of the virtues—some real—of seclusion in single rooms, and to a
misunderstanding of the true principles of the new treatment. Dormitory treat¬
ment is not the essential part of the new system, but increased supervision and
attention to the insane at night. As a matter of course, complete supervision and
attention cannot be given if those patients most needing it are separately locked
up in single rooms, and so in our pauper asylums, as in our general hospitals, to
have good supervision along with economy it becomes necessary to collect
patients, classified with care, in dormitories. Could a nurse or attendant be
supplied to every patient, and more than one where it was necessary, then the
patients might be left in their single rooms. This, however, is an unattainable
ideal. It appears absolutely ridiculous and indefensible from a medical point of
view that patients should be carefully supervised by day, checked in all insane
tendencies, and encouraged in habits of cleanliness, good order, and decency, and
when night comes that these patients should be shut up alone in dark cells, and
for want of constant supervision to allow all the good of the day to be undone at
night. To make the supervision by night equal to that by day, which, of course,
is the true medical ideal of night nursing, it is necessary to increase greatly the
numbers of the night staff. As by far the most of the patients sleep, and no
domestic work is done, it has been found in the Stirling District Asylum that a
night staff one third that of the day staff is sufficient to carry out the principle
mentioned. There are twenty night nurses and attendants on the night staff of
the asylum, which contains nearly 700 patients, and there is a night superintendent,
a trained hospital nurse, who inspects the whole asylum and sees that the night
staff is doing its work. Every patient showing active manifestations of insanity is
under immediate and constant supervision of a nurse or attendant in a dormitory,
and as a definite proof of this statement I record the fact that not one patient has
been locked up in a single room at night for six months, and with a few
unimportant exceptions not for eighteen months. The single rooms are all
occupied by privileged sensible patients, and are being furnished as private bed¬
rooms. In my asylum, therefore, the old single room system for the old class of
single room patients has been absolutely abolished. I find a few single rooms
still occasionally useful for exceptional cases, especially of noise, under special
nurses, but if they were all abolished I would not be seriously hampered.

Those who have not tried this system may imagine that the single room patients
now under supervision in dormitories would create a pandemonium, but after a
fortnight or a month the old chronics—who prove far more intractable than recent
cases—get broken in, and finally settle down and become quieter and more orderly.
The system is a perfect and demonstrable success, and those who have not tried it
themselves, but who yet, by arguments deduced from past experience, can prove to
their own satisfaction that it must be a failure, I ask to suspend their final judg¬
ment until they see the system in practice. Three years ago Drs. Elkins and
Middlemass read a paper in London on this subject recording golden truths, but with
one exception none of those who spoke recognised the epoch-making change that
they (Drs. Elkins and Middlemass) had initiated, namely, the abolition of the
abuses of single rooms, the greatest reform that has taken place since the day of
Connolly. The seed they sowed has, however, borne fruit, and this was demon¬
strated in a notable manner at the last meeting of the Scottish Division of the
Association, which was held at the Stirling District Asylum. The subject formed
an important part of the paper read there, and at this representative gathering,
which was the largest one ever held in Scotland, not one member spoke in
opposition to the new system of night supervision in dormitories, while those who

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BY FRANK ASHBY ELKINS, M.D.

3°7

1902.]

had adopted it spoke strongly in its favour. Dr. Keay, of Inverness, stated he
understood that the system was now so universally accepted in Scotland that he
did not consider there was any need to bring it forward for discussion; Dr. Marr,
of Lenzie, stated that he had found that the dormitory for noisy patients, though
it gave much trouble when first established, was now almost as quiet as any other
dormitory; and Dr. Clouston stated that he had spent a part or the night going
round the Stirling District Asylum, and recorded the fact with great pleasure that
“ he Weis impressed deeply with the quietude and with the success of the system
which he saw in operation. Not only that, but they had transferred a number of
their patients from Momingside, and Dr. Robertson had had the bad luck to get
two or three of the most evil characters from Momingside. He was beyond
measure astonished and exceedingly pleased to find a woman who was in
Momingside a homicidal dangerous inmate, and a most objectionable woman, who
was never out of a single room, lying calmly and sweetly asleep in one of those big
dormitories.”

The system, in Scotland at all events, is no longer either in the experimental
stage or on trial, but is established in many asylums, and is apparently accepted
in principle by all. In Paris it has been practised by Dr. Magnan for many years.
The system is most earnestly recommended to those who have not yet adopted it,
and the writer again records his opinion that the removal of the abuses connected
with the single room system is the greatest advance that has taken place in the
care of the insane since the day of Connolly.

Mr. Rhodes said that if the paper proved one thing more than another it proved
the doctrine he had preached, that the workhouse was not the place for imbeciles,
and that they should be treated separately, as he was glad to say the Manchester
and Chorlton Asylum Board were going to treat them. As to the treatment of
epileptics, he thought that the time was coming when they should follow the
example of the United States. He approved of employing female nurses on the
male side, and he considered that asylum nurses should be better paid. He thought
that there should be a definite system for training attendants and a recognised
standard of efficiency; also that a register of attendants should be kept.

Dr. Hayes Newington pointed out that they had a standard qualification and
a register of their own of those who had passed it, and one of the duties of the
Council was to sit in judgment on holders thereof if occasion arose. He thought
that it was impossible to have anything like a reliable general register of attend¬
ants, and an imperfect register was an extremely dangerous thing.

Dr. Yellowlees said he was very glad that Dr. Elkins began his paper by
saying that he disclaimed anything like a new discovery, because he was somewhat
at a loss to know why it had been so much talked about and so prominently
brought before them. He did not know where those fearful places were that had
been described. He could not understand it, and when he looked back at the
night work in his own asylum he found he had exactly the proportion of night
nurses which had been advocated. It seemed somewhat extraordinary that they
should have been told of these things as if they had been utterly forgetful, and had
not had sense enough to see them. He had no respect for a superintendent who
did not see when a patient was better separate, and he thought it was too late in
the day for them to discuss and promulgate this question as if they had not
hitherto appreciated it. He was glad that Dr. Elkins had made the disclaimer,
but he thought the rest of his paper did not seem quite consistent with the
exordium. Surely the whole thing might be summed up in an intelligent
appreciation of their patients’ needs and an earnest desire to meet those needs in
the best way they could. No two superintendents would meet them in the same
way. For example, in going over this admirable asylum they had seen that nurses
were sleeping in the dormitories. He was afraid that would now be utterly con¬
demned. He knew that Dr. Robertson was the apostle of night nursing with female
nurses everywhere, and he knew that the hospital trained nurse was declared by some
to be the salvation of the insane. He did not agree with that altogether. He thought
a good asylum nurse was a better nurse than a trained hospital nurse, had far higher
work to do, and could do it better, and those of them who had seen insane patients
under the care of ordinary nurses knew that there was no more helpless being than
that precious hospital nurse. She was a being whose highest function was to
observe closely and to obey; if she watched her patient’s symptoms and obeyed the

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[April,

308 ETIOLOGY OF TABES DORSALIS,

physician’s orders kindly she did her duty. An asylum nurse must use her own
judgment and act upon her discretion ; everything she did concerned her patient’s
welfare. She had a far higher function and more difficult work to do than the
hospital trained nurse ; but on the other hand he admitted that the hospital training
was a great addition, though he contended that in the asylum infirmaries nurses
might be admirably trained. The great principle of Dr. Elkins’ paper was that they
were to be wise, considerate, and kind in their care of patients during the night as
well as during the day. It was a great relief to him to find that through all the
years he was a superintendent he had been doing what had recently been pro¬
claimed as if it were a new discovery.

Dr. Mould said he should like to say a word with reference to nurses sleeping
in dormitories. It was not done in large dormitories, but only where there were
not more than four patients, who were carefully selected, and whose cases were
simply of a nervous character. The nurses were an immense relief to the nervous
patients with whom they slept. If they did not have those nurses in those small
dormitories, then the night nurses must go in, and that was very disturbing to
those unfortunate patients who could not sleep. He thought it was a most
excellent plan to select nurses to sleep with those simply nervous patients. For
more than thirty-five years it had been their custom to have all wet and dirty
cases in dormitories.

Dr. Stanley Gill concurred in Dr. Mould’s views as to the desirability of
nurses sleeping with patients in dormitories.

The Bearing of Recent Research in the Posterior Root
Ganglia upon the New Theories concerning the
^Etiology of Tabes dorsalis . By R. G. Rows, M.D.,

Pathologist to the County Asylum, Whittingham^ 1 )

Dr. ORR has shown you the normal cells of the posterior
root ganglia and the changes which they undergo in general
paralysis of the insane, and we have thought that it would be
of some interest briefly to follow the subject a little further,
and to see what is the modern view of the degenerative changes
in the cells of the posterior root ganglia and in the nerve-
fibres of the spinal cord in general paralysis and in tabes
dorsalis.

Until the last few years it was held that the initial lesion,
which led to the degenerative changes in the fibres of the
posterior columns of the cord, was to be found in the cells of
the posterior root ganglia, and marked changes, such as
destruction of the Nissl bodies, displacement of the nucleus,
and shrinkage of the cell-body, were described. Sir William
Gowers, in his article on tabes in his Diseases of the Nervous
System , said the ganglia were generally normal, and he
suggested that the degenerative changes in the nervous

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BY R. G. ROWS, M.D.

1902.]

309

system probably depended on some chemical substance, the
product of the syphilitic organism.

In 1898 Juliusberger and Meyer published a paper in which
they said they found no lesion in the cells of the posterior root
ganglia in tabes. In August of last year Marinesco published
an article in La Presse midicalc on the lesions in the cells
of the posterior root ganglia in tabes.

He first described the types of cells met with in the normal
ganglia, and then went on to mention the changes seen in
these cells in tabes, such as destruction of the Nissl bodies,
changes in the nucleus, such as diminished volume and diffuse
staining, and changes in the volume of the cell-body. These
last, however, he mentioned as being more usually a sign of
imperfect fixation than a sign of any pathological condition.

Dr. Orr also has referred to the great importance of em¬
ploying suitable fixatives in order to avoid this shrinkage.
You will see that these changes described by Marinesco in the
ganglion cells in tabes are very similar to those which we have
found in these cells in general paralysis ; but it is interesting,
from the point of view of their importance as the primary
cause of the nerve lesions in the cord, to note that he
(Marinesco) says that a breaking down of the Nissl bodies and
the above-mentioned lesions of the nucleus are very common in
morbid conditions of the spinal ganglia, and also that he found
nothing which could be considered as peculiar to tabes. He
then went on to discuss the question of the relation between
the changes found in these cells and the degeneration of the
fibres of the posterior columns of the spinal cord, and he said
that, considering the inconstancy of these changes and the
differences which exist between the intensity of the degenera¬
tion of the fibres in the cord and the relatively slight lesions
found in the cells of the posterior root ganglia, it can be
definitely affirmed that the degeneration of the fibres of the
posterior columns of the cord is not dependent on an initial
lesion of these cells.

Nor are the changes in these cells secondary to a lesion of
their central processes, because it has been shown experi¬
mentally by Lugaro and others that section of the central
process of these cells, that is of the posterior root fibres, does
not cause a degenerative change in them.

Both these degenerative changes must be considered as

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3io

AETIOLOGY OF TABES DORSALIS,

[April,

results of the same cause, viz . the presence of toxic agents in
the blood, which interfere with the nutrition of the cells and of
the fibres, and produce the degenerative changes familiar to
you all.

Recent research, then, shows that the hypothesis which
places the primary lesion in the cells of the posterior root
ganglia, and considers the nerve-fibre degeneration as secondary
to this, must be laid aside.

Sciuti, of Naples, however, has enunciated another hypo¬
thesis in an article on the pathological anatomy of tabes,
which was published in the end of last year.

He agreed with the view just mentioned that the changes in
the cells of the posterior root ganglia are too slight and too
inconstant to be the cause of the nerve-fibre degeneration in
the cord. He also gave an analysis of the fibre degenerations
which have been met with in the cord in cases of tabes, which
showed that other tracts of fibres besides the posterior columns
have often been found diseased. This analysis proved that
there were cases of simple tabes in which the posterior columns
were alone affected, but in “ combined tabes,” where some
other degeneration besides that of the posterior columns
existed, every other tract of fibres in the cord had been
associated with the posterior columns ; it may have been the
lateral columns in one case, the antero-lateral tract in another
case, and so on. He also mentioned one case in which the
tract of fibres called Burdach’s column was healthy in the
lumbar region, yet the continuation of these same fibres in the
cervical region, where they form the column of Goll, was
extensively diseased, thus showing that the same bundle of
fibres may be healthy in one region of the cord and diseased
in another. Moreover, in the affected tracts it is very common
to find many healthy fibres scattered through them, although,
of course, in prolonged chronic cases the sclerosis may be
complete.

The fibres of the posterior and anterior roots have shown
the same capricious behaviour, being healthy in some cases
and much diseased in others.

These are some of the facts on which he has founded the
following hypothesis : that “ the degeneration of tabes con¬
sists of changes in fibres which have started with some defect,
and which degenerate under the influence of some stimulus ;

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1902.]

BY R. G. ROWS, M.D.

311

and the lesions which are found on examination will depend
on the situation of the fibres which have been injured by this
congenital or acquired lesion, which fibres will, in later life,
degenerate if they are attacked by some poison such as
syphilis, alcohol, pellagra, etc.

On the other hand, there is the hypothesis that these fibre
degenerations are secondary to a morbid change in the vessel
walls. This hypothesis has been advocated by Dr. Chalmers
Watson, in a paper published in the British Medical Journal
of June last. In this paper he expressed the opinion that in
tabes and other allied diseases of the nervous system the
lesion in the vessel wall was primary, and the fibre degene¬
ration secondary to it.

Dr. Buzzard has published some cases in which he con¬
sidered the vascular lesion was primary, but he does not say
that it is so in all.

Sciuti, in his case, described marked changes in the walls of
the vessels, but he did not attach so much importance to them
as to say they were the cause of the fibre degeneration.

Seeing that # both the fibre degeneration and the vascular
change are due to the same toxic agent, it must be extremely
difficult to decide whether the fibre or the vessel wall is first
attacked, or whether both are attacked simultaneously.

In any case there can be no doubt that the morbid changes
in the vessels must play an important rdle in the advancement
of the disease, if not in its causation.

In general paralysis we find the same fibre degenerations
and vascular changes, and, in this disease, Dr. Ford Robertson
•considers that the vascular changes are primary, and that the
degeneration of the capillary walls is the primary cause of the
nerve-lesions seen in the cerebral cortex.

There are other conditions however, viz. the acute insanities,
in which the nerve-lesion is almost certainly primary. We
may say, then, that these are the two views about which, at the
present time, opinion is divided ; but whatever the seat of the
primary lesion may be, we must, in any attempt to explain the
•degenerations met with, also take into account what Sciuti has
spoken of as “ defect of the nerve-fibre/* and what Dr. Ford
Robertson has termed “ reactivity of the tissues.”

XLVIII.

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312

A FLAW IN THE ENGLISH LUNACY LAW. [April,

References,

Gowers. —Diseases of the Nervous System, vol. ii.

Juliusberger and Meyer. —Neurolog. Centralbl., 1898, Nr. 4.

Marinesco. —La Presse m^dicale, August, 1901.

Sciuti. —Annali di Nevrologia, Anno xix, fasc. 6.

Ford Robertson. —Pathology of Mental Diseases.

Brit. Med. Joum., October, 1901.

Chalmers Watson. —Brit. Med. Journ., June, 1901.

f 1 ) This paper was read at a general meeting of the Medico-Psychological
Association at Cheadle on February 14th, 1902, and was preceded by a lantern
demonstration, given by Dr. David Orr, of the normal histological appearances of
the nerve-cells in the posterior root ganglia of the dog and of the human subject,
and the degenerative phases of the latter in general paralysis of the insane.

A Flaw in the English Lunacy Law. By Ernest W.

White, M.B.Lond., M.R.C.P., Resident Physician and

Superintendent, City of London Asylum.

The following case shows the necessity for reform in the
legal procedure connected with the admission of private
patients :—E. E. S—, a lady patient, was admitted on October
26th last, upon the order of a justice of the peace who had
not seen her, and upon the medical certificate of her regular
medical attendant, and the second certificate of a neighbouring
practitioner. Within the statutory period after admission she
signed a request to be seen and examined by a judicial
authority, under 53 and 54 Viet., cap. 5, sec. 8 (2). On Novem¬
ber 2nd I made a return to the Commissioners in Lunacy
stating—“ She was insane, suffering from melancholia ; had a
dejected appearance and nervous manner, with delusions of
unworthiness ; said 1 God would never forgive her her sins *;
was agitated, restless, and dissatisfied, 1 ” etc. On November 5th
she was seen and examined by a local county justice of the
peace, who, in the face of these three certificates, and a note
in the case book by Dr. Patterson, reported that he did not
consider the patient insane. In consequence of this report she
was removed by her brother on November 26th, the Com¬
missioners in Lunacy, who apparently, under 53 and 54 Viet.,
cap. 5. sec. 8 (3), had no option in the matter, having requested
him to take this step. I may add we considered her probably
suicidal, and when she left I wrote her ordinary medical

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1902.] MENTAL CONDITIONS RESULTING IN HOMICIDE. 3 I 3

attendant advising him to watch her, and have her placed
under fresh certificates, but she declined to see him again. On
the night of December 9th (that is, less than fourteen days
after leaving the asylum) E. E. S— committed suicide on the
permanent way of the Great Northern Railway in North
London. Thus a report by a young and inexperienced justice
of the peace outweighs the opinions of two experts, the family
medical attendant, who had watched the case for months, and
a fourth medical man, who signed the second certificate on
admission. Surely this life was sacrificed through a defect in
lunacy law!

Mental Conditions resulting in Homicide . By G. T.
REVINGTON, M.D., Resident Physician and Governor,
Central Asylum, Dundrum^ * 1 )

It is with great diffidence that I venture to address you
to-day. I have not made any scientific discovery, and in my
own opinion it is great presumption to open a discussion on a
subject of which I am merely a student, and on which my
studies have not yet enabled me to form definite theories.

I had not much difficulty in making choice of a subject.
You will all agree with me that mental conditions resulting in
homicidal acts are very interesting.

In nine and a quarter years I have admitted forty-nine men
charged with murder or manslaughter. I am not dealing with
female murderers, as these cases are mostly cases of infanticide,
and are of a totally different nature. I have included one case
of attempted homicide, not in order to make a half-century of
cases, but because the case is one of extreme interest, and
throws a bright light on homicidal conditions.

The difficulties of investigating these homicidal conditions
are very great Generally the witness who knows the mur¬
derer best is his victim, and thus the most important evidence
is lost.

I do not propose to trouble you with statistics, but I may
point out, parenthetically, that wives are the commonest victims,
then children, then parents and sisters, but (and I am afraid

will be a great shock to you) I have as yet met no person

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314 MENTAL CONDITIONS RESULTING IN HOMICIDE, [April,

homicidal enough to kill his mother-in-law. Possibly such
cases are considered by indulgent juries as justifiable homicide,
and do not come under my care.

Another great difficulty is the shipwreck of the home that a
homicide causes. The children are scattered far and wide, my
letters of inquiry are unanswered, the patients are not visited,
and in many cases I neither hear nor see a single soul who
knows anything of the case.

But the greatest disadvantage of all is that I do not get
these cases under my care until months after the crime. The
homicidal fire has died out, and I have to study what I may
call a mental cinder.

There is worse to follow. These homicidal cases do not
benefit in prison. For one thing, they are supervised in a pain¬
fully ostentatious manner, as they are dreaded, and they are
doctored by the habitual criminal. There is not, I imagine,
much joy among convicts over one sinner that repenteth, but
there is considerable joy over one sinner that escapes the fatal
noose.

Every convict takes the homicide in hand, and each has a
specific receipt for cheating the hangman.

I need not detain you further, gentlemen, on these points ;
I am sure you will agree that these cases should be placed
under expert supervision while awaiting trial. You will agree,
also, that the absence of the essential witnesses, the absence of
visits from relatives, and the length of time that elapses between
the crime and curative treatment are formidable obstacles to
scientific study.

I take the case of attempted homicide first, as it is thoroughly
worked out, owing to the wonderful escape of the intended
victim. M. M—, aet 38, married, two children, profusely
alcoholic, thoroughly syphilised, feels himself growing prema¬
turely old, while his wife remains sprightly and attractive,
becomes suspicious of her, watches for indications that she is
tired of him and wants a change, as he says.

Next follow hallucinations of smell and taste; the patient
searches the room for causes, finds vapours rising from the
floor, thinks the flower-pots are watered with noxious
chemicals.

I need not describe further. You all know the class of case,
and I am sure you feel that you did not come to Cork to listen

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1902.] *

BY G. T. REVINGTON, M.D.

3 1 5

to what you hear every day in your own wards. In fact,
our worthy President might very well say, having regard to
the fine asylum that he superintends, that bringing poisoning
cases to Cork is like bringing coals to Newcastle.

Now if our patient's wife had placed her husband under Dr.
Conolly Norman's care, nothing would have been heard of
homicide, nor, I venture to say, would M. M— have been re¬
garded as suffering from homicidal mania.

But the foolish wife becomes alarmed and goes secretly to
an even more foolish member of our profession, and together
they concoct a plan of campaign that is painfully comic, and
leads to tragic results. The great idea is to treat M. M— with¬
out his knowing anything.

The results are serious. Even the secret visits to the doctor
become matters of gossip, and lose nothing in the telling.
M. M— is more than ever confirmed in his suspicions. He also
tastes the medicine in his food, and his delusions of poisoning
become certainties.

Can folly further go ? It can indeed. Coming home to his
supper M. M— finds two teapots on the hob, one for him and
one for his wife and children. He is not allowed to touch the
latter; Even a sane man might begin to doubt such a wife.
He openly challenges his wife and accuses her of being a
wanton, and wishing to get rid of him. She is terrified and
refuses to sleep in the same room. Many a woman has thus
driven the last nail into her coffin.

But the edifice of M. M—'s madness wants a final touch, and
gets it. The wife invites a male friend to sleep in the house
to protect her and the children. Even the soundest intellect
might now stagger before such an array of damning evidence,
and what chance has the alcoholised and syphilised brain of
poor M. M—?

On the night of the attempted murder the watchful husband,
supposed to be in bed, sees the male protector flit quietly from
his wife's room. You will all remember that wonderful scene
in Hamlet:

" Now might I do it pat—

And now I'll do it

When he is drunk, asleep, or in his rage,

Or in the incestuous pleasure of his bed ;

Then trip him that his heels may kick at heaven,

And that his soul may be as damned and black
As hell, whereto it goes.”

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316 mental conditions resulting in homicide, [April,

Such were the thoughts of poor M. M—, though expressed in
plainer but no less forcible language. Biding his time, he
creeps to his wife’s room with a hatchet.

The final result is that the wife recovers in a marvellous
manner after every surgeon had given her up, the hatchet was
buried in her brain, and M. M— spends the rest of his exist¬
ence in that most unpleasant pleasure—the pleasure of His
Majesty.

I have put this case so much from the patient’s point of
view that I must say that M. M— had really no cause for
jealousy, and that his wife was a good though a misguided
woman.

Now, gentlemen, have you not in your asylums many such
cases? Do you regard them as suffering from homicidal
mania ? I am sure you do not.

I do not know whether your experience will agree with
mine when I say that I have met many non-criminal delusional
cases whose great regret was that they had not killed some one
or other! I have heard them grind their teeth with fury when
they thought of the opportunities they had lost!

Have you not many patients in whom the idea of revenge is
predominant ? Have you not many cases whose first action
at liberty would be homicidal ?

I have come to the deliberate conclusion that homicide is a
potentiality in almost all cases of delusion and hallucination,
and that whether the homicide occurs or does not occur is not
so much a matter of a peculiar mental condition as a matter
of environment, a matter of the length of time that elapses
before safety is sought within the walls of the asylum.

I do not pretend to have investigated all my cases as closely
as that of M. M—. I have done so as far as possible, but owing
to the reasons already mentioned I cannot give you definite
figures. I cannot say how many of my forty-nine cases come
under the category, but I am convinced that if the loving
wives, doting parents, and devoted sisters, victims of my
homicidal patients, could speak they would tell us that they
should have sent their murderer to an asylum months or even
years before the crime was committed.

One fact that stands out before all others is the length of
time that my homicidal patients were insane before they
committed themselves. It is generally a question of years.

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1902.] BY G. T. REVINGTON, M.D. 317

A considerable number have wandered from county to county,
seeking refuge from persecution, wandered even from country
to country,—a large number as far as America. Again I cannot
give you definite figures owing to my information being so
defective, and chiefly being founded on the statements of
patients uncorroborated by other evidence.

Now if these cases had been originally or essentially homi¬
cidal the end would have come far sooner. It is absurd to call
a case homicidal who, after five years* insanity, commits a
murder. A large proportion of asylum inmates might commit
murder if allowed to remain at large.

Proceeding to analyse my cases, I find one homicide due to
epileptic frenzy, one to a similar condition occurring in general
paralysis. These, of course, you will understand.

Five murders were committed by men suffering from
congenital mental defect.

I have compared secondary dementia to a fire that has
almost gone out, and congenital defect to a fire that has
never been properly lit To continue the simile, the act of
murder in an imbecile is as if a parcel of gunpowder had got
into the smouldering fire. An explosion results, but the fire
does not light up. My congenital imbeciles may live to be as
old as Methuselah, but I venture to say that they will never
become homicidal.

In two cases the homicide was, so to speak, accidental.
Both men wished to give a certain person a good drubbing,
and went too far.

In another case a man attempted to rape an old woman of
seventy, and incidentally, so to speak, killed her.

In one case a man, who had spent years in America
amassing £200, committed murder to prevent himself being
robbed.

In two cases patients heard a voice from God, saying, "To
save yourself you must kill So-and-so.”

In one, a thoughtful, very intelligent, and religious man, in
dire distress, out of work and unable to get any, taunted to
frenzy by the upbraidings of his wife’s relations, deliberately
killed his wife and two children. He was a man of very high
character and sound morality, so much so that medical visitors
refused to believe that such a man could have committed such
a horrible crime. Yet this man often told me that it seemed

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3 1 8 MENTAL CONDITIONS RESULTING IN HOMICIDE, [April,

clear to him at the time that it was his duty to kill his entire
family and then himself. He said that he could not explain
how he could have taken such a point of view, but he always
ended, “It was as clear to me as if it was written in the Bible.”
It is very hard for us, living in times of peace, to understand
such a state of mind, but the men of Lucknow kept a last
bullet for their wives, and the men at the Pekin Embassy were
prepared to kill their womenfolk to prevent them falling into
the hands of the Chinese.

My patient arrived at the same mental condition, but with¬
out the same dreadful reasons.

In two cases, at least, the murder was due to an illusion as
distinguished from a true hallucination. In the first case, a
man, whose delusions and hallucinations should have and did
prompt him to kill his wife, sprang out of bed and killed his
child, thinking it was a wild beast about to attack him. In
the other case, a man whose father and family, including him¬
self, had been visited and severely beaten by moonlighters,
showed symptoms of insanity ever afterwards, and finally killed
his father, mother, and two brothers ; the house was described
as shambles. When he was arrested he stated that he had
killed some men who were attacking him.

Twelve cases I am unable to classify owing to want of
information and the utterly demented condition of the patients
when coming under my care.

The larger proportion of my fifty cases are now disposed of;
the exact number I cannot give you, as so many cases must be
reckoned as doubtful.

Before coming to consider the cases that might be regarded
as homicidal, I may give you the following statistics, asking you
to remember that I am giving you figures that represent cases
definitely ascertained, and that I am convinced that such
figures are in every case far below the true figures owing to
want of information :

In ten cases a very definite history of insanity was obtained,
this is equal to 20 per cent., and with fuller information the per¬
centage might, perhaps, be doubled.

Ten of the fifty cases were actually under the influence of
acute hallucinations at the time of the crime, ten of the cases
were in a state of acute frenzy, the raving madness of the older
authors. Five cases had been previously confined in other

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1902.] BY G. T. REVINGTON, M.D. 319

asylums, and twelve cases were under the influence of alcohol at
the moment of crime.

I have no doubt that all these figures are far below the truth,
could it be ascertained.

I have detained you so long, gentlemen, that I fear I must
leave the full discussion of these possible homicidal cases to
a future occasion.

You will, of course, understand that the above figures over¬
lap, and that many presented a history of insanity or drink, a
personal history of drink, and were also in an acute frenzy and
under the influence of hallucinations.

In one case I can point to a clear case of homicidal impulse.
The patient was drinking and suffering from hallucinations. He
graphically describes how he lay in his garden, hid amid the
cabbages, listening to voices telling him that his nephew was
plotting against him, intending to kill the entire family and
get the farm. One day the nephew came to borrow some agri¬
cultural implement, which was stored in a loft. The patient
procured a ladder, and held it steady, standing at the foot, with,
unfortunately, a scythe in his hand. As the nephew descended
the ladder an overwhelming impulse seized the patient, and he
made a stroke with the scythe, almost decapitating his nephew
and killing him on the spot,

I questioned the patient most carefully and many times as to
the nature of the impulse. There was no definite idea of
killing his nephew, no thought of preventing him from killing
the family, it was an impulse to strike a blow, a wild whirling
impulse to strike, regardless of consequences.

I have under my care at the present time three cases subject
to similar impulses. These impulses occur at irregular intervals
and result in assaults.

Previous to admission one of these men assaulted a police¬
man he had never seen before, attacking him with a scythe, and
wounding him severely. Another killed a fellow-patient in a
district asylum without any provocation, and the third was an
ordinary case committed for larceny, who did not develop im¬
pulses for some years.

Now these are four cases of pure impulse, but after careful
study of the conditions I am forced to the conclusion that there is,
strictly speaking, no evidence that the impulse is homicidal.
There is no attempt to get hold of some implement, the blow

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320 MENTAL CONDITIONS RESULTING IN HOMICIDE, [April,

is not aimed at a vital part, it is a blow of the fist, or even of
the open hand. I have spent many hours trying to elicit the
exact idea that was in the patient’s mind when he struck the
blow. In one case this is easy, the patient becomes quite calm
in a few hours. When asked why he struck his victim, he says,

“ I don’t know, I had no reason, I know I was wrong, but I
could not help it.” I have taken great trouble to find out
whether there was the vaguest wish to hurt any one or any
definite sensation of satisfaction at having struck the blow.
The answer is always in the negative. The other two cases are
much more difficult. After each assault they are, of course,
placed in seclusion and visited by the medical officer on duty.
They are always sulky and sullen, decline to answer questions,
refuse to meet one’s eye, and hide their heads under the bed¬
clothes. Their faces are flushed, the brain is evidently working
at high pressure, and their self-control is on the point of
breaking. One is reminded of a horse that is about to bolt,
and is hard held. These two patients always utter short,
abusive, and threatening sentences, and express a great desire
to be alone, and, undoubtedly, if I did not prudently clear out,
there would, be a sudden mad rush, and some one might get
hurt. I have frequently delayed longer than usual, and asked
further questions with the view of studying the mental state.
The result is that the patient’s excitement increases rapidly, the
limbs quiver, the body bends like a wild beast’s for the final
spring. Well, then, gentlemen, it is time to go. As the door
is shut I often say, “There is an exact picture of the mental con¬
dition that results in homicide.” This interesting condition lasts
for weeks and even months,—in one instance for five months,—
and during this period I could, at any time, have created a
homicidal mental condition.

But this is a sort of mental vivisection which I am sure you
will agree with me should not be practised, even in the interests
of science.

Even for the sake of making my paper less uninteresting I
dare not try experiments by giving these patients opportunities
of using implements or weapons,—I might not be here to-day if
I did. But can any one doubt that these patients would use
any weapon that happened to be in their hands? and then the
verdict would be homicidal mania.

After all, mental degenerations may be regarded as rever-

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BY G. T. REVINGTON, M.D.

1902.]

321

sions to the type of our savage ancestors. The carnivora are
not mammacidal, they kill to eat.

The impulse to strike that these four cases feel may, perhaps,
be best compared to the wild rush of nerve-force which hurls
the tiger on the bullock's neck.

And now, gentlemen, I will conclude by briefly referring to
the remaining classes of mental condition, the eight cases
of acute frenzy, the twelve cases of alcoholic influence, the ten
cases of acute hallucinations, and ten cases in which there was
undoubtedly an absolute break in the mental continuity—a
mental blank. These latter remember a certain action at a
definite time, and their next recollection is their arrest, or they
may not, as they say, come to themselves until they have been
some time in prison.

Of course, a large number of patients claim to have been in
the condition of mental blankness, or rather of separate mental
existence, but in only ten cases am I satisfied that this was so.
These forty cases represent only twenty-seven individuals,
three cases having been in a state of acute frenzy, mental
blankness, and under the influence of drink, two cases having
been under the influence both of drink and hallucination, and
six of the twelve alcoholics were undoubtedly in a state of
mental blankness, and two at least of the alcoholics having
been in a state of acute frenzy, though not under the influence
of hallucinations.

This disposes of the twenty-seven individuals. The ten
hallucination cases I cannot regard as homicidal, for I believe
that any hallucination case is a potential murderer, and if not
under treatment would sooner or later become one. I do
not forget those rare cases in which exceptional men recog¬
nise that they suffer from hallucinations, and can be regarded
as sane.

I recollect that my friend, Dr. Savage, had one such case
under his care, and discharged him as sane.

Of my twelve alcoholic cases, in nine mental disease un¬
doubtedly caused the recourse to drink, in one case acute alco¬
holism, and in two pronounced chronic alcoholism caused the
crimes.

I do not think that much will be gained from the study of
advanced alcoholism. I have formed my opinion entirely from
the study of a few cases of early alcoholism I have met in

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322 MENTAL CONDITIONS RESULTING IN HOMICIDE. [April*

private practice, and I have also formed the habit of studying
certain of my friends, who, I regret to say, are slightly alco¬
holic without in the least knowing that they are so.

Now what is the one prominent change which I have
observed in early, slight, but habitual alcoholism ?

It is a slight loss of self-control, a shortening of temper ; in
a word, a certain explosiveness. The patient’s mental balance
seems to be hung on a hair trigger, trivial things that would
not have ruffled the sunny surface of his good temper now
cause deep submarine explosions. The poor wives and
children of alcoholics will bear me out in this. I often
compare alcohol to the fulminate of mercury which explodes
the comparatively harmless material which fills the shell.

In nine of my alcoholic homicides drink was the result of
‘mental disease, not its cause. I do not believe that the forms
of mental disease due to alcohol are more homicidal than
diseases due to other causes, but I believe that the effect of
alcohol on a diseased brain is to increase the danger of
explosion, to increase the tendency to homicidal action.

To conclude, I have not referred you to a host of foreign
writers, whose dicta seem to gain in dignity because written
in unknown tongues. I have told you a plain unvarnished
tale of my humble studies. I have read what I fear is a
sketchy, diffuse, and discursive paper, and I leave you to
draw your own conclusions. My own I will sum up in a
word.

I believe that my homicidal cases do not suffer from any
peculiar forms of mental disease. I believe that most of them
are not criminals in any sense of the word ; I maintain that the
crime is, in practically all my cases, an accident in the mental
disease, not its essential or its typical outcome. I am
convinced that you have all under your care hundreds of
potential homicidal patients. That they did not commit
murder is, in my opinion, a lucky accident due, shall I say ?
to the grace of God, or to the caution of timorous and unloving
relatives;

None of my cases lead me to believe in such a thing as
homicidal mania, a ravenous lust for blood, a brutalised
craving to take life simply for the sake of taking life. I
believe that ordinary motives such as jealousy, misery, acute
fear, acting on morbidly active emotional conditions, are

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CLINICAL NOTES AND CASES.

1902.]

323

responsible for the lengthy list of murders which I have
brought under your notice.

I have attempted to enter into the inner temple of my
patients* minds—I fear I cannot call it a holy of holies—and to
tell you what I found there, and I say definitely that it is not
the homicidal idea that dwells there.

( J ) A paper prepared for the Annual Meeting of the Medico-Psychological Asso¬
ciation held at Cork, July, 1901.

Clinical Notes and Cases.

An Abnormal Brain of Excessive Weight . By John
SUTCLIFFE, M.R.C.S., L.R.C.P., Assistant Medical Officer,
Manchester Royal Lunatic Hospital, Cheadle ; with Patho¬
logical Report by SHERIDAN Delepine, M.B., Professor
of Pathology and Director of the Pathological and Public
Health Laboratories in the Owens College, Manchester.

Mr. B—, an accountant aet. 37, was admitted into this
hospital on February 6th, 1900, suffering from epileptic mania.
That there was insanity or other diseases of the nervous system
in his family history was denied, but his brother was said to
be very eccentric and to take too much to drink. There was
also a suspicion that another brother died of some mental or
nervous disease. The patient was married at 21, and his
wife had had four children—no miscarriages ; the eldest and
third are alive and in good health, aet. respectively 16 and
12; the second died at 2 \ years and the fourth at four
months, both in convulsions. He was always excitable and
masterful, and latterly had been very quarrelsome ; he had
always been a sober, steady, hard-working man and a good
and kind husband and father. He had built up a good busi¬
ness as an accountant and estate agent. He had had good
bodily health generally until five years ago, when he had an
ischio-rectal abscess followed by a fistula, which was cured by
operation. When he was a boy a brick fell on his head and
caused a contused wound, the scar of which is about one and

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324

CLINICAL NOTES AND CASES.

[April,

a half inches long on the leftside behind, and in which he often
had a stabbing pain. He had his first fit when he was 22
years of age, and for some years had them every fourteen to
twenty-one days. In a fit he usually turned round and fell
down, was unconscious for about an hour, slept about ten
minutes, and was then all right. Twelve years ago he was
assaulted and knocked down. He was picked up insensible
and bleeding from his mouth, nose, and ears; his eyes were
“ bloodshot ” for some time afterwards ; he was unconscious
for three days, then resumed his business. Since this accident
he suffered from very severe headaches, and the fits gradually
grew longer in duration and more frequent, until at the time of
his admission he had them daily, and sometimes several on
one day. Often during the fits latterly he had passed water
and occasionally faeces. He had left internal strabismus.
There was no syphilis. This was the first attack of mania,
and was of a week's duration. For the previous six or eight
weeks he had been excited, quarrelsome, and extravagant, but
had attended to his business. He had threatened suicide, and
to kill his wife. On his admission he was in a state of
epileptic mania, talked continuously, complained of everything,
said his food was poisoned, accused his wife and daughter of
immorality, and was very emotional. He said he had intense
pain in his head and was sure there was something seriously
wrong with it. The urine contained neither albumen nor
sugar. The excitement passed off quickly and he was dis¬
charged recovered on the 21st. He had several epileptic
attacks during his stay. He was admitted again on January
23rd, 1901, with very similar symptoms. During the time he
was at home he had not been able to do much work. When
the acute excitement passed off, which it did in a few days, it
was found that he had loss of memory and was somewhat
demented. In addition to the epileptic attacks, which were
very frequent and in which he wetted himself, he had fits which
simulated epileptic fits ; he fell down carefully and did not wet
himself. The delusions persisted, and he was always com¬
plaining. In April he said he was going blind, and on exami¬
nation optic neuritis was discovered. The urine at this time
had a specific gravity of 1022, no albumen, no sugar. The
optic neuritis rapidly went on to atrophy, and by June he was
quite blind. On the evening of July 20th he was heard

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1902 .]

CLINICAL NOTES AND CASES.

325

snoring loudly, and was found unconscious, sitting in his chair.
He could not be roused ; the temperature was 102°. Next
morning he had regained consciousness; the temperature was
102 0 , the pulse 100, full and bounding, and the skin bathed in
perspiration. In the evening he was drowsy but could be
roused, answered when spoken to, and put out his tongue when
asked to do so. The temperature was 105*8°, the pulse rapid,
and the perspiration still very profuse. About six o’clock
next morning (July 22nd) he again became comatose, and
remained so until he died at 8.15 a.m. A post-mortem
examination was made next day by Mr. P. G. Mould. There
appeared to be nothing abnormal about the skull, and there
was no sign that it had been fractured. The brain weighed
69 ounces, and was sent to the Pathological Laboratory at the
Owens College for examination.

Professor DeUpine made the following report: —Brain,
cerebellum, pons, and medulla, weight 69 ounces. All the
parts of the encephalon were enlarged, viz. brain, cerebellum,
and pons. The enlargement was more marked on the left
than on the right side in the case of the hemispheres and pons ;
with regard to the cerebellum the enlargement was more
uniform, but the right half seemed to be somewhat larger than
the left In both hemispheres the frontal lobes were chiefly
affected, then the parietal and temporo-sphenoidal. In these
parts the convolutions were flattened and much broader than
normal. Their consistence was not equal, some of the larger
4 convolutions being somewhat softer than the convolutions least
enlarged ; but the difference was by no means clearly defined.
Two convolutions were the seat of a very marked local enlarge¬
ment, and were very soft, and even myxomatous to the feel.
These convolutions were the left gyrus fornicatus and the
marginal convolution. The gyrus fornicatus was affected
specially in the neighbourhood of the genu of the corpus
callosum ; in that region it presented a well-defined swelling,
measuring about one and a half inches in diameter, and situated
almost exactly in front of the genu. Only those portions of
the marginal convolution adjacent to the calloso-marginal
fissure took part in the formation of that swelling. This
swollen portion of the left hemisphere projected at least half an
inch into the corresponding parts of the right hemisphere,

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326

CLINICAL NOTES AND CASES.

[April

which were compressed by it. Although the swelling was
sharply defined it did not obliterate the contour of the con¬
volutions, which seemed simply enlarged. On section the
white matter was found to be of the same consistence as
the grey matter, and more transparent than normal, to a
depth of nearly two inches from the surface. The callosal
fibres passing through the soft patch were quite distinct, but
more spread out than in the normal state. An enlargement
of the gyrus fornicatus and slight softening was noticeable
along the greater part of the length of the corpus callosum,
but these features were not more marked than in several other
of the external convolutions. Behind the swelling mentioned
above, the white matter of the left centrum ovale was softened.
In the right subthalamic region there was a small mass,
having the appearances of grey matter ; this caused almost
complete obliteration of the descending horn of the left
lateral ventricle. The grey matter of several of the external
convolutions appeared on section to be much altered, being
hardly distinguishable from the subjacent white matter.
Generally speaking, the grey matter was thinner and the white
matter more abundant than in a normal brain. The white
matter was in certain parts more white and opaque than usual,
in others it had, on the contrary, a brownish colour. There
was no marked congestion of any part of the brain. The
ventricles were not enlarged, with the exception of a portion of
the descending horn in the right lateral ventricle, which was
slightly dilated.

Microscopical Examination.

(a) Ascending frontal convolution and part of superior frontal
convolution,—General increase of neuroglia ; neuroglia cells
generally few ; number of nerve-cells diminished ; among the
cells of the pyramidal layer there are some which are clearly
degenerated ; beneath the layer of large pyramidal cells some
excessively large ganglion-cells are present (giant-cells of
Betz); these seem to be larger and more numerous than in the
normal brain.

(B ).Gyrus fornicatus in front of genu ,—Normal structure of
convolution undistinguishable, owing to considerable increase

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JOURNAL OF MENTAL SCIENCE, APRIL, 1902.

Fig. III.—Frontal section at the level of the anterior part of the Pons Varolii.
To illustrate paper by J. Sutcliffe, M.R.C.S., a^d Professor Del£pine, M.B.

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CLINICAL NOTES AND CASES.

1902 .]

327

of neuroglia cells, which are separated by a small amount of
fibrillated matrix (myxoglioma).

Conclusion.

So-called hypertrophy of the brain , really a diffuse increase
of neuroglia (NEUROGLIASIS) with localised gliomatous masses,
having the characters of a myxomatous glioma. The general
distribution of this lesion suggests the possibility of it being
the result of some congenital defect.

A Case of Tumour of the Frontal Lobes of the Cere¬
brum in which Sleep was a Marked Symptom .
By Thomas Philip Cowen, M.D., County Asylum,
Prestwich, Manchester.

This case, which was otherwise an ordinary one of tumour
of the frontal lobes, presented as the most marked symptom
persistent sleep.

This condition of sleepiness was first noticed about two
months after his admission to the asylum, and which persisted
to the end, some six months later.

The patient was constantly asleep, both day and night, and
had to be kept in bed, as he was apt to fall and to hurt
himself.

The sleep appeared to be quite a natural one, even up to the
end, and the appearance of the patient was that of a person
overwhelmed by fatigue.

It was quite easy to awaken him, and then he would
answer fairly rationally for a minute or so, but then his
attention waned, and he would fall fast asleep again.

Even when being fed it was difficult to keep him awake,
except by constant stimulation.

With the exception of optic neuritis, no other symptoms of
nervous disorder were noticed.

I have seen a good many cases of frontal tumour, but per¬
sistent sleep as a prominent symptom is new to me, and there¬
fore I think the case worthy of notice.

XLVIII. 23

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CLINICAL NOTES AND CASES.

[April,

M. D—, male, aet. 36, married, a policeman, was admitted to the
County Asylum, Prestwich, on June 28th, 1901, suffering from melan¬
cholia. His previous health had been good up to quite recently, when
he had a severe attack of influenza, which was followed by severe
neuralgia of the face and head. He had done his duty as a police
officer up to three weeks before admission. There was a gradual onset
of depression for about eleven days before admission.

On admission .—He is a fine stout man. Has a dejected aspect and
is very emotional; says “ he does not know what will become of him; ”
does not complain of any pain in any part; his thoracic and abdominal
viscera are normal; he shows no signs of organic disease of the nervous
system, and his pupils are equal and react well to light. Knee-jerks and
other reflexes are normal.

July nth.—He became restless and excitable at night, complaining
of constant slight pain in front of head. In the daytime he is dull and
is often asleep.

August 15th.—He has ceased complaining of headache; is now
always asleep, both night and day ; fails asleep, even at meal times, and
tends to hurt himself as he falls out of his chair when asleep. He can
be awakened, but falls asleep again directly.

September 15th.—There is no change mentally; is still always
asleep. When disturbed he is able to give a good account of himself,
but has lost the power of prolonged attention, and is apt to be very
forgetful of what has been said the moment before. No paralysis, pupils
equal, rather wide, and react badly to light. Knee-jerks rather brisk.

November 7th.—In same condition, but now is apt to make to and
fro movements of the right hand, even when asleep, but these he can
arrest when told to do so, and they are probably functional. He has
marked optic neuritis in both eyes, especially marked in the left. # He
is wet and dirty in his habits, probably from inattention. There # is no
squint or affection of facial muscles. No vomiting has occurred. No
paresis of arms or legs, and he can sit up when told to do so.

January 7th, 1902.—No further change mentally. Is now quite
blind. He says, in broad daylight, that “it is quite dark, and that he
could see me if I lighted a candle.” Pupils are wide and do not react
to light. The knee-jerks are now absent.

February 2nd.—He is at times rather restless, and tries to get up,
saying, “ I want my clothes, as I have to go on duty.” He is still dull
and sleepy for the most part, and it is more difficult to awaken him, but
when he is fully awake he still shows a very fair intelligence, and even
gives smart answers; but this he cannot keep up, and falls speedily
into a heavy sleep again. No fresh nervous symptoms. The swelling
of the left optic disc is subsiding, leaving the outer half clear, which is
of a chalky whiteness.

February 6th.—His heart began to fail rather suddenly, and he died
at 7.40 p.m. He had no fit of any sort. His temperature rose for the
first time shortly before death to 103°.

At the post-mortem a large tumour of a sarcomatous nature was
found. This tumour had grown from the membranes, and had
infiltrated both frontal lobes on their under surfaces to a depth of about
three inches.

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OCCASIONAL NOTES.

329

Occasional Notes.

The Proposed Psychiatric Clinique in Edinburgh .

The establishment of a psychiatric clinique in connection with
the Edinburgh Royal Infirmary has been strongly recommended
to the managers of that institution at a recent meeting of the
Edinburgh Medico-Chirurgical Society. The meeting was a
very representative one, the discussion being initiated by Sir
John Sibbald, and the motion moved by Sir John Batty
Tuke.

The treatment of mental in association with other
diseases in general hospitals is probably one of the most
important steps that can be taken to aid in the prevention of
insanity. The incipient stage of mental disorder is that in
which all authorities agree in describing it as most curable, but
at the present time it is the stage that receives the least
attention, and in which there is little or no provision for its
treatment. The existing condition, indeed, has been likened
to that which would obtain in eye diseases if no special
treatment could be obtained until the patient was qualified by
total blindness for admission to the Ophthalmic Hospital.

The public prejudice against insanity and the fear of the
asylum can only be overcome by teaching the people to
associate mental with other diseases in the general hospitals,
and not with the asylum or poorhouse lunatic ward.

Steps in this direction have already been made by estab¬
lishing out-patient departments at St. Thomas’s Hospital, the
Charing Cross Hospital, and at the Sheffield Infirmary. Other
London hospitals are preparing to follow in this track.

The treatment of mental disease in a general hospital is not
a new departure. In the thirteenth century a department
of the large general hospital in Cairo was set apart for the
treatment of mental disease. Mahommedans, indeed, have
always recognised insanity sis disease ; it was the Christian idea
of evil possession that led to insanity being regarded as some¬
thing quite different from ordinary bodily affliction, and this
resulted in the abominations of treatment which persisted
through the Dark Ages almost to our own times. Christian

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communities have, indeed, large amends to make for the evil
inflicted through all these ages on the insane throughout
Christendom, and they should be frankly reminded of the fact.

Psychiatric cliniques have long been established on the Conti¬
nent, and would have been still in existence at Guy's Hospital
in London, but that the clinique there was strangled by the red
tape of legal procedure.

A correspondent in the Lancet has suggested that these
psychiatric wards, if established, should be placed under the
care of a general physician.

The ignorance of mental diseases in the general body of the
profession could not be better illustrated than by this sugges¬
tion. Would it be possible that any medical man could be
found so totally unacquainted with diseases of the eye, for
example, as to suggest that the eye wards should be placed
under a general surgeon ?

The abuse of the alienist physician by his fellow-workers
has been of long duration, and in the past may have had some
justification, but in the present day we can point to a large
proportion of active scientific workers, and a large output
of scientific work, rapidly increasing.

On the other hand, the records of our case books would
furnish material giving very little encouragement to the sug¬
gestion of placing the psychiatric clinique under the general
physician, and any attempt of this kind must be vigorously
opposed by the specialty.

That the recommendation of the Medico-Chirurgical Society
will bear fruit is therefore most earnestly to be desired. The
managers of the Edinburgh Infirmary have it in their power to
become the pioneers in a procedure which is certain to be widely
followed, and which will be evidence of the progressive spirit
which has always been so prominent in Scotland generally,
but especially in its capital. Edinburgh, by setting this
example of progress, will add an additional claim to the title
of “ Modern Athens."

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OCCASIONAL NOTES.

331

Private Insane Patients .

The contrast in the stated number of private patients in the
three kingdoms has long been a striking one, and the causes of
the difference are worthy of consideration by all who are
interested in the treatment of the insane. Probably the same
causes are at work in all parts, and we propose to leave
Ireland out of the question and to seek out their true nature
by a comparison of England and Scotland

In Scotland in i860 the proportion of private to total
number of patients was about 1 in 6, and has fallen to about
I in 7 in \goo,viz. 2214 in 15,475. In England the same fall
has occurred, but in increased ratio, viz . from 1 in 8 in 1859 to
about I in 12 in 1902.

The census returns in regard to the housing of the people and
the income tax statistics both show that there is a considerably
larger proportion of well-to-do persons in England than in
Scotland. The expectation from this would be that there
would also be a larger proportion of private patients and not
the reverse, as the figures given above show.

Dr. Clouston, in adverting to this question in his 1900
report, states as a curious social fact that M the moderately well-
off Scotsman supports his insane relations without letting them
fall on the rates in twice the proportion that the Englishman
does, etc.” It is the case certainly that the proportion of
private patients to total patients was on January 1st, 1901,
I to 6*98 in Scotland and 1 to 12*05 in England; also that
private patients were on the same date in proportion to pauper
patients as I to 5*98 in Scotland and 1 to 10*95 m England,
but, to our mind, these figures do not warrant Dr. Clouston's
reading of them. From those given below it will be seen that
the proportion of private patients to population in Scotland is
getting on for twice as much as it is in England, while the pro¬
portion of pauper patients is almost identical. It might
be equally well assumed that both nations desire to be inde¬
pendent of the rates, but that Scotland has relatively twice as
many private patients to whom she can do her duty. Further,
we find that about 1 in 41 Englishmen and 1 in 44 Scotsmen
are in receipt of relief in one shape or another. We are there¬
fore driven to the conclusion that the difference in private

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332

[April,

lunacy statistics is due to circumstances rather than to indi¬
vidual or racial habit.

Population,
April 1, 1901.

Pauper patients,
Jan. 1, 1901.

Private patients,
Jan. 1,1901.

Total patients,
Jan. i, 1901.

England

32,526,000

98,223

8947

107,920

Ratios to popula¬

tion .

—

/ to 331

/ to 3^35

/ to 301

Scotland

4,472,000

13,261

2214

x 5»475

Ratios to popula¬

tion .

/ to 337

/ to 2019

/ to 288

What are the circumstances ? To begin with, we find that
in each of the Royal Hospitals at Dundee, Edinburgh, and
Montrose there is a special or district rate for private patients
actually, and in one instance substantially, lower than the
pauper rate for the district. We do not suppose that this fact
has a very far-reaching influence on the proportions in question,
but it must be discounted. . Then at most of the district
asylums private patients are admitted at pauper rates, or for
a sum but little above. Until recently such a system was
almost unknown in England. Then there can be no question
that in the middle of last century the Royal Asylum in
Scotland offered accommodation for patients just above
pauper condition to a far greater extent relatively than could
be found in England, and for that deserves all honour. * The
tendency to keep up that class of accommodation still exists, for
has not Gartnavel totally excluded paupers in favour of such
cases ? and is not Morningside eager to get rid of its City
paupers for the same reason ? The true solution of the ques¬
tion seems to lie chiefly in the amount of accommodation thus
available, and it can be summed up thus : Given accommoda¬
tion for private cases who without it would go on the pauper
list, occupants will be certainly and quickly found. The truth
of this has been shown not only at Gartnavel, but also in
England. The accommodation specially provided at Dorchester,
Claybury, and Stone for private patients apart from others is
full and overflowing, and the increase of private patients in
each of the London County Asylums since they have been
admitted on payment of the bare maintenance rate, though

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1902.]

OCCASIONAL NOTES.

333

small at present, points the same way. Yet again, the transfer
from pauper to private classes yearly and increasingly exceeds
those from private to pauper ; in fact, it may be confidently
said that if a quid pro quo is given many will make a slight
extra effort to have their friends ranked as private patients,
who would not feel justified in finding an additional four or
five shillings per week for nothing.

Another question arises : whether for the class of patients
just above those last described as much is done by the
Registered Hospitals in England as is done by the Royal
Asylums of Scotland. Our impression is that in relation to
numbers there is less scope in England, but it is hard to
say so certainly without the actual figures of number and
rates of payment in each case. The same want of information
prevents our even guessing at the accommodation afforded for
such cases in private asylums, though a glance at the numbers
in those which may be supposed to take them in would suggest
that there is not much room to spare.

For the richer patients there seems to be ample accommoda¬
tion in England, and probably in Scotland. But this class is
not likely to extend very much, certainly not to the extent of
influencing the equalisation of the ratios now being considered.

On the whole we consider that we are justified in concluding
that England would show as goodly a proportion of privately
supported patients as Scotland does if it only had the
machinery. It is possible that the extension of Registered
Hospitals, such as is now taking place, for instance, at Cheadle,
will supply some of the provision required, but for the bulk of
that provision we must look to County Councils. We earnestly
hope that if the latter bodies are persuaded to take up the
task generally it will be with a stem determination not to go
beyond the best available treatment plus moderate comfort
suitable to the financial circumstances of those to be admitted.
Anything like a brave show or a rivalry in grand buildings,
such as is not altogether unknown even in pauper asylums, will
infallibly damn the enterprise. Such institutions or additions
should be conducted on absolutely even principles, the same
treatment for all alike, any difference therein being dictated by
the medical emergencies of a case and not by payments. The
payments should be just as much as will cover maintenance
plus repayment of capital cost. When the latter ceases in

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OCCASIONAL NOTES.

[April,

the course of years there will then be room for either modifying
terms or for benevolence to deserving cases. The word
“ profit ” should not be heard in connection with the
enterprise.

The Report on the Dieting of Pauper Lunatics in Scotland .

One of the most important and valuable documents that has
ever been issued in connection with the institutional treatment
of insanity is the Report on the Dieting of Pauper Lunatics
in Asylums and Lunatic Wards of Poor-houses in Scotland , by
Dr. J. C. Dunlop. It is issued as a supplement to the forty-
third Annual Report of the Scottish Commissioners.

The results of the investigation, planned and carried out in
a thoroughly scientific and practical manner, must have a wide-
reaching influence on the dietaries of the insane, not only in
Great Britain, but in other countries.

Whatever criticism may be advanced in regard to details of
the estimation of dietetic values, etc., there can be no doubt
that these closely approximate to the truth, there being found
to be a close correspondence between the estimated values of
diets and the general nutrition of the patients.

The few exceptions in which a diet of low nutritional value
is found to correspond with an average nutritional weight of
the patients will probably be found to be accounted for by
exceptional or unrecorded supplies of food, or possibly by
exceptionally good preparation of the food, and, indeed, to be
exceptions which help to prove the rule.

The suggestions for ensuring the proper feeding of pauper
insane patients, with which Dr. Dunlop concludes his report
correspond very closely with the principles that have long
been followed in most of the best asylum dietaries, but it is of
distinct importance to have these principles confirmed on a
scientific basis, as given in this Report.

A detailed criticism of the Report has yet to be written, but
the Scottish Lunacy Commission is to be congratulated on
having undertaken a most important piece of work, which has
long needed attention, and on having entrusted its execution
to the care of so able and competent an investigator as
Dr. Dunlop.

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335

The Danger of Discharge of Insane Patients by the fudicial

Authority .

“ A Flaw in the English Lunacy Law,” to which Dr. Ernest
White draws attention^) is an example of the dangerous
power given to the “judicial authority” under the existing
Lunacy Act.

The case of which Dr. White gives the details is one in
which, in spite of the written opinions of four medical men,
two of them specialist physicians, a justice of the peace
reported to the Commissioners in Lunacy that he did not con¬
sider the patient to be insane. The Commissioners, on this
report, were obliged to discharge the patient, who thus obtained
the opportunity of committing suicide, and did so.

The criminal absurdity of giving an ordinary justice of
the peace the power of deciding on the sanity of an alleged
lunatic has never been more clearly and forcibly demonstrated ;
but the fault is in the law, and not in the judicial authority,
who possibly did not know that his report would inevitably lead
to the discharge of the patient. A young justice of the peace
would probably expect that his report would not lead to
immediate discharge, but only to an investigation by skilled
medical men. The law, therefore, needs amendment in giving
the Commissioners in Lunacy discretion in regard to discharge
on such a report, so that they may act on it, decline to act on
it, or make further investigation.

That sick persons should be liable to be discharged from
hospitals on the medical opinion of a lay judicial authority is
an intolerable injustice, and would be a ludicrous absurdity
were the consequences not so lamentable and disastrous, as
exemplified in the case under consideration.

The Lord Chancellor, if this case is brought before his notice,
will probably amend the section under which it occurred, other¬
wise we must conclude that disease is really regarded as crime,
and that we are fast approaching to the state of things depicted
in Erehwon.

(*) See page 312 of this number.

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Czolgosz.

Czolgosz, the cacophonously-named murderer of President
McKinley, is still the subject of discussion in the United States,
the question having been raised whether he was not insane
rather than a criminal.

Expert testimony was excluded from the trial, with the
result that both the medical and lay mind is in ignorance of the
grounds and methods of inquiry on which the opinion of
Czolgosz’s responsibility was arrived at.

The examination lasted three weeks, and was assisted by
a very full statement of premeditation by the assassin. How
far reliable evidence of his past life was obtained is not publicly
known, but only strong evidence of previous insanity and
insane conduct could shake the conclusion arrived at. If such
evidence existed it should certainly have been produced before
the trial. Dr. Channing, of Boston, believes that he has
evidence of a distinct history of insanity in Czolgosz, and there
will probably be much future debate on this question.

That an insane person should have been executed as a
criminal would be regrettable, and also that he should be
ranked as an anarchist, for although anarchism is a strong
presumption of insanity, the converse is fortunately not true.

General Index to ‘ Brainl

The general index to the first twenty-three volumes of
Brain , which has recently reached us, is a valuable addition to
our reference shelf. It represents a very large amount of work,
which only those who have undertaken similar work can fully
appreciate.

The list of authors is given separately from that of sub¬
jects, which is a considerable convenience. The index of sub¬
jects appears to be very satisfactory, both in cross and related
indexing. The typing, too, is well adapted to aid in speedy
reference.

The readers of Brain may be congratulated on having this
piece of work so satisfactorily completed, chiefly, we believe,
through the energy of the present editor, although his name
does not appear in connection with it.

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REVIEWS.

337

Influenza.

Influenza has been more rife than usual this wintry spring,
and although fortunately the mortality therefrom has not been
very high, its baneful influence has been more widely spread
than ever.

Whole schools have been prostrated, committees of impor¬
tant bodies scarcely able to raise a quorum, Government offices
so weak handed as to seriously diminish the supply of red
tape, and some departments of the law, never arraigned as yet
for furious speed, have come nearly to a standstill. On the
other hand, ammoniated quinine has been at a premium, nurses
have been too busy, with rare exceptions, even to prosecute
their doctors for treating them gratuitously, and seaside
resorts, especially those with golf courses, have been largely
frequented.

Lastly, but by no means least, our editors, reviewers, and
contributors have suffered unanimously, and if the JOURNAL is
late and somewhat emaciated in its appearance, this also must
be ascribed to the demonic influence of the influenza.

Part II—Reviews.

Syphilis und Nervetisystcm [Syphilis and the Nervous System]. By
Dr. M. Nonne. Published by S. Karger, Berlin, 1902. Octavo,
pp. 458, with 42 illustrations. Price 14 m.

This monograph takes the form of seventeen lectures, delivered by
the author in the autumn of the years 1899, 1900, and 1901, to practis¬
ing physicians in Hamburg. He has published them in the same form
as they were delivered, as he thinks they will thus possess greater
practical interest without being wanting in scientific accuracy. They
are illustrated by many valuable clinical facts from the author’s own
observation, and wherever possible the clinical symptoms are referred
to the basis of pathological anatomy. In his division of the subject he
is guided largely by his own experience, and by the necessities of
practical utility. This is wise, not only in view of the circumstances
under which the lectures were delivered, but also in view of the mistaken
impression of the subject which is obtained when a series of very rare

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REVIEWS.

[April,

though interesting conditions are detailed, of which the majority of
people will probably never see an example. A more correct picture is
thus given of what is likely to be the average experience of an ordinary
practitioner.

The lectures, as stated, are seventeen in number, and they review the
subject in all its different aspects. The aetiology, diagnosis, and patho¬
logical anatomy are first considered. Under the last head he recognises
three types of syphilitic disease as it affects the nervous system: (i)
syphilitic new growth; (2) chronic hyperplastic inflammation ; (3)

vascular disease. The last leads to consequences which are not of a
syphilitic character,—for example, necrosis of nervous tissue. He recog¬
nises, also, a group of post- or metasyphilitic affections which manifest
themselves in various simple degenerative processes, which, on clinical
grounds, are attributed to syphilis, though pathologically they cannot be
distinguished as specific of that disease. The three groups above
mentioned are fully described and illustrated. As regards vascular
disease in syphilis, the author considers that there is “no essential
difference between atheromatosis resulting from syphilis and that which
is found without the concurrence of syphilis.”

The author then turns his attention to the symptomatology of
syphilitic arterial disease, cerebral meningitis, disease of the base of the
cerebrum, and to the differential diagnosis and prognosis of these. He
then takes up the psychoses and neuroses of syphilis. He concludes
that there is no mental disease specifically syphilitic, and diagnosable as
such; further, that there is no form of psychical disturbance which may
not be observed as a result of syphilis.

In the ninth lecture the author states it as his opinion that general
paralysis is not a specifically syphilitic disease, though he admits that
the relations between them are numerous and intimate. He allows
that syphilis plays a part, in that it diminishes the resistance of a brain
more or less disposed to it, and that thus, at a later period, damaging
factors are able to exercise their influence. Of these factors he looks
on alcohol as the chief.

The next three lectures are devoted to syphilis of the spinal cord.
In the thirteenth the author considers the question of tabes. As in
general paralysis, he regards this disease as not a specifically syphilitic
affection, and for much the same reasons. The question is undoubtedly
a difficult one. As regards general paralysis, the greatest light appears
tb be shed by the cases of its juvenile or developmental form. In them
there are seldom any of the “ damaging factors ” to which the author
alludes to be discovered. The sole common factor in the great
majority of such cases is the existence of hereditary syphilis. It is
quite true that the pathological anatomy of general paralysis and of
tabes does not present features similar to other recognised syphilitic
processes, but after all this is nothing but a mere argument. The author
himself recognises at least three distinct forms in which syphilis may
manifest itself pathologically in the nervous system, and not one of these
primarily attacks the nervous tissue. Why, then, must one deny that
there may be a fourth or even a fifth form ? When one considers the
highly specialised structure of the nervous system, one might, indeed,
be surprised if syphilis did not affect it in a pathologically different way

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1902.]

339

from what it does in other tissues. This also is, of course, a mere
argument, but it is more likely to be true than the other.

The last four lectures deal with the cerebro-spinal forms of syphilis,
disease of the peripheral nerves, hereditary syphilis as it affects the
nervous system, and finally therapeutics.

The book, as a whole, is clear, interesting, and well written. It
contains numerous descriptions of cases the author has himself seen,
which illustrate the point under discussion, and stir fresh interest in the
subject when this might flag during the course of theoretical disquisi¬
tions. The bibliography is most complete, extending to twenty-one
pages. It is drawn from all countries, and omits no work of importance
dealing in any way with the subject. The indexes are also good.

Jas. Middlemass.

Object-Lessons in Penal Scie?ice. Third Series. By A. R. Whiteway,

M.A., Barrister-at-Law. Sonnenschein, 1902. Crown 8vo, pp.

212. 3*. 6 d. net

Mr. Whiteway has a lively sense of the defects of our police, of our
criminal laws and procedure, and of our prison system, in fact, of every
stage of our dealing with offenders, whether in catching them, trying
them, or punishing them. His heart is in his subject, he writes with
liveliness, and his book is calculated to stir somewhat stagnant waters ;
but in his recommendations for reform there is a lack of definiteness.
As existing, our system, he says, is altogether wrong, root and branch,
lock, stock, and barrel; but beyond vague declarations that things
ought to be better done, we do not get much enlightenment as to what
precise measures should be taken to reform them. Prison governors
and warders ought to be better trained, but what they are to be trained
in we are not told. The author argues against the view of Sir E. Fry
and other jurists, that at the bottom of the whole system of punishment
is the notion of fitting suffering to sin. The introduction of the last
word was unfortunate, and has given occasion to others before Mr.
Whiteway to exclaim against the assumption of a religious function by
the law; but it is perfectly obvious to any one who has read Sir E. Fry’s
article that he used the word “sin” in no religious sense, but as a wide
term to include all forms of wrong-doing. “ We have no right,” says
Mr. Whiteway, “ to punish for punishment’s sake.” I should very mufch
like to know why not. “ All we can do properly in our treatment of
criminals is to efficiently protect ourselves. If in doing so we benefit
them, that is not only a matter of duty, but one, too, to our own
exceeding great advantage.” And if in doing so we harm them, we
may regret the necessity, but we manifestly have, on these premisses, the
right to do so. “ Practical utility ” has something to say in the matter,
no doubt, but undoubtedly the earliest, and still the most operative
motive in the infliction of punishment is that very lex talionis which
Mr. Whiteway so strongly deprecates; and, pace all the efforts of all the
utilitarians, so it will remain as long as the sentiment of indignation at
the sight of wrong remains a constituent in human nature, and I for
one should be sorry to hasten its departure by a single day.

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It is a pity that such barbarous expressions as “ up-to-date ” and “ catch
on ” are allowed to appear in a bound volume, they are bad enough in
the daily press; and either the proof-sheets have not been corrected
at all or Mr. Whiteway’s experience as a conveyancer has given him
an insurmountable abhorrence of stops. Ferri Garofalo Lombroso
Tarde Fere are not the names of one man, noi are Nicolson Baker
Pitcairn Brayn, though, from the absence of punctuation, they appear
to be. Chas. Mercier.

Les Aliines devant la Justice \The Insane before the Courts ]. Par F.
Pactet et H. Colin. Paris : Masson, Gauthier-Villars. Small

8vo, pp. 176. Price 2 f. 50. Les Alienes dans les Prisons [The
Insane in Prison ]. Same authors and publishers. Pp. 172.

These two little volumes belong to the Encyclop'edie Scientifique des Aide-
Mlmoire , a now extensive series notable for the high competence of the
writers who have contributed to it and the very clear and condensed
style adopted. The authors of these two books (which may be re¬
garded as a single work) are marked out as specially fitted for their task
by the fact that one is a physician at the Villejuif Asylum, and that the
other was formerly medical officer at Gaillon, whither all cases of
insanity occurring in prisoners condemned for periods over one year are
supposed to be sent.

The main thesis of the authors is that insane persons are sent to
prison and kept there very much more frequently than the optimists
would persuade us is the case. The authors draw their illustrations
mainly from France, but also bring forward evidence to indicate that
the same thing occurs in other countries also. Although their views are
expressed very decisively, and with ample confirmatory evidence, they
preserve throughout a tone of moderation and sobriety. The attitude
adopted is entirely orthodox; indubitable and unquestioned forms of
insanity are alone taken into consideration, and no attempt is made to
trespass on the province of the criminal anthropologist. This cautious
and correct attitude adds strength to the authors’ contentions.

Considerable significance attaches to the very unequal contingents of
insane prisoners sent to Gaillon from the various prisons of France. It
appears that during a period of six years nearly half the number of
insane criminals received came from three prisons only; the other half
came from as many as twenty-eight Maisons Centrales or prisons, including
some of the largest in the country, like Clairvaux and Poissy. It can
scarcely be argued that the immense discrepancy is due to a real
inequality in the manifestations of insanity in French prisons. The
real source of the inequality becomes clear when it is pointed out that
the medical supervision of the three prisons in which insanity is most
frequently found is in the hands of experienced alienists who had pre¬
viously been attached to asylums. The other prisons furnish few
insane subjects, not because insanity is not present, but because it is
unrecognised, or regarded as too trivial for special treatment. It is
pointed out that a similar condition of things prevails in the United

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341

States, Elmira, with its more careful and thorough management, sending
a very disproportionately large number of insane prisoners to
Matteawan.

The chief argument brought forward, however, lies in the records of
clinical histories which make up a considerable part of these volumes.
Twenty-five cases are given in which various classes of crimes were com¬
mitted by insane persons (mostly general paralytics), who were con¬
demned and sent to prison; in some cases they were sentenced for
fresh offences several times before the insanity was discovered. In the
second volume twenty-eight cases (general paralysis, delusions of per¬
secutions, imbecility, etc.) are detailed.

The authors’ recommendations are clear and definite: (1) in all cases
there should be a medical examination of the mental condition of the
accused immediately after arrest, usually there need only be a very
summary examination; (2) greater care in the selection of experts, all
alienists competent to give evidence being inscribed on an official list;
(3) special inspection of prisons by alienists, whose sole function it
would be to discover and report cases of insanity.

Havelock Ellis.

Die Unterbringung Geisteskranker Verbrecher [The Disposal of Insane
Criminals]. Von P. Nacke. Halle: Marhold. Large 8 vo,
PP- 57 , 190*.

Dr. Nacke’s pamphlet, appearing at the same time as the books just
reviewed, discusses some of the same problems and brings forward
some of the same arguments. “The day has gone by,” he remarks, “when
the statement that prisons contain many psychopathic and even insane
persons was regarded as a calumny; it is now a commonplace.” He
proceeds to summarise some of the evidence on this point, and mentions
that, in his own experience, of fifty-three women from one fifth to one
fourth were improperly sent to prison, while Sommer came to the
conclusion that very few of his insane criminals were normal before
their deed. The evidence leads to the conclusion that “ the majority of
insane criminals were insane at the time of the deed, but their insanity
was not recognised.” That this conclusion holds good for English
prisons is, Nacke thinks, proved by Baker’s statistics. The majority of
those who really become insane in prison belong to the class of criminals
by passion.

There are, however, wide differences, both in opinion and practice,
concerning the best method of disposing of insane criminals. The
greater part of Dr. Nacke’s pamphlet is devoted to a condensed but
thorough discussion of the various methods. The chief varieties are
three: (1) central institutions for all insane criminals; (2) annexes to
prisons; (3) annexes to asylums. One of the practical difficulties in
settling this question lies in the fact that insane criminals belong to
very various categories. The author is, however, decidedly of opinion
that recidivists and really criminal characters are rare among them, and
that it is unjust to allow our treatment of the majority to be influenced

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[April,

by the small minority. The “ moral insane ” or moral imbeciles ought
to be sent to a special institution, which would provide the peculiar
treatment they require; and this institution might be an annexe
to a prison, but on the whole the author favours the annexe to the
asylum as generally the best method for disposing of the criminal
insane, at all events on the Continent of Europe. While fairly
presenting the case in favour of great central institutions such as exist in
England and America, Dr. Nacke does not consider that these form
good models for imitation. At the same time he has no wish to drive
a principle to death, and he considers that various kinds of institu¬
tions may, under varying circumstances, be the best.

Havelock Ellis.

Twenty-Sixth Year-book of the Elmira Reformatory (1901).

Considerable changes have lately taken place in the management of
this institution. Mr. Brockway, who was superintendent of the prison
from its establishment, has resigned, as also has Dr. Wey, the physician.
Dr. Frank W. Robertson has been appointed superintendent and Dr.
Christian physician. With these new appointments are associated
various other changes, both in the personnel and the management of the
institution. Some fear may naturally be felt lest these sweeping changes
may involve a disastrously retrograde movement in the management of
the institution which has so long served to teach the world the direction
in which prison reform must be directed. Fortunately it cannot be
said that there are any apparent signs of degeneracy about the Elmira
Reformatory. On the contrary, it would appear that the recent appoint¬
ments have involved no radical change of policy, but, on the other hand,
have led to increased efficiency. Splendid as were Mr. Brockway’s
achievements, there can be no doubt that some infusion of new blood
was required. The late superintendent emerged, on the whole,
triumphantly from the exhaustive official investigation to which his
actions and policy were submitted a few years ago, but there can be
little doubt that that investigation weakened his moral authority and
interfered with the discipline of the Reformatory. The time had clearly
come for the reins to be placed in other hands. It is satisfactory to find
that corporal punishment, Mr. Brockway’s use of which was the most
debatable point in his management, has now been entirely abolished.
It is also most satisfactory to find that—as all prisons should be—the
institution is now in charge of an alienist. Dr. Robertson, previous to
his appointment to Elmira, had been for five years the medical chief of
the Pavilion for the Insane at Bellevue Hospital, New York. It is not
surprising to find that he has set himself resolutely to deal with the
question of insanity at Elmira, and a considerable number of cases have
been transferred to asylums. Dr. Robertson is strongly of opinion that,
as a matter of routine, the mental and physical condition of prisoners
should be carefully investigated before sentence is pronounced. This
would result in securing valuable information which would materially
assist the judge in properly disposing of the case, and would prevent the

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1902 .]

sending of certain classes to an institution of this character. “ Each year
we receive a number of imbeciles, epileptics, and insane criminals,
who would doubtless have been sent elsewhere had their actual con¬
dition, at the time of imposing sentence, been known and understood by
the court” It is pointed out that some insane criminals had already
been convicted several times previously. It is therefore reasonable to
suppose that in many cases a morbid state of mind existed at the first
conviction, and might have been discovered by skilled investigation.

While this report bears witness to Dr. Robertson’s energetic ad¬
ministration of the practical affairs of this great institution, we miss any
record of scientific work achieved. The new superintendent, being
aided by an assistant and by two resident physicians, is in a much better
position than his predecessor. It is to be hoped that he will not allow
himself to be absorbed by the multifarious practical details of his office,
but will utilise his great opportunities to increase that stock of scientific
knowledge on which alone real progress in practical treatment can be
based. Havelock Ellis.

jRetspsykiatriskc Erklaeringer afgivne af Dr. Knud Pontoppidan: en
Eksempelsamling til drug for Laeger og Jurister [Medico-legal Re¬
ports on Insanity: a Collection of Cases for the Use of Physicians
and Jurists\ Demy 8vo, pp. 322. Copenhagen, 1901.

The learned author here presents to us a collection of 235 cases
taken from a very wide circle of observations, all dealing with real or
assumed abnormal mental actions. In most instances the subjects
have brought themselves within the grasp of the law; some were not
brought to trial, others declared insane or detected in simulation. In
other cases questions of testamentary incapacity had been raised. Dr.
Pontoppidan’s wide experience has brought him in contact with every
phase of insanity. Many of the reports deal with the different forms
of alcoholic delirium. Cases of imbecility and deaf-mutism are also
recorded. The reports vary in length from one to four or five pages.
They show much graphic power and skill in the selection and presenta¬
tion of details. So varied are the forms of mental derangement about
which the opinions of medical men are asked, that definitions are
escaped and no one instance is quite like another ; nevertheless it must
be an instructive exercise to read how such cases have been regarded
by a master in medical science and in the lore of insanity like Dr.
Pontoppidan. Altogether this is a useful addition to the works upon
insanity and diseases of the nervous system, which have raised so high
the reputation of the author. William W. Ireland.

LEpilessia ,— eziologia , patogenesi e cur a. By Dott. Paolo Pini.

Milano: Ulrico Hoepli, 1902. Small i2mo, pp. 278. 2 1 . 50

This small volume is practically a critical digest of the recent work
in connection with epilepsy, and especially of its therapy. There are
XLVIII. 24

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EPITOME.

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three main divisions in the work. The first, comprising about eighty
pages, deals with the aetiology and pathogenesis ; short sub-sections
treat of the toxic properties of the various fluids—the urine, the
sweat, the blood, the cerebro-spinal fluid, etc. The second division is
devoted to a consideration of the various therapeutic agents, and in¬
cludes the psychical and physical methods of treatment. Each agent
has a short sub-section to itself with a separate bibliography, a similar
system being also followed in the first division of the book. The litera¬
ture dealing with the results obtained by any particular drug or system
of therapy can thus be readily obtained. The third section gives a
short account of epileptic colonies, and also of the legislation in various
countries. The book is well written, and will be found of great service
by those who desire a concise knowledge of the present views with
regard to epilepsy, or who may wish references to the recent Continental
and especially Italian papers on the subject. The book is brought up
to date by the inclusion of a short appendix giving the results of Ceni’s
recent researches on the serum-therapy.

Part III—Epitome of Current Literature.

i. Anthropology.

Concerning the Frequency and Significance of Transverse Ridging of the
Nails in the Normal\ the Criminal, and the Insane \Jntorno alia
Frequenza ed al Significato della Striatura ungueale trasversa nei
Normali , nei Criminali, e negli Alienati]. (Arch, di Psichiat ., vol.
xxii,fasc. 6.) Treves.

In a previous communication to the Turin Academy of Medicine, the
author called attention to the frequency of transverse ridging of the
nails in the insane, and suggested that the phenomenon was a sign of
oscillations in histogenetic activity dependent on unstable conditions
of metabolism in mental disease. The present paper is a further
discussion of the subject.

The author first points out that there is a lack of correspondence in
the frequency and situation of this ridging in the nails of the different
digits. By staining the nails with nitrate of silver, it was ascertained
that these variations are due to differences in the rate of growth; the
finger-nails are renewed within a comparatively short period (two to
seven months), the period differing with each digit, and being longest in
the case of the thumb ; the toe-nails, on the contrary, grow more slowly,
but the rate is practically the same in all the digits ; complete renewal
is effected in from eight to twenty-four months. Hence the toe-nails
are able to register a longer series of nutritional disorders, but are
incapable of showing the slighter degrees of such disorders, which may*

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1902 .]

appear on the finger-nails. From a medico-legal point of view, this
ridging of the nails might conceivably be a useful guide to the occur¬
rence, and in some measure to the date, of recent grave disorders of
nutrition.

Having thus established the significance of the phenomenon, Treves
has investigated its frequency in different categories of individuals.
He finds that it is rare in the normal (about 10per cent,), and that,
when it does occur, it can usually be traced to some recent severe
illness. In criminals and prostitutes and in the insane, on the contrary,
it is very frequent (about 50 per cent .); it is most common in the
insanities of the degenerate type. A table appended to the paper gives
the exact percentages for the different groups of abnormal subjects.

W. C. Sullivan.

Three Cases of Polydactylism [Tre Cast di Polidactilia\ (Arch, di Psi-
chiat '., vol. xxii, fasc. 6.) Portigliotti .

The three cases of this anomaly reported by the author, were met
with in a population of about 2700 persons. In two of the cases, both
hands and feet presented six digits; in the third case the condition
existed in the feet only. An exhaustive examination of the family
history of the cases through three generations failed to disclose any
hereditary tendency to polydactylism or any degenerative taint In
only one of the cases were the parents of kin second cousins. One of
the subjects was above the average in intelligence, the other two were
somewhat weak-minded. W. C. Sullivan.

The Influence of Social Class and of Creed on Anthropological Characters
\Der Einfluss dtr socialen Schichtung und der Confession auf die
anthropologischen Charaktere]. (Zeit. f Morphy Pd. iv, H. 1,
1901.) Pfitzner , IV.

Professor Pfitzner has continued his interesting “social anthropological
studies ” at the Strasburg Anatomical Institute by an attempt to inves¬
tigate the influence of social rank and of creed, an attempt not without
difficulties, owing to the slight range of social class among the persons
dying in hospital, and the absence of any fit standards of comparison
among persons of higher social class. As regards the latter point he has,
so far as size of head is concerned, reached certain results, though not
without the expenditure of much time and diplomacy in gaining infor¬
mation from hatters, in the course of which he was compelled to acquire
a large number of hats. He found that while the sizes of very cheap
hats range very well with the sizes of the heads of his subjects at the
Anatomical Institute, the more expensive hats have a different and
higher range of size. He himself possesses a remarkably large head,
and he finds it impossible to obtain a hat that fits him among the very
cheap class of goods, even the manufacturers, when the tradesmen
offered to procure the article desired, being unable to supply the right
size ; but among the expensive class of hats he has no difficulty in
finding one to fit him, or even one that is too large. He concludes,
therefore, that the well-to-do social classes have larger heads than the
lower social classes. In a somewhat similar manner, by acquiring skill
in estimating the height of well-to-do persons as they passed his

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EPITOME.

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shoulder in the street, he was able to convince himself that the hospital
subjects are short as compared with the well-to-do, and that, in fact,
heights which are fairly common among the latter practically never
occur at all among the former.

He then proceeded to make more exact comparisons by establishing
differences of social class among the hospital subjects themselves. The
best classification was found to be on the basis of burial. On this basis
three classes were formed: “A” those persons for whom no funds were
available for burial; “ B ” those whose burial expenses were wholly or
partly defrayed by clubs, etc.; “C” those whose burial was paid for out
of their own or their friends’ resources. The “ B ” class is represented
as standing for the main body of the hospital inmates, the “ A ” class
representing a selection downwards, the “ C ” class upwards. As
regards difference in hair and eye colour the results were not clear, but
there was a distinct increase in height in passing from “ A ” to “ B,”
and from “ B ” to “C,” the last class being in both sexes about 2 cm.
taller than the “ B ” class. Exactly the same kind of difference was
found as regards circumference of head. Differences in cephalic index
do not plainly appear in the same progressive manner, this being due
to the fact that in passing from “ A ” to “ B ” the head increases mainly
in length, in passing from “B ” to “C” mainly in breadth ; the more
dolichocephalic are thus found in “ B.” No notable results could be
found as regards other anthropological characters.

As regards creed, about 60 per cent. Roman Catholics are found
among the hospital subjects to 30 per cent . Protestants (the remainder
being of unknown faith). The only definite anthropological difference
between Catholics and Protestants that could be found was that the
former are rather more broad-headed, the latter rather more long-headed.
This agrees with a generalisation of the late Canon Taylor’s regarding
Europe generally. Havelock Ellis.

Primitive Offenders and Offences \Delinquenti e Delitti primitivi\
( Riv . Mensile di Psichiat '., Nos. 8-9, 1901.) Penta .

Professor Penta has for many years been occupied in studying
criminals in the prisons of Naples, one of the most favourable regions in
Europe for such studies. In the present paper he sets down some of
the latest of his general conclusions on the subject of the nature of
criminality. These conclusions differ widely in many respects from
those of Lombroso. He notices in the first place that he finds a very
great difference between those prisoners who are confined in establish¬
ments reserved for minor offenders and those, convicted of more serious
offences, who are confined in the convict prisons; the first are a much
more dangerous class than the second, much more incorrigible, and
much more often lacking in moral sense. He finds also that while the
first group—the more dangerous persons who only commit slight
offences,—come mainly from the cities, the others come from the
country. The individuals of the first group also belong in much larger
proportion to the class considered by Lombroso to be merely insane.
So that the offence and its punishment, taken by themselves, furnish a
very fallacious criterion for diagnosis and treatment

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1902.]

Very low and ape-like types (of which some portraits are presented)
may frequently be found among these prisoners, especially among those,
coming from the country, who have been guilty of serious crimes;
but, asks Penta, are these types really degenerate ? Do they, in other
words, reproduce, from pathological causes, archaic forms, which dis¬
tinguish them from their families and social class ? Penta is inclined
to answer this question in the negative. He finds that these individuals
in the prisons with receding foreheads, prognathism, large cheek-bones,
massive jaws, etc., merely present in an exaggerated form the types of
their race and class in the rural districts of Southern Italy. We are in
the presence not of atavistic returns to savage or anthropoid conditions
but of survivals. These persons are potential criminals who become
actively criminal under the influence of bad social conditions, where
justice is often only attainable by the rich, where many crimes do not
meet with any disapproval, economic crises are frequent, and hard con¬
ditions of life prevalent. Penta has some interesting remarks on the
Sicilian mafia , which is, he states, quite unlike the camorra . The
latter is merely an abject society of criminals, but the former is an in¬
visible and intangible association which cannot be attacked because it
exists everywhere in popular sentiment.

A number of cases are brought forward to illustrate this conception
of primitive criminality. There is undoubtedly an element of truth in
the author’s contention, though it may be pointed out that he admits
that the criminals are an exaggeration of the popular type, and that he
fails to explain why it is that under bad social conditions that press on
all some become criminals and others not. Havelock Ellis.

Pain \Der Schmerz ]. (Zeit. f Psyche Bd, xxvi, H\ 1 and 2, 1901.)

Tschisch , W. von .

In this paper Professor Tschisch sets forth his conception of pain as
a form of death. Pain, he points out, does not depend on the intensity
of the stimulus ; a Paquelin cautery at a white heat causes much less
pain than at a lower temperature. The really significant fact is that
those chemical substances which produce pain kill living tissues. Pain
is bound up with the existence of nerves, and appears before the tissue
is killed; so it is that it arises under comparatively weak stimulation,
while strong stimulation produces death. “ Those chemical substances
which excite no pain cannot kill any living tissue. Every chemical
agent which changes living tissue into dead arouses pain.” Thus it is
that excitations like strong light, loud sounds, repulsive smells, cause
no pain; while heat, cold, mechanical and electrical stimuli, poisons,
arouse pain. It is true that some poisons cause no pain ; such poisons,
however, do not act directly on living tissue ; those which act directly
on living tissue, like corrosive sublimate, produce pain. Pain is thus the
first reaction of the organism to stimuli which kill living tissue; it is the
guardian of the organism, the messenger which brings warning of ap¬
proaching danger; it announces that death has already begun to appear.

When a destructive stimulus begins to work on the organism pain
begins to appear in consciousness. But there is more than that:
changes take place in the organism, in the pulse, in the condition of

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EPITOME.

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the pupils, etc. Pain is a physiological as well as a psychological
phenomenon, and it cannot be correctly defined as a purely subjective
manifestation.

Why is pain so soon forgotten ? Tschisch answers that it consists of
a sensation and a feeling, and that the stronger the stimulus is the less
the sensation; but a state of consciousness which has been lived
through can only be retained in memory as a whole. If the sensation
is lost the whole can no longer be retained in memory, for memory
cannot reproduce feelings separated from sensations. Every healthy
mother has experience of this. This property of pain to be swiftly for¬
gotten is one of the conditions of human progress. It is because we
forget pain so easily and moral suffering with such difficulty that the
latter influences our actions so much more than the former.

The author remarks in conclusion that pain, being so easily for¬
gotten, has no educational value, and that as punishment it is useless,
cruel, and unwholesome. Havelock Ellis.

3. Physiological Psychology.

Ambidexterity [L 1 Homme droit et F Homme gauche: les Ambidextres].

(Revue philosophique, October , 1901.) Biervliet, J. J. van.

Professor van Biervliet has now completed his very careful study of
right-sidedness and left-sidedness (already summarised in the Journal)
by a still more careful investigation of ambidextrous persons. In the first
place by photography, according to a special and uniform method, he
finds that in the ambidextrous the two sides of the face, as well as the
arms, are fairly alike, the face being slightly more developed on the
right side, as among left-sided people, but not in so marked a degree.
They occupy much the same position, indeed, throughout the investiga¬
tion. When compared with right-sided and left-sided people as regards
sensory acuteness, it is found that while the right-sided have pre¬
dominant sensory acuteness on the right side, both the left-sided and
the ambidextrous can see further, hear better, possess more acute
tactile and muscular sense, on the left side, so that ambidexterity may
be regarded as a variety of left-sidedness of more symmetrical anatomical
type. In all respects the ambidextrous almost or quite resembled the
left-sided.

A further and somewhat interesting investigation was made on twenty
right-sided, left-sided, and ambidextrous persons with regard to the same
characteristics in the sphere of psychic function. Biervliet attempted to
compare visual memory and auditory memory when the right eye or ear
only was used with the result obtained when only the left eye or ear was
used, and to compare these results with those obtained when both sides
were brought into action. During the tests the subject sang a vowel
note to avoid articulation. It was found that in the right-sided the
memory of the right eye is clearly and constantly superior to that of the
left eye, and almost equal to that of both eyes acting together, which
seems to indicate that when we look at an object we really fix it with

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PHYSIOLOGICAL PSYCHOLOGY.

349

our best eye. The left-sided have a marked superiority of memory on
the left side, which is, again, nearly always equal to that of both sides
acting together. Much the same result was reached as regards the ears,
the better ear being, indeed, in many cases superior to both ears acting
together, so that it would seem that the ear which listens is somewhat
distracted by the ear which merely hears. Both as regards auditory and
visual memory, the ambidextrous behaved in the same way as the left¬
sided. The author concludes that, from the point of view at all events
of the sensory nervous system, the so-called ambidextrous person is
really a left-sided person. Havelock Ellis.

Stimulation and Fatigue \Notes sur PExcitabilite dans la Fatigue].

(Comptes rendus des Seances de la Socilti de Biologie , December ,

1900, to July , 1901.) Ferly Ch.

Fer^ has always consistently upheld the doctrine that states of fatigue
constitute the physical basis of very many psychoses and neuroses.
His experimental work has largely been devoted to the illustration of
this relationship, and he has lately carried out, in accordance with an
elaborate but uniform method, a long series of observations showing the
results of very various stimuli in affecting fatigue, as measured by work
done.

The experiments were carried on with the ergograph, uniformity being
always observed as regards the series of experiments and the duration
of the pauses. While many incidental points of interest were brought
out, the general result was to show that sensory stimuli of very various
kinds produced a swift effect in increasing, more or less, the amount of
work done over the normal, sometimes almost doubling it, but that
the subsequent fall was correspondingly great, so that the total amount
of work done was never greater under stimulation than without it, and
often less. A few of the special cases may be noted.

The effect of cold temperature was to produce a considerable diminu¬
tion of work, followed by a slight and brief increase, and then rapid
exhaustion. The effect of unpleasant stimuli (as disagreeable odours)
was very similar. Pleasant odours produce an immediate increase of
work, but, as Fer£ puts it, they cannot feed the fire they light, and the
greater the stimulating influence the greater the fatigue; if the stimula¬
tion has been prolonged the depressing influence is clearly marked, even
if an hour's interval is allowed to elapse. Theobromine has an
immediate effect in increasing work by nearly 50 per cent. } but the
effect is not very prolonged, and the total amount of work is decidedly
below normal. Caffeine produces very powerful stimulation, but the
total amount of work never exceeds the total done without stimulation,
and the more prolonged the work the greater the balance in favour of
the work done without stimulation. F^re notes that the lowering of
arterial pressure which is manifested in the fatigue following the appli¬
cation of other sensory stimuli is absent or notably diminished in the
fatigue of theobromine and caffeine; caffeine must still, however, be
regarded as an accelerator of fatigue. Work done under the stimuli of
light passed through red glass is as much increased as under the
influence of caffeine, but the total result remains the same. Hasheesh

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in small doses produces a stimulating influence rapidly lost, and in large
doses produces a depressing effect from the first. Stimulation of taste
(one to three drops of essence of cinnamon placed in the mouth) acts
similarly to hasheesh. Much the same also may be said of the
influence of opium, and whether the dose is small or large the total is
always below normal. Auditory stimuli, acting just before work is
begun, cause unusual activity, and if varied this activity may be pro¬
longed, but if monotonous (an electric bell) marked fatigue soon results.
Cutaneous stimulation by a mustard plaster produces slight stimulation
as soon as the irritation is perceived, but, though removed after the first
series of trials, depression sets in, and the total work done is deficient
by a third. Digestion produces a very depressing effect on work ; two
eggs, taken without any addition, two hours after breakfast, produce a
slight decrease in work; three eggs, taken under the same conditions,
produce a marked decrease; a little salt held in the mouth afterwards
produces a marked but only temporary stimulation. If three eggs are
taken during fasting, instead of being more stimulating they have a more
depressing effect than when taken only two hours after breakfast; a
cigarette, smoked afterwards, produces the same temporary stimulation
as the salt, but in a higher degree.

It may be added that F^rd has gone over much the same ground,
and in some respects with greater detail, in an interesting series of
papers on the variations of excitability in fatigue, published in the
Annte psychologique for 1900. Havelock Ellis.

The Alcohol Question as a Cultural and Race Problem. (Quarterly
Journal of Inebriety , October , 1901.) Forel.

This paper is an English version of an address read at the Vienna
Congress against Alcohol.

Forel points out that as the potential qualities of the future being
exist within the germ-plasm of the two cell nuclei from whose union he
develops, any poison which is capable of injuring the germ-plasm of the
procreators must imperil the development of the offspring, and these
effects on the germ-plasm are permanent, are variations transmitted by
way of heredity.

Alcohol is such a poison, as has been abundantly proved by clinical
evidence, which shows that parental alcoholism is an important agent
in the production of degeneracy. Forel quotes an interesting parallel
in certain colonies of ants, amongst whom morphological degeneracy is
very common, as a result of their addiction to imbibing the secretions
of a particular species of beetle.

Given favourable conditions, a degeneration of the whole of civilised
humanity through chronic alcoholisation is quite conceivable.
Certainly nothing supports the theory of a spontaneous evolution of
sobriety through the elimination of the unfit; on the contrary, the
facts show that no such adaptation of a society to alcohol has ever
occurred, and, so far from limiting the undesirable elements in the
community, alcohol is constantly recruiting them by poisoning healthy
stocks.

Forel’s conclusion is that the only remedy for the alcoholic peril is
total abstinence W. C. Sullivan.

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PHYSIOLOGICAL PSYCHOLOGY.

351

The Influence of Alcohol and Tobacco on Work \JOInfluence de rAlcool
et du Tabac sur le Travail ]. (Arch, de Neurol ., November and
December , 1901.) Fire.

In this very interesting paper F 6 r 6 reports a further series of experi¬
ments supporting his theory of the nature of the stimulant action of
alcohol and tobacco.

The experiments were carried out with Mosso’s ergograph, series of
ergograms performed under the influence of small doses of the drugs
being compared with a standard series taken under normal conditions.

In the first group of experiments a dose of 10 c.c. of absolute alcohol
in water was administered before work was commenced ; the result was
a gain of 4 per cent, in the first set of ergograms, the gain being
followed by a very rapid fall in energy, so that the total work in the
series amounted only to 47'61 kilogramme-metres, as compared with
the normal 143 to 150. A second and third dose of the same strength
gave even slighter stimulation, followed by more rapid exhaustion.
When fatigue was well marked the same dose of alcohol was merely
taken into the mouth and not swallowed ; the result was a rise in the
first set of ergograms from the fatigue point of 7*61 per cent, to 146 per
cent, of the standard, and this increase of energy, through the purely
peripheral stimulation, persisted much longer than was the case when
the drug was swallowed.

Throughout the second group of experiments this peripheral mode
of stimulation was used exclusively, no alcohol being swallowed. The
effect was a great initial increase of energy, amounting to 73 per cent.
above the standard; this increase lasted for a longer period, and,
though the consecutive fall was more considerable, the total work done
in the series was more than double that performed in the experiments
where the alcohol was absorbed—98'61 kilogramme-metres, instead of
47 ‘61. It was, however, a good deal below the normal.

The authors conclusion is that the stimulant effect of alcohol—to
which alone he would attribute its use—is due essentially to the irrita¬
tion of the sensory nerve-endings, and especially to the nerves of taste.

A series of ergograms under the influence of cigarette-smoking
showed that nicotine had a similar transitory stimulant effect, also most
marked in conditions of fatigue. The first set of ergograms gave a gain
in energy of 21*67 per cent., but the total work of the series was con¬
siderably below the normal, amounting only to 96*06 kilogramme-
metres.

In the case of both alcohol and tobacco, the rapidity with which ex¬
haustion follows the stimulation leads to a repetition of the stimulus,
and so to the formation of a habit.

Presumably the influence of these drugs on visceral function is
similar; that is to say, they produce an over-action followed by a corre¬
sponding depression.

The present experiments go to confirm Fare’s well-known views as to
the nature of stimulant and narcotic action.

The observations appear to have been made on a single individual.

\V. C. Sullivan.

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EPITOME.

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3 . j4Etiolo gy of Insanity.

Melancholia and the Toxcemic Theory: a Clinical Sketch. (Scot. Med.
and Surg. Journ., February, 1902.) Clouston, T. S.

This is really a valuable setiological study, and is important in that it
contains the author’s views regarding some recent pronouncements by
what one might call the newer pathological school. Otherwise the
paper is a reiteration of Dr. Clouston’s well-known teachings on
melancholia, a position as strong to-day as when first taken up some
years ago, and strengthened, if anything, by the opposing and divergent
character of present-day views.

There seems to be a tendency just now to absoluteness in formulating
views on psychiatrical subjects, which is unfortunate. Medicine in
any of its branches is not an exact science, and never can be,
especially as regards mental problems. It is possible, however, that
this tendency is a vigorous recoil from the too frequently wordy non¬
committal—indefinite, though scholarly—pronouncements of some of
the older writers.

Dr. Clouston is unable to accept the absolute toxaemic origin of
insanity, particularly of melancholia.

Considering the latter, he points out that, as a rule, there is in the
first place an “over-sensitiveness” either in the patient or in his
ancestry—the emotional reflex is exaggerated. The neurons in certain
tracts are unstable in their molecular and chemical constitution, and
pass into the katabolic condition too easily, and remain too long in
that state. Given a brain thus affected, and let it be subject to any
form of toxaemia or anaemia or exhaustion of its energies, and you have
all its weak points accentuated. This emotional katabolism is likely to
be accentuated in the progeny, and if this sort of brain is in youth
“ educated highly,”—feelings more cultivated than inhibition—if subse¬
quently life has been one of stress and strain, general health and body
nutrition becoming below par, when the turn of life sets in and
senility approaches, then we have the materials for the making of an
attack of true typical melancholia. All emotional stimuli are then apt
to excite undue mental pain, and there is also a basis for the painful
feelings and delusions in a constant vague sense of organic ill-being.
A striking characteristic of the brain is its solidarity of function and
structure. There cannot be a mental disturbance without some
nutritional, motor, or sensory change, and in melancholia there is
almost always some intellectual, volitional, circulatory, or nutritional
disturbance. There is a reaction in lower organic and nutritional
processes. Painful emotions cannot exist for long without affecting the
bacterial life within and without the organs, the leucocyte action, the
metabolism of almost every cell in the body, and the chemical composi¬
tion of every secretion and excretion. This leads to an enormous
amount of mere “ treating of symptoms ” in melancholia, instead of
looking to the origin in the cortex cerebri.

Dr. Clouston next deals with the toxaemic origin of insanity, which
has of late assumed a position of great importance, such as bodily

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ETIOLOGY OF INSANITY.

35 3

disease, auto-intoxication, alcohol, lead, arsenic, diseased eye, absence
of thyroid, septicaemia, influenza, altered intestinal and urinary
secretion.

Bruce and Alexander teach that melancholia is a disease of dis¬
ordered metabolism, and that treatment should be directed towards
getting rid of waste products through the channels of the urinary and
integumentary systems. Ford Robertson speaks equally strongly; he
proclaims that toxic action is the main factor, and that the large
majority of cases of insanity are not primarily diseases of the brain.
“ Bodily disease ” as secondary to “ mental disease ” is in general
founded upon an erroneous conception of what is taking place. Mott
dwells on the auto-poisoning by choline and other products of nerve-
degeneration. D’Abundo and Agostini think that in idiocy toxaemia
may pass into the foetus from the maternal blood, etc.

In general, Dr. Clouston cannot accept this teaching as thus stated.
There is no evidence for D’Abundo and Agostini’s hypothesis.
Mott’s statements need far more proof. As regards the modem
pathologist’s views he speaks with no uncertainty. “Their absolute¬
ness is far too great, and does not take into account at all sufficiently
the mental, ethical, and hereditary facts, and if this is so it is a
premature and incorrect scientific generalisation.”

Toxaemia is unquestionably the chief exciting cause in many cases
of insanity, the “ primary condition ” in very few. The latter is a
hereditary brain weakness and instability, without which toxaemia will
not cause melancholia or adolescent insanity, these together being by
far the most numerous and the most characteristic of the psychoses.
“ Given a perfectly sound brain cortex by heredity, no such autotoxins as
will thus affect its mental functions will ever be created. Even the
exogenous toxins, though they may affect mental actions, will not set
up insanity properly so-called.” Epochal insanities are primarily the
result of cortical nutritive arrests or perversions incident to nerve-cell
development or retrogression, and about one fourth of pubescent and
adolescent cases, and more than half of the climacteric and senile
cases, exhibit melancholic symptoms. He admits that some of the
acuter senile cases do show signs in the brain cortex and vascular
systems of an irritation which may be toxsemic, yet most climacteric and
the less acute senile cases exhibit no provable toxaemic symptoms
whatever, either during life or after death.

On the other hand, he thinks that there can be little doubt that
toxaemic conditions play the chief part—though in many not the
primary part—in general paralysis, puerperal insanity, alcoholic and
syphilitic insanities, rheumatic and gouty insanities, and possibly in
phthisical insanity.

Dr. Clouston then gives a series of cases of melancholia, all
interesting, and sketched as he alone can sketch the clinical side of
insanity.

It all points to the fact that insanity is a complex problem, intricate
and difficult, and not a simple matter, as some would have us believe,
and that it can practically never be explained by any single aetiological
factor. John R. Lord.

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EPITOME.

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Stigmata of Degeneration in the Viscera of General Paralytics and
Normal Persons [Einige “innerc” somatische Degenerationszeichen
bei Paralytikern und Normalen , zugleich als Beitrag zur Anatomie
und Anthrofologie der Variationen an den innern Hauptorganen
des Menschen\ (Allg. Zeit.f Psychiat '., Bd. Iviii , H 6.) Ndcke , P.

Dr. Nacke has here supplemented his valuable and elaborate study
of the external stigmata of degeneration in general paralytics by a study
of the internal somatic stigmata. The investigation covered the heart,
lungs, liver, kidneys, and spleen. The subjects included 104 general
paralytics and 108 normal subjects. The inquiry has been carried out
with the care and thoroughness which always mark this investigator’s
work. He admits, however, the existence of an Achilles heel in his
investigation. He was unable to carry out the inquiry on the normal
subjects himself from lack of material, and this part of the work was
undertaken by Professor Nauwerck, of Chemnitz. The material was so
far as possible identical in racial and other respects, and everything was
done to ensure, so far as possible, identity of method, but it is admitted
that a small margin must be allowed for the varying personal idiosyn¬
crasies of the two workers. It may be added that it seems fairly clear
that such allowance cannot vitiate the main results reached.

The author explains that by “ sign of degeneration ” he simply means
“rare variety,” without prejudice to any debatable question involved as
to the significance of such rare varieties. Varieties of this kind were
found in the proportion of 4 per cent . among the general paralytics and
3*2 per cent, among the normal subjects. The difference may appear
small, but further analysis of the results makes their significance more
decisive. Thus it is found that the subjects with a large number of
such anomalies (over five) occur very much more frequently among the
general paralytics than among the normal subjects (22 to 9), and that
the cases in which several organs were affected (more than two) are also
much more numerous among the general paralytics (47 to 15).
Moreover, it was found that (leaving out of account the liver because of
its notable tendency to variation) the graver anomalies occurred chiefly
in the general paralytics. These results are fairly parallel with those
previously reached in the study of the external signs of degeneration.
They point to the conclusion that heredity plays a very large part in
general paralysis, and that the majority of general paralytics possess ab
ovo an invalid brain. Such a conclusion does not exclude the rdle of
syphilis, for neither do all syphilitics nor all degenerates become general
paralytics.

After a full account of the conditions found, the author proceeds to
explain what are the conditions which he regards as really significant.
These are, as regards the lungs, abnormally large or small size, whether
of the whole or of the parts, genuinely multilobular types, and absence
of large lobe. For the heart he admits as significant distinct hypo¬
plasia, hypoplasia or hyperplasia of the large vessels, and the so-called
double apex; clearly visible traces of the foramen ovale in adults were
counted as stigmata, and the persistence of the ductus Botalli in adults.
For the liver abnormally large or small size and very abnormal shape,
especially of the left lobe, are counted, also abnormal length, diverticula*

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 355

and constrictions of the gall-bladder. The significant stigmata of the
spleen are abnormal size and very deep fissures, and of the kidneys,
besides abnormal size and shape, marked inequality, union or doubling
of ureters, and vascular anomalies of the hilum. The anomalies named
are much commoner in the general paralytics than in normal subjects.
These investigations, the author remarks, might profitably be extended
to other organs and structures—the thyroid, thymus, pancreas, glands,
vessels, nerves, muscles, etc. He considers that the internal stigmata
are probably more important than the external, although they usually
run parallel with them. Sometimes the one set of stigmata would seem
to replace the other. As in his previous works, the author emphasises
his belief that stigmata of degeneration, though often arrests of develop¬
ment (probably due to disturbance of nutrition), are very seldom
atavistic, and also that they must be marked and numerous to be of any
significance. Somewhat similar results to these here found by Nacke
would doubtless be discovered in other forms of insanity, and the field
seems a promising one for investigation. Havelock Ellis.

4. Clinical Neurology and Psychiatry.

Spontaneous Fractures in General Paralysis [Des Fractures spontanees
dans la Paralysie generate]. ( XIII 9 Cong . internal de Mid.,

1900, Sect, de Psychiat .) Lalanne , M.

The author comments upon the rarity in general paralysis of sponta¬
neous fractures, i. e. fractures arising from some slight cause, and out of
all proportion to that cause,—when it is a known fact that in most
maladies of the nervous system these fractures are comparatively
common. When one remembers the deep and varied changes produced
in the organism by general paralysis this is all the more remarkable.

He quotes M. Christian’s announcement at the Antwerp Congress of
1895 that he had no belief in any change in the osseous system super¬
vening upon a condition of general paralysis and manifesting itself in a
greater tendency to fractures, and that when any undue fragility of
bones was met with in this disorder it was purely accidental.

The author then proceeds to quote a number of cases in support of
his belief that in general paralysis there is a condition tending to spon¬
taneous fractures. One of these is that of an officer of high rank in the
army, 53 years of age, and who, up to the time of his admission into
an asylum, was actively engaged in his duties. This patient was attacked
with general paralysis of the most pronounced type. It was learnt that
two years previously, during a fit of coughing, he fractured a rib. This
fracture, which was only ascertained some days after the accident, was
bandaged, and the uniting was perfect. Two years after this he showed
the first symptoms of general paralysis, which subsequently became
pronounced. In this case all idea of traumatism due to the rough
handling of attendants may be set aside, for the patient was filling with
brilliancy his position in the army.

The author concludes by deducing that, just as in tabes spontaneous

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356

EPITOME.

[April,

fracture has been known to manifest itself as a first symptom in the
pre-tabetic period, so may it exist in the pre-paralytic period as a first
and signal manifestation of a condition of general paralysis.

John R. Lord.

A Case of Catatonia [ Un eas de Catatonic], {Bull, de la Soc, de Mid,
ment. de Belgique , September , 1901.) Sano et Heilpoin.

The interest of this case is enhanced by the fact that minute clinical
descriptions of this particular form of insanity are few in number.

The authors state that they have met with some cases very nearly
resembling the classical descriptions of Kahlbaum, Weisser, Schiile,
Aschaffenburg, and Kraepelin, but that the one here described (in the
early stages of the illness) does so most closely. After quoting the
definitions of catatonia given by Kraepelin, Kahlbaum, and Sommer,
and mentioning that one of them has had the advantage of seeing
some cases of this kind recognised and demonstrated as such by the
first-named author and others, they proceed to give a very full history
and clinical description of the case, of which a very brief summary is
here given, following the authors’ own order of arrangement of history,
mental and bodily symptoms, etc.

Apparently there was no family history of insanity. The father
was healthy, mother suffered from a malignant tumour of the scalp,
two brothers and one sister, the latter lame. Three years ago
there occurred numerous family jars, in the earliest of which he
was not to blame. On one occasion, he was struck on the head
with a belt (no internal injury) and then strapped down in a room.
He felt so humiliated that he contemplated suicide. During the
last year he became impulsively violent, and worked to excess,
particularly at developing photographs, which the authors think was
likely to predispose him to chronic chemical poisoning through the air
passages. He became exacting and hard to please, and worried about
his work. He was sent to visit some friends, but became much worse
when half-way there, and had to be sent for and brought back, and
placed in the Stuivenberg Asylum (June 25th, 1901). When seen by
the authors next day he was lying quietly in his bed, but he had been
very excited, gesticulating, shouting, and striking extraordinary atti¬
tudes, and had had to be restrained by handcuffs.

Physical Examination .—^£t. 19, well developed, without apparent
stigmata of degeneration, in good bodily health, but somewhat anaemic.
The deep and superficial reflexes were all markedly increased. The
plantar reflex on both sides showed extension of all the toes. There was
general hyperaesthesia. He flinched from being touched, and contorted
himself in a persistent and exaggerated manner after the simplest con¬
tact. The sternal and left infra-mammary regions were especially sensi¬
tive. There was a certain degree of exophthalmos, and he rolled his
eyes to the utmost limit, his eyelids being wide open. These move¬
ments were sometimes accompanied by a passing nystagmus; some¬
times the left eye was immoveable, and the right eye moved backwards
and forwards in a transverse direction, the patient’s whole body being
in a state of tonic spasm. The first of the two excellent photographs

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 357

accompanying the authors’ article shows the patient in a condition of
relative calm, the neck, however, being contracted, and the eyes
persistently fixed with a set gaze on the observed object. The second
shows him in the state of tonic spasm above described. The
pupils were contracted; they reacted to light, but had a tendency to
dilatation, particularly during excitement. After the eyes had been
closed for a moment there was a rapid but very transient contraction
of the pupils, soon followed by dilatation. At times there was a
paradoxical reflex, light producing a mydriasis, closing the eyelids a
myosis. Owing to the patient’s excited condition the fundus of the eye
and the special sensibilities could not be examined.

The patient could read and write and speak le ntcrlatidais , German,
and a little French. The authors then describe his speech and actions,
remarking that at first sight one might think that one had to deal with
a case of hysteria. He knew who he was, where he was, and what
actions he had committed ; he could tell the date and day of the week,
and he recognised those about him. After performing some antic he
would appear to know what he had done, and would even regret it. He
would sing the same refrain for many hours together, repeat a set phrase
at the pitch of his voice, accompanied by dramatic gestures. At other
times he would whistle; he would pretend, for hours together, to mount
a horse, and set off at a gallop, among other movements. When having
a bath he would sing and shout, and then suddenly become silent.
Any tactile irritation provoked exaggerated contortions, going as far as
opisthotonos at times. When he was induced to make a rythmical
movement he would continue to do so for some half-score times. His
muscles exhibited “ flexibilitas cerea.” The muscular tonicity was in¬
creased; suggestibility of movement clearly existed. It was equally
easy to put the limbs in different positions; there was catalepsy. These
latter characteristics were constant, and occurred especially when the
patient was calm and appeared to be in an almost normal condition.
On the following days the patient improved and became much quieter.
The digestive organs had kept in perfect order, and the appetite remained
good. He loved solitude, and became excited by the presence of
strangers ; the stage of mental depression then began to show itself.
Formerly a freethinker, he became religious, self-accusatory, depressed,
and taciturn. The convulsions, contortions, and queer attitudinations
began again in an intensified form. The next note on his case states
that he suffered from time to time from generalised tonic contractures
and shiverings. He would not speak, turned his head as far as possible,
carrying his eyes to their utmost limit; occasionally he laughed spas¬
modically. Idiomuscular irritability was increased in the arms; pres¬
sure of the nerves was slightly painful. Deep and superficial reflexes were
well marked ; pharyngeal, cremasteric, and plantar reflexes could not be
examined. Hyperalgesia of the lower limbs was very marked. Pupils
responded irregularly to light, sometimes contracting and sometimes
dilating, or contracting at first and then dilating; often there was an
alternation of contraction and dilatation not isochronous with the pulse.

He was mentally depressed and morbidly religious. Next day
patient was making rhythmical movements with his head, would not
speak, assumed strange attitudes, and allowed himself to fall on the

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358

EPITOME.

[April,

floor. When persuaded to write at first made large disconnected
characters, then, with a malicious expression, wrote an epithet he
intended to be insulting. During the following days the bodily sym¬
ptoms somewhat improved, and the pupils became normal. He
continued to make eccentric movements, and would only answer “yes” or
“no.” The only hallucinations may have been those of vision, but if they
were present they were fugitive and rare. The patient was transferred
to the Mortsel Asylum after being under the authors’ observation for
twenty-seven days.

Then follows a summary of the observed clinical phenomena grouped
into successive periods :

^EtiologicalElements. —Depressed moral emotions, chemical poisoning,
anaemia.

First Period. —Increasing mental irritability, insomnia, impulsive
attacks (some months).

Second Period. —Hyperaesthesia and hyperalgesia, exaggeration of
reflexes with alteration of the plantar and pupillary, maniacal excitement
with catatonia and catalepsy, convulsive attacks (a slight remission at
the beginning of this period, which lasted fifteen days).

Third Period. —Hyperaesthesia and hyperalgesia, exaggerated reflexes,
transient catatonia and catalepsy, convulsive attacks less frequent,
melancholia, depression with self-accusations (six days).

Fourth Period. —Hyperaesthesia and hyperalgesia, silence and stupor,
passing catatonia and catalepsy, convulsive attacks less intense and less
frequent (this condition afterwards maintained during several weeks at
least).

In conclusion, in giving their reasons for believing this case to be one
of catatonia and not of hysteria, they state that although one must not
err in giving too great importance to the modifications of the cutaneous
reflexes, especially when transitory, they are of opinion that extension of
the toes on excitation of the plantar reflex indicated a serious lesion
of the neurons constituting the pyramidal tracts. A. W. Wilcox.

Acute Delirious Mania and Urcemia \Dilire aigu et Urlmie\ (Arch, de
Neurol\ December , 1901.) Cullerre .

The author records two cases in support of his view that the syn¬
drome of acute delirious mania is frequently an effect of renal disease,
is, in fact, a hyperacute uraemic insanity.

Observation 1.—A woman aet. about 55, of unknown antecedents, was
admitted to the asylum with symptoms of hallucinatory delirium, which
within a few days became very intense and were associated with high
fever and profuse foetid diarrhoea. With a brief period of intermission
the case ran a rapid course, and terminated fatally seven weeks after
admission. The autopsy showed very contracted granular kidneys, and
no macroscopic brain lesions.

Observation 2.—The patient was a man with bad heredity; father
suicide, mother insane, brother alcoholic and insane. At the age of 41
patient had his first attack of insanity, in which he presented symptoms
of maniacal excitement, followed by catatonic phenomena, and later by
a phase of deep melancholia. Recovery appeared complete. After

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1902 .]

TREATMENT OF INSANITY.

359

nine years of mental health he was readmitted to the asylum in a state
of agitated melancholia, and two days after reception symptoms of
acute delirious mania were developed with suppression of urine and
persistent vomiting. No autopsy was held, but the uraemic symptoms
made the nature of the case clear. The author also suggests that
latent uraemia had something to do with the earlier attack, its influence
being shown by the occurrence of catatonic phenomena, which do not
belong to the psychoses of the adult. W. C. Sullivan.

Some Obscure Injuries following the Toxic Use of Alcohol. (Quarterly
Journal of Inebriety, October, 1901.) Crothers.

Dr. Crothers puts forward the thesis that in a certain number of
cases the development of psychoses and of organic diseases of the
nervous system is due to a single profound intoxication by alcohol. In
some instances the symptoms of the nervous affection follow im¬
mediately on the intoxication; in others a considerable latent period
intervenes. Puberty and late middle life are pointed out as times when
intoxication is peculiarly liable to be followed by these paralcoholic
disorders. The author believes that morbid inebriety appearing late in
life has often this origin.

Reference is made to several cases showing the sequence of
phenomena described by the author; the question, however, of their
causal connection in the manner suggested remains necessarily doubtful.
The paper is an extremely interesting one. W. C. Sullivan.

5. Treatment of Insanity.

On the Action of the Bromides during Hypochlorisation [Mecanisme de
VAction des Bromures avec P Hypochloruration\ {Rev. de Psychiat.,
September, 1901.) Laufer, R. J.

Reference to this subject has been made on more than one occasion
in the pages of this Journal, but the matter is of sufficient importance
to call for further notice. Dr. Laufer considers as proved that hypo¬
chlorisation, /. e. the reduction of the chlorides in the dietary, enhances
the efficacy of the bromides in the treatment of epilepsy. This
method of treatment we owe to Drs. Ch. Richet and Toulouse. The
object of the present paper is to explain the modus operandi. It is
pointed out in the first place that, without the addition of an atom of
salt, the dietary, provided that it is a physiological one, contains a
sufficiency of NaCl, that the customary use of salt as a condiment
and as a culinary addition furnishes a luxus supply, and that the with¬
drawal of this luxus, without producing any harmful effect, makes
itself felt as a slight reduction in the NaCl exchange of the
tissues. Next reference is made to the tendency of bromides to
accumulate in the tissues generally, and in particular in those of the
liver and brain, observers differing as to the greater relative affinity of
these two organs for the bromide. We are then asked if it would be
XLVIII. 25

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EPITOME.

[April,

surprising that in the presence of a deficiency of chlorides such
kindred salts as the bromides should fix themselves in the tissues in
.greater quantity after the manner of a substitution. That such sub¬
stitution does in fact obtain has been proved by various observers by the
demonstration, e.g , 9 that hydriodic and hydrobromic acids appear in the
stomach, and to some extent replace hydrochloric acid when animals
are given iodides and bromides in appreciable quantities; and yet
more directly it has been shown that the administration of bromides
during hypochlorisation may raise the bromide contents of the tissues
above that of the chlorides even (Nencki and Schumow Simanowski).

Study of the urine of patients taking bromides gives further proof of
the relation of these salts to the chlorides, for we observe that in a
manner they show what might be termed displacement equivalents,
and it is on this matter that Dr. Laufer records some experiments.
Thus he shows that when a given dietary, say of milk (therefore
hypochlorised), together with a fixed dose of bromide, has been main¬
tained for sufficient length of time to establish a fixed proportion
between the excretion of bromides and of chlorides in the urine, the
administration then of an increased dose of chlorides augments the
output of the bromides from the accumulated store in the tissues, the
significance of this being that in the absence of a luxus supply of
chlorides the bromides have taken their place for the time being, to
again give place on a restoration of the excess of chlorides. This
comes out quite clearly in the experiments. The reverse, also, would
appear to take place, viz, the displacement up to a certain point of
chlorides by bromides, so that the giving of full doses of bromides to
persons saturated with chlorides leads to a larger elimination of
chlorides,—in excess, indeed, of the intake. To a certain extent, then,
this relative absorption and elimination by the tissues of kindred
salts appears to be as much a question of balance as of affinity.

This question of the saline exchange of the tissues is a very im¬
portant one, touching directly, as it does, the large subjects of
accumulation, saturation, and elimination.

From Dr. Lauferis experiments it would also appear that other salts,
less immediately related, are vitally affected by the rate of supply of
each other. Thus the administration of an excess of chloride of
sodium led to an increased output of phosphates and of urea.

The practical outcome of these considerations is as follows :

1. That we understand why it is that the reduction of the sodium
chloride in the diet enables us to reduce the dose of the bromide
therapeutically, because viz. the latter is better absorbed or assimilated
by the tissues, and therefore is more potent.

2. That having obtained our bromide effect on the hypochlorised
-diet we shall avoid the sudden transition to a full saline diet, since this
will mean the rapid expulsion of the bromide salts, and will be
tantamount to the sudden reduction of the bromide dose.

3. That in passing from a full saline diet to a reduced saline diet in
the case of a patient under bromide treatment, we shall reduce the
■bromide dosage pari passu .

4. That in cases of bromism with disturbed digestive tract, where
the diet has been the ordinary saline one, it may suffice to put the

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TREATMENT OF INSANITY.

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361

patient on a hypochlorised diet, since we are thus enabled to reduce
the bromide. Thus we may be able to maintain our therapeutic effect,
and yet save the alimentary tract.

5. That in cases of severe bromism, if we desire to remove the
bromine as rapidly as possible from the system, we shall do so best by
adding freely of salt to the dietary, e.g ., 60 grains of salt to the litre of
milk.

6. That lastly, supposing the patient under the influence of the
bromides develop a febrile affection, necessitating a milk diet, we shall
not forget that this is a hypochlorised regimen.

Harrington Sainsbury.

Effect of the Combined Action of Bromides with Hypochlorisation on
the Convulsive Seizures of Epilepsy and their Psychic Equivalents
[Effets de la Bromuration combinee avec VHypochloruration sur les
Acch convulsifs et les Equivalents psychiques Spilcptiques\ (Rev.
de Psychiat., October , 1901.) Toulouse et Meunier.

This paper describes a case of inveterate epilepsy, in which periods
of mental calm along with convulsive seizures alternated with periods
of delirious excitement without convulsions. The effect on this case of
the above-mentioned treatment was to suppress wholly the delirious
periods, whilst at the same time the spasmodic attacks were greatly
diminished.

The object of the paper is simply to demonstrate the efficacy of the
method in respect of a symptom which appears to have been the
psychic equivalent of a convulsive attack. Harrington Sainsbury.

The Open Door and Bed Treatment in the Argentine Republic—the
National Asylum at Lujan , Buenos Ayres [L’“ Open-Door ” et le
Traitement au Lit dans la Republique Argentine—Colonie nationale
(TAlilnls de Lujan , Province de Bubios-Aires]. (XIII e Cong,
internat . de Mid., 1900, Sect, de Psychiat.) Gabred, D .

The housing of the insane was doubtless one of the most interesting
questions dealt with at the International Congress for Psychiatry in
the year 1900.

For some years past new methods of treatment of acute insanity,
such as that of the open door and rest in bed } have made their appear¬
ance, modifying greatly the prevailing systems. The happy results
achieved by these methods in the asylums of Germany and of Scot¬
land (where I had the opportunity of observing them in 1896), and
those which I have myself noted in the asylum of Las Mercedes at
Buenos Ayres, where I introduced them on my return from Europe,
have imbued me with a feeling of certainty, both as regards their efficacy
and the necessity of applying them as widely as possible. •

In what manner can these two methods of treatment be secured in
the housing of the insane in order that their efficacy may be as com¬
plete as possible ?

A study of the plan of the National Colony of Lunatics, which is
being established in the Argentine Republic, answers to some extent
the question. It combines the open door housing of the quiet and

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EPITOME.

362

[April,

chronic insane with the clinico-therapeutic treatment of the acute as
practised in Scotland, Germany, Russia, North America, and, to some
extent, in France.

Description of the Asylum.

The new lunatic asylum which has been founded in the Argentine
Republic, upon an extremely picturesque site near the village of Lujan,
is situated on the banks of the river of the same name, and about sixty
kilometres from Buenos Ayres. Two lines of railway run close to the
asylum, that of the West, some five kilometres distant, and the Pacific,
1500 metres away. The estate, which covers an area of 530 hectares,
is raised, slightly undulating, and very fertile. It is covered for an
extent of twenty hectares with great trees, which form splendid shelters
and avenues.

The future population of the colony will consist of 1400 pauper
lunatics and 150 private patients. This number of patients at first
sight appears very large, but one must remember that there lunatic
asylums are very scarce,—in fact, one may safely affirm that half of the
patients needing hospital treatment do not receive any.

The system called by the Scotch the “ open door ” has been the
one observed in the new asylum, and the asylum of Alt-Scherbitz has
been principally the model for its construction, but there have been
introduced some important modifications in the various sections
destined for the patients as well as in the administrative departments.
The admirable organisation of the Prusso-Saxon asylum has been
combined with the comfort of the British, while at the same time
sections have been formed which are not found in the latter.

The new asylum is composed of two parts : one, the central asylum;
and the other the colony, properly so called.

The former is for the patients who have to be kept under constant
observation, who have to be isolated, or have special medical
treatment, measures which will be pursued in the villas, which have,
each one according to its class of patient, appropriate arrangements.

The latter, intended for the treatment of the larger portion of the
lunatics (some 80 per cent), is designed for the application, on the
most ample lines, of the open door and agricultural labour principles,
without excluding other kindred occupations, and allows for the utilisa¬
tion of the different abilities of the patients.

In the central asylum are situated, in addition to the villas destined
for the clinical and administrative staff, four villas for constant observa¬
tion, four for the excited, and three for subacute cases (all such cases
treated by rest in bed). Moreover, two villas for convalescing cases,
two for paralytics, two are infirmaries, one as a hospital for infectious
diseases, one for criminal lunatics, one for anatomical and pathological
purposes, and lastly the furnace for cremation and the cemetery.

From this one can see the important place treatment by rest in bed has
in the central asylum, so much so that the greater portion of the patients
will be treated on these lines. The observations which, as I have before
said, I have made in Europe and in the Argentine Republic upon the
efficacy of this treatment, which constitutes, as my learned friend Dr.
Slrieux puts it, “ one of the greatest advances of contemporary

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TREATMENT OF INSANITY.

363

1902.]

psychiatry,” have led me to establish it as largely as possible. In fact,
apart from the good effect as a sedative for nervous excitement which
the bed treatment has proved to have, remembering also the advantages
which it yields for the examination of the lunatic, and the good influence
which it exercises upon nutrition, this treatment greatly facilitates the
observation of the patient, and in most cases permits of doing away with
the use of the single room.

Thus, for example, in the asylum of Las Mercedes, in which 1300
lunatics are confined, and where, in the year 1896, there were
constantly in single rooms some forty or fifty maniacs daily, after the
installation of the clinico-therapeutic system they were reduced to less
than three daily, and then only for a few hours.

The central asylum will be, therefore, almost exclusively intended for
this form of treatment, excepting the convalescent villas, in which
lunatics will only remain for a short time before being sent into the
colony, and the villa for criminal lunatics.

Villas for Constant Observation .—The arrangement of the villas is
extremely simple, being modelled on similar villas in the asylums of
Alt-Scherbitz, Giessen, Uchspringe, and Halle. In these villas the
patients occupy the ground-floor, which comprise, first, two dormi¬
tories which communicate with each other, each one having fifteen beds;
second, a large vestibule in communication with the dormitories; third,
two isolation rooms; fourth, a bath-room with water-closets, which is
likewise in communication with the dormitories. The villas have, more¬
over, a small upper storey, where are several rooms for the linen and for
the nursing staff. The basements serve as general stores. A walk,
three metres wide, surrounds each villa, and this is bounded on all
sides by a quickset hedge two metres high. The interior arrangement of
this section allows, as may be easily understood, of the maintenance of
strict observation.

Villas for Acute and Subacute Maniacs .—These are each fitted
up for thirty patients, and their interior arrangements are of such a
nature as to have for their principal object treatment by rest in bed.
Therefore, in place of a number of single rooms, they are arranged like
the observation villas, domfitories on the ground-floor in communica¬
tion with bath and annexe, and one side room for each group of fifteen
patients. The latter is four metres long, four wide, and five high, well
ventilated, and fitted with natural and artificial illumination, which may
be regulated as desired; it does not, therefore, resemble in the remotest
degree the cell of the old “ closed ” asylums.

The lunatic will only occupy it for a short time, when some period of
extreme exaltation prevents him being kept in bed. There is also on
the ground-floor a small dining-room and a small social room. The
linen stores and the rooms for the nursing staff are on the upper floor.
A quickset hedge, two metres high, likewise surrounds these villas, each
being provided with a large open space where the maniacs in their rest¬
ful periods may lounge in the sun and breathe the pure country air.

Convalescent Villas .—These are designed for housing for a few
days such patients as come from the constant observation or maniac
section before they proceed into the colony. We may call them the
transition stage between the central asylum and the colony, and their

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364

EPITOME.

[April,

object is to act as a stepping-stone to the great freedom allowed the
patient in the colony. They have a ground-floor and an upper storey.
On the ground-floor are the social room and dining-room, the baths
and water-closets; on the upper storey, the usual dormitories, the
linen store, baths, etc.

Villas for Paralytics .—These are likewise designed with a ground-
floor and an upper storey, where are the dormitories, small social rooms,
small dining-rooms, baths, etc.

Although these villas only have an area equal to the others, yet they
possess a larger number of beds, this being explained by the fact that
they are designed for patients who have arrived at the third period of
their illness and are bedridden for the greater part of the time. They
are also surrounded by large open and covered walks which allow the
patients to take the air and to bathe in the sunshine, lying at length in
their long chairs. These villas are provided with lifts.

Infirmaries .—These have, like the villas already described, a ground-
floor and an upper storey. On the ground-floor are, first, two wards,
each for twelve patients; second, bath-rooms and water-closets; third,
dispensary; fourth,, a room for the hopeless cases; fifth, a room for the
nurses; sixth, a linen store; seventh, a medicine store. The same
arrangement is repeated on the upper floor, and there is a lift. As an
annexe to the infirmary, and connected to it by a passage, is the operating
room.

Infection Hospital. —Right away from all the various sections is the
villa for contagious diseases. Provided with every convenience and as
comfortable as the other villas, it is divided into two parts, one for
paupers and the other for private patients. It will accommodate
twenty of the former and five of the latter.

Villa for Criminal Lunatics. —This will contain fifty patients, and is
composed of a ground-floor and an upper storey.

On the ground-floor are the dining-room, some workshops, a social
room, baths, and water-closets. On the upper floor are rooms for
lodging one, two, and four patients, dwelling rooms for the observation
staff, linen store, baths, etc.

This villa, the largest of the establishment, is the only one which has
its windows provided with iron guards (grilles), and likewise the only one
surrounded with a wall four metres high and with a saut de loup. The
wall, being situated eighty metres from the building, allows of a good
space for exercise.

Pavilion for Pathological Anatomy. —This is composed of an autopsy
room, a deadhouse, a laboratory, a museum, etc.

Crematorium .—This furnace is in connection with the little cemetery
of the asylum, and the corpses of pauper lunatics which are not claimed
by their families will there be cremated.

Colony.

The explanatory notes accompanying the plan almost render any
description of this portion of the asylum superfluous.

In the first place, the colony is separated from the central asylum by
an avenue thirty metres wide as well as by laige gardens. The villas, as
in the case of the central asylum, are spread about, without boundaries

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1902.] TREATMENT OF INSANITY. 365

or fences, and the whole forms a picturesque village, which removes all
thought of isolation and bears no semblance to an asylum. They are
distant from one another about fifty mitres, and those which are
intended for administrative uses are grouped in the centre of the
establishment.

Villas for Pauptr Lunatics .—As a general rule, these are designed for
thirty lunatics, but some can accommodate as many as forty. They
have a basement, a ground-floor, and an upper storey. The basement
serves as a depot for stores. On the ground-floor are the dining-room,
the office, the social room, baths, lavatories, urinals, and water-closets^
The upper floor is taken up by the dormitories, linen store, lavatories*
baths, etc.

The villas, or ch&lets, are simple in their appearance, and although
all in their construction conform to the type indicated they are so
varied in their designs that amongst the thirty-one which compose this-
section there are not two which are alike. Surrounded with walks three
metres wide, they are situated in the midst of parks and gardens.

Villas for Private Patients. —Replete with every convenience, these
villas may come under four heads: those of the third class can each
contain twenty lunatics, those of the second, ten; and those of the first
class, four. The villas for special private patients are each designed
for a single case.

Villas for Imbecile Children .—One of these is designed as a home; in
it are dormitories, social room, baths, etc. The other is appropriated
for a school, gymnasium, and workshops ; that is to say, both medical
treatment and instruction can be carried out in a complete manner.

Pavilion for Hydropathy. —This is situated almost in the centre of
the colony, and is composed, first, of a large piscina, thirty metres
by twelve, with a continual flow of water; second, of a room with cold,
fine sprays; third, bath-rooms of warm air; fourth, sulphur baths;
fifth, tepid baths; sixth, a massage room; seventh, small rooms
for storing the linen ; eighth, a room for electro-therapeutics.

The Theatre. —Having seating capacity for fully 300 people, it serves
not only for the presentation of plays but also for balls and concerts.

The Church. —This has likewise room for 300 people, and although
the greater part of the lunatics are Catholics, those who are not are
free to receive the visits of priests of other religions.

Administrative Departments. —Kitchen, laundry, steward’s offices,
linen store, etc, are placed, as has already been said, in the very
midst of the establishment.

The Engine Room. —This is intended to provide the kitchen with
steam, the workshops with power, the heating of the greater part of the
asylum, and also to run the dynamos for the electric light. The
fitting up of the workshops, the stables, the pigsty, the poultry-yard,
and the pigeon loft have been the object of very special care, as
well as the cultivation of the ground, which goes to the upkeep of the
asylum.

The above brief description will give an idea of this unique and
complete asylum, conceived with the object of helping the lunatic on
the no-restraint, open-door, rest-in-bed principles, and by the applica¬
tion of agricultural labour with the widest possible scope.

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EPITOME.

[April,

The cost of construction of this establishment has been calculated
at 3J million piastres of the national currency, and above this sum
94,000 piastres have been paid for the acquisition of the site; thus the
total cost is about 3,594,000 piastres of the national currency. This
sum reduced to francs at the current rate of exchange represents
7,825,325 francs, thus making the cost of each bed 4742 francs. 1

The very simple designs of the asylum explain the low cost of each
bed; this is especially noticeable when one compares it with the cost
per bed in the regular “ closed ” asylums of the large towns.

John R. Lord.

6. Sociology.

Considerations on Infanticide \Quelques Considerations sur lInfanticide ].

(Arch. (TArth. crim.,January 1 8 th, 1902.) Audiffrent '.

In this paper Dr. Audiffrent deals with the mental conditions that
commonly prevail in cases of infanticide, and with the influence which
such conditions should exert on the social and legal attitude towards
infanticide. With special reference to a case in which a young woman
escaped from an asylum and killed herself and her child, the author
considers the peculiar psychological conditions of pregnancy and ihe
puerperal period, and suggests that there are biological reasons why a
woman in whom, from whatever cause, abnormal mental conditions are
set up, should be impelled to destroy her child. This impulse is not
confined to the human female, but is found throughout nature,
and leads, for instance, a bird whose young have been confined in a
cage to enter the cage and kill them, while many animals, if interfered
with after parturition, will kill or eat their young. The author considers
that this tendency is recognised outside civilisation, and that it
lies at the basis of the wide-spread belief that the mother is the
mistress of the child she has carried in her womb, that it belongs to
her like any other object that she produces, and that no one has any
right to contest her rights over her infant’s life.

The author does not propose to return to this conception of a
mother’s rights, but he concludes that a strict study of the phenomena
accompanying childbirth shows that the mother is not in full possession
of her faculties at this critical moment of her existence, and that we
must be very cautious in pronouncing judgment on her guilt.

Havelock Ellis.

7. Asylum Reports.

Some Scottish Royal Asylums .

Aberdeen Royal Asylum .—We note that Dr. Reid has had fitted up
an electric bath—in a position where it can be used for either sex.

1 I understand that the Argentine piastre is worth about 1 franc 20 centimes,
making cost per bed 2782 francs, or 6$.—J. R. L.

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ASYLUM REPORTS.

367

1902.]

An extract from his report:

An interesting and gratifying feature is that no less than six former patients
voluntarily applied for admission at the door of the asylum. These were either
labouring under morbid depression with the usual accompanying delusions, or were
seeking the protection of the asylum from imaginary tormentors. This would
seem to point to the fact that former patients appreciate the value of the treatment
they have received, and would go to disprove the erroneous ideas and prejudices
entertained by many of the general public in regard to the working of such an
institution and the treatment of the patients.

We are much struck with the few cases (twelve out of 308 admissions)
where the causation is ascribed to “ moral ” troubles. About the same
proportion obtains at Momingside, the respective numbers for that
institution being seventeen and 472. At Montrose and Perth the
proportions are very much higher, while the five-year average table of
the English Commissioners shows moral causation in 21 per cent, of
the admissions. Some interesting reflections arise in connection with
these divergences, which probably cannot be accounted for by variations
in attributes or circumstances of the patients themselves.

Royal Edinburgh Asylum .—The past has been a record year as far
as admissions are concerned, no less than 472 new cases having been
received. The increase has been entirely in rate-paid patients, and the
possibilities of offering care and treatment to private cases have been
correspondingly reduced. Dr. Clouston points out that if such
increases are maintained the arrangements made at the new asylum of
West Bangour will be upset. Looking, as he usually does, in consider¬
able detail at the cause for the increase, Dr. Clouston fixes his
attention on alcohol, against which he delivers himself with more than
wonted vigour. In this we think he is right, and he is also right in
preaching self-care, self-education, and self-respect in the individual,
not only in alcoholic temperance but in the general ordering of life, as
the real antagonism to insanity. He draws his population from an area
where strong drinks abound, but where also apart from such things strong
purpose and strong good sense likewise abound. While for many super¬
intendents the uttering of warnings and exhortations is but preaching
in the wilderness, he has the chance of exerting with some success the
weight of his personal opinion. We believe that good would arise if
more would follow his example. Who shall put before the people the
physical, moral, and intellectual degeneration threatened by indulgence
if the head of an asylum does not ? What evidence can be used as a
better means of arousing attention and securing reform than that of
the asylum ?

Dr. Clouston touches on a delicate point in the matter of watching
suicidal cases. As is well known, close supervision in such cases,
though essential at first, is often found to be irksome and irritating, and
therefore prejudicial, to an improving case. And unfortunately
experience shows that just at the time of a patient’s feeling his feet
again a suicidal wave may pass over him. The question then is, as Dr.
Clouston puts it, shall cure come before care ?

Montrose Royal Asylum .—We extract the following very interesting
item from Dr. Havelock’s report:

The Prevalence of Suicidal Tendency .—A large number of those admitted had

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368

EPITOME.

[April,

made suicidal attempts, and for long periods after admission showed that they
would take advantage of any opportunity to carry out their insane purpose. The
following statistics compiled by Sir John Sibbald, now published for the first time,
show that Forfarshire and the neighbouring county of Kincardine have a larger
proportion of suicides compared to population than the rest of Scotland.

Number of Suicides during Eighteen Years (1877-94) compiled from Reports of
Registrar-General for Scotland, by Sir John Sibbald

Methods.

Forfar.

Kincardine.

Scotland.

S/-2

SS 2

Hanging .

V Q.

to 0

Drowning

Wounding

73 ^

2 e

c.2

Poisoning.
Otherwise

Total .

With reference to above statistics, Sir John, in writing to me, states:—“ I have
not arrived at any decided opinion as to the special frequency shown by the numbers
for Forfar and Kincardine. Some would say it was due to special honesty of
registration in these counties—that suicide was more frequently concealed in other
counties. Some would say it was due to the absence of the Celtic element in the
population. Others to a want of due regard for the chances of punishment in the
great hereafter. The counties on the east coast of Scotland all show higher
suicidal rates than the western counties. It is curious that the city of Dundee
shows a lower rate than the rest of Forfarshire. It is so far in favour of the views
of those who say that Celticism and Catholicism prevent suicide, for I suppose
Dundee contains the largest proportion of Irish Catholics of any part of Forfar¬
shire.”

An analysis of the admissions to Montrose Asylum for 1900-1 shows that 29 per
cent, of the cases from Forfarshire and 40 per cent, of the cases from Kincardine¬
shire had a pronounced suicidal tendency. My own observations during the last
twelve years bring out that certain parishes in the counties of Forfar and Kincardine
send a very high proportion of suicidal cases to the asylum, and that suicides are
specially frequent in these parishes. A possible explanation of this seems to be
that of inherited predisposition, for suicidal tendency is strongly hereditary in
most cases, and is prone to increase unduly in districts where the population is
stagnant and stationary. The whole subject of suicide is beset with problems of
extreme interest and difficulty.

James Murray's Royal Asylum , Perth .—The accommodation is here
becoming so short that it is in contemplation to provide more. Dr.
Urquhart finds that detached houses are limited in their use, and are as
a matter of fact more acceptable to patients’ relatives than to the
patients themselves, the latter preferring the larger current of life in the
main building. But he does not approve of too much main building,
and suggests, as a compromise, self-contained buildings connected to the
asylum by corridors, a plan successfully adopted at Momingside. Of
his forty admissions no less than eight men and one woman were the
victims of chronic alcoholism—a large proportion. One case admitted
had an attack of severe influenza and developed an internal abscess in
the right aural region. After surgical relief the mental symptoms
abated, and he was discharged recovered.

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1902.]

NOTES AND NEWS.

369

Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

A Council and General Meeting of the Association were held at the
Cheadle Royal Hospital, Cheadle, near Manchester, on February 14th last (1902),
through the kindness and courtesy of Dr. Mould, and it proved to be one of the
most appreciated and interesting of General Meetings held in the provinces.

The Council was attended by Drs. Oscar T. Woods (President), J. Wigles-
worth, H. Hayes Newington, C. K. Hitchcock, C. A. Mercier, R. Percy Smith, A.
Miller, T. S. Adair, J. B. Spence, and Robert Jones.

Apologies for non-attenaance were received from Drs. Fletcher Beach, A. R.
Urquhart, H. T. S. Aveline, A. R. Turnbull, C. Hubert Bond, D. Bower, H. A.
Benham, L. A. Weatherly, and P. W. MacDonald.

The following members attended the General Meeting:—James Stewart, J.
Wiglesworth, L. A. French, David Yellowlees, Frank A. Elkins, E. B. Whitcombe r
James Rutherford, James Middlemass, W. S. Kay, C. A. Mercier, R. J. Legge,
W. F. Farquharson, A. Miller, T. S. Adair, C. K. Hitchcock, Bedford Pierce,
H. Corner, G. E. Mould, T. Seymour Tuke, James Chambers, W. Scowcroft r
L. R. Oswald, W. F. Menzies, Oscar T. Woods, ! J. R. Gilmour, J. Carlyle John¬
stone, J. C. Nixon, R. Percy Smith, J. S. Bolton, J. O’C. Donelan, H. H.
Newington, W. Starkey, T. S. Sheldon, J. B. Spence, David Orr, J. C. McConaghey r
Henry J. Mackenzie, Stanley E. Gill, David Blair, Frank Perceval, and Robert.
Jones. Visitor : Mr. J. M. Rhodes.

Apologies for non-attendance at the General Meeting were received from those
already recorded for the Council, and from the following additional members:—
Drs. James Rorie, David Nicholson, F. W. Mott, G. H. Savage, R. StilwelL
John McClintock, T. L. Rogers, W. B. Tate, J. A. Oakshott, J. G. Soutar r
E. H. O. Sankey, J. F. G. Pietersen, and C. S. Morrison.

During the morning the members were conducted over the buildings and
grounds, and afterwards they were hospitably entertained at luncheon by Dr.
Mould.

The President, in proposing Dr. Mould’s health, felicitously referred to the
fact that the meeting was being held on the fortieth anniversary of Dr. Mould’s
tenure of office as Medical Superintendent of the Cheadle Royal Hospital.

The General Meeting was held at 3 p.m.

The President, at the commencement of the proceedings, announced that at
the Council Meeting that morning, very much to the regret of every one present.
Dr. H. A. Benham had sent in his resignation in consequence of illness. The
Council had passed a vote of sympathy with him, and had appointed Dr. Alfred
Miller to act in his place till the Annual Meeting.

The President also announced that the Chief Secretary for Ireland had
acknowledged the resolution which had been sent to him.

The Normal Posterior Root Ganglia and their Degenerative Phases
in General Paralysis of the Insane.

Drs. Orr and Rows described the normal histological appearances of the nerve-
cells in the posterior root ganglia of the dog and of the human subject, and the
degenerative phases of the latter in general paralysis of the insane.

The special technique by which shrinkage is avoided was explained in detail,
and an excellent demonstration, by means of lantern slides, was given of the five
types of cells which have been distinguished in the posterior root ganglia, and of
the different ways in which the cells degenerate.

The demonstration afforded proof of the view that the actual amount of cell
destruction was quite insufficient to explain the degenerations found in the posterior
columns of the cord. These degenerations were ascribed to the action of toxins
attacking the fibres in their length.

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37 o

NOTES AND NEWS.

[April,

Dr. Rows then read a paper entitled “ The Bearing of Recent Research in the
Posterior Root Ganglia upon the New Theories concerning the Etiology of Tabes
dorsalis ” (see page 308).

Dr. Bolton said he was afraid this subject hardly lent itself to discussion, as
Dr. Orr had carefully avoided expressing any opinion upon the causation of the
appearances which he described; and while Dr. Rows had referred with considerable
•detail to the views which had been held on the pathology of tabes dorsalis, he,
again, had not referred to any general pathological question. He should like to ask
them some questions with regard to the changes in the posterior root ganglion cells
which they had described. The greater part of the changes shown by them were,
in his opinion, acute. Acute changes purely of the kind shown could not possibly,
under any circumstances, produce degenerative changes in the posterior columns,
and it looked as if the general secondary toxsemic condition of general paralysis
was probably the cause of the recent chromatolytic changes which they had been
shown. They certainly did find similar changes in other acute general toxzmic
states, as after alcoholic excess and childbirth. He should like to have Dr. Rows’
and Dr. Orr’s opinions as to whether those changes were of a secondary nature of that
kind, and common to all parts of the nervous system, or peculiar to the posterior
root ganglia. With regard to the changes in the posterior columns in tabes, which
Dr. Rows had referred to, one might expect to find very chronic atrophic changes
in the cells, and it was quite probable, as they knew so little concerning the normal
structure of these cells, that such changes might occur in the posterior root
ganglion cells, and possibly be the explanation of certain of the different types
described. He would also like to know whether those changes occurred equally in
all the cells of the five types shown or only in a number of them. Had they
formed any opinion with reference to the relative functional value of the different
types of cells?

Dr. Jones said that beyond the actual pathological value the demonstration bore
some influence upon the prevention of the disease, general paralysis of the insane
being one of those diseases, the origin of which, in many instances at any rate,
might be prevented, and it was not improbable that an educated democracy might
call for measures of control in regard to it, and, perhaps, in the not distant future.
In his experience a certain number of the cases of general paralysis had locomotor
ataxic symptoms. There were a certain number of general paralytic cases also
that never came into asylums at all, and he believed those might form about 15
per cent, of the total cases of general paralysis. Possibly 5 per cent, of the total
cases of general paralysis had locomotor ataxic symptoms, and 80 per cent, were
the typical cases which we, as clinicians, meet with in asylums. Fournier had
stated that 20 per cent, of all cases presenting symptoms of tertiarjr syphilis
presented those of cerebral syphilis in some form, so that we can readily see the
influence which this toxic agent bears in the production of insanity, and the great
need there is for some protective measures in regard to it. Dr. Jones stated he
was interested in the question put by Dr. Bolton as to the relative value of the
five different cells in the posterior spinal ganglia. We knew, he stated, as
clinicians, the grossly fat stage which occurred in the course of general paralysis,
and we knew also that assimilation, nutrition, and general metabolism depended
upon the condition of nerve-cells, whether of the spinal, or sympathetic, or both
was uncertain ; and he would like to emphasise the question put by Dr. Bolton if
some of these nerve-cells had not a viscero-vascular influence, and perhaps Dr.
Orr and Dr. Rows might be able to give some information upon this point. Dr.
Jones concluded by saying that the subject of the demonstration was a most
interesting one, and he thought their best thanks were due to the joint authors of
this work.

Dr. Orr thanked the Association for the manner in which they had received the
•demonstration. In reply to Drs. Jones and Bolton regarding the function to be
attached to each of the five types of cells, he regretted that at present he was quite
unable to give any opinion, and suggested that such a question might be determined
by experimental research. He was convinced that the nerve-cell changes shown and
described were of a chronic nature, and drew attention to the fact that they differed
from the acute forms of nerve-cell degeneration found in the posterior root ganglion
cells in certain forms of acute insanity. He further pointed out that many cells
showed the typical appearances found in cells undergoing a regenerative phase, as

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1902.]

described in certain experiments, and expressed the view that they could pass
through the phases of degeneration and recovery more than once before they finally
succumbed. On these grounds, therefore, he did not consider Dr. Bolton’s conten¬
tion, that the changes were of an acute nature, as tenable. He begged to remind
Dr. Bolton that he had given as his opinion that the lesions described by him and
Dr. Rows were caused by the general toxic condition found in general paralysis.

Dr. Rows, in reply to Dr. Bolton’s question with regard to the causation of the
changes in the nervous system in tabes dorsalis, said that they were an affection of
parts of the nervous system, the whole of which had been exposed to the toxine
which produced them, but only those parts had given way whose powers of resist¬
ance had been diminished by some antecedent injury. These changes he considered
to be the result of the primary toxine of the disease, and not of any secondary
toxemic condition, although this latter development exercised a great influence on
the whole organism. He agreed with Dr. Orr that no definite reply could at present
be given to the questions of Dr. Jones and Dr. Bolton with regard to the relative
value of the five different types of cells in the posterior root ganglia. In all proba¬
bility they had distinct functions. This view was supported by the results obtained
by Dr. Alexander Bruce, who examined the posterior root ganglia after amputation
of a limb. He also said that there can be no doubt that the changes which occur
in these cells are of a chronic character. The appearances seen were quite distinct
from those met with in acute cases.

Dr. Elkins read a paper entitled “ Some further Remarks upon Night Nursing
and Supervision in Asylums ” (see page 289).

Mr. Sutcliffe contributed the clinical record of a case entitled “ An Abnormal
Brain of Excessive Weight,” and read the pathological report thereon by Professor
Sheridan Del£pine (see page 323).

A cordial vote of thanks was accorded to Dr. Mould for his hospitality.

In the evening the members dined at the Queen’s Hotel, Manchester.

SCOTTISH DIVISION.

The Autumn Meeting of the Scottish Division of the Medico-Psychological
Association was held, on the invitation of Dr. George M. Robertson, in the-
Stirling District Asylum, Larbert, on Friday, November 29th, 1901, Sir John
Sibbald in the Chair.

There were also present Drs. Clouston, Easterbrook, Farquharson, Carlyle-
Johnstone, Keay, MacDonald, Hamilton Marr, Mitchell, Richard, Ford Robertson,
G. M. Robertson, Rorie, Rutherford, jun., Sturrock, Batty Tuke, Turnbull,
Watson, and Yellowlees, with Dr. Bruce (Secretary).

Dr. Baugh, Dr. Hilda MacFarlane, and Mr. Skene attended as visitors.

The Chairman said that there was nothing that could give him greater pleasure
than to be allowed on an occasion of that kind to take the chair. It was an honour
at any time, and he felt it especially an honour in his case, and a proof that
the members of the Association were exceedingly good friends of his, as he
believed they had always been. This meeting he expected to be a successful one,
meeting as they did in an asylum where there was a great deal to be seen that was
of very great interest to them, and where they were sure to be made exceedingly
comfortable and happy in Dr. Robertson’s hands. (Applause.) He thought that
the chief feeling they all had on the present occasion was one of sadness at the
death of their friend Dr. Campbell Clark. He had been ill for a long time, and
his illness was now over. He thought it would be the pleasure of the meeting to
show their respect for his memory by expressing their sympathy with his
bereaved relatives. He did not think that they should pass from his name without
acknowledging that he had been one of the most conscientious, one of the most
industrious, and one of the most successful of superintendents, and, especially,
that they had lost a member of exceptional ability. There was also another*
matter that he thought he ought to draw attention to, vt'*. that they had lost
Dr. Turnbull as Secretary, and he was sure they were exceedingly sorry that they-
had lost him, although, no doubt, he was very glad to hand over his duties to a.

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[April,

younger and enthusiastic member. Dr. Turnbull had exceptionally high qualities
tor the secretaryship; his courtesy and his attention to business were beyond all
praise. (Hear, hear, and applause.) He thought that he was only expressing
the feeling of the Association when he said how very much they thanked him for
doing as he had done for them. That did not prevent them from welcoming Dr.
Bruce, who was here for the first time as Secretary. (Applause.) Perhaps he
might also mention, as a subject of pleasure to them, that Drs. Oswald, Marr, and
Parker had become superintendents of asylums since they last met.

On the motion of Dr. Yellowlees, seconded by Dr. Clouston, it was resolved
that the Association should incorporate in its minutes a copy of the minute sent to
Mrs. Clark and also that they should record their special thanks to Dr. Turnbull.

Dr. Carlyle Johnstone said he should like to add a word to what had been
already said in regard to their friend Dr. Clark. He was a friend of his of twenty
years’ standing. The? were fellow-workers together at Morningside. He had
visited him at Bothwell, where he converted what was really an inferior dwelling
into a first-class district asylum, and he had also visited him frequently at Hart-
wood, so that he could speak as one who knew him very well. He was gentle and
generous, a simple and broad-minded man, a man who never harboured any
rancour or bore any malice. He was certainly the enemy of no man. He thought
that if Dr. Clark’s spirit could possibly be listening to them it would be a pleasure
to him to know that he was appreciated during his lifetime, and that at his death
he was not going to be forgotten. He had gone to a rest which he had honourably
earned, and his name would be added to that honourable list of names of those
who had worked among the insane, for the insane, and given their lives for the
insane.

The Chairman requested the Secretary to draw up a minute in both of these
cases.

The minutes of the last meeting were read and approved of.

The Secretary then read letters of apology from Drs. Oswald, Parker, Allan,
Urquhart, and others.

The Chairman said that in accordance with the resolution of the last meeting the
discussion would be resumed as to the questions of publishing the “ Report of
the Committee on Nursing Staffs of the Scottish Asylums.”

After a prolonged discussion it was resolved that the report should not be
published.

It was further resolved that the copies of the report which had been printed and
marked “for private use only” should be sent to the members of the Scottish
Division.

Dr. G. M. Robertson read a paper entitled, “ Hospital Ideals in the Care of the
Insane: a statement of certain methods in use at the Stirling District Asylum,
Larbert” (see page 261).

A cordial vote of thanks was accorded to Sir John Sibbald, who had to leave
before the termination of the meeting, and Dr. Rorie was chosen to fill his
place.

A paper contributed by Drs. A. R. Urquhart and W. Ford Robertson entitled,
“ A Case of Epilepsy following Traumatic Lesion of Prefrontal Lobe,” was not
read owing to the advanced hour of the day.

A vote of thanks was enthusiastically accorded to Dr. Robertson, and the
meeting terminated.

IRISH DIVISION.

A Meeting of the Irish Division was held at the College of Physicians, Dublin,
on February 18th, 1902.

The following members were present: President, Dr. Oscar Woods, in the Chair.
Drs. Molony, Nolan, Cullinan, Donelan, Mills, O’Mara, Harvey, Drapes, Oakshott,
Leeper, Ellison, Moore, Hetherington, Lawless, Dawson, Eustace, Rambaut, Conolly
Norman, and Arthur Finegan, Hon. Sec., etc.

The minutes of the last meeting having been read and confirmed, Michael

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Curran, M.A., M.B., Assistant Medical Officer, St. Patrick’s Hospital, Dublin, was
proposed for membership by Drs. Molony, Leeper, and Finegan, and unani¬
mously elected.

The President read a letter of apology from Dr. O’Neill, of Limerick* in whose
name a notice of motion stood on the paper. Dr. O’Neill explained that he had
met with a serious accident and was unable to be present.

The President proceeded: The first resolution is in the name of Dr. O’Neill.
In his absence no doubt some one will propose it for him.

Dr. O’Mara. —Dr. O'Neill asked me to propose the resolution standing in his
name, which I do. It runs as follows :— 44 That the Irish Division of the Medico-
Psychological Association of Great Britain and Ireland earnestly desires to call the
attention of Government to the injustice inflicted on Irish asylum officials by the
permissive clause of the existing Act of Parliament dealing with the question of super¬
annuation. It respectfully urges on the Government to make more secure the pro¬
vision for old age in the asylum service. The arduous duties, responsibilities, and
constant contact of asylum officials with the insane call for exceptional considera¬
tion as regards superannuation. It was apparently intended that the granting of
pensions under the Act 53 and 54, cap. 3, though nominally permissive, should
practically be recognised as a matter of right, but the word 4 may ’ leaves it entirely
at the discretion of committees to grant anything they wish, and from which
decision there is no appeal. The Division respectfully urges on the Government
an alteration of the said clause by the introduction of the word 4 shall,’ instead of
4 may,’ or by the introduction of a pension scheme securing assured pensions. That
a copy of the foregoing resolution be forwarded to the Right Hon. George
Wyndham, M.P., Chief Secretary for Ireland.” In addition to that I got a circular
this morning from Dr. O’Neill, containing a very important modification of this
resolution.

The circular, which was here submitted by Dr. O’Mara for Dr. O’Neill, con¬
tained the draft of an entirely fresh scheme for pensions, altering the terms under
which superannuation could be sought in many important particulars.

Dr. Finegan proposed that, as there were several schemes to be considered, it
would be well if they were discussed together first before coming to a conclusion
with regard to any one of them.

The President approving it was agreed to adopt this course.

Dr. Harvey seconded Dr. O’Mara’s resolution for purposes of discussion. He
said: That it is desirable to get compulsory pensions which the resolution aims at
no one has any doubt. But the questions arise, Is the present a desirable time to
approach this matter ? and What are our chances of success ? As regards the point
whether this is an opportune time or not, there is no doubt that under the
changes which the asylums in Ireland have recently undergone there is a strong
feeling in favour of keeping authority as much as possible in local hands. At the
same time it is practically acknowledged we are entitled to a pension. I know
that my committee so far have dealt very fairly in the matter. I summoned
my staff together and explained the matter to them, and we decided that at
present we have no complaint; but we are prepared to follow any course
which the majority of the asylums decide on. With regard to the possibilities
of the success ot a scheme for compulsory pensions, I do not think there
would be great opposition. It might be a very wise course to ask the asylum
committees to meet a committee of this body to consider the question. I think
the asylum committees might be very glad to have a regular fixed scale when
giving their decisions. I had the honour of being appointed, when the Local
Government Bill was going through, to go over to the House of Commons with
Dr. Norman and Dr. Finegan, and we interviewed a great many members of
Parliament. They all acknowledged that if any service was entitled to a pension
that ours was. I am sure Dr. Finegan will bear me out. The Government
also acknowledged the justice of our contention, but they said they would not
give us anything except what we already had.

Dr. Nolan moved, on notice, " That the attention of the Chief Secretary for
Ireland be directed to the grave disadvantages to Irish asylum officials arising out
of the repeal of secs. 3 and 4, 53 and 54 Vic., cap. 31, by the Local Government
(Ireland) Act, 1898, and that he be ur^ed to introduce an amendment at the first
opportunity restoring the deleted sections of the Pauper Lunatic Asylum (Ireland)

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Superannuation Act, 1890.” With regard to this resolution, it does not attempt
to discuss any new scheme; it merely suggests we should strive to get what Dr.
Harvey said he was assured we could easily secure, namely, the same terms as we
had before recent legislation. My resolution claims for us at least the right we
had under the Pensions Act of 1890, the right of appeal. This we are now
deprived of under the Local Government Act. Dr. Nolan went on to say it
appears to be an extraordinary thing that we should be asked at one of our
divisional meetings to formulate a scheme right off which can be taken up by
the Legislature at any time. Instead of one well-considered scheme being brought
up for ratification there are several schemes, none of which, except the one Dr.
Finegan honoured us by sending round, have been considered by the super¬
intendents or the people interested. I do not think any other body of men occupy¬
ing the position we do would approach a subject of this magnitude in the same
complacent manner. No real attempt has been made to formulate any one
scheme that could be put before Parliament. I do not think there is the slightest
chance of getting any new scheme passed at this particular time. All we can hope
to do is to secure the rights we had under the old Act. The whole conduct of this
business seems to be most unfortunate. One of our superintendents goes over to
the English meeting and puts forward a proposal there. We have not heard
what came of this. Then we are asked to attend to-morrow a meeting of
our subordinate officers without having had full time to consider all the schemes
before us. I think it a very unhappy occurrence that we are summoned to attend
the meeting to-morrow, considering how we are placed with reference to our staffs.
These men will come to consult us on the question of pensions, and we ought to be in
a position to advise them. Up to this year in the history of the Association the
medical officers always managed their own affairs. On the question of super¬
annuation, in which the interests of the superintendents are identified with those of
the staff down to the most junior servant, it might have been assumed that what-
ever the superintendents decided was the wisest and best course would prove to be
for the benefit of all in the institution. Instead of that we are called to meet to¬
morrow a number of people coming up from different parts of the country with
ideas of different schemes. I do not know how we could possibly in the short
interval think over the schemes that are here to-day. In England, when they had
a similar movement, it was only proposed after the most elaborate statistical
investigation, with the aid of chartered accountants, and all the information that
could be possibly brought to bear from every possible source was in the hands of
the members for months previously. Here we are brought up to-day and we see
on the agenda paper several schemes, and we have agreed to meet our subordinates
to-morrow, who will have a number of schemes. It appears to me to be altogether
most unwise. The only course at this eleventh hour is to decide on some
unanimous line of action which will commend itself to common sense and to
the people from whom we have to ask favours, and not to ask for an absurd scheme
of pension which would not be sanctioned, or allow the meeting to-morrow to
ask for an absurd scheme.

Dr. Hktherington. —We had better discuss the thing generally before £oing
into any special scheme. We have to ascertain whether there is any probability of
any scheme whatever being adopted by our own committees. I thought most of
the medical superintendents would have consulted their own committees before
coming to this meeting, and ascertained the general feeling about adopting any
scheme. I did it with my own committee, and found, on the whole, they were
rather in favour of having some definite scheme adopted; they said it was unfair
that the amount of the pension should be left to the opinion or caprice of a
committee. It may happen that when one man comes up for a pension the
members of the committee are in a bad humour, and may thus give him very much
less than he deserves, while on another occasion they may deal too generously
with an applicant. The first thing we should ascertain is whether our committees
are really in favour of anything of the sort; otherwise there is not the slightest
use in going on. Dr. Harvey’s suggestion that there should be a sort of con¬
ference between the representatives of the committees and the medical superin¬
tendents to see if they can agree on any scheme, or even on the principle of any
scheme, leaving the details to be proposed afterwards, should be decided on before
we can advance one step. I sent forward a scheme to my friend Dr. Finegan ; I did

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1902.]

not expect to see it on the notice paper. My sole object was that we might have
something before us. I do not think any man can expect his scheme, or any scheme,
to be adopted as a whole; 1 think that what Dr. Nolan says is very reasonable.
My committee has always, and in a great many cases, dealt liberally, and given up
to the full amount that the Act allowed, and seem inclined to do so as far as I
can see. For these reasons I would not like to have any scheme adopted without
'submitting it to my committee. If the committees oppose us I think we could do
nothing. We drew up what we thought might be the lines of a scheme. It is quite
a different scheme from some of the others I have heard of. I do not think that
“there is any use in reading it over. We made it permissive as regards some
-of its provisions; it is merely a matter to bring before you for discussion.
It never crossed my mind for a moment that at our proceedings to-morrow
-on this very important question we could arrive at any definite conclusion. I
■think that the meeting to-day should spend its time in arriving at some conclusion
how to conduct the meeting to-morrow. There are a great many deputations from
various asylums, and I am sure some of them will be so sanguine as to want to
-pass an Act of Parliament to-morrow.

Dr. Donelan. —The whole matter is a question of expediency. We would all
•be very glad to have permission changed to certainty, but is there much likelihood
of it being done ? Outsiders will say, If this change is effected, there must be a
certain amount of giving up on our side. With regard to many of the asylums,
pensions seem to be dealt with fairly and reasonably, and the same certainly
applies to the asylum I am connected with—the Richmond. The important ques¬
tion is, Would we prefer a certainty on a lower scale P Would we thus do better
-than by leaving things as they are ? Dr. Nolan’s suggestion is probably the wisest.
If we can secure its adoption, we shall be placed in the same position as we were
before the Local Government Act came into operation.

Dr. Moore pointed out the futility of discussing proposals on this occasion,
when, as the Division was aware, a meeting of representatives of all the asylum
•employes in Ireland had been summoned by one of our members to assemble in
Dublin next day to discuss the same subject. If we adopt one scheme to-day,
what guarantee have we that the majority at to-morrow’s meeting will not vote
against it P

The President regretted that the matter was brought forward at the present
time, which he considered inopportune, but, he said, there is no help for it; the
-matter has been brought forward, and it is better to discuss it, and, if possible,
formulate a scheme. If we go forward as a united body with recommendations to
the staffs to-morrow, I think we will go very far to secure the adoption of our
views. There are four schemes in the air. There is the scheme proposed by
Dr. O’Neill. Dr. Finegan takes up different lines altogether; Dr. Hethrington
has another scheme which he has not read to us; and I think an unfortunate
proposal is emanating from the Killamey Asylum—the staff of which is
already canvassing the members of Parliament to have it carried. In bringing
forward any scheme I think we must consider the possibility of carrying it, and my
opinion is, it is out of the question to think of getting any pension scheme without
unanimity of opinion amongst the Irish members—Nationalists and Unionists. In
order that the members of Parliament may take it up, I think we must have the
support of our committees of management. Without their support I think we
might as well do nothing. If we get their support, and they would approach the
local members of Parliament, the latter would probably consent to bring in a Bill
-which would be practically unopposed, and which I think would pass; otherwise I
think our schemes are bound to fail. With regard to what has been done in
England, I have here in my hand the confidential report that has been drawn up by
the committee formed to consider the pension question in England. I received
-this letter only this morning, and it i|;ows the enormous difficulty with which this
pension question is beset.

Dr. Finegan said: My impression is that we can never get assured pensions
unless they are on the same basis as the Poor Law Medical Officers’ Association,
“that is, that we should make some small contribution from our salaries towards the
-pension fund or towards the expenses of the asylum. In Ireland, above all places,
there is an outcry against rates. In another few months we will have asylum
government more democratic even than the present, and the democratic members

XLVIII. 26

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NOTES AND NEWS.

[April,

of our Committee object in the strongest terms to giving pensions to individuals
who they consider at the present time are too well off. I have come to the con¬
clusion that neither the members of Parliament nor the local boards throughout
the country will support the pension we have been in the habit of getting hereto¬
fore. They will not support giving any such pension because they are not given to
any other class of officials. You may say that asylum officials are more entitled to
it than any other class. I grant you that, but 1 am an official myself. Other
people do not see it in that light; they think we are too well off. Possibly we might
be told to join in with the Poor Law Officers’ Association, which woula be a great
misfortune to asylums. I myself am under the impression, if we do adopt anything,
that the only one form of pension scheme that we can carry out with any prospect of
success is that in which there is a deduction made from the salaries by way of
contribution. Some eighteen months ago a very old and efficient official of
Mullingar Asylum got phthisis. I reported her to my board as being in
the last stages of consumption and unfit for duty. The woman had twenty
years’ service; she was a most excellent nurse in every sense of the word,
in one of the most trusted positions in the house. The committee asked
what she was entitled to, and I said ^40 a year, and they said, “ Pre¬
posterous ! how can the rates stand that ? If we are going to pension all
at that rate we will have to come into the asylum ourselves.” After a
very great appeal from a clerical member not to allow this woman to go
into the workhouse after her twenty years’ service in the asylum, they at last
consented to give her £2° a year, taking 25 per cent, off what she should
have got. They then proposed a resolution that this should be the last pension.
In the discussion which followed it was stated that it would be very hard
that officials of long service should not get pensions, at least in the case of
existing officers. At last a compromise was effected in the matter, they saying,
" We are agreed to give pensions if the officials themselves make contributions
to these pensions, otherwise we will give no pensions.” I was directed to
draw up a pension scheme and submit it to my board, which I did. It was
approved of by my committee, and I was directed to send it round to the other
asylums and see what they had got to say, and also to communicate with the Local
Government Board. The Local Government Board sent us a communication to
the effect that the committee’s action in establishing such scheme was altogether
ultra vires. Then the committee passed a resolution asking the Chief Secretary
to legislate so as to enable our own asylum in Mullingar to establish a scheme of
this kind.

The Chief Secretary, in replying, said that " fresh legislation would be necessary
to legalise any pension scheme such as that submitted by the committee, but
that it would not be advisable to legislate on this subject for a particular asylum, as
any such legislation should apply to all district asylums. His Excellency is further
advised that if legislation could be introduced to grant asylum officials assured
instead of permissive pensions, it would be a great boon to a very deserving class
of public servants, especially if such a scheme could be arranged with the concur¬
rence of the local authorities. In this connection I am to refer the Joint Committee
of Management to the actuary’s report on Poor Law officers’ superannuation
which is being circulated to local bodies.”

My committee then decided to ask the other Irish asylums to co-operate with
them in establishing some form of pension scheme on a similar basis, that is,
making deductions from salaries. Furthermore, my staff, who are particularly
anxious for pensions, seeing that the other asylums did not take up the matter,
said if the other asylums in Ireland do not wish to take action it is their own loss.

I called a meeting of the officials, and they instructed me to get a Bill drawn up by
a lawyer and submitted to the Government, to secure permissive legislation if
possible for this Mullingar scheme. The Bill is actually being drafted at the
present time by a member of Parliament and a lawyer in Dublin. Of course that
has to go on in any case, as I have been acting from the beginning not on my own
initiative, but on the instructions of my committee and of my staff. By the
instructions of my committee I have had to draw up a scheme, and by an instruction
from my staff I am getting a Bill introduced. A member of the House of Commons
has promised to introduce the Bill when drawn, but he states that it is certain to be
opposed. I dare say most of the officials know this scheme. If you bear with me

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1902 .]

for a few minutes, I will just run over the heads of the scheme. First, the officials
to be not less than fifty years of age, and to have served no less than fifteen years,
excepting in the case of permanent incapacity for duty through illness, when the
committee may think fit to grant a pension. Second, on the completion of fifteen
years’ service, a minimum pension shall be awarded of fifteen thirtieths of the salary
and value of allowances, and a maximum of twenty thirtieths on the completion of
twenty years’ service; one thirtieth of salary and value of allowances to be granted
for each year served between fifteen and twenty years’ service. Third, any official
who may be dismissed by order of the committee of management without
the privilege of resigning forfeits all claim to pension or refund of money
paid in. Fourth, in the event of any official dying in office all right to a refund
of contribution ceases, except in the case of married people, when the committee
shall allow the contribution to the relatives of the deceased. Fifth, deduc¬
tions to be on the scale laid down by the Poor Law Officers’ Superannua¬
tion Act of 1896 as follows, viz. officials with less than five years’ service,
2 per cent.; officials with more than five years’ service and less than ten years'
service, 2} per cent.; officials with more than ten years’ service and less than
fifteen years’ service, 3 per cent, on their salaries and value of allowances. Sixth, all
deductions to cease after twenty years’ service. This latter is a most important
provision, for the simple reason that the majority of men who have got twenty
years’ service at the present time have nothing to pay. I myself have not a
service of twenty years, but have served fifteen, and I shall have to pay for five
years; there are others would have to pay for longer; there is a very large
majority of the medical officers of the Irish asylums who would have to pay
nothing at all because they have served over twenty years. There are several here
with twenty years’ service, and from that point of view it is extremely good.
Seventh, officials resigning voluntarily under five years’ service shall forfeit
all right to a refund of contributions, except in the case of illness, when the com¬
mittee may allow a refund of part or the entire of the contribution. Eighth,
officials resigning voluntarily after five years’ and under ten years’ service shall be
entitled to a refund of 73 per cent, of the contribution. Ninth, officials resigning
voluntarily after ten years’ and under fifteen years’ service shall be entitled to
recover all deductions contributed. This scheme aims not alone at benefiting the
officials, but also aims at improving the condition of the asylum service in this way :
The course of asylum service as regards officials at present is that those who serve
for one, two, three, or four years leave when they are trained and are beginning
to be of some use. If the service is less than five years all contributions are
forfeited. If he remains for five years he gets back 75 per cent, of his contribu¬
tions ; if he remains for ten he gets the whole of his contributions; and if for
fifteen years he gets half his salary and allowances. I think that it is an extremely
fair and liberal method. It will also improve the service and make an enormous
pension fund—just consider the number of employes coming into the asylums,
and the number of changes for the first five years. In Mullingar Asylum sixty-
seven of the officials are under five years, eighteen over five, seven over ten,
seven over fifteen, and three over twenty years. To bring matters to a head
I propose definitely that this scheme of the committee of Mullingar Asylum be
accepted as a basis for the pensions of asylum officials generally throughout the
country. If the Division would approve of this scheme it would strengthen my
hands to go to the members of Parliament and the other asylums to get permissive
legislation.

Dr. Harvey said that since he heard that the scheme had not emanated from the
officials, but from the committee of the asylum, he was favourable to it, and would
therefore be very glad to withdraw in favour of it.

Dr. O’Mara. — I am quite sure Dr. O’Neill is not in favour of withdrawing his
scheme in favour of the Mullingar scheme. I put the Mullingar scheme before the
staff, and they would not consider it; they unanimously rejected it. As far as my
staff are concerned, they are very badly paid, and they could not offer to contribute
anything at all. Some of my female attendants are only paid £g a year. My
committee marked the Mullingar scheme “ read,” and would not consider the
matter any further. That scheme places us in a rather awkward position,
inasmuch as it is going before Parliament, embodied in a Bill at present, and any
scheme that is propounded by the Association will be rather upset, I think, by Dr.

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NOTES AND NEWS.

[April,

Finegan’s scheme. How can we go and ask members of Parliament to support
one scheme for Mullingar and another scheme for other asylums ? We must go
before the meeting to-morrow with some definite scheme from the Association;
there is no use going in and saving, " Dr. Finegan has a scheme; Dr. O’Neill has
another scheme.” I want to have the assured pension under the old rules if I
possibly can; even if the time is extended to twenty or twenty-five years I do not
object. I am sure Dr. O’Neill would not.

The President. —I think it very important some decision should be come to
about this scheme. I do not think there is very much good in putting it before the
meeting to-morrow. I believe it will be rejected by ten to one. However, if we
approve of it, it should go forward. It is too favourable a good deal to say that
any attendant with a salary of £80 a year, if he contributed for twenty years a sum
of £i los. a year will be absolutely entitled for the rest of his life to a pension.
If we commit ourselves to a contribution, when we go forward to Parliament, and
it is rejected as inadequate, we shall then be told, “ You are in favour of a con¬
tribution, now get up a scheme, as the Chief Secretary says, on the lines of the
Poor Law officers’ scheme.” For asylum officials with their arduous work and
many risks this would be altogether an insufficient scheme.

Dr. Nolan. —I am bound to say that the history of the evolution of the
Mullingar scheme has been so completely startling that I really feel we are in a
much more serious position than before. I merely thought these schemes were on
paper for the committee; now I find that actually a Bill for Parliament is being
drawn up which we are asked to sanction. It appears to me an easy way of
determining; what we ought to do to-morrow is to record definitely our complete
disapproval of the Mullingar scheme, and unanimously reject anything of the sort.
Now what have we heard from Dr. Finegan ? He has told us the history of what
happened about the committee and the attendants and the members of Parliament;
and the mere fact of his touching the question at all landed him in this grave
position, that he actually finds himself now in the hands of a Parliamentary
lawyer, who is presumably a Nationalist member of Parliament, and who does
not hold out good hopes of even getting the Bill through as it stands. It is
appalling to me to think that the members should find themselves in the
position of coming here, not with a free hand, but merely to endorse the Mullingar
scheme, which is open to so numerous objections that it is absolutely impossible
to deal with them. I would hope that at to-morrow’s meeting, whatever is done,
one resolution should be certainly hostile to the Mullingar scheme, and unanimously
refusing to be bound by it in any way.

Dr. Conolly Norman. —Owing to the unfortunate circumstances of being in
court all the morning, and not being able to be present here in the early part of this
most valuable discussion, I do not know what is in order for discussion just at
present. Is the agenda paper still before the Chair, or are we only discussing
the question of Dr. Finegan’s scheme ? Is the proposal of Dr. O’Neill as it stands
on the agenda paper at this meeting still before the Chair P

The President. —Yes.

Dr. Norman. —The proposal of Dr. O’Neill appears identical with the proposal
introduced by Dr. O’Neill at the meeting of the Medico-Psychological Association
of Great Britain and Ireland held in London on November 2ist. In both these
documents the Association is requested to urge upon the Government the alteration
of the seventh clause of the Pensions Act, 1890, by the introduction of the word
“ shall ” instead of “ may.” The resolution put before the Medico-Psychological
Association in November last was adopted, and you are asked now to reaffirm it.
I have read very carefully and repeatedly the Act 53 and 54 Viet., cap. 31,—the
Pensions Act of 1890. It has been pointed out to me, and I can endorse it by my
own observation, that the Act in question does not contain the word “ may,” and
therefore I beg to submit that we are considering a proposition that has no
reference to fact at all, and that we are asked to endorse the action taken in London
in November, calling upon the Government to alter an Act by leaving out a word
that is not in it, and by substituting the word “ shall,” which is already there. Was
a more pregnant Irish bull ever delivered ? With regard to Dr. Finegan’s scheme
in connection with the proposed rebate out of our incomes to provide a pension
fund, I do not see where the fund is to come from. It seems a case somewhat
similar to the proposed Poor Law Superannuation Bill, with reference to which the

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1902.]

Government actuary, when called upon to look into it, stated that the scheme would
require a fund, money advanced by somebody or other, of at least .£10,000 to start
the thing. I do not know where we are to get that £10,000 from. Reference has
been made to a meeting to be held to-morrow; it has been said at this meeting
here to-day that we should adopt some definite formula for to-morrow. I think
that is a very bad line of reasoning. The meeting to be held to-morrow was
summoned without consultation with this Assdciation. It was summoned by
gentlemen who no doubt had the most amiable intentions, but without consultation
with anyone, and summoned for the day after this meeting, which was, in my mind,
a very grave error. I think that that meeting, supposing it to have been duly
authorised, supposing that there was proper authority for convening it at all, should
have been summoned for some day which would have given us time to have made
up our minds after to-day’s discussion, and time to have communicated with the
various persons interested, ascertaining their views and finding out how we really
stand before taking action. Are we to be told, forsooth, that because without any
authority of ours a meeting has been called for to-morrow elsewhere we must there¬
fore make up our minds to-day P Is not this very like bull-dozing this meeting ?
These matters require very careful consideration. I do not think it competent to
any member of this Association, or any individual who happens to be connected
with asylums, to go, ring a bell, and call up anybody he likes at any moment he pleases
and pass a resolution affecting our gravest interests without any due consideration.
I fail to follow the argument addressed to us that we must make up our minds
to-day on a matter of importance as to which we are probably quite incapable of
deciding on so short notice, in order to present to-morrow a programme to another
meeting, when the organisers of that meeting had not the courtesy or common sense
to wait until they heard our views before calling themselves together.

Dr. Finegan. —I do not like to have Dr. O’Neill condemned wholesale
on this point: he is entirely responsible for that meeting; he communicated
with me unofficially to say he wished for representatives of all officials of
asylums to appear at our Medico-Psychological meeting. 1 told him that this
would be impossible, and that if he wished to have a general meeting of the asylum
officials he should convene that meeting himself, that I could have nothing what¬
ever to do with it. Whether he had taken that letter from me as an official
sanction from the Association I do not know. I can assure you that is all the
authority I have given in the matter. Dr. O’Neill is entirely responsible for his
own actions with reference to this second meeting.

Dr. Drapes. —Several members have said before it is absolutely impossible for
this meeting to decide in favour of any particular scheme; the most we can do
would be to decide on the principle whether the members are in favour of a scheme
involving contributions from the staff or are wholly opposed to it. If the majority
are against the scheme which involves contributions, the thing there and then ends.
If, on the other hand, they are in favour of some scheme which involves contribu¬
tions, then it will be time to go into some definite scheme. I regret extremely
that the action of Mullingar was so precipitate. Anything adopted here by the
medical superintendents should at least have the authority and approval of the
Medico-Psychological Association. I think in a thing of this kind that nothing
could be done by one asylum, but with the unanimous consent of all asylums ana
the almost practical consent of the committees something might be done. I still
think that if any scheme is going to be adopted, to have any chance of success,
there should be a conference between the representatives of the committees as well
as the representatives of the asylums. Ir we can get them to agree on some
scheme there is some chance of it passing, otherwise there is not the smallest
possibility of success. Dr. Norman alluded with particular point as to where
the funds were to come from; if these contributions are an annual aid to paying
pensions under that scheme, no fund can be formed whatever unless a certain pro¬
portion is set aside to augment every year. We merely pay a certain amount of
contributions, but where a fund is to come from I do not think we have heard.

After some further discussion, in which Drs. Mills and Ellison, among others,
took part, it was proposed by Dr. Nolan, seconded by Dr. Conolly Norman, and
adopted:

“ That this meeting resolves that at the meeting of the asylum officials to be held
on the 19th inst., the action of the members of the Medico-Psychological

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NOTES AND NEWS.

[April,

Association present be confined to a suggestion that a representative committee of
all classes of asylum officers be formed to consider and report as to the best
scheme for superannuation.”

Dr. Lawless proposed, and Dr. Moore seconded—“ That this meeting does not
approve of a contributory scheme for pensions.” The resolution was carried on a
show of hands.

Dr. Nolan’s original notice of motion was then again considered at some
length. Finally, Dr. Drapes moved, and Dr. Donelan seconded, an amendment
thereto in the following terms:

“ That Dr. Nolan’s resolution with regard to restoring the deleted sections of
the Superannuation Act of 1890 be referred to a committee to be appointed to
deal with the question of pensions generally, and that if a committee for this
purpose be not appointed at to-morrow’s conference, a committee of this
Association be so appointed.”

This amendment was adopted on a division, and being put as a substantive
motion was unanimously adopted.

A rather protracted discussion took place (introduced by the President) upon the
claim of Dr. Taylor (Medical Superintendent of the Monaghan Asylum) to be
assisted to meet the expenses in his action against the Irish Local Government
Board, taken with success to compel that body to assess under the Local Govern¬
ment (Ireland) Act the amount of increase in salary due to him for increased duties
imposed upon him by the Act. It was recognised that Dr. Taylor’s case was a
valuable precedent, but as he is not a member of the Association it was felt that
the matter should be left rather to the individual discretion of the superintendents
than dealt with by the Division.

The proceedings then terminated.

On the same evening fifteen members, including the President, dined together at
the Shelbourne Hotel.

A MEDICO-LEGAL CASE.

Communicated by Sir John Batty Tuke.

[The Editors request that members will oblige by sending full newspaper reports of
all cases of interest as published by the local press at the time of the Assizes.]

The following curious trial is taken from records of criminal trials before the
High Court of Justiciary in Edinburgh, in volume iii of * Ancient Criminal Trials
in Scotland/ compiled from the original records, etc., by Robert Pitcairn. Printed
for the Maitland Club, 1833.

" 16 Deer. 1561 James Guyld, indicted for Stealing etc. as after specified.

“ Mr. Alexander Sym, as prelocutour for James Guyld, beand callit to underlye
the law upone his lyff, allegit that he is minor, within the zeiris of xviij their aid,
as it may be considerit be inspectione of his face, lyik as he is in deid, and salbe
profin gyff neid beis; and thairfoir aucht nocht to underly ane Assyse upone his
lyif, nor to thoill iugement thairupone, nother be the Commoune law, nor Munici¬
pal law, or use of this realme. And attour the barne him selff is ydiot of natur,
nor hes nocht the knawlege to deceme the perrell and the feir of deid ; and thair¬
foir aucht not for to underly ane Assyse, as said is, of lyif : And forder, is subdewit
to ane malancolius humour, naturallie descendand from his progenitouris, swa that
he is mair desyrus to dee nor to leif, as be experience is notour, the samekill that
his fader exponed himselff sindr£ tymes to the perell of deid, and wald have
drowned him selff in the North Loch, wer nocht he wes releved theirfra be nycht-
bouris; and syclyik Maister Walter Guyld, his fader bruder, occupiit with the same
humour, slew him selff in Paris. And thairfoir, the said James, beand bayth
minor, and approacheand mair to pupillaritie nor maioritie, and occupiit with the
said humour, mair willing to d£ nor to leif, and haifand na cuyr of deid, aucht not
to underly the law for the lybellit pretendit cryme, etc.

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381

1902 .]

“ And eikis allegeance, that the same boy ranne sindrie tymes nakit to Ingland,
and left his claytnis behind him : and swa may be understuid that he hes this
said humour, as said is: and offeris him to preif the said allegeance sufHcientlie.

“ The Justice findis be Interlocutour that the said mater sould pass to Assyse,
nochtwithstanding ony allegeance, because of the practik sene of befoir.

“ Verdict .—James Guild, Convict, be deliuerance of the said Assyise, of arte and
parte of the thiftius steling and taking furth of the purse of Elizabeth Daniel*
stoune, the spous of Neill Layng, hingand under hir aprone, in the moneth of
Apryill, upoun ane Monunday, ane mercat day of Edinburgh, scho being upone the
Hie Streit, standand at the crame of Willeam Speir, indueller in the said burgh, in
comoning with him, the tyme of the putting of ane string to ane penner and
yncome quhilk scho had cort fra the said cramer, of ane signet of gold: ane vther
signet of gold, sett with ane cornelene; ane gold nng sett with ane grite
sapheir: ane vther gold ring with ane sapheir formit like ane harte; ane gold ring
sett with ane turquhase; ane small dowble ring of gold sett with ane dyamont ana
ane rubye, ane aid Angell-Nobill, and ane Cussett dukett.”

Appended is a rendering of the above into English or Scotch of the present day:

Mr. Alexander Svm, as counsel for James Guild, called to underlie the law for his
life, pleaded that he is a minor, under eighteen years old, as may be judged by
inspection of his face, and as he is indeed, and shall prove if need be, and
therefore ought not to undergo an assize for his life, nor to suffer judgment
thereon, either by the common law, municipal law, or usage of this realm. And,
moreover, the bairn himself is a natural idiot, and has not knowledge to discern
the peril and fear of death, and, further, is subject to a melancholy humour,
naturally inherited from his progenitors, so that he is more desirous to die than to
live, as by experience is notorious, so much so that his father exposed himself
sundry times to the peril of death, and would have drowned himself in the North
Loch had he not been rescued therefrom by neighbours. And so also Walter
Guild, his father’s brother, possessed by the same humour, killed himself in Paris.
Therefore the said James, being a minor, and nearer pupillarity than majority, and
possessed of the said humour, more willing to die than to live, and having no fear
of death, ought not to underlie the law for the pretended crime, etc. And it
is further alleged that the same boy ran sundry times naked to England, and left
his clothes behind him, and so it may be understood that he has the said humour,
and offers to prove the said allegation.

The Justice finds by interlocutor that the said matter should pass to an Assize,
notwithstanding any allegation, because of former practice.

Verdict .—James Guild, convicted by deliverance of the said Assize of being art
and part in the theftuous stealing and taking out of the purse of Elizabeth
Danielstoun, wife of Neill Laing, hanging under her apron, in the month of April,
upon a Monday, a market day of Edinburgh, she being on the High Street,
standing at the booth of William Speir, resident in the said burgh, communing
with him while he was putting a string to a pencase and inkhom which she had
bought from said booth-keeper, a gold signet ring, another gold signet ring set with
a cornelian, a gold ring set with a great sapphire, another gold ring set with a
sapphire formed like a heart, a gold ring set with a turquoise, a small double ring
of gold set with a diamond and a ruby, an old angel-noble, and a cusset ducat.

The editor of this collection of trials mentions that the Assize or jury in the
above case consisted of thirteen burgesses, and further observes, “No traces are
left on record of the fate of this poor creature, but it is likely that the punishment
was trivial, and that his relations would be bound over under penalties for his
future good behaviour.”

THE PROPOSED PSYCHIATRIC CLINIQUE IN EDINBURGH.

A special meeting of the Edinburgh Medico-Chirurgical Society was held on
February 19th, 1902, in the Royal College of Physicians, for the purpose of dis-

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382

[April,

cussing " the treatment of incipient and transient mental disorders in the Royal
Infirmary.” Professor Fraser presided over a large gathering.

The Chairman explained that this subject had been brought into prominence
by Dr. John Macpherson, Commissioner in Lunacy, and Sir John Sibbald, who
formerly held that office. The Edinburgh Medico-Chirurgical Society very com¬
pletely represented the medical views of the city and of a large part of Scotland,
and it was therefore of some importance that the views of its members should be-
obtained. There were two great problems before them. They had in the first
place to endeavour to define what kinds of mental disorder were likely to be bene¬
ficially and properly treated in a*general hospital, and in the second place to come
to some conclusion as to the best place in which provision could be made for that
treatment. They had also to let the public know what accommodation was
required, how many cases were proposed to be treated, how far that provision
could be obtained in the Royal Infirmary, to what extent the pecuniary resources
of that institution would be drawn upon, and in what respects treatment in the
Royal Infirmary would confer benefit upon the patients and upon the general
public.

Sir John Sibbald then read a paper entitled “ The Treatment of Incipient
Mental Disorder and its Clinical Teaching in the Wards of General Hospitals ”
(see page 215 of this number of the Journal).

The Master of Polwarth, Chairman of the General Board of Lunacy, said it
had been the Board's policy to encourage every new movement which seemed
likely to conduce to the benefit of those who had the misfortune to suffer from the
most terrible forms of all disease. Such a scheme as now proposed would help to
remove the stigma attaching to sufferers from mental disease, and to enable those
cases to be dealt with in which there was strong aversion to going to a lunatic
asylum.

Sir John Batty Turk expressed the great feeling of satisfaction he had when
he heard that this movement had taken shape. For the last twenty years he had
on every available occasion tried to lay before the public the advantage that would
accrue by the treatment of early and incipient cases of insanity in the general
hospitals of the country. Sir Arthur Mitchell, when the new Infirmary buildings
were in course of erection, made a strong and earnest endeavour to get wards such
as were now proposed, but even his great influence failed. The scheme would
reduce the number of lunatics, and would exercise a great and wide-spread educa¬
tional influence. The burden of expenditure under which the taxpayer was
groaning was spent for the most part in the interests of the chronic lunatic,
whereas little was done to avert the manufacture of chronic lunatics. He believed
that if they excluded general paralytics and epileptics, and treated cases in the
earlier stages, they would get 70 per cent, of recoveries. The increase of chronic
lunatics was not in the upper classes, which could afford early and efficient treat¬
ment, but in the lower classes, which could not. The educational influence would
be important and wide-spread. It would break down popular misconceptions, and
probably in time affect legislation. Above all, the gradual education of the public
mind would rapidly do away with the stigma which attached to insanity, and which
had no more right to attach to it than to any other form of disease. It would be
the duty of that meeting to press upon the Infirmary managers as strongly as
possible the propriety of entertaining such a scheme as this. If the managers did
so they would have the credit of being the first hospital authorities to take a wide,
a broad, and a munificent view of the nature and treatment of insanity.

Dr. Affleck said that, from his experience as an infirmary official, he was con¬
vinced of the need of some place—in the Infirmary if at all possible—where patients
suffering from mental disturbance through ill-health or hardship could be admitted
for rest and treatment, so that their temporary derangement might be prevented
from becoming permanent. He admitted that there were serious practical diffi¬
culties in the way of the Infirmary managers, but he believed they were not
insuperable.

Dr. Clouston mentioned that of the 900 admissions to Momingside during the
last two years only eighty were discharged recovered within six weeks, and about
160 within two and a half months. This pointed strongly to the conclusion that it
would be a very economical thing for the parish council to come to some business
arrangement with the Royal Infirmary to treat incipient cases, and thereby prevent

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1902.]

the rates being burdened by their becoming chronic. Such a scheme would give
the poor the same chance as the rich now had of securing recovery by the aid of
the best possible advice. He was not inclined to speak in an apologetic way about
the clinical teaching in mental diseases. It had enormously improved, and the
asylums were not devoid of the milder cases from which to teach. At the same
time he admitted that the Infirmary wards for such cases would afford a much
larger field. He estimated that about forty beds would be necessary.

Dr. Alexander Bruce, of the Royal Infirmary, also supported the scheme, and
said the removal of the stigma of having been in an asylum was one of the
strongest arguments for the proposed change.

Dr. Urquhart said he believed the speakers had been preaching to the
converted, for the members of the Society were apparently of one mind as to the
establishment of a psychiatric clinique in the University of Edinburgh.

Dr. Carswell, Adviser in Lunacy to Glasgow Parish Council, described a scheme
which that body has had in operation for several years, and is now about to put on
a permanent footing for the treatment of insanity in its early stages. A mental
block for fifty patients was being erected in connection with one of the poor-house
hospitals, where the patients would be treated on hospital lines. Last year 212
patients were treated. Of these 28 were afterwards removed to asylums, 10 died,
167 were discharged recovered, and 7 remained under treatment at the end of the
year. With better facilities and a larger staff he believed they would be able to
pass through the wards about 300 patients per annum, or more than one third of
the cases of mental disorder. The parish council hoped also to establish an
outdoor clinique, and thereby anticipate the stage at which asylum treatment
became necessary.

Dr. Wilson, Mavisbank, hoped that at least an out-patient department for
mental cases would be established in Edinburgh Royal Infirmary, and if a special
department could not be instituted, the rules of the Infirmary might be modified so
as to admit such cases to the general wards.

Sir John Batty Tuke then formally moved—“That this meeting urges
strongly on the managers of the Royal Infirmary to seriously consider the
expediency of providing wards within or in the immediate vicinity of the institution
for the treatment of incipient, transitory, and recent cases of insanity.”

The Master or Polwarth seconded the motion, which was unanimously
adopted.

Professor Rankin mentioned that a committee of the Infirmary managers had
been appointed to meet a deputation from the Society. The committee had
considered the question of locale , and it seemed primd facie as if it would be
impossible to have mental wards within the walls of the Infirmary.

Sir John Sibbald thanked the members for the attention they had given the
subject, and the meeting then adjourned.— Scotsman, February 20th, 1902.

THE PATHOLOGICAL STUDY OF INSANITY.

Down District Asylum.

At a meeting of the committee of management of the Down District Asylum,
held in the board room of the institution on Saturday, Dr. M. J. Nolan, Resident
Medical Superintendent, having submitted the statement by the Special Committee
(of which he is a member) of the Medico-Psychological Association, of Great
Britain and Ireland on the necessity for the establishment of a central laboratory in
Ireland for the more particular investigation of the pathology of insanity, it was
unanimously resolved—“That we, the committee of management of Down
District Asylum, desire to express our warm approval of the proposed central
laboratory for research in the pathology of insanity. We hereby state our readiness
to affiliate this institution with such an undertaking when it assumes a practical
shape, and to contribute towards its maintenance a sum of ^25 per annum. We
are of opinion that the project is deserving of general support, believing as we do
that the prevention and the most effective treatment of mental disease must be

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NOTES AND NEWS.

[April,

largely aided by an accurate knowledge of the morbid physical conditions associ¬
ated with it, and feeling that any step that tends to promote such knowledge must
ultimately prove an important factor in the reduction of the burden of the lunacy
charges of the country .—Northern Whig , March 17th, 1902.

ASYLUM ACCOMMODATION IN LANCASHIRE.

A meeting of the Lancashire Asylums Board was held at the County Hall,
Preston, yesterday afternoon, Mr. Scott Barrett presiding over a large attendance
of members. A deputation attended from the Lancashire unions with reference to
asylum accommodation in the county.

Mr. G. Rooke, of Manchester, who was chairman of the Conference of Boards of
Guardians held in Manchester in January, introduced the deputation, and said that
twenty-four out of the thirty-one unions were there represented. At the Conference
it was decided to ask the Asylums Board to receive a deputation from the guardians,
not in any complaining or critical spirit, but simply to ask the Board to confer
with them as to the best means that could be taken to prevent the difficulties under
which the guardians of the county were placed, owing to the congested state of the
asylums. The members of the deputation had themselves large establishments to
administer, and could therefore well understand and appreciate the ability, con¬
sideration, and anxiety with which the Board’s huge establishments were conducted
throughout the county. At the same time they thought they might ask the Board
to confer with them, seeing the difficulties they had been placed in had been so
great in the past, so as to obviate as far as possible such a condition of things
again occurring.

Mr. Leech, of Rochdale, who acted as secretary of the meeting, read the resolu¬
tion passed at the Conference, which was as follows :—“ That in the opinion of this
Conference it is desirable to appoint a deputation to wait upon the Lancashire
Asylums Board for the purpose of urging upon the Board the absolute necessity
of providing sufficient accommodation for pauper lunatics dangerous to themselves
or others, or requiring curative treatment. The Conference also authorises the
deputation to discuss with the Lancashire Asylums Board all questions arising out
of the present insufficiency of such accommodation.”

Mr. Humphreys (Prestwich) and Mr. Grimshaw (Chorlton) also addressed the
Board.

The Chairman said the deputation would be aware that the Asylums Board were
fully conversant with the wants of the county, and that they had been doing every¬
thing in their power in order to provide accommodation for the increase in lunacy.
But they understood it was a thing which could not be done in a day, a week, a
month, or in a year. (Hear, hear.) With regard to the 4s. grant, the effect had
been to crowd the asylums which were built for acute cases, and therefore they had
been obliged to spend these large sums of money to provide accommodation. He
ventured to think that if the 4s. grant had never been made the asylums that day
would have been large enough for the patients. Already 510 patients had been
taken in at the Winwick Asylum, and in a short time they expected there would
be 200 more, and there were only 231 vacancies in the asylum. It showed how
rapidly lunacy was increasing. They had found, however, that different boards of
guardians had sent a large number of patients to Winwick, and the class was of
the very lowest type. They were nearly idiots, and, as he had said, they were not
the sort of people that asylums were built for. (Hear, hear.) The Winwick
Asylum was built for chronic cases, and if they were going to have it filled with
imbeciles they were going to be in the same place as they were in before. (Hear,
hear.) The Board thought the workhouses would have to provide for people of
that class as paupers. They had that afternoon three sites before them, and he
assured them it was a very difficult matter to select a site that would be suitable in
every way for an asylum, seeing that it meant the spending of £300,000 or ^400,000.
On this asylum he was sure they would not wish the Board to hurry over the selec¬
tion of a site. The deputation then retired.

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NOTES AND NEWS.

1902.]

3*5

In accordance with notice of motion, Mr. J. Miles moved—“ That in view of the
pressing and urgent need of increased asylum accommodation, as emphasised by
the recent Conference of Boards of Guardians, the report of the Sites Committee
(appointed May, 1900) stating that they had reserved the three sites named below
for further inquiry be forthwith considered, and that, in pursuance of the resolution
passed on August 29th, 1901, directing two sites to be acquired, one at least, if
approved, be forthwith selected and submitted to the Lunacy Commissioners for
their sanction/' The sites referred to were respectively at Chadswell, near
Clitheroe; Longworth, near Bolton; and Shuttleworth, near Bury.

After some discussion an amendment to the effect that the previous resolution
of the Committee be adhered to was carried by a large majority. Mr. Miles's
resolution was therefore rejected .—Manchester Guardian, February 28th, 1902.

THE TREATMENT OF EPILEPTICS.

The Manchester and Chorlton Joint Scheme.

In view of the fact that the capacity of the Manchester and the Chorlton Union
workhouses has been severely tried, and of the needs of epileptic patients, consider¬
able interest attaches to the joint scheme of the two unions for the treatment of
these sufferers. It appears that there are between six and seven hundred inmates of
the imbecile wards of the workhouses. The joint committee of the Boards of
Guardians for Manchester and Chorlton have decided to establish at Langho, near
Blackburn, buildings for a “ colony ” (so called from the system, as distinct from
the “ barrack ” system at present in force) for the accommodation of epileptics
and imbeciles. The type of building which it has been decided to erect at Langho
is similar to that adopted in the Poor Law cottage homes. It is thought that by
this method better classification of the patients will be secured, whilst their sur¬
roundings will be of a more home-like character than can be attained in asylums.
The homes, some detached and some semi-detached, will be built in different parts
of the estate—which comprises 165 acres—and grouped for the respective classes
after the fashion of villages. The buildings are to be so designed as to afford
facilities for the extension of the accommodation for every class, but at the outset
there will be accommodation for 370 imbeciles (in homes of about fifty or sixty),
100 adult epileptics classed as insane, 30 epileptic children, 150 sane epileptic
adults, and 50 sane epileptic children, making a total of 700 patients, exclusive of
sick and probationers. The villages or colonies may be 300 to 400 yards apart,
and the homes in them from 50 to 150 feet apart. The homes will vary in size, and
will accommodate from twenty-five to fifty or sixty patients. The buildings will
include, beside the homes, a central administrative block containing the offices and
apartments for the resident staff, also the general kitchen offices, stores, laundry
offices, a committee room, and th$ superintendent’s and clerk's offices and work¬
shops. The cooked food from the kitchen will be distributed to the various homes,
probably by motors furnished with arrangements for keeping the food warm. A
receiving ward is to be built near the general hospital. The hospital will contain
two general wards of twelve beds each for each sex, the remaining accommoda¬
tion for each sex being comprised in separation wards for from two to four
patients each, one of these separation rooms on each side being reserved for
purposes of isolation. Residential accommodation for six nurses, a recreation or
assembly room, and possibly a chapel, are also included in the plans. The resident
staff will be provided with accommodation in the central administrative buildings.
None of the staff, except the foster-mothers in the homes for sane epileptic
children, will reside in the homes. The plans, however, provide for the accom¬
modation for the other members of the staff as follows:—Steward and chief
engineer in semi-detached cottages; an assistant engineer and ten male attendants
in an independent block; two assistant medical officers, one matron, and an
assistant matron, one cook and an assistant, laundry woman, superintendent nurse
and assistant, forty female attendants, and twenty aomestic servants. The equip¬
ment will be completed by the provision of stores, receiving-houses, coal stores,

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NOTES AND NEWS.

386

[April,

places for an electric light installation, a power-house, a railway siding, and storage
tanks for at least a seven days’ supply of water .—Manchester Guardian p
January 7th, 1902.

CORRESPONDENCE.

The following communication has been addressed to the Editors of the
Journal.

Gentlemen, —It is a matter of general faith that all of us in this free country
are the better for having our public doings or writings criticised from time to time.
This no doubt is the motif of the review of the Commissioners’ Blue Book which
appeared in your last number. I have but little hope of attaining that success in
improving the critical abilities of the gentleman who undertakes the annual scolding
of those officials, which probably he expects from his own attentions to their Report,
but with your permission I will do my best.

One thing is certain about criticism: if the manner is to be vigorous, the matter
must be more than reasonably accurate. On the other hand, shakiness in inferences
and conclusions is readily condoned by suavity.

I am forced, as probably others are forced, to the conclusion that your reviewer's
manner is vigorous, too vigorous, and I am equally forced to the conclusion that
some of his complaints ana many of his recommendations cannot be justified. For
instance, at the outset he is much exercised by the manner of taking the yearly
census of the insane as on December 31st of each year. Every one knows that
this process is not accurate; indeed, no lunacy calculations can be exactly accurate
in the absence of certain definitions. But he proposes to take the average residence
of the year as a more accurate basis. Has he considered what this entails?
On the one hand, we must leave out of consideration all the lunatics in the
metropolitan district asylums, those in workhouses or with their friends, or, on
the other hand, we must have the average yearly residence of these classes. The
first would be wrong on account of the perpetual osmosis going on between asylums
and other institutions; the second would be unattainable in these days of fretful
boards and variolous tramps. But really the increased accuracy of his method, as
far as it could be adopted, would be immaterial, as will appear from the following
figures:

Total enumerated insane, exclusive of paupers in workhouses or residing
with relatives.

Average number

Resident on

resident in

December 31st. Discrepancy.

the year.

Discrepancy.

1900.

. 85,189

...

84,246 + 292

83,954

1899.

. 83,304

... 83,310

+ 6

82,486

— 180

82,666

1898.

■ 81,673

81,537

-136

80,302

— 106

80408

1897.

• 78,931

... 79,026

+ 95

77,677 +32

77 , 64 s

1896.

• 76,423

... 76,422

— 1

75,000

—200

75,300

189s.

• 73*577

73,740

+163

72,444 +161

... 72,281

1894.

• 7 I. 3 I 4

71,314

70,406 -1-58

70,348

1893.

• 69,499

... 69,608

+107

68,367

-301

68,868

1892.

. 67,836

...

The figures in italics are the means between those immediately above and below
them, and would represent the actual residence on a June 30th or December 31st,
as the case may be, if the movements proceeded in regular fashion.

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NOTES AND NEWS.

387

1902.]

An aberration from even progression which in eight years varies from nothing
to 0*004 per cent, can surely be contemplated with some approach to calmness.

Your reviewer wants an analysis table to show the reasons for, the results of,
the antecedent residence of, and the nature of each case of transfer. There were
only 2800 last year, and 3500 the year before. The bulk of these probably are
<due to opening of new asylums or of new enlargements, and would give no results
of any value. The purpose of the suggestion is to “ guide alienist physicians to a
due appreciation of the practical utility of transfer as a mode of treatment. 1 ’
Truly if these alienists do not know the fact without support from figures they
had better turn to general practice.

Your reviewer seems also rather mixed on the subject of recovery ratios. " We
go further, however, and maintain that, considering the magnitude of the yearly
aggregate increase in non-recoverable cases, and the merely fractional diminution
in the recovery rate, the inference that the asylums show no improvement in their
recoveries is altogether a false one.” In passing I may say that I find no such
inference in the Blue Book. There is a statement that the recovery rates calculated
on admissions do not show any substantial advance or much variation, which is a
patent fact and not an inference. Your reviewer chooses to read in an inference
that the number of recoveries is more satisfactory than would appear from the
stated facts, but the Commissioners appear to be more cautious in their remarks.
Returning, however, to the sentence quoted above, if he, in using the term recovery
rate, refers to that which is calculated on admissions, he is doing that which is not
lawful to a statistical expert by considering it in relation to yearly aggregate
increase. On the other hand, if he is meaning the recovery rate in proportion
to average numbers he is clearly wrong in talking of its diminution as “ fractional,”
for in the next sentence to that on which he founds his criticisms the Commis¬
sioners state that the recoveries when computed in the latter method show a fall
from 11*54 per cent, in the quinquennium 1873—1877 to 9*99 in the quinquennium
*893—1897. This fall can hardly be called fractional, as it is over 12 per cent.

Then he makes a suggestion which I feel might well be called disastrous if it
were adopted. Dissatisfied with both of the accepted methods of computation,
he suggests the following reckoning of all cases admitted in a given quinquennium.
(I apprehend that the quinquennium would be altered each year by knocking out
the stalest and taking in a fresh one.) He proposes to show that out of all the
<3ises admitted so many recovered, so many died, so many left in the quinquennium,
and so many remained at the end thereof. Touching the recoveries, the first effect
would be that to get an approximate rate the computation must be delayed at least
for two years ; to get an exact rate it would have to be held over for many more.
Taking the first asylum report which comes to my hand (Aberdeen), I find that in
1900, of the 136 recoveries thirty-seven were admitted in 1899, six in 1898, while one
entered as far back as 1891, and another in 1890. Touching the deaths, matters
would be far worse, for of the eighty-one deaths no less than five occurred in
patients of thirty or more years’ residence 1 Many of us will be angels, or other¬
wise, before we get to know what we have been doing in the present year of grace
if the suggestion is adopted.

He quarrels with the Commissioners’ method of statistically showing that there
are ratably fewer general paralytics than there were, while the fact is patent that,
in spite of increase of numbers of all patients, there are absolutely less suffering
from that disease.

He scouts the “obsolete” division of causes into “moral” and “physical,”
though the Association is responsible for it and not the Commissioners. It is not
so long ago that, consuls Hack Tuke, the causation table was reviewed and ratified
by a strong committee of the Association.

He is pleased by the disappearance of the table of causes of general paralysis.
Why P Is he wedded to the belief that syphilis or any other given cause is a sole
factor in any given case ? His Scottish confrere takes up a much sounder position.

I cannot weary you any more in this matter. It is not mv business, nor, indeed,
the business of any one of us, to appear as the champion of the Commissioners in
their statistics; but a sense of justice compels us to state that, so far, they have
been ready to listen to representations. As stated above, they have adopted our
causation table, and, if I remember rightly, they asked assistance in constructing a
satisfactory death causation table. It is open to us to believe that they would

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388

NOTES AND NEWS.

[April,

gladly accept any well-grounded advice offered them by a responsible committee of
our body with the sanction of an annual meeting. Justice also compels us to own
that the blame for any shortcomings in scientific information which appears now
in the Blue Book lies more at our door than theirs, and the excuse on our part
would be the same as they are entitled to offer, vt*., the intolerable pressure of other
routine duties. One little improvement 1 would suggest to them on my own
responsibility is that each table should have at the head or foot a reference to the
corresponding table of the preceding Report. To those who seek solid information
it is somewhat embarrassing to follow the changes in order, which have neoessarily
to be made from time to time.

I hardly like to ask further space from you, gentlemen, but a word about the
reviews ot the Scottish and Irish reports seems justifiable.

It is a word, indeed, as to Scotland, for to my mind that review is cast in
absolutely correct form. It points out the value in the volume rather than the
value of the reviewer.

As to Ireland there is plentiful hammering of the Report, but the tone is jovially
direct. There is distinct humour in the suggestion that the Blue Book should be
exalted to a mission of earnest exhortation, warning, and advice as to what a man
should do (eat and drink P) to save himself and his kin from the scourge of
insanity. Were Dr. Courtenay to fall to the temptation I am sure that no one would
more enjoy the task of cutting the manifesto into ribbons than your delegate.
Why, gentlemen, there is only one man in England—or to be more correct, in the
United Kingdom—who could preach this thing roundly and effectively. And when
Ezekiel had prophesied could he teach a stronger lesson to the people than
is daily taught to them by the removal to the asylum from their midst of
those who, to their knowledge, have neglected the duties of Jife of morality and
sobriety ? The man in the street and the man in the cowshed alike know the road
there as well as any one can teach it to them.

A suggestion, made by way of humour apparently, to include birth as a cause
has some real scientific value, for I remember to have seen somewhere in the
Journal not long ago some statistics about injury to the head in cases of instru¬
mental delivery. But it is a wonder that the suggestion did not go farther back—
some 280 days. If it were possible to obtain and digest accurate facts as to
parental state at the time of conception—poverty or wealth, disease or health, vice
or virtue, worry or happiness, fear or resignation—we should go some way further
towards solving vital problems.

With many apologies for so lengthy an intrusion,

I am, Gentlemen,

Your obedient servant,

Rbsartor.

OBITUARY.

William Charles Hills.

We regret to announce the death of Dr. Hills, which occurred on January 18th
last from cardiac failure, shortly after retiring to rest at his house in the Chantry,
• Norwich. He had been in indifferent health for some eighteen months past, but
the end came suddenly and unexpectedly. Dr. Hills was the second son of
Mr. Monson Hills the elder, Resident Apothecary and Cupper of Guy’s Hospital,
and was born within its precincts on February 25th, 1828. He was therefore
nearly seventy-four at the time of his decease. On leaving Merchant Taylors’
School he commenced his medical training at Guy’s Hospital, where he was
intimately known to Sir W. W. Gull, Mr. Bryant, Sir Samuel Wilks, and many
others. Upon obtaining the diplomas of M.R.C.S. and L.S.A. in 1850, he was
elected House Surgeon at the Surrey Dispensary, and subsequently, in 1854,
Assistant Medical Officer at the Kent County Asylum at Banning, under Dr.
James Huxley, who is still living, the brother of the late Professor Huxley. In
1859 he graduated as M.D.Aberd., and in 1861 was promoted to the Medical
Superintendency of the Norfolk County Asylum at Thorpe, near Norwich. He
succeeded a lay superintendent, and many troubles and difficulties beset him at the
outset, but his tact and sympathy, combined with firmness, carried him safely

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NOTES AND NEWS.

389

1902 .]

through these to the lasting benefit of the patients and institution. He quickly
gained the entire confidence of the committee of county magistrates who controlled
the asylum, and retained it to the full until his retirement in January, 1887, when
he was granted a pension of £600 a year. The remaining fifteen years of his life
were employed in consulting practice in mental diseases, and in gratuitous
medical work amongst the poor of Thorpe. He was laid to rest on January 22nd
in the picturesque churchyard of Postwick, beside his second wife and only son,
whose death at Charterhouse School in 1886 was a grievous blow to his parents.
He leaves one daughter, Mrs. Aubrey A. Blake, to mourn his loss. The funeral
was largely attended by medical friends, including Messrs. Wm. Cadge, Charles
Williams, Charles Muriel, Thomas H. Morse, Dr. Ernest White, and Dr. Law,
the Acting Superintendent of the County Asylum in the absence of Dr. Thomson
through ill-health. Chief Attendant Fox and several of the older members of the
staff of the institution were also present as a mark of respect for their old
superintendent.

Samuel Alexander Kenny Strahan.

Many members of our Association will hear with regret of Dr. Strahan’s
untimely death, which took place on February 21st in London.

Born in Belfast in August, 1853, the second son of John Strahan, Esq., of that
city, he was educated privately and at Queen’s College, Belfast, where he had a
distinguished career. He gained distinction also in his clinical work, being
awarded the Malcolm Exhibition at the Belfast Royal Hospital, and the Gold
Medal at the Belfast Hospital for Children. He graduated in medicine and
surgery in 1879. He began practice at Callington, in Cornwall, in 1880, but not
liking general practice he abandoned it for the appointment of Assistant Medical
Officer at the East Riding Asylum, Beverley. In 1881 he obtained a similar post
in Northampton County Asylum, where he remained until November, 1897, when
he resigned, having the previous year been admitted a barrister of the Middle
Temple.

In 1898, owing to poor health, he went for a tour round the world with Dr.
Perry Patterson of Canterbury, returning to England the following year. After
this he divided his time between living in the Middle Temple and travelling until
the outbreak of the war in South Africa, when he offered to go to the front as
surgeon, but on account of his age was not successful. Subsequently he made
several voyages to Natal, where he frequently assisted in the military hospital at
Durban and up country. His last visit was in 1901, when he had a very severe
attack of dysentery, and after his return home he lived chiefly at Brighton in order
to recuperate. While on a short visit to town he died suddenly from heart failure
on the date mentioned.

From the beginning of his professional career Dr. Strahan devoted much of hia
energy to literary work. His first contribution was in 1890 to the Lancet , and his
last in October of last year to the Humanitarian . Most of his writings were on
professional subjects, especially dealing with questions relating to mental diseases.
Besides his numerous articles on these subjects in our own Journal, the Lancet ,
British Medical Journal, Westminster Review, etc., he published works on Marriage
and Disease and Suicide and Insanity. These had a wide circulation.

In 1801 he read a paper before the British Association on “ Instinctive
Criminality,” which was the subject of a long and bitter controversy in the Press-
Dr. Strahan did not confine his literary activity to professional subjects, but con¬
tributed a good deal of fiction to magazines and published two short novels; all
of these were published anonymously.

Dr. Strahan was a man of brilliant abilities and wide sympathies, kind-hearted
to a fault, and was as an assistant loyal to the backbone. Politically he held
extreme views, but had a great respect for his opponents. For many years he was
a member of the Savage Club in London, and its members cancelled the Saturday
night house dinner on the occasion of his death.

He never married. He leaves two brothers, James Andrew Strahan, barrister-
at-law, Assistant Reader of the Law of Property, Lincoln’s Inn; and George
William Strahan, a solicitor and partner in the firm of Biggar and Strahan,.
Belfast. His only sister is the wife of Dr. McKee, of Belfast.

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390

NOTES AND NEWS.

[April,

APPOINTMENT OF REGISTRAR.

Dr. Alfred Miller, Superintendent of the Warwick County Asylum, was, at the
Council Meeting on February 14th, 1902, appointed to fill the post of Registrar
until the next Annual Meeting.

NOTICES BY THE REGISTRAR.

\ Next Examination for Nursing Certificate.

The next examination will be held on Monday, May 5th, 1902.

Note .—As the names of some of the persons to whom the Nursing Certificate has
been granted have been removed from the register, employers are requested to
refer to the Registrar in order to ascertain if a particular name is still on the roll of
the Association. In all inquiries the number of the certificate should be given.

Examination for the Professional Certificate.

The next examination for the Certificate in Psychological Medicine will be held
in July, 1902.

For further particulars respecting the various examinations of the Association
apply to the Acting Registrar, Dr. Alfred Miller, Warwick County Asylum,
Hatton, Warwick.

Prize Dissertation.

Although the subjects for the essay in competition for the Bronze Medal and Prize
of the Association are not limited to the following, in accordance with custom the
President suggests—

1. On the advantage of providing hospitals in asylums for acute mental cases.

2. Causation of colitis in asylums, and how it can be prevented.

3. State care of the insane.

The Manuscript Prize Dissertation and every accompanying drawing and pre¬
paration will become the property of the Association, to be published in the
journal at the discretion of the editors. The dissertation, for the Association
Medal and Prize of Ten Guineas, must be delivered to the Acting Registrar, Dr.
Alfred Miller, Warwick County Asylum, Hatton, Warwick, before May 30th, 1902,
■from whom all particulars may be obtained.

THE CRAIG COLONY PRIZE FOR ORIGINAL RESEARCH IN

EPILEPSY.

Dr. Frederick Peterson, of New York City, offers a prize of $200.00 for the best
original unpublished contribution to the pathology and treatment of epilepsy.
Originality is the main condition. All manuscript should be submitted in
English. The prize is open to universal competition. Each essay must be
accompanied by a sealed envelope, containing the name and address of the author
and bearing upon the outside a motto or device, which is to be inscribed also upon
the essay. All papers received will be submitted to a committee, consisting of three

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NOTES AND NEWS.

39*

members of the New York Neurological Society, and the award will be made
upon its recommendation at the annual meeting of the Board of Managers of the
Craig Colony, October 14th, 190a.

Manuscripts should be sent to Dr. Frederick Peterson, 4, West Fiftieth Street,
New York City, on or before September Toth, 190a. The successful essay becomes
the property of the Craig Colony, and will be published in its medical reports.

NOTICES OF MEETINGS.

Medico-Psychological Association,

General Netting .—The next General Meeting will be held in London on
Wednesday, May a 1st next.

A discussion on “ The Treatment of Sleeplessness in Mental Disease ” will be
opened by Dr. Rayner. All asylum medical officers are invited to join in the dis¬
cussion and record their observations. The following, among others, have
promised to take part c^-Drs. BJandford, Harry Campbell, Hyslep, Merder, Savage,
Claire Shaw, and Outterson Wood.

Annual Meeting .—The Annual Meeting will be held at Liverpool, under the
presidency of Dr. Wiglesworth, on July 24th and 25th next. Any member
desiring either to contribute papers, to record cases, or to give a demonstration
should, at the earliest date possible, communicate with the Hon. Secretary at 11,
Chandos Street, Cavendish Square, London, W.

Northern and Midland Division .—The Spring Meeting will be held on Wednes¬
day, April 16th, at Shaftesbury House, Formby, Liverpool. Papers will be read
on " Calcification of the Pericardium,” by Dr. F. V. Simpson, and on 99 Pupillary
Symptoms in the Insane and their Import,” by Dr. T. P. Cowen.

South-Western Division .—The Spring Meeting will be held at the County Asylum,
Cotford, near Taunton, on Tuesday, April 22nd. Business meeting at 245 p.m.
Papers will be read on “ The Evolution of Delusions in some Cases of Melancholia,”
by Dr. Weatherly, and on “The Care of Idiots and Imbeciles,” by Dr. Sproat.

South-Eastern Division .—The Spring Meeting will be held at the Surrey County
Asylum, Brookwood, on Wednesday, April 30th. Papers will be read on ** The
Treatment of Colitis,” by Dr. Niel Harrismith MacMillan, and on 99 Some Cases
of Morphinomania,” by Ur. Robert Jones.

Irish Division .—The next meeting will be held at the Royal College of Physicians,
Dublin, early in May, 1902.

AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION.

Annual Meeting at the Windsor Hotel, Montreal,

June 17TH, i8th, 19TH, 20th, 1902.

President, R. J. Preston, M.D., Marion, Va.; Vice-President, G. Alder
Blumer, M.D., Providence, R.I.; Secretary and Treasurer, C. B. Burr, M.D.,
Flint, Mich.; Auditors, Wm. M. Edwards, M.D., and Nelson H. Beemer, M.D.

The fifty-eighth annual meeting of the American Medico-Psychological Associa¬
tion will be held in Montreal the third Tuesday, Wednesday, Thursday, and
Friday in June (17th, 18th, 19th, and 20th), 1902. The meeting follows that of the
American Medical Association at Saratoga, which occurs in the second week in
June. The matter of transportation has been placed in the hands of the Com¬
mittee of the latter Association, and it is hoped to obtain special railroad rates for
both meetings.

The annual address will be delivered by Dr. Wyatt Johnston, Lecturer on
Medical Jurisprudence, McGill University Law Faculty. Subject: 11 The Medico-
Legal Appreciation of Trauma in its Relation to Abnormal Mental Conditions.”

XLVIII. 27

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[April, 1902 ;

392 NOTES AND NEWS.

Papers ha ve been promised as follows:

Dr. Henry M. Hurd, Baltimore, Md., 44 Folklore of Insanity.”

Dr. E. G. Carpenter, Columbus, Ohio, 44 Insanity and Degeneracy.”

Dr. J. H. McBride, Pasadena, Cal., 44 Boarding out for the Chronic Insane.”

Jas. M. Buckley, D.D., LL.D., Morristown, N.J., 44 The Possible Influence
of Rational Conversation on the Insane.”

Dr* A. B. Richardson, Washington, D.C., 44 Women Nurses in Hospitals
for the Insane.”

Dr. Geo. ViUeneuve, Longue Pointe, Que., 44 Conjugal Jealousy as a Cause
and Excuse for Crime from a Medico-legal Standpoint.*'

Dr. las. Russell, Hamilton, Ont., 44 The Psychology of Anarchism.”

Dr. William Rush Dunton, Towson, Md., 44 Dementia Praccox.”

Dr. E. D. Bondurant, Mobile, Ala., 44 The Early Diagnosis of General Paresis
and the Possible Curability of the Disease in its Initial Stages.”

Several other papers, of which the titles are not yet announced, are promised.

CONGRESS OF FRENCH ALIENISTS AND NEUROLOGISTS.

The Annual Congress of French alienists and neurologists will be held this year
at Grenoble, from August 1st to 8th, under the presidency of Dr. E. Rlgis, Professor
of Psychiatry in the University of Bordeaux. The questions proposed for dis¬
cussion are--{i) Nervous Pathology: Tics in General (to be introduced by
M. Nogufes, of Toulouse); (a) Mental Pathology: Anxious States in Mental
Maladies (to be introduced by M. Lalanne, of Bordeaux); (3) Forensic Medicine:
Self-accusers from the Medico-legal Point of View (to be introduced by M. Ernest
Duprd, of Paris). The Secretary-General of the Congress is Dr. Bonnet, Physician
of the Asylum of Saint-Robert, Isfcre.

APPOINTMENTS.

Gemmel, J. F., M.B., C.M.Glasg., appointed Medical Superintendent of the
Whittingham Asylum, Preston, Lancashire.

Jackson, Arthur M., M.D.Oxon., appointed Medical Superintendent of the Notts
County Asylum.

Jones, Helena G., M.B.Lond., appointed Assistant Medical Officer to the
District Asylum, Mullingar.

Zimprd, Adolph, M.B., M.S.Aberd., appointed Junior Medical Officer to the
Lunacy Department of New South Wales.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]

No. 202 [ n no“66.* 8 ] JULY, 1902. VOL. XLVIII.

PART I.

REPORT OF THE TUBERCULOSIS COMMITTEE OF
THE MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

To the President and Council of the Medico-Psychological
Association of Great Britain and Ireland*

In the October number of the Journal of Mental Origin of the
SCIENCE, 1899, appeared an essay, which was awarded the committee ,S
Bronze Medal of the Medico-Psychological Association, by
F. G. Crookshank, M.D.Lond., entitled, “ The Frequency,

Causation, Prevention, and Treatment of Phthisis pulmonalis
in Asylums for the Insane.”

On November 9th, 1899, Dr. Eric France read a paper
before the Association, “ The Necessity for Isolating the
Phthisical Insane.” 1

After a discussion, in which, among others, Sir William Broad-
bent, Bart., Sir James Crichton-Browne, and Professor Clifford
Allbutt took part, the following resolution, brought forward by
the Council of the Association, was unanimously adopted :

“ That it be referred to the Council of the Association to
consider the appointment of a sub-committee for the investiga¬
tion and collection of evidence and for practical suggestions
as to the isolation of phthisical patients in asylums.”

At a Council Meeting held on May 10th, 1900, a Tuber-

XLVIII. 28

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394

REPORT OF TUBERCULOSIS COMMITTEE. [July,

Mode of
procedure.

Phthisical
death-rate
in asylums.

culosis Committee was duly appointed to carry into effect the
resolution passed on November 9th, 1899.

The Committee consisted of Drs. D. M. Cassidy, A.
Campbell Clark, T. S. Clouston, F. A. Elkins, Eric France,
Mr. G. T. Hine, Drs. F. W. Mott, Conolly Norman, R. Percy
Smith, J. B. Spence, L. A. Weatherly, J. R. Whitwell, and J.
Wiglesworth.

Dr. Cassidy and the late Dr. Campbell Clark resigned on
July 27th, 1900, and Drs. Perceval and Turnbull were
appointed in their place on August 17th, 1900.

Mr. Clifford-Smith, not being a member of the Association,
was added to the Committee, after reference to the Council, in
an advisory capacity.

As it was evident that we had to obtain various statistics
before coming to any conclusion as to the prevalence of
phthisis in asylums, causes for such prevalence, if ascertain¬
able, and as to sundry other matters, we decided to draw up a
series of questions to be answered by the medical superinten¬
dents of the asylums of Great Britain and Ireland.

[These questions will be found in Appendix B, p. 429.]

We have to here thank those medical superintendents who
so kindly responded to our wishes.

The answers to the questions were brought before us, and
were duly arranged by us in certain groups, but it became
quite clear to all that only one person could compile and
arrange these statistics.

We deputed Dr. Eric France, our Honorary Secretary, to do
this, and from time to time he brought up his reports, which
were duly and carefully considered and amended where
necessary. His full report, approved of by this Committee, is
herewith appended, and will be found on p. 411, together with
the Tables and Charts in Appendix A, p. 427.

We here desire to record our warm appreciation of his work,
his energy, and his ability, and we feel that not only this
Committee, but the whole Association, owe him a deep debt of
gratitude for all the time and care he has so well bestowed
upon this difficult subject.

Generally we may say that the statements made by
Drs. Crookshank and France in the papers which originated
this Committee have been, to our minds, fully proved by our
investigations, and that it is a fact beyond contradiction that

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REPORT OF TUBERCULOSIS COMMITTEE.

395

phthisis is prevalent in our public asylums to an extent which
calls for urgent measures .

We are satisfied that large numbers of patients contract Production of
phthisis after admission into the asylums. asylums 11

Dr. Cassidy (Lancashire Asylum) has, during the past few
years, isolated as many as possible of his phthisical cases in
an isolation hospital; and Dr. Brain, in his paper on this
subject in the April number of our JOURNAL, 1900, mentions
the fact that of the seventy-four consecutive cases of phthisis
so treated, with ages ranging from twenty to sixty-two, only
three had acquired phthisis before admission to the asylum.

The character of the population of all asylums has evidently
much to do with this acquired phthisis, for it is proved that the
death-rate from this disease is twice as high in those asylums
which have an urban population, as in those filled from the
rural districts. The susceptibility to develop this disease is
considerably increased in the town dwellers ( vide Hon.

Secretary’s report, p. 422).

Influences bearing on the Phthisical Death-rate in Asylums .

As Dr. France has pointed out in his report, it is very
difficult to demonstrate with any degree of certainty any one
particular fact which especially influences the death-rate, and
which could be proved by the figures which have been brought
before us.

Yet there is no doubt in our minds that overcrowding Overcrowd-
and consequent deficient day and night cubic space must be ing *
the most important factor conducing to this high death-rate.

We are satisfied that there is not sufficient cubic space per
patient in the great majority of our large asylums.

It will be seen that the asylums which stand on a good and Soil,
dry soil have a considerably lower death-rate than those built
on a bad and damp soil.

We find that the death-rate bears a ratio to the number of Insufficiency
hours spent in the open air by the patients, which proves con- ^open air.
clusively the benefit arising from giving the inmates of our
large asylums as much time in the open air as is possible.

We refer the Council to the special report, on this subject,
drawn up for our Committee by Messrs. Hine and Clifford- an d heating.
Smith, which will be found on p. 405.

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REPORT OF TUBERCULOSIS COMMITTEE. [July

Elevation of
asylums.

Uncleanly

habits.

We are unable to come to any conclusion on this point, as
our data are insufficient. It is now generally considered that
elevation has but little to do with the incidence of phthisis,
and that other factors must be brought in to prove definite
influence.

We need not emphasise the great danger there must of
necessity always exist to the inhabitants of our large asylums
unless the greatest care is taken to prevent the habit of spitting.
We refer to this later on.

SUGGESTIONS.

His Majesty the King when, as Prince of Wales, he in¬
augurated The National Association for the Prevention of
Tuberculosis, asked the question : " If consumption is prevent¬
able, why not prevented ? ”

That question must be ever present in the minds of all who
take an interest in the health of the nation.

That it is a preventable disease we all now know, and what¬
ever value may be placed upon the lives of those members of
the community who have to be treated in asylums, our duty is
clear.

We must do all in our power to prevent the ravages
of this deadly scourge, not only in order to diminish the
death-rate from this disease in our institutions for the insane,
but also to lessen the danger of disseminating consumption
among the general population. We all know the large
numbers who are discharged each year from the asylums
of this country, and we also know what a considerable number
of the staff of these asylums migrate from place to place, and
although no statistics are available on this point there is evident
risk that the public asylums of this country, with their large
number of phthisical inmates, may act as disseminators of
the disease among the general community.

It becomes our duty, now, to recommend for your serious
consideration the measures which we feel must be taken if
success is to be the result of our efforts.

These may be dealt with appropriately under the following
two heads:

1. What we should do in the interests of the uninfected.

2. What provision should be made for the infected cases.

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

397

(i) In the Interests of the Uninfected.

Overcrowding must be checked before we can hope to lessen Air and cubic
our phthisical death-rate. More especially does this apply to space *
the sleeping accommodation in our large asylums. We are of
opinion that in a very considerable number of our asylums
there is not sufficient cubic space per patient. Not only should
dormitories be free from overcrowding, but the greatest care
should be taken that plenty of renewed fresh air passes through
these rooms during the night time. We are of opinion that
the predisposition to, and the actual infection of, phthisis is to
a very large extent started in the sleeping rooms of our over¬
crowded asylums, and is likely to be increased by large
numbers of patients being congregated in huge dormitories.

No dormitory, we think, ought to contain more than fifty beds.

We feel bound to enter our protest against the present
tendency to build huge asylums. The Lunacy Commissioners
have, we know, tried their best to limit this dangerous method
of dealing with our insane population, but so far their opinion
seems to have been set at defiance. Professor Clifford Allbutt
has told us that when he was a Commissioner the Board urged
that henceforth no asylum should be built for more than 1000
patients. We most cordially support this opinion, and we go
further, and would urge that when once the Commissioners have
passed the plans of an asylum for a definite number of patients,
that number should under no circumstances be allowed to be
increased without a corresponding increase of accommodation.

It is evident that more power should be given the central
authority, in order that this dangerous overcrowding of asylums
may be put a stop to.

The special report on “ Ventilation ” deals so fully with this
question that we need not dilate any further upon it here.

We desire to point out the great importance of keeping Hours in open
patients out in the open air as much as possible. While the air *
wards and corridors are empty care should be taken that plenty
of fresh air passes through these spaces. We consider this of
vital importance.

The careless, dirty habits of many of the inmates of asylums Cleanliness,
render the danger of infection from the expectoration of
phthisical patients a very grave one. The utmost care should

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398

REPORT OF TUBERCULOSIS COMMITTEE. [July,

Dietary.

Early dia¬
gnosis of
phthisis.

be taken to prevent the filthy habit of spitting on the floors,
the paths, etc. Rules and warnings against such habits
should be enforced, and we see no reason why specially
designed spittoons should not be placed in the wards and
corridors. A wide-mouthed cup with contracted neck could be
fastened to the walls by a padlocked band, and could contain
some disinfectant.

The nurses and attendants should have definite rules given
them to deal with the objectionable habit of spitting indis¬
criminately, and a mop, with rag or paper, which should be
afterwards burnt, must always be handy to immediately wipe
up any sputa seen.

Mattresses and bedding of every patient should be frequently
and freely exposed to the fresh air and sunlight .

It is essential that in order to diminish the disposition to
become infected by the tubercle bacillus, everything must be
done to build up the constitutional vigour of our patients.

Plenty of good fresh air by day and by night has been
shown to be of great importance, but added to this we must be
watchful that our dietaries are carefully balanced as regards
their different constituents, contain a sufficiency of fatty
elements, and are arranged to be as varied as possible. Dr.
Clouston has brought to our notice a most excellent Report
on the Dietary of Pauper Lunatics in Asylums and Lunatic
Wards of Poor-houses in Scotland , which was furnished
to the Scotch Commissioners in Lunacy by Dr. J. C.
Dunlop, of Edinburgh. This report has been published by
the General Board of Commissioners in Lunacy in Scotland as
a supplement to their Forty-third Annual Report, and we
cordially recommend it for the consideration of all interested
in this important question of asylum dietary. In this report
Dr. Dunlop insists upon a variation of dietary as essential, and
we are quite with him on this point.

. If we all recognise great difficulties in the positive diagnosis
of consumption in its early stage among our sane population,
how much more difficult must it be to determine, with any
degree of certainty, that an insane patient is developing this
disease; and yet how important it is, not only for the patient,
but also for those among whom the patient is living, that this
diagnosis should be made as early as possible.

We would advise that patients in whom there is the least

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 399

suspicion of this disease should be weighed once a week, and
have their temperature taken at least four times a day, viz .
morning, noon, at four o’clock, and in the evening.

A rise of temperature at any part of the day, with loss of
body weight, are two most important symptoms of the early
stage of phthisis, but as this rise may vary as to time in
different cases, it is wise to have the chart kept as suggested.

We have seen cases of consumption in which, while the
morning and evening temperatures were normal, there was a
definite rise at about four o’clock in the afternoon, while in
others the increase has been noticed at noon.

It must be remembered that in the very early stage of
phthisis we cannot expect to find the presence of the tubercle
bacillus in the sputum.

The tuberculin test, advocated by Dr. Eric France in the
Journal of Mental Science, October, 1897, and January,

1900, has been fully discussed at the International Congress last
year, and though we fully recognise its value, if most carefully
and judiciously used, we think its general adoption may be left
to the discretion of individual superintendents.

Haemoptysis, however slight, must be looked upon with the
greatest suspicion, and it is undoubtedly often the earliest
objective symptom of the disease, before any definite physical
signs are present (vide Le Diagnostic prtcoce de la Tuberculose
pulmonaire y par Drs. Jourdin et Fischer).

Rontgen rays have been used with some measure of success
in determining the early diagnosis of phthisis (vide Dr. Hugh
Walsham’s paper, read at the International Congress).

We consider that the isolation of phthisical cases in asylums is Isolation.
imperative .

We recognise the difficulties to be overcome to carry this
into effect, but we are of opinion that it is so urgent a matter
that no efforts should be spared to impress upon the com¬
mittees of our large asylums the utmost importance of this
measure. Our suggestions as to the ways and means of
isolating these cases will be found under “ Treatment.”

The following asylums have already adopted the isolation of
phthisical cases, and the good effects on the death-rate of
phthisis in these institutions is clearly proved :—Lancaster
County Asylum, Rainhill Asylum (partial), Whittingham
Asylum (partial), Leavesden Asylum (partial).

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REPORT OF TUBERCULOSIS COMMITTEE. [July,

Hair picking.

At Leavesden the tubercular patients are housed in separate
wards, 346 beds being apportioned to them. Two female
and two male infirmary wards of thirty-five beds have been
allotted to the more advanced cases, with 100 square feet of
floor space per patient by night and by day, while the incipient
cases of phthisis have sixty square feet of floor space by night
and thirty square feet by day. Rustic shelters have been
erected in the four airing courts used by the tubercular patients
and they spend as much time as possible in the open air ( vide
Dr. Elkins’ Annual Report for year 1901).

At the County Asylum , Lancaster , Dr. Cassidy has isolated
his phthisical cases in separate wards for the past twelve years.
He has utilised a detached isolation hospital for female
phthisical cases for some four or five years, and has now plans
before the Commissioners for an isolation hospital for male
cases. Since isolation of these cases has been carried on the
phthisical death-rate in this asylum has decreased 50 per cent.

At Whittingham Asylum Dr. Perceval tells us that during
the last three years portions of wards have been reserved for
phthisical cases, and that for some years every precaution
against infection for these cases has been taken.

At Rainhill Dr. Wiglesworth reports that a few female
patients have been treated in the isolation hospital for in¬
fectious cases.

In the District Asylum of Belfast the committee has advised
the building of special cottages for isolation of phthisical cases.

The new Leicester and Rutland Asylum is to have detached
isolation blocks for consumption. Plans have also been passed
for two isolation blocks at the Warwick Asylum.

In our opinion it must , of necessity , take some few years after
the adoption of isolation of these cases before the full benefit of
this measure can be realised.

We are of opinion that the occupation of hair picking, unless
most carefully supervised, is a dangerous one having regard to
phthisis.

The patients chosen to work in the upholsterer’s shop in order
to pick hair are usually the feeble, demented, and imbecile
patients who are unfit for other occupations, and themselves,
therefore, peculiarly liable to become infected with phthisis.

Work amongst hair is always dangerous to the lungs.
Small particles of sharp-pointed hair dust are inhaled, wound

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 401

the lung, and so allow the ready access of germs such as the
tubercle bacillus.

In this way persons working amongst hair become predis¬
posed to pulmonary tuberculosis. On account of the dirty
habits of insane patients the mattresses used in asylums often
contain hair which may be impregnated with germs of many
kinds, so that hair picking in asylums may be considered more
dangerous than outside asylums.

An upholsterer’s shop in which hair picking is done should
be specially well ventilated and absolutely above suspicion
with regard to sanitation and cleanliness, and each individual
working there should have not less than 1000 cubic feet of air.
Whenever the weather admits of it, the hair picking should be
done out of doors under sheds.

The hair to be picked should first be disinfected by steam , or
by some other equally approved method of disinfection.

No consumptive patient, or any patient with such a pre¬
disposition, should be allowed to have anything to do with this
occupation.

(2) Provision for the Infected Cases.

However we decide to isolate our consumptive patients, we
must bear in mind that we have to arrange at the same time
for their treatment on the most modem lines.

The great difficulty in carrying out this idea of isolation and The ideal
treatment of the phthisical insane arises from the fact that plan *
provision must be made for patients with every phase of mental
disorder. A sanatorium or isolation hospital for such cases
must therefore be built on lines to meet all exigencies—must,
in fact, be an asylum in miniature. The requirements as to
situation of such an asylum sanatorium should be pure air, a
sandy or gravelly soil, absence of damp and fog after sunset,
free exposure to the sun, adequate protection from north and
east winds, an environment suitable for outdoor life.

We think such a sanatorium should be built for not less than
50, and for not more than 200 patients.

We are satisfied that if the asylum to which such a sana¬
torium belonged had not sufficient phthisical cases to fill it,
the accommodation would be gratefully accepted by other insti¬
tutions for the insane not so well situated.

The Commissioners in Lunacy have, we believe, advocated

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REPORT OF TUBERCULOSIS COMMITTEE. [July

the union of two or more asylums for the purpose of erecting a
joint sanatorium for isolation and treatment of the phthisical
cases in a suitable position, and we most cordially support
such a plan. We cannot see that anything against it, on the
ground of expense, can for a moment be entertained.

Increased accommodation for our insane is continually being
required. Why should not such increased accommodation be
given by the erection of these asylum sanatoria, which, while
enabling medical superintendents to carry out the imperative
work of isolating and treating on modem lines their consump¬
tive patients, sets free in their existing institutions beds for
their ever-increasing admissions ?

We may here at once state our opinion that if an asylum is
badly situated as to soil, protection from winds, and free
exposure to the sun, although isolation of phthisical cases must
be a benefit to the uninfected patients, we cannot expect much
result from treatment. We would strongly urge that the
consumptive cases of such an asylum should be boarded out in
other institutions which have not only suitable accommodation
for such cases, but which are also, from their situation and
surroundings, adapted for the now accepted open-air treatment
of this disease.

It must be, therefore, evident that each asylum whose site and
surroundings fulfil requirements already stated, might, with
great advantage, build such an asylum sanatorium, which should
be large enough to accommodate not only its own phthisical
cases, but those from adjoining asylums lacking these advan¬
tages.

We think that such a sanatorium should be kept for the
recoverable cases of phthisis, and that the unfortunate hope¬
less cases, with, may be, a few months only to live, should
be isolated in a separate block of the hospital, as has been
already carried out by Dr. Elkins at Leavesden.

This, then, should be the plan to be aimed at, but it must
of necessity take some time before it can be generally adopted.
We, however, urge upon the Association to do all in its power
to hasten the adoption of our suggestions, believing that such
a plan would be of the greatest possible use in restoring many
lives otherwise doomed, and in greatly lessening the death-
rate from this dreaded disease.

In the meantime isolation and treatment should be carried

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 403

out, either in temporary buildings erected in suitable situa¬
tions, or in special wards and airing courts set aside for such
cases.

It would serve no purpose to make any more definite
suggestions. Each asylum must devise a plan for isolation
and treatment according to its position, surroundings, and
general construction.

Isolation and special treatment of the consumptive insane
must be carried out in some way or other if we are to hope
to lessen the death-rate from this disease in our asylums.

It is not in the province of this Committee to suggest plans
of sanatoria suitable for asylums, or plans of temporary
buildings, or alterations to existing wards, and airing courts for
the carrying out of these measures.

Once let the principle be recognised as imperative, the
details are easy of solution, and can be safely left in the hands
of the medical superintendents of each asylum.

SUMMARY.

Phthisis is prevalent in our public asylums to an extent
which calls for urgent measures.

A very large number of cases of phthisis have acquired that
disease after admission to the asylum.

The special causes for this increased prevalence of phthisis
in our asylums are, in our opinion :—

Overcrowding, with consequent insufficient day, and especially
night cubic space per patient,

Insufficiency of hours in the open air,

Defects in ventilation and heating,

Uncleanly habits,

Faults in dietary.

The Means of Prevention should be.

Early diagnosis of phthisis,

Isolation of all phthisical cases,

Limiting the size of future asylums,

Checking overcrowding,

Increasing day and night cubic space,

Restricting number of beds in dormitories,

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404 REPORT OF TUBERCULOSIS COMMITTEE. [July

Increased and more thorough natural ventilation per patient
The greatest care to prevent the spread of this disease by
promiscuous spitting,

A careful supervision of dietary,

Properly constructed and situated hospitals and sanatoria
with adequate and suitable surroundings for the isolation of
these cases, and their treatment on the most modern lines,
Failing such special hospitals or sanatoria, then either
temporary isolation hospitals or special wards and airing courts
set apart for this purpose.

(Signed) C. W. Clifford-Smith, M.I.C.E.

T. S. Clouston, M.D.

F. A. Elkins, M.D.

G. T. Hine, F.R.I.B.A.

F. W. Mott, F.R.S.

Conolly Norman, F.R.C.P.I.

F. Perceval, M.R.C.S.

R. Percy Smith, M.D.

J. B. Spence, M.D.

A. R. Turnbull, M.B.

J. R. Whitwell, M.B.

J. Wiglesworth, M.D.

Lionel A. Weatherly, M.D. {Chairman).

Eric France, M.B. {Hon. Sec.).

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

405

REPORT ON HEATING AND VENTILATION.

The Tuberculosis Committee of the Medico-Psychological
Association have referred to us in their difficulty of dealing
with the complex question of heating and ventilation, inviting
us to give them a supplementary report on the subject; and,
while we see the difficulty of treating fairly a matter of such
magnitude in so necessarily condensed a form, we have done
our best to comply with their request.

Heating and ventilation, as applied to most buildings, are
more or less inseparable, but it will be convenient to deal with
the latter subject first, as being, for the purpose of this report
the more important, and to which the question of heating
should be made subservient.

Broadly speaking, ventilation may be obtained by natural or
artificial means. Natural, by constructing a building in such
a way as to obtain all the advantages of atmospheric pressure
and, consequently, free passage of air into and out of every
habitable room. Artificial, by various mechanical methods
described later on.

To obtain natural ventilation is sometimes a difficult task, as
only a limited number of rooms have an outside wall on more
than one side ; but much can be done by using properly con¬
structed windows, such as those of the isolation hospital type,
with a fanlight over a transom and sliding sashes below, by
which air can be admitted without a direct draught, also by
well-arranged inlet and exhaust ventilators. In a well-designed
and properly administered asylum a natural system of ventila¬
tion can be made effective in, perhaps, 320 out of the 365
days in the year, and by utilising the heating system to assist
ventilation, the non-effective days can be further reduced.

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406 REPORT OF TUBERCULOSIS COMMITTEE. [July,

We shall probably be met with the objection that to ensure
successful ventilation by natural means a more intelligent and
watchful type of attendant is required than is generally met
with in asylums ; but while we feel that it is perhaps not for us
to criticise administration, we are of opinion that it is better to
aim at training the staff to a higher degree of efficiency than
to resort to automatic appliances for every emergency, in which
there is always a danger of lowering the intelligent usefulness
of the attendant.

Artificial ventilation is obtained by various methods,
generally either by the fan or the so-called air-pump ventilator
as an extracting power, or by the application of heat in the
extraction shaft, which rarefies the air and induces an upward
current. Sometimes both these forces are applied reversely on
the plenum system, by using the fan as a propelling power to
drive fresh air into the building, or by applying heat for the
same purpose in a ventilating radiator fixed with its back to
an outer wall, having an inlet flue through which air is
drawn from the outside by the heat of the coil and admitted
with some velocity into the room, thus displacing polluted air,
which escapes up the chimney or through outlet flues provided
for the purpose.

Both these systems are more or less elaborated in various
ways, which it is neither necessary nor possible for us to enlarge
upon in this report

The disadvantages of artificial ventilation are those arising
from mechanical construction and the upkeep of the plant; the
dangers resulting from the fouling of the air flues, many of
which are necessarily too small to be possible of proper and
constant cleaning ; and, where combined with heating, as these
systems generally are, the difficulty of regulating the tem¬
perature in rooms of varied size and position. In this con¬
nection, however, we would express the opinion that, while, on
a suitable soil and under careful direction, the plenum system
may be made a more perfect substitute for natural ventilation,
combined with heat, than any method we know of, there is,
perhaps, generally less danger in an extraction system than in
one of propulsion, as in the former the inlets may be direct
from the outer air, with a flue limited in length to the thick¬
ness of the wall; while in a plenum system the air must be
passed through a considerable length of underground trunks

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

407

and branch flues, which may become contaminated in a variety
of ways, and from which the air might, possibly, be driven into
the wards in a noxious condition.

There is similarly a danger of fouling in the extraction flues,
though to a lesser extent, but as the air generally passes out
of the wards through these extraction flues, the danger arising
from contamination of these trunks is minimised.

While on this subject we must not omit to refer to cubic
space, to which ventilation is so closely allied.

It is an axiom that an adult requires 3000 cubic feet of
fresh air per hour, and it is frequently asserted that to obtain
this 1000 cubic feet of space is necessary. We would, how¬
ever, point out that the hygienic properties of a room are not
so dependent on the amount of air it contains, as on the fre¬
quency of its change ; and, while probably a large room,
where the air is only changed two or three times in the hour,
may be more agreeable to live in, it is quite possible, as we
have proved in experience, to change the air in a properly
ventilated room five or six times in the hour without undue
draught.

Without any desire to minimise the urgency of the plea
against overcrowding, we foresee the difficulties that would
arise in enlarging our asylums to give more cubic space per
patient, owing to the great increase of cost that would be in¬
volved in the erection of these already too costly buildings ;
and we would, therefore, more emphatically urge the importance
of efficiently ventilating all day-rooms and dormitories, even at
the risk of occasional complaints of draught.

We are, however, satisfied that the Lunacy Commissioners’
standard of space is sufficient to ensure a healthy condition in
a well-constructed building, if properly maintained and venti¬
lated.

Turning to the question of heating, there are, as is well
known, a variety of methods in use. The open fire-place,
which is, perhaps, as a question of hygiene, the most perfect,
is also the most extravagant; the hot-air principle, either by
propulsion or induction ; the hot-water and steam systems,
both of which involve an elaborate arrangement of pipes and
coils in every room where heat is required, have all been tried
with more or less success in a variety of forms.

It is impossible for us here to enlarge upon the details of

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408

REPORT OF TUBERCULOSIS COMMITTEE. [July,

these numerous heating systems, and it will be sufficient if we
point out the salient objections in most of them.

In the hot-air system there is the danger already referred to of
contamination of the flues, and also, as some medical writers
assert, the unhealthiness of breathing air warmed artificially to
a sufficient extent to impart heat externally to the body, as
distinct from heat radiated from the open fire or hot-water coil,
which necessarily does not warm the air equally throughout
the room.

In the steam or hot-water system the main objections are
the presence of pipes and coils in the room, which need con¬
stant attention and repair, the interstices in the heating
batteries proving most dangerous receptacles for dirt and refuse
secreted by patients. It will be objected that if these radiators
are regularly and properly cleansed the danger is removed, but
we would point out that in phthisical cases, when the patients
frequently expectorate into the heating coils, the mischief is
done before the cleansing can be effected.

Moreover, in this cleansing there is both difficulty and
danger; for if cleaned, as they should be, with damp cloths, it
is troublesome, if not impossible, to get to all parts effectually;
and if cleaned with brushes, or by other dry methods, the air
around becomes immediately laden with the dry and pul¬
verised products of phthisical lungs.

Other objections to heating systems in the wards arise
from the mechanical inefficiency of the fittings, such as valves,
pet cocks, coil cases, and opening gear to the inlet ventilators ;
but greater than all is the difficulty of regulating the heat to
suit the varying external temperature, the result very frequently
being excessive heat in the wards.

In our experience this last-named evil is met with in too
many asylums which are artificially heated, particularly in the
dormitories, where a temperature is frequently maintained
injurious to health, and very much higher than the patients
have been accustomed to in their own homes.

It will be gathered from the foregoing remarks that we do-
not view with absolute favour any artificial systems of either
ventilation or heating, and we must admit that we have still
much to learn, and until a perfect system of artificial ventilation
is discovered we are of opinion that it is better to depend on
natural ventilation, and to aim at constructing our buildings in

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 409

such a way as to make the forces of Nature available to the
greatest possible extent, rather than resort to artificial means
which are open to so many objections.

For phthisical cases we would [urge the importance of
providing separate buildings properly constructed to freely
admit fresh air, with louvred openings all round the rooms
immediately below the eaves ; and to a lesser degree
Ihe same principle might be introduced into some of the
wards of the main asylum, so that the air inlets could
not be entirely closed, thus rendering powerless the efforts
of the attendants to obtain the comfort which frequently
Jails.

When we have attained the ideal, and, possibly, most econo¬
mical form of construction, viz. one-storey buildings, for our
asylums, we shall be able to do more towards simplifying our
methods of heating and ventilation. With a properly constructed
and protected stove in the centre of a room, which radiates heat
on all sides, as well as from the stove pipe carried up bare
to the ceiling, the present wasteful coal fire will become, perhaps,
the most economical and effective mode of heating; and by
enclosing this pipe, from the ceiling upwards, in an air shaft
carried through the roof, a most effective and simple form
of extractor is provided. Fresh air can be admitted through
draughtless windows of the type before referred to, or by some
other simple form of inlet ventilator.

To revert again to the subject of heating ; while waiting for
the discovery of means to store up the sun’s rays by day
and release them when he has gone below the horizon, we
have conceived the idea of converting the walls of our asylums
into heating radiators, the hollow cavities in them filled with
warm air, which, circulating again and again through the
calorifier, loses none of its heat except by radiation, and thus
warms the rooms without entering them, like steam in a
jacketed pan. There is thus no danger of the atmosphere
becoming vitiated by overheated air, and with the walls
maintained at a moderate heat, fresh air may be admitted
freely without danger of the patients suffering from chill. We
throw out this as a suggestion for some inventive mind to
bring to practical effect

Before concluding we desire to say a word on the improve¬
ment of the sanitary condition of old asylums, which,

XLVIII. 29

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410 REPORT OF TUBERCULOSIS COMMITTEE. [July,

according to the statistics submitted, show generally a higher
death-rate than that of more modem buildings.

It has been suggested that in an old and decayed building
there are greater opportunities for the secretion of dirt and
disease germs than in a more modem structure. This is true,
particularly when we consider the rough type of construction
in asylums of an early date, where the walls were merely
pointed and colour-washed, and the floors covered with wide
boards, or sometimes stones, both having open joints.

Much, however, might be done, and at no great cost, to restore
these older buildings to a sanitary condition ; the unplastered
walls might be coated with cement, or with one of the modem
forms of hard plaster, worked up to a fine smooth surface ; the
floors laid with papyrolith or some other material impervious to
moisture, and without joints or cracks. The woodwork, which
would probably require renewing, should be introduced in
limited quantities ; plain sash window frames ; no linings nor
architraves, but rounded angles worked in cement; no framed
dadoes nor moulded skirtings ; no moulded door linings, but
solid frames with rounded edges, and doors constructed with¬
out ledges to catch dirt

This form of construction would perhaps appear bald to the
educated or artistic eye, but to the majority of the patients a
bright coloured dado of paint would compensate for the
absence of the more elaborate wooden one.

By thus treating our old asylums we should improve their
hygienic properties, and we venture to think that their present
death-rate of 4 or 5 per cent, could be reduced to something
like v 6 per cent., as has been done at Hanwell.

(Signed) G. T. Hine, F.R.I.B.A.

C. W. Clifford-Smith, M.Inst.C.E.

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

411

FINAL REPORT ON STATISTICS COMPILED
FROM SCHEDULES.

Presented to the Tuberculosis Committee of the Medico-Psychological
Association by the Honorary Secretary .

Approved and accepted February 10th, 1902.

Gentlemen,

I have the honour to present to you my Final Report on
the statistics compiled from the schedules sent to the various
superintendents.

Of the 203 schedules which were sent out to the medical
superintendents of the asylums of Great Britain and Ireland,
hi were returned. Of these 83 were considered by the Com¬
mittee as being sufficiently valuable to be uspd.

The statistics which have been tabulated and compiled from
these 83 returns I now present to you ( vide Appendix A).

The information has been arranged in two main Tables, A
and B. Each of these Tables has been divided into four
groups:

Group I. —County asylums of England and Wales .

Group II. —Borough, city, royal hospitals, metropolitan district,
idiot, and naval and military asylums of England and
Wales.

Group III. —Royal and district asylums of Scotland.

Group IV \—District and criminal asylums of Ireland.

In Group I

statistics from

49 asylums

are shown,

„ II

„ HI

„ iv

>»

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412

REPORT OF TUBERCULOSIS COMMITTEE. [July,

Table A.

Table A*.

Table A deals with the purely numerical data received from
these asylums. These figures have been arranged in seven
columns:

Column i shows the number of average daily residents during
the five years 1895—9.

Column 2 shows the ratio per cent, to average daily residents
of deaths from all causes during the five years.

Column 3 shows the ratio per cent of deaths with active
tubercle during the five years.

Column 4 shows the ratio per cent, of deaths from all causes
during 1899.

Column 5 shows the ratio per cent, of deaths with active
tubercle during 1899.

Columns 4A and 5 A indicate the percentage-comparison between
col. 4 and col. 2, and between col. 5 and col. 3 respec¬
tively.

Column 6 gives the average length of residence in asylums of
those dying during 1899 with active tubercle.

Column 7 gives the form of insanity at death of the same
cases.

Table B contains in columns (from 1 to 10) the remainder
of the information received, and deals with the general hygienic
conditions of the asylums, the average time spent by patients
out of doors, the cubic space allotted to patients by day and
night, the character of the population from which the patients
are drawn, and like matters. This Table will be referred to in
detail later.

Table A* is a summary of Table A (cols. 1 to 5A), showing
the average totals in the four groups.

This Table shows very clearly that the figures at our disposal
represent, with a degree of accuracy never before attained, as
far as I know, in asylum statistics, the true facts regarding the
number of patients who die in the asylums of Great Britain
and Ireland with active tubercle. This arises from the fact that
we have been able to collect our information from two sources,
first from death certification, and, secondly, from post-mortem
examination. As has been previously pointed out^ 1 ) the
fallacy of the statistics on this subject which are given in the

( J ) Journ. Merit. Sri., January, 1900, p. 2.

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 413

Commissioners’ Blue Books arises chiefly from two sources : (< a)
The fact that the cause of death is certified in many cases in
asylums before the post-mortem is made. ( 6 ) The fact that
only one disease may be returned as a cause of death in the
Commissioners’ forms for the Blue Book.

It was pointed out in 1899 by both Dr. Crookshanks (*) and
myself (*) that we had reason to believe that the proportion of
cases dying in asylums with active tubercle to those shown in
official returns stood in the relation of nearly 2 to 1. Here
we find confirmation. While the ratio of deaths from all causes
to average daily residents is, as worked out from the schedules,
naturally the same as that to be found in the Blue Books, the
ratio of deaths with active tubercle to average daily residents,
comparing our figures (Table A # , cols. 3 and 5) with the Com¬
missioners’ official returns, stands thus :

Public asylums (England and Wales).

From Blue Book figures.

From schedules.

Average for five years (1895-9).

For year 1899.

X ‘4 per cent.

i*5 per cent.

2 ‘l per cent.

2*3 per cent.

It will be noticed also from Table A # (col. 5A) that in each
group of asylums in the United Kingdom, deaths with active
tubercle show an increase when we compare the ratio in 1899
with the average ratio for the five years, 1895 to 1899. The
highest increase occurs in Irish district asylums (*6 per cent.),
and the lowest (’I per cent.) in borough, city, etc.* asylums,
England and Wales. But, inasmuch as it will be seen from
the same table (col. 4A) that there has been a corresponding
increase in the ratio of deaths from all causes to average daily
residents in these institutions, too much importance should not
be attached to this point.

With regard to the incidence of tubercle in the various
asylums (as shown in Table A, col. 5), I find that in the public
asylums of England and Wales (Groups I and II) twenty-
seven asylums out of sixty-six (41 per cent.) show a tubercular
ratio which is above 2*3 per cent., the average ratio for these
institutions.

f 1 ) Joum. Merit. Sci. f October, 1899, p. 659.

(*) Ibid., January, 1900.

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414

REPORT OF TUBERCULOSIS COMMITTEE. [July,

Length of
residence in
asylum.

Form of
insanity at
death.

The asylums which stand highest are :

County

Stafford county .

Per cent.
. 8

„ Bumtwood

• 5

Lane., Rainhill .

• 47

Derby

. 46

N orthumberland

■ 4'3

rLeavesden .

• 3-8

\ Newcastle city .

• 3*4

IMiddlesbro* borough

• 3*2

In Scotland (Group III) five asylums out of ten (50 per
cent.) show a tubercular ratio above their average of 1*9 per
cent.

The highest are:

Per cent.

Roxburgh district . . . .27

Perth (Murray’s Royal). . . .2*4

In Ireland (Group IV) two asylums out of seven (28*6 per
cent.) are over the average of 2*2 per cent.

The highest are:

Per cent.

Limerick district ..... 4*6

Cork ....... 3*4

In Table A, col. 6 shows that the AVERAGE LENGTH OF
RESIDENCE in asylums of those cases dying with tubercle
during 1899, was as follows :

Both sexes.

England ..... 6-5^ years.

Scotland ..... 4 „

Ireland .... • 5 tV »

This gives an average length of residence for all asylums of
Great Britain, for both sexes, of years.

These figures have an important bearing upon the question
as to whether the majority of patients are infected in asylums
or bring the disease in with them, and will be alluded to later
in connection with that point.

Col. 7 shows that the FORM OF INSANITY of the tubercular
deaths during 1899 occurred in the following order of fre¬
quency. The average number of patients dying with active
tubercle under each form of insanity in each asylum also works
out as follows:

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

415

In England:

I. i

fDement and 1

Average.

llmbecile J

•

• 17

2 .

Mania ....

. 6

3 -

Melancholia

• 4 k

4 -

General paralysis

■ 3 f

5 -

Epileptic

• *4

In Scotland:

▼ A

fDement and)

• 3 i

Llmbecile J

•

2. ■

f Mania, )

(Melancholia /

3 -

Epileptic

■ 4

4 -

General paralysis

• T?o

In Ireland:

2. ■

Mania ....
fDement and 1
llmbecile f

■ 7

• 44

3 -

Melancholia

•

• 4 *

But the numbers are too small to enable one to draw any

very definite conclusion from them.

The whole of the information contained in the schedules
returned from eighty-three public asylums of Great Britain
and Ireland is to be found in a concise and, it is hoped, a clear
form in Tables A, A # , and B.

Coming now to Table B, it will be seen that it has been Table B.
divided into four groups (as in Table A), dealing respectively
with:

Group /. England and Wales, county asylums.

„ II „ „ borough, city, etc., asylums.

„ III Scotland.

„ IV. Ireland.

In the four groups the GENERAL HYGIENIC CONDITIONS
relating to each asylum are arranged in ten columns:

Column 1 shows the tubercle death-rate.

Column 2 shows height of asylum above Ordnance data.

Column 3 shows nature of soil.

Column 4 shows average number of hours spent out of
doors.

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General

remarks.

416 REPORT OF TUBERCULOSIS COMMITTEE. [July,

Column 5 shows cubic space per patient by day and night.

Column 6 shows character of population.

Column 7 shows type of ventilation.

Column 8 shows type of heating.

Column 9 shows whether floors are scrubbed or polished.

Column 10 shows whether milk is sterilised or not.

It will be at once remarked that the facts contained in
these columns are for the most part of very varying and
dissimilar characters, and although it may justly be presumed
that they all have collectively some definite influence upon the
general health of an asylum, yet when these varying facts are
regarded separately, as they apply to any particular asylum, it
is found to be a matter of considerable difficulty to discover,
and of still greater difficulty to demonstrate satisfactorily,
what degree of importance is to be attached to any particular
fact as regards its influence upon the incidence of a particular
disease, such as tuberculosis.

For instance, one asylum may stand on a good soil, provide
for its patients an air supply above the average, and carry out
the most modem ideas as to heating, ventilation, and the
cleaning of floors, etc., yet show an alarmingly high tubercular
incidence rate.

Another asylum may be lacking in many or all of these
advantages, and yet be comparatively free from tubercle.

Yet, again, in other asylums—and this applies to some with
a high as well as to some with a low tubercular death-rate—
the hygienic conditions may be neither wholly good nor
wholly bad, but simply conflicting. In all cases the difficulty
was to find a common denominator. My duty, however, was,
if possible, to so arrange these varying facts that definite
conclusions might be drawn from them, and then to present
these conclusions in a way that would be convincing, not only
to you as a Committee, but to those who will read your final
report. It was not until I had studied and worked at these
tables for some time that I fully realised that it was quite
impossible, from the facts at our disposal, to state dogmatically
why Asylum Y should have a higher tubercular death-rate
than Asylum Z.

On the other hand, it appeared possible that one might be
able to suggest why one set or group of asylums differed from

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

417

another set or group in this respect. The question then arose
as to what basis was the best to use as a standard of compari¬
son—a basis which would give the most accurate results in
the clearest way without an embarrassing complexity of tables
and charts.

After trying many methods, I decided that it was advisable
to adopt the method presented in the accompanying tables.

The asylums in each of the four groups in Table B have
been divided into two divisions.

In each division the asylums are arranged in the progressive
order of their tubercular death-rate.

Division /.—Contains the asylums in which the tubercular
death-rate is below the average tubercular death-rate for that
group.

Division IL —Those asylums in which the tubercular death-
rate is above the average.

On the line immediately below the titles of the various
columns in each division is given the averages for the whole
group, while on the bottom line appear the averages for the
division itself.

Thus, in the first group (Table B 1) (with a general average
tubercular death-rate of 2*4 per cent.) twenty-eight county
asylums of England and Wales, whose tubercular death-rates
range from *5 per cent., to 2*2 per cent., are compared with
twenty-one in which the death-rate ranges from 2*4 per cent,
to 8 per cent.

In the second group (Table B 2) (with a general average
tubercular death-rate of 17 per cent.) seven city, borough, etc.,
asylums of England and Wales, with a tubercular death-rate
ranging from *i per cent, to 1*3 per cent., are compared with
ten ranging from 17 per cent, to 3*8 per cent.

In the third group (Table B 3) (with a general average
tubercular death-rate of rg per cent.) five royal and district
asylums of Scotland, with a tubercular death-rate ranging
from ’9 per cent, to 1*9 per cent., are compared with five
ranging from 2*1 per cent, to 27 per cent.

In the fourth group (Table B 4) (with a general average
tubercular death-rate of 2 '2 per cent) four district asylums
of Ireland, with a tubercular death-rate ranging from *6 per
cent, to 2 per cent., are compared with three ranging from 2*2
per cent, to 4*6 per cent

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Col. 2:
Elevation of
asylum.

Character of
soil.

418 REPORT OF TUBERCULOSIS COMMITTEE. [July,

We come now to the examination of the facts in detail in
each group:

First, HEIGHT OF ASYLUM above Ordnance datum.
Group i (Table B I, col. 2). The general average elevation
above O. D. is 213$ ft. The average for Division I is 158 ft.,
and for Division II is 280 ft.

Thus the asylums below the average death-rate (Division I)
are situated on ground which is, on an average, 122 ft. lower
than those with a higher rate (Division II).

In Group 2 (Table B 2, col. 2) a similar condition exists.
The asylums in Division I are, on an average, 3 5 ft. lower
than those with a higher death-rate in Division II.

In Group 3 (Table B 3, col. 2) the asylums in Division I
stand, on an average, 235 ft. higher than those in Division II.

In Group 4 (Table B(4, col. 2), as the height above O. D.
is given in only two cases out of seven, no average can be
struck.

It would seem that no definite conclusion can be drawn
from this particular column, inasmuch as only forty out of the
eighty-three asylums give any information on this point;
further, it is generally held that mere height above sea level
has little effect upon the incidence of tubercle. Besides, we
have no information regarding such important points as
prevailing winds and the extent of shelter from them.

The influence of the soil upon the health of the community
living on it depends upon several factors—the slope of the
land, the distance below the surface of the impermeable
stratum, the depth of sub-soil water, and the efficiency of sub¬
soil drainage, for instance. On none of these points have we
any information. In col. 3, Table B, however, we have some
information respecting the character of the soil and sub-soil of
the various asylums.

Regarded especially with reference to their effect upon the
incidence of tubercle, these soils have been divided into
“ good ” and “ bad,” according as they were considered to be
porous, dry, and warm ; or impervious, damp, and cold.

In the first, or “ good,” category come gravel, sand, lime¬
stone, or chalk ; in the second, or “ bad,” list are clay, marl,
and peat.

It may be pointed out here that the warmth of a soil is
important, and generally corresponds to its porousness.

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 419

The power of absorbing heat differs in different soils, and
has been proved by Schiibler to be as follows :

(Standard 100.)

Sand with some lime . . . 100.

Pure sand ..... 95'6.

Gypsum ..... 72 - 2.

Clay ...... 66'2.

Reverting to our table, it will be seen that in—

Group 1. — -Division I (Table B 1, col. 3), twenty-one asylums Col. ^3:

(or 78 per cent) are on “ good ” soil, while only six asylums ‘ 1 ‘
(or 22 per cent) are on “ bad.”

In Division II, with the high tubercular death-rates,
there are only six asylums (30 per cent) on “ good ” soils,
and fourteen asylums (70 per cent) on “ bad.”

Group 2. —-In Division I, five asylums (71 per cent.) are on
“ good " soils, and two (28 per cent) are on “ bad.”

In Division II, “ good,” four (40 per cent.); “ bad,”
six (60 per cent.).

Group 3.—In Division I, “good,” three (75 per cent.); “bad,”
one (2 5 per cent).

In Division II, “ good,” one (20 per cent.) ; “ bad,”
four (80 per cent.).

Group 4.—In Division I, “good,” three (75 per cent.); “bad,"
one (25 per cent.).

In Division II, “good,” one (33 per cent).; “ bad,"
two (66 per cent.).

Taking the groups together the results stand thus—

Division I.

Division* II.

Good.

Bad.

Good.

Bad.

Group x

78 per cent.

22 per cent.

30 per cent.

70 per cent.

,» 2

• 7 1 » ,»

38 „ „

4 ® »» if

60 „ „

»» 3

• 75 1# »»

25 „

20 „ „

80 „ ,,

,, 4

75 »» » »

25 „ „

33 11 19

<56 „ „

Average.

. . 74 per cent.

25 per cent.

31 per cent.

69 per cent.

This shows an overwhelming majority for the whole king-

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420

REPORT OF TUBERCULOSIS COMMITTEE. [July,

Col. 4:
Hours out of
doors.

Col. 5:

Cubic space.

dom of an average of 74 per cent, of “ good ” soils in
Division I, against 31 per cent, of “ good ” soils in Division II.
While there are only 2 5 per cent, of “ bad ” soils in Division I
against 69 per cent, in Division II.

Looked at from another point of view, I find that the
average tubercular death-rate in asylums on " good ” soils is
19 per 1000, as compared with a tubercular death-rate of 30
per 1000 in those on “ bad ” soils.

In col. 4, which gives the AVERAGE NUMBER OF HOURS
spent daily by each patient OUT OF DOORS, both in and
beyond airing courts, little disparity exists between Division I
and Division II as far as the public asylums of England and
Wales are concerned. In the county asylums (Group 1) the
average is six hours in each division.

In city, borough, etc., asylums (Group 2) there is an average
of half an hour more in Division II than in Division I.

In Scotland (Group 3), on the other hand, Division I shows
an average of one hour per head more than Division II.

In Ireland (Group 4) the difference is still more marked.

Division I gives an average of 84 hours as against 3$ hours
in Division II.

Taking Scotland and Ireland together, therefore, we find
that the patients in the asylums with the lower tubercular
death-rates (Division I) were out of doors on an average seven
hours, as compared with four hours in those asylums with the
higher death-rate (Division II).

But this point need hardly be laboured, as the advantage of
an abundance of exercise in the open air is universally
acknowledged. On the other hand, the practical absence of
disparity on this point between the two divisions of the English
asylums seems to show that exercise in the open air is alone
of small service in lowering the incidence of tubercle if the
patients have to return to work and sleep in an atmosphere
charged with the tubercle bacillus.

We come now to the important question of CUBIC SPACE
PER PATIENT by day and night. Col. 5 gives the figures
under this head.

Group 1.—In Division I the average cubic space for each

asylum is 499 cubic feet by day and 650 by night.

In Division II it is 483 by day and 618 by night.

Division I thus giving an average of 16 cubic feet

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1902.] REPORT OF TUBERCULOSIS COMMITTEE. 421

by day and 32 cubic feet by night more per patient than
Division II.

Group 2.—In Division I the average cubic space is 516 cubic
feet by day and 699 by night.

In Division II it is 534 by day and 641 by night.
Division I thus giving an average of 18 cubic feet
less by day, and 5 8 cubic feet more per patient by night
than Division II.

Group 3.—In Division I the average cubic space is 453 by day
and 843 by night.

In Division II it is 437 by day and 798 by night.
Division I thus giving an average of 16 cubic feet
by day and 45 cubic feet by night more per patient than
Division II.

Group 4.—In Division I the average cubic space is 472 cubic
feet by day and 697 by night.

In Division II it is 353 cubic feet by day and 600

by night.

Division I thus giving an average of 119 cubic
feet more by day, and 97 cubic feet by night than
Division II.

Taking all the groups together the results stand thus :

Division I.

Division II.

Cubic feet.

By day.

By night.

By day.

By night.

Group 1

499

650

483

(- 16)

618

(- 32)

„ 2 . .

516

699

534

(+ 18 )

741

(- 58 )

»» 3

453

843

437

(- 16 )

798

(- 45)

„ 4 •

472

697

353

(- ««9)

600

(- 97)

Average .

1 48s

772

45 i

664

It is at once apparent that, taking the asylums of Great
Britain, those with the lower tubercular death-rate (Division I)
provide on an average 34 cubic feet per patient more by day
and 108 cubic feet per patient more by night than do those
with the higher death-rate (Division II). Or, taking the cubic

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422

REPORT OF TUBERCULOSIS COMMITTEE. [July,

General
remarks on
cubic space.

Over¬

crowding.

Col. 6:
Character of
population.

space by day and night together, the patients of asylums in
Division I have, on an average, 142 cubic feet each more than
those in asylums in Division II.

It may be pointed out here that Parkes has laid it down—
and his calculations are still quoted in the most modem books
on hygiene—that the average healthy adult requires, per
hour, 3000 cubic feet of air, and as it has been hitherto
extremely difficult to ensure by the ordinary means of ventila¬
tion that the air in any room be entirely changed more than
thrice in the hour without inconvenience to the occupant, it
follows that every person should have in his sleeping room at
any rate 1000 feet of cubic space.

It is acknowledged by sanitary engineers that a room of this
space should not be more than 12 feet in height. Every
healthy adult, then, should have at least 83 square feet of
floor space allotted to him for sleeping on, and that would
only be sufficient if the air were completely changed three
times in the hour. For the unhealthy and sick, 100 square feet
(giving 1200 cubic feet) per patient should probably be the
minimum provided.

In this connection it may be pointed out that, according to
the Commissioners’ 54th Report for 1899 (Table II, col. E), it
is admitted that, out of the seventy-nine County and County-
Borough asylums in England and Wales, only forty-nine pro¬
vide their patients with even the inadequate air supply upon
which the Commissioners are supposed to insist. It is a
lamentable fact that on January 1st, 1900, thirty of these
seventy-nine asylums contained amongst them 1273 more
patients than they were built for, or were sanctioned by the
Commissioners to contain.

Passing to col. 6, Table B shows some interesting facts
regarding the effect upon the tubercular death-rate of the
CHARACTER OF THE POPULATION from which the patients
are drawn.

It would be rational to assume that those patients who,
previous to their admission to an asylum, had lived an outdoor
life, and whose work had been chiefly of an agricultural kind,
would be more likely to resist the attacks of the tubercle
bacillus than those who were drawn from the unhealthy
environment of the factory and the slum, and although the
facts shown in this column run only on the broadest lines, and

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

423

do not pretend to deal with the finer distinctions, yet it is
interesting to find that, as far as the county asylums of
England and Wales are concerned, our figures show a distinct
difference between the susceptibility of the rustic and the town-
dweller.

In Division I (Table B 1) there are thirteen asylums with a
rural population, but there are only three such asylums in
Division II.

Taking the character of the population as a basis, I find
that the average tubercular death-rate is nearly twice as
high in the asylums with an urban population as it is in
those with an agricultural population, thus:

County asylums
(England and Wales).

Asylums with
agricultural
population.

Asylums with
urban
population.

Asylums with
mixed
population.

Tubercular death-rate (per 1000 )

25 j

The results obtained from the remaining columns 7, 8, 9, Cols. 7 and 8:
and 10 cannot be considered to be striking. With regard helting tl<>n;
to columns 7 and 8, for instance, the questions of VENTILA¬
TION AND HEATING are so complex and difficult, and involve
so many considerations upon which we have no data here,
that one could hardly have expected otherwise. The mere
statement that an asylum is ventilated by natural means
conveys no idea of the thoroughness with which it is done,
neither have we here any means of knowing whether the
artificial system adopted works efficiently or not.

With regard to the question of METHOD OF FLOOR Col. 9 :
CLEANING (col. 9), only six asylums out of the eighty-three o/floors"*
return scrubbing .as the sole method. These six are among
the county asylums of England and Wales. All the other
asylums of Great Britain polish their floors either wholly or in
part, so that no basis of comparison is afforded on this point.

(The six scrubbed asylums have an average tubercular death-
rate of 26 per 1000, and the polished 24 per 1000.)

In col. 10 it will be seen that only eighteen out of the Col. 10 :
eighty-three asylums state that their milk is sterilised, and ^uk** 1011
these eighteen are divided equally between Division I and

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Duration of
phthisis.

424 REPORT OF TUBERCULOSIS COMMITTEE. [July,

Division II, so that no definite deduction can be drawn from
this fact.

This completes the analysis of Table B.

I must now refer to the question (to which I have already
alluded), vis . are the majority of the cases of tuberculosis
produced in the asylum ?

It has been already shown (Table A, col. 6) that those patients
who died with active tubercle in the public asylums of Great
Britain and Ireland during 1899 had been in residence, on an
average, over five years (those in the county asylums of England
and Wales having been inmates for over six years). About the
average duration of phthisis various opinions have been
expressed by experts. The mean duration has been thus
stated :

“In 50 per cent, of cases less than nine months.” (Louis.)

“Twenty-three months.” (Louis and Boyle.)

“Two years.” (Laennec and Andral.)

“ Four years.” (C. J. B. Williams and Sir J. Clark.)

“The average duration of 3500 cases attending the out¬
patient department of the Brompton Hospital was two years
and nearly seven months.” (Pollock.)

The general conclusion from a consideration of these facts
and authorities is that by far the greater number of patients
who die in asylums with active phthisis have acquired the
disease in the institution.

It is not for a moment suggested that no patients enter
asylums with the disease, but it is most strongly my opinion
that the number of such patients is comparatively small, and
that the large majority contract the disease after admission.
If the contrary were the case, and the majority of cases were
introduced from outside, it would be reasonable to argue that
the tubercular death-rate in each of the county asylums of
England and Wales would be likely to bear some relation to
the tubercular death-rate of the particular county from which
the majority of its patients were drawn. But I find that this
is not the case.

The tubercular death-rate in each registration county was
shown in the Registrar-GeneraPs sixty-second Annual Report
for 1899 (Table 26) to be for 1899 (to estimated population
in the middle of 1899) in England and Wales i # 3 per 1000,
and it ranged from •9 to r8 per 1000.

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1902.] REPORT OF TUBERCULOSIS COMMITTEE.

425

The average tubercular death-rate for the asylums of these
counties for 1899 (as shown in our table) was 24 per 1000,
and ranged from 5 to 80 per 1000.

I find that there is not the faintest relation between the
variations in the county tubercular death-rates and the varia¬
tions in the tubercular death-ratps in the corresponding
asylums. This appears to me to be another strong reason for
believing that a large proportion of patients contract tuber¬
culosis in asylums.

In this connection I wish to make it quite clear that no
comparison is being drawn between the tubercular death-rate
outside and that in asylums, as not only are the circumstances
vastly different, but the methods of obtaining the figures and
results cannot with any propriety be compared.

A further question to which I consider that considerable Chart 1 .
interest attaches is : JESS?

In how far does the age of the asylum affect the incidence tubercle.

of tubercle?

Upon arranging the asylums of Great Britain and Ireland
in groups, according to their respective ages (Chart I), I find
that the average tubercular death-rate gradually rises in direct
ratio to the antiquity of the asylum.

Thus while the tubercular death-rate of asylums built less
than twenty years ago stands at 18 per 1000, it reaches 28
per 1000 in those asylums built from eighty to a hundred
years ago. It will also be observed that the tubercular death-
rate rises about 10 per cent, for every twenty years added to
the age of an asylum.

This may, of course, be accounted for, to a slight extent, by
the general superiority of the modern asylum ; but, that being
admitted, one cannot escape from the conclusion that the
older a building of this kind is, the more opportunity it has,
not only of becoming infected with the tubercle bacillus, but,
by the general tendency to decay of its structure, of providing
more and more suitable sites for its growth and dissemination.

Another reason seems to be that the older an asylum grows
the more numerous becomes the residuum of hopeless wrecks,
whose faulty habits are so inimical to the general sanitary
conditions of their immediate surroundings.

This appears to me to be, among others, a strong reason for Separation of
not classing the irrecoverable dement with the patient forwent? C

XLVIII. 30

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426 REPORT OF TUBERCULOSIS COMMITTEE. [July, 1902.

Chart II.
Number of
patients in
relation to
tubercle.

whom recovery is to be expected. The modern tendency to
provide a separate detached mental hospital for recoverable
patients has certainly this marked merit, that quite apart from
mental advantages, it prevents them from being exposed to
the physical contamination of irrecoverable wreckage.

I have also worked out the relation of the total number of
patients in the public asylums of Great Britain and Ireland
to their respective tubercular death-rates (Chart II) with most
interesting results.

Arranging the various asylums in groups according to their
average daily number resident, I find that the tubercular death-
rate in those asylums with less than 300 patients is 17 per
1000, while those asylums which accommodate from 1100 to
2000 have an average tubercular death-rate of 29 per 1000.

The death-rate bears a direct ratio to the number of patients
living in one institution, and as in the other chart (I) is seen to
increase about 10 per cent, for every increase of 200 in the
number of patients.

The herding together of large numbers of patients has
frequently been protested against. Here the consequent
results, on the incidence of tubercle at any rate, are clearly
tabulated.

I have the honour to be, Gentlemen,

Your obedient servant,

(Signed) Eric France,

Hon. Sec.

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APPENDIX A

TABLES AND CHARTS.

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mpiled from Schedules

COUN

ASYLU

Beds, Herts, a

2. Moulsford
Bucks.

3. Aylesbury
Cambs.

4. Fulbourne
Chester.

5. Upton ...
Cornwall.

6. Bodmin...

38. Woodbridgi
Surrey.

39. Brookwood
Sussex (West).

40. Chichester
Warwick.

41. Hatton ...
Wight, Isle of.

42. Newport
Wiltshire.

43. Devizes ...
Worcestershire

44. Powick ...
Yorkshire.

45. Clifton ...

46. Wakefield

47. Wadsley

48. Menston

49. Beverley

Com- Average length of
nts paring Residence

1890 in Asylums

withAv. of these Cases
of $ yrs. (Column 5).

I Yrs. I Mos. Yrs. Mos
O O O ' O

s I r g 31 8

• 31+1
I -I -

13 I 12
i 0 7

-I- 4 0

- -I 2 I O

— *4 1 6

+ '5 81

+ *3 on

- *4 4 "

|-M'i °i 7 :

7 . 1 6 | 2j | 5 | 9i

age for 43 asylums.

Form of Insanity at Death of these

Cases, dying in 1899
(Column 5).

G.P. Man. Mel. Er.

Dem.

Imb.

Other

forms

3 f M.

. 2 I

1 F.

4 15 * 3

J M.

I . 2

1 F.

. I

1 M.

. I I

i F.

2 3 ...

...

f M.

2 41 1 ...

1 F.

... 7 | ... 2

f M.

4 1 1 |.

1 I

1 F.

... i*| ...'! 3“

i M.

. 1 1

1 F - 1

... ... ... «

{ M.

... I 1 2 2

1 F.

... 3 1 «

/ M.

... 1 . ... 1

1 F.

... 1

J M.

1 I ;

I F -

... ! 1 2 ...

/ M.

4 2 1 2

1 F.

... | 1 6 ... |

1 ;

J M.

... 1 1 2

1 |

1 1

1 F -

... 4 2 I

...

1 j

I M.

i , ... 6 2

...

) F.

1 1 ... |

...

/ M.

2326

1 1

i F ‘

1 1 5 2 2

/ M.

1 2 2 ...

1 F.

2 22 2

r M.

ri 21 jrs 12

3*6

i *3

•5 3 ’ ,»-6 **»

Digitized by

BOROUGH

ASYL

I Bristol.

1. Fishpond
Derby.

2. Rowditch
| Leicester.

3. H umbers

! London (City)

4. Stone ..
Yorks.

5. Middlesb
Newcastle (C

6. Gosforth
Nottingham ('

7. Mapperle
j Plymouth.

8. Ivybridge
Norwich.

9. Hillersdo
Sunderland.

10. Ryhope

hospi:

Gloucester.

11. Barnwoc
Oxford.

12. Warnefc

MET. DIS

Dartford.

13. Darenth
Watford.

14. Lcavesd

NAVAL, CRIM

I Yarmouth.

15. Royal N
| Berks.

16. Broadrrn
1 Redhill.

17. Earlswo

Digitized by

ROYAL AND DIS
ASYLUMS.

Royal.

1. Aberdeen

2. Edinburgh

3. Montrose

Digitized by

Form of Insanity at Dkath of these
Cases dyintf in 1899
(Column 5).

Dem. Imb.l

forms.

I I

2 2 ... 2 I

IO 5 I ; 4

15 8 7

- I 1 3 I 3 *

2 3 1 ; 2

4 1 1 | 2

... I 2 .j I

2 I ... I 2

3’5 21 3 I'9 7

35 2*1 I 2 " *2

7‘ 4‘2 ‘4 3 9 9

X P.Ms. for 1899 only.

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kriNG Average Totals.

4 A

5 * 1

nt. to

Residents

with

RCLK.

Ratio per cent, to
Average Daily Residents
of Deaths from
all causes.

1899*

Com¬
parison
of 1899
withAv.
of 5 yrs.

Ratio per cent, to
Average Daily Residents
of Deaths with
Active Tubercle.

1899.

Com- I
pari son 1
of 1899 |
withAv.
of 5 yrs.

1 Total.

F. !

Total.

England

i. Coi

2*2

U '5

89 ,

IOI'

+ ’4

2*5

2*4

+ 2

• 2. Boi

1*6

io*5

6*7 1

+ *6

i '4

+ I

2*1

9*8

2*3

Scotlani

3 * R °:

1*4

10*4

8*8

+ i ‘5

2*3

i *5

i *9

+ -5

Ireland.

4. Dis

i*6

69 j

6*6 j

6*8

+ 6

2*1 ]

| 23

2*2

+ *6

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Digitized by

LES—County /

4 to 8'o.

Not included. .

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^ty, etc., Asylums.

Vision II .—Tubercular Death-rate = 17 to 3’8.

son. .»*«

Oxford.

12. Warnefc

4.00 Red 9
Berks. c lav

16. Broadm. 7

r — Sand —

London (CiI and

4 * Stone gravel

Dartfori
13. Darenth

Leicester
3. Humb
stone I

11. Barnwcx
House

8. Ivybridj

Heavy 7
clay

Good 4
(40 per
cent.)

Cubic

space.

• Day.

Night.

536

668

500

600

700

480

600

—

500

IOOO*

600

650

492

800

2672

3850

534

641

population.

Mixed,

imbecile,

and

infirm

Heating.

How floors
are

cleaned.

—

Both

Polished

Artificial

Both

Artificial

Polished

Open fires

Both

Artificial

Open fires

Polished

Artificial

Both

Fires 2
Artificial 5
Both 3

Polished 5 y
Scrub 01
Both 5 1

* Not included.

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Digitized by

j -Tubercular Death-rate = 2'I to 2“j.

FIVE

ASYLUMS.

Tuber*

cle

, kver-
igc

Cubic space.

Character

Ventilation.

Heating.

How floors
are

Milk

stcri-

death

rate.

ours

tsidc.

Day.

Night.

population.

cleaned.

Used.

Average, all
! asylums

Per cnt.

445

818

—

7. Lanark . .

430

850

Urban

Both

Artificial

Polished

8 . Midlothian .

Edinburgh.

2. Royal . .

i *3

i*6

360

800

Agricul.

9. Perth. . .

i*8

5 *

600

720

Mixed

Artificial

Both

>»

—

Aberdeen.

1. Royal . .

1*9

—

900

—

Natural

Artificial

i. $

—

360

720

Mixed

Both

—

Totals . .

1750

3990

Agricul. 1
Mixed 2
Urban I

Natural 2
Artificial i
Both 2

Fires 0

Artificial 3
Both 2

Polished 5
Scrub’d 0
Both 0

Yes 0
No 3

Averages, Division I .

437

798

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Chart I. —Relation of Age of Asylum to Tuber - Chart 3. —Relation of average number Resident to

cular Death-rate in 78 Public Asylums of Tubercular Death-rate in 77 Public Asylums of

Great Britain and Ireland. Great Britain and Ireland.

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APPENDIX B.

(COPY OF SCHEDULE SENT TO MEDICAL
SUPERINTENDENTS.)

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London County Asylum,

Claybury,

Woodford Bridge,
Essex ;

October , 1900,

MEDICO-PSYCHOLOGICAL ASSOCIATION OF
GREAT BRITAIN AND IRELAND.

TUBERCULOSIS COMMITTEE.

MEMBERS OF COMMITTEE.

T. S. Clouston, M.D. Conolly Norman, F.R.C.P.I. A. R. Turnbull, M.B.
Frank A. Elkins, M.B. Frank Perceval, M.R.C.S. J. R. Whitwell, M.D.
G. T. Hine, F.R.I.B.A. R. Percy Smith, M.D. J. Wiglesworth, M.D.
F. W. Mott, M.D., F.R.S. J. B. Spence, M.D.

Lionel A. Weatherly, M.D. {Chairman),

Eric France, M.B. {Honorary Secretary).

Dear Sir,

At the last meeting of this Committee it was resolved that a circular
letter should be sent to the medical superintendents of all public
asylums in Great Britain and Ireland, and of those private asylums
with thirty patients and upwards, inviting them to answer certain
questions herewith appended. The Committee is aware that this will
involve the spending of some time and labour on the part of those
medical superintendents who are willing to supply the information asked
for. It is earnestly hoped, however, that the importance of the subject,
and the very great value of the information you can give, will encourage
you to co-operate with the Committee in their work.

I am, dear Sir,

Your obedient servant,

(Signed) Eric France,

Honorary Secretary .

To the Medical Superintendent,

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432 REPORT OF TUBERCULOSIS COMMITTEE. [July,

1. Average daily number of patients in your Asylum

2. Total number of deaths (all cases)

3. Number of deaths (certified) from Tubercle

4. Number of cases in which active Tubercle was found P.M. (not including those cases returned

under No. 3) ... ... ... ... ... ... ...

5.—( a ) Average length of residence in Asylum of those dying of Tubercle or in whom active Tuberc

(b) Proportion of these cases in which Tubercle was recognised on admission

6.— (a) Site, soil, and drainage of your Asylum

(£) Dietary, including sterilisation of milk, etc.

( d) Cubic space for patients:—(i) by day

(ii) by night

(e) Character of population from which patients are derived

(/) Ventilation, light, and artificial heating

(g) Are your floors scrubbed or dry-polished P

7. Has anything been done in your Asylum to isolate or specially treat tuberculous patients P If so,

8. Have you any further remarks or suggestions to offer on this subject P

◄

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1902.] REPORT OF TUBERCULOSIS COMMITTEE,

433

434

TOXAEMIA IN MENTAL DISEASE.

[July,

Original Articles.

Toxctniia in the Etiology of Mental Disease . A
Discussion opened by T. S. CLOUSTON, M.D., at the Spring
Meeting of the Scottish Division of the Medico-Psycho¬
logical Association, Glasgow, March 28th, 1902.

Dr. Clouston said that when he suggested toxaemia to the
secretary as a suitable subject for a discussion at this meeting he
had not intended to be the first speaker, because his object was
to bring out more fully the views of the younger members who
had recently committed themselves so strongly to the toxaemic
and bacterial etiology of insanity, and so to get light thrown on
some of the difficulties which he and others had felt in
applying this theory to many of their cases in practice. It was
not that he did not believe in the toxic theory as explaining
the onset of many cases, or that he under-rated its importance,
but that he could not see how it applied so universally or
generally as some of the modern pathological school were now
inclined to insist on. He knew that it was difficult for those of
the older psychological and clinical school to approach the
subject with that full knowledge of recent bacteriological and
pathological doctrine which the younger men possessed, or to
breathe that all-pervading pathological atmosphere which they
seemed to inhale. He desired to conduct this discussion in an
absolutely non-controversial and purely scientific spirit. To
do so he thought it best to put his facts, objections, and
difficulties in a series of propositions which could be answered
and explained by the other side. He thought it important to
define toxaemia, but should be willing to accept Dr. Ford
Robertson’s definition of toxines, viz., “ Substances which are
taken up by the (cortical nerve) cell and then disorder its
metabolism.” He took the following extracts from his address
at the Cheltenham meeting of the British Association ( l ) as
representing Dr. Ford Robertson’s views and the general trend
of much investigation and hypothesis on the Continent.

“The various toxic conditions which tend to affect the nerve
cells may result from:—(1) Exogenous toxic agents; (2)
infections ; and (3) auto-intoxication and auto-infection. . . .

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1902.]

T. S. CL0UST0N, M.D.

435

“ In concluding, I would reiterate my conviction that by far
the most important factor in the pathogenesis of insanity is
toxic action.

“I would further say that the large majority of cases of
insanity are not primarily diseases of the brain at all, but are
dependent upon the action of toxines derived from elsewhere,
which affect the functional activity of the cortical nerve cells by
disordering their metabolism and often permanently damaging
or even destroying many of them. The common view that the
‘ mental disease * is the primary condition, and that any
accompanying 4 bodily disease * is secondary, is, in general,
founded upon an erroneous conception of what is taking
place.”

He took Mott’s recent views as to the auto-poisoning of the
cerebral cortex by choline and other products of nerve ( 2 )
degeneration as representing another strong toxaemic current
in our scientific literature. Dr. Lewis Bruce’s views represented
the most recent conclusions of the younger clinico-pathological
school. ( 3 ) Those views must be fully proved, to be accepted, in
the vast scope which their authors clearly intended. Were they
so proved? Must they now concentrate their attention on
toxines in nearly every case of insanity as the chief etiological
factor ? He had already discussed the question as it concerned
melancholia. ( 4 )

i. In considering the general pathology and etiology of
every case of mental disease they must keep in mind certain
relevant psychological and physiological considerations as to
brain working, the chief of which were the following:—The
kinetic action of the nerve cell was explosive in character, and
in many ways rhythmical and periodic, its normal explosiveness
passing most readily into pathological explosiveness with no
line of demarcation between the two. In those and many other
ways it was markedly different from the processes of nutrition,
secretion, and excretion, so that analogies between the effects of
bacterial and toxic action in the two kinds of function were apt
to be misleading. Mind was so unique, so great, and so
dominant that it could not be rightly regarded as an 44 effect ”
and not a “cause.” It seemed to him unphilosophical and
unscientific to say it 44 could not rank as an etiological factor ”
of mental disease. This seemed contrary to plain clinical fact.
The action of 44 mind on mind” was too palpable a thing to be

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436

TOXEMIA IN MENTAL DISEASE.

[July,

thus put aside. To set aside the mental treatment of insanity
would be to deprive themselves of their chief therapeutic
resource in many cases.

2. Consciousness and mental conditions generally might be
changed enormously in physiological states, as in sleep,
dreaming, hypnotic states, etc. Why should not an exaggera¬
tion of such physiological states produce still more divergent
conditions of consciousness and feeling, such as they found in
mental disease ? Clinically, this seemed to occur constantly.

3. Many cases of mental disease were so absolutely sudden
in onset and disappearance that they seemed inconsistent with
any known forms of toxic action, but quite consistent with
exaggeration or perversion of such physiological conditions as
produced sleep and dreaming.

4. The quality of reactiveness of the cortical cell to stimuli,
irritants, and depressants from within and without was the
most important of all its physiological attributes in relation to
insanity. Its mental function certainly reacted most strongly
of all to purely mental stimuli, but it also reacted markedly to
sensory stimuli, to the endogenous stimuli from every organ,
and to the chemical influences of body secretions and toxines.
When this quality of reactiveness was in a condition of morbid
activity or abnormal torpor they unquestionably might have,
arising from mental and sensory stimuli, pathological states
of mind, sensation, and motion, those taking the forms of
mental depression, volitional paralysis, loss of consciousness,
delirium, paraesthesia, neuralgia, and convulsions or motor
paralysis, with no proof of causal toxic action. This was
often well seen in neurotic children.

5. The reactiveness of any brain was determined by its
ancestral hereditary qualities more than by any other cause.
Clinical and statistical facts went overwhelmingly to show that
the typical insanities occurred far most frequently in persons
with an heredity towards mental and nervous disease. This
was, therefore, the first factor in all such insanities. Given a
high degree of tendency to a morbid reactiveness in the cortical
cell from a bad heredity in any brain, it seemed to be following
on physiological lines that it should be subject to mental dis¬
turbances from any kind of unusual stimulus, whether it be
mental, toxic, or otherwise. The clinical evidence was far too
strong to be set aside that such over-action frequently took the

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437

1902.]

form of attacks of various forms of insanity—in many such
cases the mental disease thus arising being simply an ex¬
aggerated mental physiology.

6. The processes of brain and mental development up to the
age of twenty-five, and those of involution and decadence after
sixty, and their mental accompaniments were strictly physio¬
logical. But where a bad heredity existed those processes
were frequently irregular and accompanied by mental dis¬
turbances. Why were not adolescent, climacteric, and senile
insanities thus pathologically explicable on a purely develop¬
mental and involutional hypothesis without toxic influences,
which in most cases were not clearly proved to exist ? More
than half the cases of mental disease occurred in and took their
special character from the physiological characteristics of those
periods of life. A cortical cell grew, energised, decayed, and
died by virtue of its inherent law of life. Given hereditary
weaknesses, those processes became abnormal in character, and
the result was naturally mental disturbances, which usually take
their colour from the dominant mental life of the period.
During development they were mostly explosive, periodic, and
sexual; during involution they were depressive, anergic, and
asexual. Toxines might disturb the action of the nerve-cell,
but they would not give a special age character to the mental
symptoms.

7. In many cases the mental disease was merely the gradual
evolution of the original character of the brain, over-sensitive¬
ness passing into melancholia, suspicion into delusion, irritable
temper into uncontrollable violence, weak volition into obses¬
sion. Such cases did not seem to need any toxaemic theory
for their explanation.

8. The conditions of nerve exhaustion, fatigue, and anaemia,
which they had hitherto reckoned of such enormous etiological
importance, seemed sufficient to cause many cases of insanity
without the intervention of toxines, or, at all events, in such
cases the toxines came in as secondary and resultant phe¬
nomena.

g. If insanity was as toxaemic and bacterial as smallpox, etc.,
might they not expect immunity in some form in many cases ?
There was no phenomenon in the least analogous to im¬
munity seen in the clinical or pathological history of mental
disease. Why did not toxic and bacterial action on the brain-

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438 TOXEMIA IN MENTAL DISEASE. [July,

cells have a period of incubation of active destructiveness and
then exhaust their destructive energy like such action else¬
where ?

10. Mere elevations of temperature might be produced by
stimulation or over-action of the thermic centres in the brain
apart from toxic action.

11. Was it not a more scientific view of many cases of in¬
sanity to suppose that they had as the initial fact a morbid
weakness through heredity in the cortical cell, as the second
fact some unusual stimulus acting on and disturbing its kinetic
action, the third fact nutritive disturbances in many organs
with bacterial over-development and consequent toxaemia, this
last, no doubt, accentuating and prolonging mental dis¬
turbances ? Was it a scientific view of such a case to put the
toxaemia first in importance ? Did they not in many cases of
incipient mental disease correct and cure the mental dis¬
turbances by mental treatment, by change of environment, and
by nerve tonics before the toxaemic stage was reached ?

12. On the modern pathological theory that disease consisted
in non-resistiveness, or a weakness of the defences against forces
inimical to life, were not nerve exhaustion, a bad heredity,
mental depressants, and processes of development and involu¬
tion, as sufficient an explanation of the morbidly kinetic condi¬
tions of brain cortex as toxic action ? The toxaemists seemed
sometimes to forget that to account for toxaemia they must first
account for the non-resistiveness out of which it arises.

13. One might grant that the trend of the modern theory of
disease generally was bacterial and toxic. Yet when they had
to do with mind and nerve kinetics that were sui generis , supple¬
mentary and different etiological factors of disease might have
to be introduced to attain scientific truth.

14. The medical psychologist must hold strongly to the view
that the cerebral cortex w r as the real controlling centre of the
whole organism, the regulating centre of secretory and excre¬
tory processes, and of nutrition, thus in its inaction and action
causing and counteracting those states of non-resistiveness
through which injurious bacteria and toxines were developed or
destroyed. By this theory toxaemia might be accounted for in
many cases as a secondary and not a primary factor in mental
disease. It would not be good practice to disregard the weak¬
ness of the animal on which the vermin had fastened. They

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1902.] W. FORD ROBERTSON, M.B. 439

must strengthen the organism, otherwise some enemy would
certainly find its weak point and end its life.

15. It was admitted on all hands that there were some cases
in whom the toxic element was the primary cause, such as in
most of the puerperal, alcoholic, syphilitic, rheumatic, and
gouty insanities, as well as in general paralysis, and possibly in
stupor or confusional and markedly hallucinatory cases, in
phthisical and many epileptic cases, though in most of those
cases an hereditary predisposition to the neuroses seemed to
determine the toxic point of attack. But, on the other hand,
simple melancholia and mania, the milder delusional and ob¬
sessional cases, the developmental and decadent insanities,
mental disease from deprivation of the senses and of social
stimuli, cases where periodicity and alteration were the chief
features, and hysterical cases seemed to be more explicable on
other etiological lines.

16. It was of the highest importance to recognise the rdle of
toxaemia in the causation and prolongation of mental disease,
and one would like to get hold of and believe in the general
application of a theory of insanity so simple and satisfactory;
but he could not see that the physiological, hereditary, and
clinical facts would bear it out. Mental disease seemed, in
fact, too complex a result of brain exhaustion, of evolution on
wrong lines or of reversion to be explained by any single etio¬
logical factor.

Dr. W. Ford Robertson said he did not know that he had
any right to follow Dr. Clouston in this discussion, as there were
many older members of the Association present, but since he
had been called upon he would say, in the first place, that he
was sure they were all very much indebted to Dr. Clouston for
bringing this important subject before them. They were in¬
debted to him especially for the clear manner in which he had
stated his views. Dr. Clouston had alluded to his recent
paper in the Scottish Medical and Surgical Journal , and he (the
speaker) trusted it was in order to answer certain statements
which Dr. Clouston had made in that paper. He thought that
the differences of opinion that existed between Dr. Clouston
and himself arose chiefly from the fact that they were regarding
insanity from two very different points of view. Dr. Clouston
looked at it especially from the standpoint of the clinician and

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440 TOXEMIA IN MENTAL DISEASE. [July,

the psychologist; he, on the other hand, regarded it from that
of general pathology. It was, however, an error to say that the
modern pathology of insanity ignored the hereditary element in
mental diseases, and that it attributed all insanity to toxaemia.
Practically the difference of opinion amounted mainly to this,
that Dr. Clouston did not admit that so many cases of insanity
were associated with toxaemia, as certain other persons con¬
tended.

Dr. Clouston had asked for a definition of toxaemia. He
thought that it was rather for Dr. Clouston to define the term,
and for them afterwards to try to pick holes in his definition if
they could. For his own part, he thought that the term should
be used in its widest sense. Any chemical substance which, on
being brought to a cell and taken up by it, caused disorder of
its metabolism, was a toxine for that cell.

One of the chief respects in which Dr. Clouston’s point of
view seemed to him to differ from that of modern general
pathology was in regard to the r 6 le assigned to heredity.
Included under “hereditary predisposition to insanity” there
were at least three entirely different conditions which ought
always to be distinguished, namely (i) cerebral anomalies that
are essentially the product of ontogenetic evolution (degenera¬
tive conditions); (2) cerebral derangements, the result of intra¬
uterine or early extra-uterine toxaemia or traumatism; and (3)
inherent characters of brain reactivity to its environment.
Extremes of these reactive characteristics were not necessarily
degenerative in nature; biologically they merely represented
directions of individual variation. They were not special to
the brain; they might concern any organ or tissue in the body.
Indeed, it had lately become apparent that some conditions that
were commonly regarded as manifestations of special inherent
brain-weakness, were really dependent upon inherent defects in
other organs, in consequence of which special toxines were
developed. For example, this had recently been maintained in
regard to idiopathic epilepsy. Dr. Clouston, who, in speaking
of hereditary brain weakness, was clearly dealing chiefly with
special individual reactive characters of the cerebral tissues,
contended that this weakness was the prime factor in the
causation of insanity, even in those cases in which the mental
disturbance was “ secondarily caused by something ab extra”
such as toxaemia. He (the speaker) argued that from the point

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W. FORD ROBERTSON, M.B.

441

of view of general pathology such inherent reactive characters
could not be allowed to rank as determining causes of disease.
They were simply properties of the material upon which the
pathogenetic forces operated. They merely rendered a person
liable to disease, just as a man sailing in a boat was liable to
be drowned, whilst a man on the top of a mountain was not.

With reference to a case of melancholia which had been
cited as one in which the mental disease was determined by a
cataclysm, and in which toxaemia could be excluded, he said
that he quite recognised that insanity could be determined in
this way, but he was strongly inclined to the view that in such
cases there was generally an already established state of
toxaemia, such as was obviously present in another very similar
case that Dr. Clouston had described. He had been severely
criticised for refusing to admit strong mental impressions as
causes of insanity. In this matter he was simply being mis¬
understood. He fully recognised that from the psychologist’s
point of view it was perfectly correct to regard such mental
impressions as causes; but from the standpoint of general
pathology, which was the one he was taking up throughout the
paper to which Dr. Clouston directed so much of his criticism,
such mental phenomena could not rank as causes, because they
were manifestations of the functional activity of an organ, and
therefore effects. He had analysed mental phenomena as the
combined products of a highly elaborated physical basis, sensory
impulses, and a nutritional state. The sensory impulse was
the determining cause of the mental phenomena ; their nature
depended upon the original physical basis and the elaboration
it had undergone, and upon the nutritional state of the cell-
elements forming the physical basis. Therefore, in cases of the
kind cited by Dr. Clouston, he had tentatively regarded the
sensory impulses as the determining cause, in order to en¬
deavour to bring the pathology of mental diseases into line with
general pathology. If the psychologists could tell him a more
scientific way of dealing with mental phenomena in considering
the pathogenesis of insanity, he would be glad to learn from
them; but he was certain of this, that in general pathology they
could never allow what was obviously the manifestation of the
functional activity of an organ to rank as a cause of disease.
It was an effect, and its causes must be analysed.

He could not admit that the cerebral cortex had the great

XLVIII. 31

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442 TOXEMIA IN MENTAL DISEASE. [July,

importance that Dr. Clouston attributed to it in controlling the
development of bacteria in the body. According to modern
observations both natural resistance to bacteria and specific
immunity were due to vital and chemical conditions in the
establishment and maintenance of which the nervous system
played at most only a very subordinate part.

With regard specially to melancholia, Dr. Clouston main¬
tained that its fons et origo was in the cerebral cortex, and that
it was far better explained by a neurotic than a toxaemic hypo¬
thesis. ile took just the opposite view, and believed that
melancholia was pre-eminently a disease that depended upon
toxaemia. The determining cause was not necessarily in every
instance toxaemia, but, as he had already indicated, he thought
that even in cases in which the onset of the malady could be
attributed to a strong mental impression, there was generally
an already established toxaemic condition of some kind without
which the mental shock would not have been able to determine
the development of the melancholia. But whether the condi¬
tion was determined by a mental shock or by toxaemia, it was
essentially maintained by toxaemia. He pointed out that pro¬
found mental depression could be produced in some persons by
certain chemical substances, such as oxalates and salicylates,
and that melancholia often supervened in the course of various
diseases known to be of a toxic nature, such as influenza,
chronic gastric catarrh, qualitative anaemia, septic uterine
disorders, etc. The evidence of experimental pathology and of
pathological anatomy also most strongly supported the view
that melancholia was constantly associated with toxaemia. He
could not accept the view that this toxaemia was sufficiently
explained as being caused by the cortical disturbance. Melan¬
cholia of the climacteric period was obviously dependent upon
a toxic condition connected with the involution of the repro¬
ductive organs. He did not think that senile melancholia
could be satisfactorily explained upon the hypothesis that it
was the result of senile involution of the cortical nerve-cells.
It was essentially a toxaemic condition. The fact was that
there was now the most abundant scientific evidence that it
was not the nervous system that generally first broke down in
the struggle of the body with the inimical forces in its environ¬
ment. The organs that first gave way were those that bore
the brunt of the battle, those that stood in the first line of

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W. FORD ROBERTSON, M.B.

44 3

defence, such as the gastro-intestinal tract and the bone
marrow. In his opinion the gastro-intestinal tract was the
fons et origo of the toxins that produced senile insanity as well
as many other clinical types of mental disease. He agreed
with the view maintained by Agostini that, with a few excep¬
tions, all forms of insanity occurring in persons in whom the
personality had developed normally, were of toxic origin.
He would go further, and say that all cases of insanity
occurring in such persons, without any exception whatever,
depended upon the action of a pathogenetic force in the
environment of the nerve-cells. The healthy, living nerve-
cell was in the condition of a body in motion, and it would
maintain its rate of motion and its direction unless these were
changed by some external force applied to it. To assert that
the change could arise from within the cell, amounted to
arguing for the creation of kinetic energy. The applied
pathogenetic force was not necessarily in every instance a
toxine.

To look upon insanity as merely a disease of the brain, was
similar to regarding chronic Bright’s disease as a disease of the
kidneys, locomotor ataxia as a disease of the cord, pernicious
anaemia as a disease of the blood. A pathology of that kind
had served a useful purpose, but he was convinced that its day
was done. Modern pathology demanded that the whole field
of operations should be considered, and that pathological pro¬
cesses should be traced right to their origin. It attached as
much importance to the nutritional environment of an organ as
to the organ itself, for it saw that a kidney, or a brain, apart
from continued correspondence with its environment was simply
an anatomical specimen and nothing more. It looked on
disease as disordered nutrition, the reaction of the living tissues
to inimical conditions which were threatening their life. He
contended that morbid states, such as chronic Bright’s disease,
locomotor ataxia, pernicious anaemia, and acquired insanity,
were not primary diseases at all, but late events in what was
often a very long series of pathological processes. He main¬
tained that, in the light of modern science, melancholia
depended upon the occurrence of a disorder of metabolism, and
that to endeavour to ascertain the nature and the cause of this
disorder should be the great aim of the physician when a case
of the kind came before him. As yet the means at their dis-

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444 TOXEMIA IN MENTAL DISEASE. [July,

posal for the attainment of this end were most imperfect, and
hence arose the urgent necessity for the equipment of labora¬
tories in which investigations into such subjects could be
carried out.

Dr. G. R. Wilson said that it seemed to him that they could
not treat this subject except as controversial matter. He was
what Dr. Ford Robertson would call a toxaemist. He did not
think that Dr. Clouston understood Dr. Robertson’s paper, and
he was sure that he himself did not understand it. He thought
that was because the statement as set forth in Dr. Ford
Robertson’s paper was an unintelligible statement and full of
many errors and fallacies—logical, physiological, and psycho¬
logical. He particularly objected to the discussion of any case
as a test case, and he thought they would agree with him.
Dr. Robertson had said that they must not take a pin-hole
view of the subject, but he thought it was taking a pin-hole
view of it to speak of the cause of a case of insanity. Insanity
was a long process, developing very slowly, and depending
upon an infinite number of factors, and the only way they could
get a grasp of it was to take the internal and external condi¬
tions of the case and consider each of them dispassionately,
and get as far as possible to the bottom of them. If they were
going to discuss the whole relation of insanity and toxaemia
they might talk for hours. They must confine themselves to a
few points. One of the points that he wanted to insist upon
was that their friends, who had brought to them this very
valuable conception, were inclined to say that deficiency of
nutritive material was not of very much practical importance.
The nervous system and the heart during starvation would live,
they were told, at the expense of the other organs. Now, he
thought that that was just the kind of consideration in which
clinical observation took the place of histological observations.
He thought that they all knew that when they were hungry
they were irritable and excitable; if hunger was prolonged, and
if they were deprived of the necessities of life, their tissues did
not have the same chance as if they were fully supplied with
food and drink, and the mere fact that in cases of inanition
the toxines got the better of the living cells, and so induced
toxaemia, showed that the presence of sufficient food or oxygen,
or sufficient water, was an important condition. He was not

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G. R. WILSON, M.B.

445

1902.]

going to use the word “ cause ” if he could help it. His chief
quarrel was on the psychological side. The pathologists could
not be expected to have any psychology, but if they did not
enter into the psychological side they might refrain from
slanging those who did. There was one point he would like
to put to Dr. Ford Robertson, and he thought it was a very
fair one. Dr. Robertson said that the deprivation of sense
sometimes caused insanity. He had a case recently of double
cataract in a lady who became melancholy and later on excited.
There they had shut off from the highest centres the processes
which were necessary for those cells. To take an analogous
case, suppose a man and a woman who had grown up together
as husband and wife, and that the man had worked all his life
in relation to the thought of his wife, and suppose that some
day that wife was abducted or killed. Did not this deprivation
of a wife have as much effect on the nutrition of the whole
brain as the deprivation of an eye or an ear ? These domestic
activities had a physiology just as vision had, and yet they
were asked to disregard that. The other point he wished to
raise was that about the conception of primary disease occur¬
ring in the brain. He would like to ask Dr. Robertson, or any
of the others, what determined the durability of the somatic
structures. As to the question of the durability of the cells,
Dr. Robertson and Dr. Clouston both spoke of a physiological
process of involution ; but senile degenerations cannot properly
be called physiological. Dr. Ford Robertson asked them to
believe that there was not a great difference in the durability
of cells in different individuals to account for differences in
longevity, say between a man who dies at seventy and another
at ninety, and he wanted them to believe what they could not
believe. They were born into the world with an initial vitality,
and there were many who had that very far short of the
normal. He was glad to associate himself with those who
were entirely out of the line of modern pathological science if
modern science taught that we should disregard the constitu¬
tion of the bodily mechanism in which all vital reactions occur;
the construction and quality of a machine were surely as
important in determining reactions as the kind of stimuli. He
would like to say that he was a toxaemist in principle and in
practice, and he thought that metabolism of the excretory
organs and in the intestinal tract was of very great importance

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446 TOXAEMIA IN MENTAL DISEASE. [July,

in insanity, and that they should direct their attention to it.
But because his eyes had been opened to the importance of
that factor, he was not going to disregard the other factors
that they had been accustomed to so long. Insanity was often
due not only to the presence in the blood of things that ought
not to be there, but also to the absence from the blood of
things that were necessary. Nor was he going to give up the
old psychological conceptions to which their friends would
come when they had acquired a working knowledge of
physiological psychology.

Dr. Yellowlees said the Association was rich in enthusiasts.
They had enthusiasts in things practical and also in things scien¬
tific, as that afternoon had shown. He was sure they all admired
the very moderate and reasonable tone in which Dr. Clouston
introduced the subject, and he was sure they would regret that the
tone in which it was responded to was different. It was a weak¬
ness of all enthusiasts to think that people who did not exactly
see as they saw were behind the day, and blind to the light of
“ science.” He thought that those who looked at the subject
from an opposite point of view were entitled to some considera¬
tion, and that men so proud of their science ought to have open
minds, and not jump to conclusions so hastily. There was a
good deal of needless confusion in mere terminology to begin
with. Dr. Robertson spoke of variations in the natural re¬
activity of the cortical cells, which was only a roundabout way
of expressing what Dr. Clouston called hereditary predisposi¬
tion. His great objection to what Dr. Robertson and his school
advanced with such positive certainty and emphasis, was that
it excluded mental causes altogether. They degraded mind to a
mere secretion or function of brain cells—nothing else and
nothing more—and they utterly despised the idea that insanity
could arise from the mental side at all. If he (Dr. Yellowlees)
had learned anything, it was the very opposite of that. He was
certain that the mind reacted on the organism, and that
insanity might begin, and often did begin, from the mental
side. A patient of his, a bricklayer, was busy at his work
laying bricks when a man suddenly said to him, “ Your brother
has just been killed at the mill over there.” Instantly he
dropped his tools, became stuporose, then subacutely maniacal,
and remained so for several months. Did anyone believe there

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DR. BRUCE.

447

was toxaemia there, or any time for it? The pathological
enthusiasts had no right to tell them that toxaemia covered the
whole field when a case of that kind existed, and no one who
looked at cases from the clinical side could accept their dictum.
He welcomed all that pathology could tell them, but he did not
think it wise or becoming that the pathologists should ignore
what was learned in another field than their own. They were
told that melancholia followed constipation, uterine disturb¬
ance, and many other disorders. This was true, but the
opposite was equally true, that melancholia already existing
produced constipation and other bodily disorders. He did not
know why the pathologists would look at a case only from their
side, and never look at it from the other side. One thing had
struck him very much, and that was that there had been no
allusion to the insanity which, of all others, had seemed to him
the one which supported the toxaemic theory, viz. recurrent
insanity. It seemed explicable only on the theory that some
materies morbi gradually accumulated in the organism and pro¬
duced the attacks, yet their very best efforts failed to eliminate
the poison and avert the recurrences. Another thing that
struck him was that they had a much simpler toxaemia than
this obscure and all-explaining toxaemia which the pathologists
proclaim. They had toxaemia produced from without the
organism. Some parallelisms might have been expected, but
not a word was said on the subject. No doubt the pathologists
were doing good work, but they were far too hasty in their
conclusions, and far too certain of their correctness. They
were too apt to ignore the clinical facts which did not suit their
theories, and too ready to tell us that we are all dwellers in dark¬
ness unless and until we accept their great revelation.

Dr. Bruce said that in the causation of insanity no one could
deny the power of hereditary predisposition. The fact that the
chief insanities appeared during the periods of evolution and
devolution of the body was a fact which could equally well
support the toxic and the antitoxic views. The real crux of
the question narrowed itself down to the following proposition:
“ Do the mental symptoms precede the physical, or do the
physical symptoms precede the mental in the onset of acute
mental disease ? 99

He believed that the majority of insanities were of toxic

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448 TOXEMIA IN MENTAL DISEASE. [July,

origin, and for purposes of description he thought they fell
naturally into three great groups :—(i) The metabolic group ;
example, simple melancholia. (2) A group purely toxic in
origin—source of toxine unknown, but probably bacterial—pre¬
senting no marked metabolic disorders ; example, pure mania
and all forms of excitement where the excitement is the pre¬
dominant symptom. (3) The mixed group, in which you find
combined the toxines of Groups Nos. 1 and 2.

In Group No. 1, the metabolic group, he had seen the
physical symptoms precede the mental symptoms by quite a
week’s duration in three cases. Probably the general prac¬
titioner saw this much more frequently than the asylum
physician. On the other hand, he never remembered a case which
recovered in which the physical improvement did not precede
the mental improvement.

In Group No. 2, the pure toxic group, he had never seen a
case early enough to say that the physical symptoms preceded
the mental in the onset of the disease ; but here again, upon
recovery, the physical always preceded mental improvement.
In all cases of this group the leucocytosis is the infallible index
as to the condition of the patient. When the patient suffers
from a hyper-leucocytosis that patient is mentally excited.
The hyper-leucocytosis is nature’s method of combating the
toxine. When the leucocytes fall the patient is better—nature,
by means of the leucocytes, has temporarily overcome the
toxines. If you artificially stimulate leucocytosis you produce
a temporary improvement in the patient’s condition. If by
the introduction of antitoxic substances you assist nature in
combating the toxine, the leucocytosis falls, and again you
produce temporary improvement. To his mind, these facts
were very strong proofs that this class of disease was of toxic
origin, and that the only treatment of the future likely to meet
with success is an antitoxic one.

With regard to Group No. 3, he would only say that the
cases combined the symptoms of Groups 1 and 2, and the
proofs of toxicity were easily demonstrated. If the brain cells
can originate disease per se, without any outside cause, then
they were probably the only cells in the body capable of such
morbid action.

He strongly supported the toxic theory because it held out
hope of some advance in treatment. If we are to believe that

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DR. MARR.

1902.]

449

the brain cells, per se , become diseased, then there can be no
treatment.

Dr. Marr said he hardly knew what to say in this discussion,
as it had ranged over a very wide field. He was inclined to
think that Dr. Clouston and Dr. Robertson did not differ so
much as they appeared to do in the discussion. In the
neuroses of development by Dr. Clouston it was shown very
clearly that cases of developmental general paralysis were due
to syphilis. Syphilitic poison in these cases had produced the
degeneration known as general paralysis. He expressed his
dissent from Dr. Ford Robertson’s ideas concerning this
disease, and agreed with Dr. Mott, who held that the syphilitic
poison had so exhausted the nerve-cells that they succumbed
to degeneration on any unusual stress, and this degeneration
was accelerated by auto-intoxication. Dr. Clouston had
said heredity was a factor in general paralysis, but he (Dr.
Clouston) could not conceive of heredity affecting the brain-
cells so profoundly as to produce this disease. In cases
where heredity was proved, congenital syphilis was invari¬
ably found; and if the syphilitic poison could make such an
impression on the other tissues of the body as to notch the
teeth, change the contour and composition of bones, etc.,
surely it could make an impression on the nerve-cells and
deprive them, as Dr. Mott said, to a large extent of their
vitality, and so render them liable to degeneration. He under¬
stood that the word toxaemia simply meant poison circulating
in the blood, and probably this wide meaning had to do with
the variety of opinions expressed. He was strongly of opinion
that cases of acute delirious mania were due to toxaemia, and
this opinion was accentuated by the fact that many ob¬
servers, including himself, had found micro-organisms in
the meninges of the brain. In such cases they could say
with accuracy that the insanity was due to toxaemia. Revert¬
ing to the subject of general paralysis, he disagreed with the
opinions of Dr. Bruce, who held that general paralysis was the
result of microbic toxaemia. In general paralysis the degenera¬
tion of the nerve-cells was spread over years. In juveniles
general paralysis had sometimes extended in duration to as
much as twelve or fourteen years. If this degeneration was
due to a microbic toxaemia it would be natural to expect a

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450

TREATMENT OF DELUSIONAL INSANITY, [July,

parenchymatous inflammation, but such was not the case. He
thought that Dr. Mott had more clearly proved his case in
stating that the decay in general paralysis was accentuated by
the degenerate products of the nerve-cells circulating in the
system ; in short, by auto-intoxication. He thought that in
connection with the whole subject it was better to hasten
slowly, and prove by actual research that toxaemia really
produced insanity. In all that had been done in connection
with this subject in this country he had noticed that not a
single corroborative biological test had been made or even
mentioned, and until these tests were made regularly with
other clinical and pathological work it was well to keep an
open mind on the subject.

The Chairman said that he had listened with very great
interest to the discussion, and had pleasure in conveying the
thanks of the Association to Dr. Clouston for the very temperate
and clear manner in which he had brought forward his views.

(') Brit. Med. Journ October 26th, 1901.—(*) Proc. Roy. Soc., London, 1899.—
( s ) The Lancet , August 24th, 1901; Brit. Med. Journ., June 29th, 1901.—( 4 )
Scottish Med . and Surg. Journ., February, 1902.

The Surgical Treatment of Delusional Insanity based
upon its Physiological Study . By T. Claye Shaw, M.D.

The manifestation of delusions is so striking a proof of
aberration of mind that we seem tempted to inquire if the
study of them will in any degree help us to an elucidation of
the actual physical change which must either be the cause or,
at any rate, the accompaniment of them.

Just as we may study the movements of a piece of
mechanism, and by consideration of them work back, as it
were, to an understanding of the structure, so may we not
possibly inquire into and succeed in postulating certain
physical arrangements? more especially as it does not seem
likely that by examining the structure we can explain the
defects themselves of the resultant or concomitant action.

To argue from effect to cause has before now led to striking
results ; it is, indeed, to us as physicians the usual way of

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451

working, but with the experimental observer the first thing to
do is to modify the conditions which we take to be the
proximate cause, and then to record changes in the effect.
Why cannot we do the same with this subject of mental
physiology ? Because to experiment under natural conditions
is rarely possible, and pathology has not hitherto helped us
much. Experiments upon animals are useless, because,
though we can obtain motor effects, we are not able to learn
anything about ideas.

If, after deliberation, an act of “ will ” results, are the cells
which have been concerned in the deliberative process the
very ones which give the motor impulse ? Or is this influence
communicated to others which bring about the direct motor
result ? Are there cells which are susceptible to impress, to
change, in a certain way only, or can they be modified
differently according to the nature of the presentation, i. e . is
their receptivity general or particular ?

After a group of cells and processes has been impressed in
a certain manner (one is bound to use mechanical expressions
in discussing this subject), is that group bound to energise in
the same manner under recurrent stimuli, or is it susceptible
of modification ?

We must ignore the objection that has been made (Wundt)
that there are not enough cells in the brain for each to have
its own metier, because it would seem from observation that
the material of the brain is never used up, even in a long and
active lifetime; there is always present the potentiality of
more capital for use than has ever been called upon. Does a
man whose brain remains sound ever get to the limit of his
knowledge ? He is always able to go on acquiring startling
new projects, receiving impressions of a kind quite different in
quality from any hitherto presented.

If we go on the theory of psycho-physical parallelism as
being the most acceptable of all our endeavours to understand
the connection between psychical and physical processes, we
seem bound to acknowledge that some change, some physical
alteration, must occur in cells that are called upon to act in
obedience to stimuli. Of the nature of this change we know
nothing, whether it consists of a rearrangement of particles, a
molecular change, or of one of a chemical nature; but we can
scarcely conceive that the condition physically of a brain that

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452 TREATMENT OF DELUSIONAL INSANITY, [July,

has been stimulated is the same, qu& material static remanet,
as one that has never been brought under external influences.
The microscope does not enlighten us, nor have any experi¬
mental facts as yet thrown light upon any material change
either in nerve cells or fibres that we can associate with the
objective display of internal mechanism.

Let us then analyse what we may suppose to occur in a
psychical content, say the idea of wealth.

There have been more or less frequently and intensely
stimuli of sight, touch, and hearing, of a mixed but still
definite character, and associated with these the word
“ wealth,” which is the abstract correlate of all these various
impressions. Whenever the word “ wealth ” is brought into
consciousness and kept there, there is a revival of the various
sense impressions that have, at one time or other, con¬
tributed to the idea, be it money, land, size in any direction,
or whatever else has been the predominant agent in the pro¬
cess of abstraction ; and we can scarcely conceive other than
that the same parts are concerned in the revival of the image
as were at first concerned with its formation.

In accordance with what we see of ordinary healthy
function, the structures concerned with this particular con¬
sciousness pass into the background when the stimulus is
removed, and do not again obtrude themselves except on
occasion.

But suppose now that from disease, such as may be brought
on by over-functioning, from an inflammatory process, from an
altered composition of blood or what not, some temporary or
permanent change is wrought upon the tissue of an irritant
nature; it is but natural to conclude that the temporary
functioning in response to stimuli is changed into a continuous
one by the abnormal local conditions, and that so long as the
irritable condition lasts, so long will the impress of the con¬
cerned structures continue to assert itself in the absence of
external sense stimulation ; and inasmuch as consciousness is
limited by structural states at the moment existing, so long
may the individual be out of harmony with his environment,
because he cannot escape from the tyranny of an ever-present
possession.

The man who is in an ever-present worry because of
straitened circumstances, of some moral or social lapse that he

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453

has committed, is never free from the damnable constancy
of the persistent action of his over-acting cells until other
stimuli set up relieving processes in other centres and permit
functional rest to a jaded tissue.

This I take to be the condition of things in the insane, and
with it must be included the emotional tone that accompanies
the delusion. Explain it as we may, there is to be acknow¬
ledged a pleasurable feeling accompanying ideas of the satis¬
fying order ; a painful feeling tacked on to, or part of, those
of a dissatisfying kind ; and these feeling-accompaniments we
seem to be incapable of doing more than note, sufficient it is
for us at the moment that they must always be taken into
account as part of the result of a functioning element.

So with the man who suffers from delusions of a depressed
kind. What we must suppose is that certain cells and con¬
nections have been impressed (there is no other word so con¬
venient) in a definite manner; they have been tuned to
answer to vibrations of a certain sort, and have their corre¬
sponding emotional tone; and if by the advent of a disease-
process they become temporarily or permanently involved, so
long will excessive functioning in a special direction go on.

Whether any cell and its processes are able to receive
stimuli of polar kinds and to exhibit corresponding emotional
states is quite unknown ; as it is also whether a cell which
has once been set to vibrate in one direction can receive im¬
pulses of another sort; whether, in fact, the higher structures
are subject to the laws of local signature somewhat analogous
to the hot and cold points in the skin.

An explanation of this sort seems too simple for so
complicated a structure, but in our present inability to com¬
prehend purely psychical processes we seem to be driven to
material explanations.

It may be objected that many insane persons are not always
in the presence of their delusions, as they should be if their
new self is dependent upon a local material change. I believe,
however, that they are always in the presence of their new
conditions, just as the sane man is always in his own conscious
being ; and it is quite in accordance with what we clinically
know of consciousness that habit should render the insane man
less attentive to, and less demonstrative of, his new state, just
as it does the ordinary sane person.

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TREATMENT OF DELUSIONAL INSANITY, [July

Disease of the brain is never universal, and along with the
morbid tracts there must be many untouched centres able to
function more or less normally ; and so we never see a com¬
plete lunatic ; some residual product is invariably to be detected
which shows that “ denudation ” has only been partial. That
motor changes are generally seen in states of mania or melan¬
cholia is what we should expect, because sensory and motor
processes are so bound together that an alteration in one is
sure to affect the other. The man whose brain is tired by over-
stimulation loses perfect motor control (or, at any rate, has to
employ effort to accomplish what before was a reflex), even
though his motor side may have been quite subordinately
engaged. One very frequent effect of mental fatigue is that
the walking co-ordination loses its purely reflex type, and the
subject has to pay attention to his steps ; so with explosive
conditions, such as anger or strain, not only does the person
feel unable to walk, but he is also unable to talk without
tremor, or to write without shakiness.

No doubt a good deal of this may be attributed to circulatory
impairment, but not all ; because in the absence of emotion in
long-sustained work of a neutral-toned character we may notice
the motor prominence; while in the decided emotion-toned
ideational states of mania and melancholia the muscular
affection is apparent to anyone.

The above reference to local signature is worthy of a little .
more consideration.

If, as Kiilpe says, local signs are a specific qualitative
colouring, if they are the physiological peculiarities of peri¬
pheral excitation, so that every impression is referred to a
distinct locality (and this appears to be a much simpler way
of explaining localisation phenomena than by introducing
“ association ” to explain them), then why may we not extend
Kiilpe’s theory to the higher centres, and say that every idea
may be referred to a distinct locality ?

I would not, of course, suggest for a moment that cells are
capable of receiving impressions only of a certain kind, though
many would probably with correctness urge that cells and pro¬
cesses connected with the auditory or any other centre are
incapable of receiving direct impressions from any other
peripheral organ (except by association) than the one of which
they are the local sign.

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BY T. CLAYE SHAW, M.D.

455

For anything we know to the contrary, a group of central
structures concerned with, say, the idea of a palace, might be
the possible physical basis of the idea of a hovel ; but having
once been made the exponents of a definite local signature, it
is difficult to see how they can vibrate in response to a peripheral
or central stimulus of another quality.

If we look at any object or listen to any sound, the very fact
that we recognise certain parts of the presentation is surely
proof that some part of the originally stimulated centre is
again responding, and it almost postulates that, as to quality,
there is an absolute central local signature; and though it
would be absurd to talk of wealth, or poverty, or persecution
cells, for these are abstractions which are embodied only in
words (which may themselves have a material basis), it is not
absurd to suppose that the experimental bases of the abstractions
are definite local signatures capable of acting in consonance
with the recognised laws of stimulus and result

If the above be true, or in a measure true, if it is a workable
hypothesis, to what does it lead us ? To this among other
things, that in treating insanity we should first of all address
ourselves to ascertain the radical basis of the abstractions—
for delusions are chiefly abstract ideas,—to find out which
group of local signatures was primarily affected, whether the
aural, optical, touch, or smell centres were probably the
first affected, and to pay no attention to the secondary centres,
which are merely displaying their associative connection with
the real seat of disease.

It may be that more than one group of centres is primarily
disarranged ; if so, the greater in intensity, in diffusion, will be
the display of signature.

In examining any patient who exhibits explosiveness or
delusions, I always try to focus the primary lesion if possible,
to determine which centre was first to show irritative continuance
of action, and in some instances we shall, by bearing this in
mind, meet with success in dispersing the whole range of
symptoms.

In general it is only by attacking the periphery that our
localising efforts are rewarded, but I look forward to the time
when surgery will be our great aid, by applying direct local
treatment to a specific centre. Unfortunately the peripheral
mode of attacking central lesions is of little avail, because in

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TREATMENT OF DELUSIONAL INSANITY, [July,

the majority of cases the more highly elaborated internal
structures are especially involved, and so the usual methods
are simply the employment of symptom-remedies such as
sedatives to control excitement, rest by endeavouring to divert
processes of thought into other channels, or other indirect
means, which either have no effect at all, or are positively
harmful by doing nothing to get rid of the fundamental
mischief. I own, also, that there may be conditions of the
blood, due to the presence of toxins, which may, with advancing
knowledge, be capable of treatment, and it also seems feasible
that bacteriology may help us in the future.

Some time since I advocated the use of surgical measures
in alleviation of pressure symptoms in general paralysis of the
insane, and I published cases where there was no doubt about
the relief by operation of some of these symptoms. I look
forward to the time when operative treatment will be recog¬
nised as the only way in which the cortical lesions must at
certain stages be dealt with ; operations directed to the imme-
date local treatment of centres inaccessible by the present
indirect methods.

It is not always easy to locate the centre first attacked ;
indeed, there are often many centres involved by the uniformity
of action of the cause, especially in lesions due to blood poisons
or toxins ; at other times there is no uniformity, for a cause
involving primarily an auditory centre in one case will attack
an optical centre in another; all the same there remains
incumbent the duty of finding which centre is the one first or
chiefly involved, and of applying our attention to it.

It would seem that the morbid anatomy of special centres is
well deserving the attention of pathologists, and as it is seem¬
ingly true that every organ is represented in the brain, so must
we look to the discriminate recognition of these representative
parts as the seat to which treatment should be specially
directed. What is done with success in Jacksonian epilepsy
should be possible in ideational insanity; and it may be con¬
fidently said that many cases of chronic delusional insanity with
all the associated symptoms of violence and irregularity are left
uncured because we have not the courage to attack them surgically.

Localisation is the immediate and pressing need in the
treatment of brain symptoms, whether in the general domain
of neurology or in the particular one of insanity.

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BY T. CLAYE SHAW, M.D.

457

If what I have written is in any way correct, we must con¬
clude that the presence of delusions is not due to what Dr. H.
Jackson calls the positive, t. e. the untouched, but to the nega¬
tive or diseased elements and their associations; recognising
always that the normal action of the parts untouched by dis¬
ease may be temporarily disorganised by interference with
their normal associations.

The great difficulty one has is to explain abstract ideas, but
it is scarcely necessary to suppose more than that old perception
paths are involved, because in all abstraction there is present
some embodiment of a former sense impression.

Much of the present-day treatment of the insane is indis¬
criminate. It is sufficient that a patient is excited to put
him in a blue room, or that he is depressed to place him in a
red room, when his optic centres may be only secondarily
affected ; or to send him to hear music or to the theatre when
his auditory centres require rest. I have seen out-of-doors
treatment aggravate symptoms, and on the other hand, many
advise it as the panacea for all sorts of mental impairment.

This I am, I think, warranted in saying, that universal rest
treatment, such as is now carried out in some " homes,” is often
very dangerous to the integrity of the patient; everything
calculated to stop general central action being enforced to a
painful degree, with the result that either introspective abstrac¬
tion is the only resource, or that an over-acting centre is left
to rush along to an unhindered dissolution.

The surgeon has already usurped much of the territory of
the physician. It seems time that he took in hand some of
the problems of insanity.

I feel strongly the incompleteness of what I have been
urging. It must be that there are diseased elements in the
brain that are only remotely connected with sense-centres, and
that if any sense-centre is apparently involved, it is in reality
only secondarily so.

I can understand that one might say, "Take the case of a
person who has ideas of persecution by a secret society; or of
a woman who takes objection to her husband and makes state¬
ments of an utterly false character as to bad treatment and
neglect; or of another individual who passes his time in per¬
forming arithmetical absurdities, or in evolving extravagant
moral theories; where is the surgeon to begin his work here ? ”

XLVIII. 32

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45 8 TREATMENT OF DELUSIONAL INSANITY, [July,

I can only confess that in the inability to trace the origin
of such ideas from the internal senses there seems no remedy
to suggest. That there is a tissue change of a definite nature
I am bound to believe, but beyond this we can hardly go. For
such there seems to be no direct remedy available.

Let us seize upon whatever appears to be the central local
sign of each organ in the body ; we can afterwards consider the
material of abstract ideas.

If, as a last resource, operative measures are taken, it may
fairly be asked how far they should go, and what direction
should they take. I suggest that a primary trephining to
inspect the region of disease indicated can, as an operation, do
no harm. Nowadays there is little danger, and it can be
quickly performed. There may be found some membranous
thickening, or adhesion to the underlying convolutions, and
this may be removed, as its continual presence may be causing
pressure or irritation. Much good is likely to result from the
relief of congestion, and in my experience there need be no
fear from after results, such as the growth of membrane over
the opening.

If, on removal of the dura mater, the membranes appear
misty, they might be punctured and drained. As to inter¬
ference with the cells themselves, one would be guided by their
appearance. Anyhow, we should obtain material for prog¬
nosis, impossible by other modes of treatment

May I invite the attention of pathologists and of those
with opportunities for the clinical study of symptoms to the
importance of noting specially the condition of the sense
centres, with the object of establishing the correctness of the
opinion that changes will be found in them which may be of
use in leading us to what is very desirable if it be possible, viz.
a more complete localisation of perception or ideation than we
at present possess ?

I remember a case where, with persistent olfactory hallu¬
cinations, there was found after death a sclerosis of the olfac¬
tory centre. Unfortunately I did not preserve the specimen,
but I should know now how to make better use of it, for I
believe that operative treatment was really the only one likely
to have done any good.

I must apologise to the Society for not producing more
clinical support in favour of what I have been urging, but I

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BY T. CLAYE SHAW, M.D.

459

hope that others may be able to supply the deficiency, and
that members will kindly extend their consideration in the
reception of the very debatable question which I have ventured
to raise. Success in the medical management of insanity
appears at a standstill ; it is time that we consider more deep
searching means.

Discussion

At the General Meeting, London, May 21st, 1902.

Dr. Hyslop said he would have liked to have had an opportunity of discussing the
paper more fully than time now permitted, because many of the points traversed
by Dr. Claye Shaw were of the very utmost importance. Whether unconsciously
or not, he thought the author had touched upon some points along which many
great advances might be made in the future. When one began to discuss the
diagnosis of hallucinations, one followed those possible disturbances up the various
brain tracts until one came to what was considered to be the psychic centre. The
interpretation of the hallucination had to be accounted for, and that, as far as was
known, was spread over the whole cortex. Therefore, from the localising point of
view, he feared they were not much further forward. If the psychic centres were
localised, well and good, but how could the delusions and misinterpretations be
accounted for P That was a very much wider subject. He had been working for
seven years trying to make out those brain tracts, and he had prepared 350 illus¬
trations while trying to get at the real diagnosis of hallucinations. Hallucinations
of taste had nothing whatever to do with the psychic centre for taste. A pure
hallucination of taste was an unknown quantity practically. So also with regard
to smell. There were many who would disagree with that, but he was prepared to
argue it out. Thus those centres were cut out of account. Next there was the
centre for touch, and that opened up one of the widest possible fields. Dr. Claye
Shaw’s words were, to him, pregnant with meaning, and opened out as great a
vista in psychology as the origin of species did in biology. He hoped that now
Dr. Claye Shaw had started upon the subject he would follow it up. With regard
to hallucinations of sight and hearing, one got much nearer, but did not know
which side was most concerned with hearing. There were many most important
physiologico-anatomical problems which had yet to be determined. One might
detect hallucinations and imagine which side they came from, but one did not
know the anatomical relations or the cross-relations with the tracts of hearing.
With regard to vision, they were getting nearer and nearer, and the work had been
multiplied enormously by thousands of writers. Yet they had not reached the
point of interfering surgically. One argued that there was an interruption of the
current, and that there was some bodily defect sufficient to interfere with the
current; but when one came to the ideational and emotional centres, and those for
volition, one got into regions with respect to which there were no data, and he
thought the time was far distant before surgery could be employed with regard to
those regions.

Mr. C. B. Lockwood said that he had been requested by his friend Dr.
Claye Shaw to perform some of the operations to which he had alluded.
The circumstances, as far as he recollected, under which he had operated for Dr.
Claye Shaw were as follows: The patients upon whom he was asked to operate
-were, to his mind, proper subjects for operation, because there seemed a reasonable
prospect of relieving them from the intense pain which they were said to have
been suffering from. The question which naturally arose was whether that relief
from pain was purchased at too great a risk. From his own small experi¬
ence of operating upon those people he had come to the conclusion that the
risk of opening the cranial cavity and incising the membranes of the brain was,
under proper conditions, a very minor one, and the recent advances in the matter
of asepsis had rendered the risk considerably less. It would, perhaps, be scarcely
agreeable to the Association if he were to enter upon any narration of the details

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SLEEP IN RELATION TO NARCOTICS,

[July,

of the operations he had performed for Dr. Claye Shaw; bat in choosing a place
at which to open the skull he always selected a point far back beyond the motor
areas, for obvious reasons. He concluded it would be wise to remove a very large
disc of bone, which was by no means an easy matter, because, in his experience,
those people had very thick and hard skulls. Thus it was necessary to have special
trephines constructed. He regarded it as quite safe and wise to proceed further
and to open the dura mater, and even the arachnoid, so as to expose the cerebral
cortex. A further question arose in one of Dr. Claye Shaw’s patients. Dr. Claye
Shaw asked him to ascertain whether there was fluid in the ventricles of the brain.
He did not mind doing that, but thought it was a step which should be avoided,
because there was the obvious danger of producing haemorrhage into the ventricle
from puncture of the vascular structures within it.

In reference to the effects, from his own humble point of view—he was not in the
least familiar with mental disease—he had been very much struck by the effect in
one of his patients. First of all, the headache, which appeared to be very severe,
was relieved; his strange and torpid mental condition was entirely altered, and
some months afterwards he was surprised to see the man apparently well, and
talking in a rational manner. A long time afterwards he was earning his living
and conducting his business himself.

Another patient he recalled was shown to him afterwards by Dr. Claye Shaw, very
materially improved with regard to his pain, and he believed also in his mental
condition, but as to the latter Dr. Claye Shaw could speak better.

He had referred simply to his own experience. He would like to briefly refer,
however, to a circumstance which produced a profound impression upon his mind.
At the Glasgow meeting of the British Medical Association, Professor MacEwen
showed a patient who had passed his life, or the greater of it, as a very pious, God¬
fearing man, and had brought up a large family in a most exemplary manner.
In the course of his work a rivet fell upon his head and caused a depressed
fracture of the skull. After that accident the man become irascible, took to drink,
and turned out his family. Professor MacEwen trephined him, and he then
reverted to his former mental condition. To him (Mr. Lockwood) that was a
striking illustration of the profound influence of physical causes on mental states.

Dr. Claye Shaw, in reply, thanked Dr. Hyslop for his criticism. He confessed
the difficulties of the paper and the subject. He knew people who had been
working at the subject for a long time, and he had himself indicated to Dr. Hyslop
the way in which, by increasing accuracy in localisation, surgical means could be
taken such as were spoken of by Mr. Lockwood. If a surgeon in Mr. Lockwood’s
position could say there were certain physico-psychical conditions which could be
relieved by operation, and that those operations were comparatively harmless, then,
after all other means had failed, surgery should be tried rather than allow the
patients to lapse into chronic dementia.

Sleep in Relation to Narcotics in the Treatment of
Mental Disease . By Henry Rayner, M.D.

Sleep, the state in which man spends a third of his exist¬
ence, is so intimately related to bodily and especially to mental
health, that it must ever be a subject of the greatest interest to
alienist physicians. No apology therefore is needed for once
again bringing under discussion a subject so familiar.

Sleep involves such a wide extent of physiological conditions,
and sleeplessness is related to so many patho-physiological

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1902.] BY HENRY RAYNER, M.D. 461

problems, that to attempt to discuss either in the limits of one
sitting would be like trying to measure up a continent with a
two-foot rule. I propose, therefore, to limit my consideration
of sleep to such aspects of it as are related to the question of
the treatment of sleeplessness by narcotics ; to consider
whether the state of narcotic sleep or narcotic stupor is as
reparative as normal sleep, and whether the relief of the sym¬
ptom sleeplessness by the use of narcotics may not be too
dearly purchased by the harm done in other directions.

The question at the present time is an urgent one. New
narcotics are being invented every day, are being forced on the
profession and the public by the most ingenious quasi-scientific
literary devices, and supplied by all chemists in the most easily
obtainable, most portable, and tasteless form. Their immediate
action is often obvious, vrhile the remote end effects are not so
easily traceable. Hence a popular use of these drugs to an
extent which is really a very serious danger to the public
health. I see so much of their abuse that I am inclined to
ascribe to it a considerable proportion of the nervous and
mental disorders of the educated classes at the present day.

A brief glance at the nature of sleep and at its relation to
other conditions of unconsciousness is a necessary introduction
to the subject, although it may appear a repetition of too
familiar facts.

A mere enumeration of the theories of sleep would be a serious
matter. Sleep has been described as purely psychic rest, or as¬
cribed to tire of the vaso-motor centre, to exhaustion of the nerve-
cells, to the contraction of the dendritic processes, to the expan¬
sion of the neuroglia cell and processes, insulating the nerve
processes, etc. Sleep, however, is older than all these, older than
consciousness, older than dendritic processes, or vaso-motor
centres. It represents a rhythm of organic habit, going back
to the primitive unicellular state, and traceable in all forms of
organic life. In primordial life, no doubt enforced by the daily
withdrawal of light stimulus, but even now in higher organisms,
the effects of light and darkness are still manifest. Shade a
plant or a low animal organism, and sleep, with all its reversal
of nutritional activities, at once ensues. Eclipse the sun at
noonday and the hens go to roost

In man any definite relation between sleep and darkness is
(perhaps unfortunately) lost, except so far as the withdrawal of

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SLEEP IN RELATION TO NARCOTICS, [July,

light coincides with the withdrawal of other stimuli. In
children the removal of peripheral stimuli is sufficient to ensure
slumber, and in some primitive races sleep similarly supervenes
on their simply assuming an attitude of muscular quietude.

Animals deprived of their brains are practically in a con¬
tinuous state of sleep, broken only by some excitation from
without or arising within, as for example the feeling of hunger.
When wanting food the brainless animals are restless, immedi¬
ately becoming quiet when this is supplied.

The fact that in fatigue, sleep often supervenes in spite of the
strenuous efforts of will, and in spite of many parts of the
brain being still active, is also significant of the important
share that the body takes in sleep.

Our brains often keep us awake, but are of comparatively
little use in sending us to sleep. Belmondo, long since dead r
said, “ The whole organism sleeps, and the brain only sleeps
because the organs of sense sleep”

The fact that deprivation of sleep produces death more
rapidly than deprivation of food, is additional proof of the
predominant need of sleep by the body.

In starvation there is little disorder of the general nutrition,
so that the lower organs and tissues are gradually used up, the
brain being the last to suffer. But in deprivation of sleep the
general disorder of nutrition is so great that the brain suffers
from the outset. These evidences of the large share which
the body has in the production of sleep indicate that in treating
insomnia attention to the condition of the body is at least of
equal importance to that of the brain.

I shall not attempt to discuss the various chemical and toxin
theories of the production of sleep, but merely allude (as
bearing on the point that I propose to discuss) to the one fact
in the brain state in sleep on which all observers are agreed,
viz. the arterial anaemia. This, also, has been described as a
cause of sleep, but the fact that, in infants, the fontanelle does
not sink until after sleep is established disproves this theory.
The arterial anaemia of the brain is, indeed, secondary to the
general dilatation of the peripheral vessels (especially those of the
skin) which precedes sleep. This has been ascribed to tire of the
vaso-motor centre, but the facts already adduced would make it
more probable that it is rather due to the need for rest in the
peripheral vessels.

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463

This dilatation of the peripheral vessels antecedent to sleep is
evidently, from Hill’s experiments on the circulation of the
brain, one of the most important physiological facts in con¬
nection with sleep and sleeplessness.

The states of unconsciousness from narcotics and the dis¬
ordered consciousness of the mesmeric state are often spoken
of as sleep, and, as this gives rise to some confusion of ideas, I
wish, in passing, to contrast the psychical condition of these
states.

In sleep, as Mosso’s experiments have shown, every peripheral
stimulation is conveyed to the brain, immediately affecting its
circulation. We know also that excitations of hearing, smell,
taste, and common sensation, and even luminous stimuli, may
cause reflex movement in sleep, proving that the sensory centres
of the brain are still active, and these may occur without
awaking the sleeper, or leaving trace in memory. The psychical
condition in sleep, therefore, is one of unconsciousness without
loss of sensibility.

In narcotic or other coma, when profound, the most active
stimulation of the nervous periphery fails to produce evidence
of the action of the cerebral centres. Memory is also in
abeyance; the condition is one both of unconsciousness and
insensibility.

In the mesmeric state (hypnosis and hypnotic sleep are so
misleading that I prefer a non-committal term until a psycho¬
logically descriptive one is accepted) the sensory activity is in
abnormal excess. Ideas suggested from without or arising in
the patient’s mind are projected outwards and result in sensory
hallucinations. The patient, moreover, acts on these hallucina¬
tions, thus demonstrating in conduct the disorder of con¬
sciousness. The state has been, therefore, rightly described by
Tuke and others as temporary insanity. Neither consciousness
nor sensibility is lost, but both are disordered.

To recapitulate briefly: in. sleep there is unconsciousness
without insensibility; in narcotic coma there is unconsciousness
with insensibility ; and in the mesmeric state there is disorder
both of consciousness and sensibility.

These three psychic states differ very widely, and to associate
them together as forms of sleep appears to me to be very
erroneous and misleading. In place of the popular term
hypnosis, I should prefer to see mesmeric stupor employed,

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464 SLEEP IN RELATION TO NARCOTICS, [July,

and in place of narcotic sleep, narcotic stupor or narcosis. Of
mesmeric stupor I have no more to say, but must beg your
attention to a brief sketch of the differences in the physical
conditions of sleep and narcotic stupor.

Sleep is found to be accompanied by activity of all the
bodily functions (except that of consciousness).

Digestion and assimilation may proceed with unabated
vigour.

Respiration, although shallow and slowed by four breaths per
minute, has each inspiration increased in duration by a fifth,
a form of respiration probably favourable to the absorption of
oxygen, which is found to be increased.

The elimination of carbonic acid is decreased from 58 to 42
per cent, according to Pettenkofer and Voit, but this is
related rather to the lessened development of carbonic acid in
the body than to lessened functional activity of the lungs.

The circulation of the blood shows a lessened pulse rate and
a lessened blood-pressure, the latter especially due to the
dilatation of the peripheral vessels and the absence of the erect
posture. There does not appear to be any depression of the
cardiac or vaso-motor centre by which similar conditions are
produced in narcosis.

The lymphatics are certainly more active, slight oedema often
being absorbed during sleep, which may therefore be believed to
be favourable to the removal of waste products from the tissues.

With regard to excretion, that of urea Vogel has found falls
from 42 to 36 grammes, but if allowance is made for the
fact that active exertion and the ingestion of food during
the day largely affect this, the night excretion would appear to
be relatively more active than that of the day.

The elimination of phosphates, although similarly diminished,
if allowance is made for the diminished formation of them, due
to the absence of mental action, does not point to any marked
diminution of excretory activity.

The reparative nutritional activity occurring in sleep is
evidenced on waking by the increased number of the red
corpuscles and the greater oxygen carrying power of the blood,
by the greater vigour of the circulation, with generally increased
functional power, activity, and endurance of fatigue.

In the nervous system the reparation of the nerve-cells during
sleep has been microscopically demonstrated.

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BY HENRY RAYNER, M.D.

465

In coma from compression of the brain we know, from
recorded cases of depressed fracture, that a man may remain in
a state of insensibility for long periods without any serious
disorder of nutrition, and that on the relief of the pressure the
brain at once resumes its function. It is only in the more
extreme degrees of coma, when circulation and respiration are
affected, that the toxic condition develops, which ends in the
familiar “convulsions and death” Any marked degree of
uncomplicated coma would not probably be as favourable
for nutritional repair as the condition of sleep.

In narcosis, however, there can be little doubt of the extreme
interference with nutrition. Narcotics, according to recent
views, can be divided into two groups, and there is no real dis¬
tinction in action (according to Marshall) between anaesthetics,
hypnotics, and narcotics. This division of narcotics into
two classes has been arrived at independently by Meyer and
Overton, and is based on chemico-physical grounds. The
common factor possessed by the majority of narcotics
they found is a comparative insolubility in water, and a
greater or less solubility in ethereal and fatty acids, and Baum
and Meyer suppose that the narcotic action of a substance is
a function of its solubility in fat compounds.

Overton describes the narcotics as falling into two groups,
the indifferent and the basic, connected by intermediate mem¬
bers. The indifferent narcotics, such as chloral and sulphonal,
pass over into the lecithin- and cholesterin-like constituents of
the nerve-cell, and thus change the physical condition of this
“ brain lipoid.” The basic narcotics, on the other hand, form
combinations with the cell proteids; of these morphine is the
type.

We may, therefore, in considering narcosis, probably be
content with examining the action of these two types.

The action of opium (and its alkaloids) is so well known
that it is scarcely necessary to repeat the summary of Wood,
that “ it checks all secretion,” and that its chronic use results
in emaciation and yellowness, dyspepsia, constipation, irrita¬
bility, depression, and sleeplessness.

The awakening from opium stupor is certainly not accom¬
panied by feelings of refreshment or evidences of a rested state
of the nervous system, but rather of a jaded condition of
nervous tremor, irritability, and easy over-tire.

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466 SLEEP IN RELATION TO NARCOTICS, [July,

Narcotics of the indifferent type, of which chloral, sulphonal,
butyl-chloral, and trional are chemically homologous examples,
slow and weaken respiration, lower the blood-pressure, and
weaken the heart’s action, weaken the vaso-motor control, and
lower the bodily temperature, all these results being due to
depression of the corresponding nerve centres. Their continued
use results in anorexia, indigestion, constipation or diarrhoea,
defective urinary secretion, albuminuria, and even anuria. In
porphyrinuria, which occasionally results, Hoppe Seyler describes
destruction of the red blood-discs, and Franz Muller (differing
from Percy Smith) asserts that there is a great reduction of the
haemoglobin. Foster and Eason have recently shown that sul¬
phonal markedly interferes with the elaboration of nitrogen
into urea and diminishes the excretion of sulphur in the oxi¬
dised form. In death from sulphonal widespread fatty degene¬
ration is found sometimes affecting the heart, but usually the
liver and kidneys.

Both chloral and sulphonal under continued use produce
conditions simulating general paralysis. The action of this
series of drugs on the brain circulation is strikingly shown by
FriedlandePs experiments, who found that rabbits under the
influence of isobutyl alcohol slept with the head down, waked
with the head up.

The waking from stupor produced by the indifferent narcotics,
although at first pleasant, the patient remaining for some hours
under the influence of the drug, is by continued use followed by
intense depression.

The contrast of the effects of sleep and narcosis on the
nerve-cells is still more striking. Hodges’ examination of the
cells of birds and bees before and after sleep shows that fatigue
produces very definite changes in the nerve-cells, that may be
summed up as a state of rarefaction, which is removed by sleep.
On the other hand, one of the most recent observers, Hamilton
Wright, has shown that in narcotised animals the condition of
the cells in the layer of the cerebrum, corresponding to the
pyramidal layer in man, is similar to that found in fatigue, and
that these changes are in direct relation to the duration of the
narcosis. The cells rarefied in transient narcosis become skeleton
cells after prolonged narcosis. Their margins are disintegrated,
the nuclei become eccentric, swollen, and granular, the nucleoli
enlarged and irregularly stained, the glia cells augmented in

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1902.] BY HENRY RAYNER, M.D. 467

number and turgid, while many leucocytes cluster about, and
in not rare cases actually penetrate within the most profoundly
affected cells. All the apical dendrons by the silver stain are
seen to be moniliform. The tips and stems of the extensions
of many of the pyramidal cells showed moniliform enlargement.
All these changes being proportioned to the continuance of the
narcosis, and similar to the changes recorded by Mott in
suddenly induced anaemia of the brain.

These changes Hamilton Wright regards as pathological and
due to direct action of the narcotic on the nerve-cells. Beyond
this he found, in the brain generally, evidences of capillary
anaemia and venous engorgement together with excess of
leucocytes, in the pericapillary spaces, and swollen glia cells
containing granular matter.

An important point to remark in these experiments is that
the brunt of the narcotic action falls on the pyramidal cells of
the brain, which are analogous to the cells which in man
have been termed “ psychic cells.” It is well to remember, too,
in regard to the use of narcotics, that in the animals experi¬
mented on these cells were normal, while in conditions of
sleeplessness or disease they are probably very far from normal,
and that the narcotic action is, therefore, likely to still further
disorder their nutrition.

The few facts that I have advanced, a mere sample of very
many more of similar import, almost conclusively indicate that
the action of narcotics on the body and on the brain is not
conducive to assimilation, that they are directly antagonistic to
the elimination of waste products, and to nutritional repair,
especially in the most important nerve structures of the brain.

The results, although pathologic, are not of very extreme
degree, as evidenced by the long period that they can be borne
in healthy individuals without very marked effects. On the
other hand, in unhealthy conditions and defective organisation,
just as in alcoholic abuse, the result of an inconsiderable
amount of drugging is much more serious.

The great interference with nutrition in narcotism may not
be so marked in the smaller dosage, where these drugs are used
as mere adjuvants in the production of sleep. Their tendency
is, however, in the same direction, as is abundantly proved by
the necessity for increasing the dosage if their use is protracted.
In these slight conditions of insomnia other means of producing

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468 SLEEP IN RELATION TO NARCOTICS, [July,

sleep, although more troublesome to the patient, and requiring
more consideration from the physician, are equally or rather
more certainly efficacious and are not attended with the dis¬
advantages of narcotics. Hydrotherapeutic means, for example,
often not only produce sleep, but improve nutrition by pro¬
moting elimination.

Insomnia being related to every bodily and mental ill that
flesh is heir to, a full consideration of the causes and associated
conditions would necessitate a review of every physical and
mental disease. The results of these causes, however, may
fortunately be summed up under a few headings. Defective
nutrition of the brain-cells must be inevitably present in all
cases, and with this is associated sooner or later a toxic condi¬
tion of the blood, the supply of which may be either in excess
or defect, or the anaemia and hyperaemia may alternate. Lastly,
the brain may be irritated directly from painful environmental
conditions or from the periphery as in pain, and indirectly,
through the vaso-motor, cardiac, or respiratory centres. So that
our considerations of treatment may be concentrated on these
few conditions.

I have already discussed the effect of narcotics on the
nutrition of the cerebral cells and nutrition generally, and will
add nothing to what I have already advanced, except to point
out that the induction of narcotic stupor, which the patient
considers as sleep, often encourages the neglect of other means
of cure, and the continuance of active exertion at a time when
more or less complete rest is indicated ; thus the malnutrition is
greatly prolonged and accentuated.

The use of narcotics in toxic conditions, whether these are
due to associated disease or the result of sleeplessness itself, is
still more difficult to explain or justify. The existing
condition of defective elimination must be still further increased
by the necessity of eliminating the narcotic itself or the products
of its decomposition.

Although narcotics may relieve conditions of anaemia and
hyperaemia of the brain, it must be remembered that they do
so by depressing the cardiac, vaso-motor, and respiratory
centres, and can scarcely be held to be curative of the many
various conditions on which the anaemia or hyperaemia is based.
These vascular conditions, moreover, often alternate in the same
case. Hence, where narcotics are fully used, it often becomes

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1902.] BY HENRY RAYNER, M.D. 469

necessary to follow up the sulphonal stupor, which has relieved
the hyperaemic night state, by a dose of morphine in the
morning to relieve the morning depression. It is difficult to
understand how this action of the narcotics can be curative of
the various conditions of the brain circulation.

Lastly, although narcotics may be used to relieve pain and
irritation, they certainly are not curative of the causes on which
they depend, and where the irritation is indirect, as for example,
when the cardiac centre is irritated by arrested digestion in the
stomach, the narcotic will almost certainly exaggerate the
evil.

If, therefore, narcotics produce favourable effects, these
would not appear to result from their direct action in restoring
nutrition, but in an indirect way by saving one organ or tissue
at the expense of another, just as a limb is ablated to save life,
the skin blistered to relieve an internal viscus, and the unfor¬
tunate intestinal mucous membrane irritated by aperients to
relieve various other organs. They must be given, indeed, on
the principle of doing evil that good may ensue. This is
undeniably a right principle, so long at least as the lower and
less important organ is sacrificed to save the higher, but in this
case it is the higher, nay, the very highest, that is made to bear
the brunt. The acceptance of the principle is not so easy, and
must necessarily be adopted with greater control and limitation,
and the number of such cases in which it can be applied must
indeed be limited. No one would deny that if sleep could
be obtained by means which did not interfere with cerebral
nutrition and repair, and which did not tend to exaggerate, but
rather to relieve associated states of bodily disease, that such
means would be preferable to the use of narcotics.

Here, therefore, we arrive at the question that I wish to
raise, viz., “What are the conditions in which the use of
narcotics is beneficial, and whether, even in these, treatment by
other means would not be more advantageous ? ”

These questions are very much a matter of personal opinion,
and I specially wish to elicit in the present discussion the
opinion of this association, which has so many members with
such wide experience in the treatment of sleeplessness in con¬
nection with mental disease.

The question of the results of treatment is always the same,
is the post hoc a propter hoc ? The patient has been given a

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470 SLEEP IN RELATION TO NARCOTICS, [July,

medicine and recovered. One man accepts this as a cure
effected by the medicine ; another, of the doubting school, denies
it, and says your patient recovered not by reason of but in
spite of the drug. The rest, removal from worry, the diet,
and other favourable conditions and not the drug effected the
cure. If you had not given the drug your patient would have
recovered more quickly, and, possibly, more quickly still if you
had adopted other means of treatment. It is impossible to
exactly repeat the conditions of any one case, and hence in no
single case can a definite conclusion be reached. No large
series of cases has as yet been treated on lines by which the
results of narcotic or non-narcotic treatment can be gauged,
and we are, therefore, obliged at present to rely on the general
experience and observation of individuals.

My individual experience has led me gradually to discard the
use of narcotics, altogether in narcotic dosage, and only at
rare intervals in the hypnotic form, and then only in the form
of bromide, or a small quantity of alcohol.

For many years in earlier life I tried narcotics again and
again, selecting for their use cases which appeared to correspond
to the cases in which I had seen their employment advocated,
but I was not satisfied with the results.

The chloral epidemic which raged in the seventies first
opened my eyes to the evils of narcotism in treating the insane,
these being the arrest of improvement which I noted in
patients when taking this drug, together with the cases of
suicidal melancholia and the pseudo-general paralysis developed
by its abuse. Then at Hanwell, where I found a large number
of cases habitually taking sleeping draughts, I observed that
the restlessness and noisiness at night greatly diminished
after narcotics had been omitted and work and exercise sub¬
stituted. There I had frequent opportunities of noting how
rapidly cases improved after admission by rest and other
means, who, prior to admission, had been taking narcotics.

My experience in this respect in consultation practice has
been still more convincing. A very large number of cases
are brought under my notice in which it appears to me that
simple conditions of disease have been complicated by the
use of narcotics, and I have constantly found where narcotics
had been given until they failed even to produce any effect, the
resort to means of treatment such as rest, elimination of

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1902.]

BY HENRY RAYNER, M.D.

471

toxic matters by hydrotherapeutic measures in their endless
variety, and by careful treatment of associated conditions of
disease, has been satisfactorily successful.

I have therefore come to the conclusion, and this I have
now carried out in practice for many years, that with very rare
exceptions, so rare that in as many years I could probably
count the doses on the fingers of my hand, narcotics can be
avoided with advantage.

My position in regard to the use of narcotics is identical
with that in regard to mechanical restraint. I will not debar
myself from using them if I consider it necessary, but I
practically do not use them because the necessity so rarely
occurs.

It may seem to many here that in all this I am flogging a
dead horse, but I expect there are some of our own number
who still use narcotics extensively. The text-books of medi¬
cine, after a very brief caution against their use, generally
give elaborate directions for their employment, and rarely
suggest any alternative treatment. As a result a large number
of general practitioners resort to their use as the sole and only
means of treatment.

The members of the Psychological Association have to deal
with insomnia on a larger scale, and in more severe forms,
than any other body of medical men, and they treat their cases
under more complete control. If they can make any definite
pronouncement against the excessive use of narcotics, and bear
testimony to the possibility of largely discarding them, they will
influence the writers of text-books, and through them the general
body of the profession, thereby saving the community from
much evil which now occurs. It is to ascertain the state of
opinion and practice in the speciality that I have undertaken
to raise this discussion.

(*) Nord. Chron., November, 1901.

Discussion,

At the General Meeting, London, May 21st, 1902.

Dr. Blandford said it was not his intention to enter into the physiological
question which Dr. Rayner had touched upon with regard to sleep, but if we knew
more about the vaso-motor system of the brain, we should know more about sleep.
With regard to the subject in hand, namely, the use of narcotic medicines in
mental disease, he had a good deal to say, but would not venture to unduly occupy
the time of the Society. Dr. Rayner evidently entertained a very great prejudice

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472

SLEEP IN RELATION TO NARCOTICS,

[July,

against sedatives and narcotics of all kinds, and he (Dr. Blandford) could not say
that he agreed with him. He had been treating patients for forty years, and a
great number had come to him not in an early stage of insanity, but in one of
threatened insanity, in which insomnia was a very marked feature. He was as
certain as he could be of anything that a great number of those patients had been
saved from insanity, and been materially benefited, by the use of some medicine
whose object was to give them sleep. It was possible to give a narcotic dose which
would reduce the person to that state of insensibility which Dr. Rayner spoke of;
but one could give a dose of the medicine which should have no narcotic effect at
all, but should have a thoroughly therapeutic effect, and produce a sleep which
should be indistinguishable from natural sleep, resulting in the greatest benefit to
the patient. He had seen that happen very often, and had haa patients coming
back after a time saying they got well after taking the medicine ordered for them.
Of course it was necessary to select the particular drug suitable to the case, and a
careful judgment should be formed as to the dosage. He felt sure that in the
practice of a great number of medical men—not in their own speciality, but in
general practice—far too large doses of narcotics were habitually given, and they
frequently produced unpleasant effects. Also, such medicines were often continued
for too long a time. With regard to the selection of the medicine, he recollected
the time when there was absolutely no medicine in the Pharmacopoeia for pro¬
ducing sleep except morphia, which in many cases did not cause sleep, and perhaps
such drugs as conium and hyoscyamus; now there were numerous drugs available.
The one which Dr. Rayner had so much to say against, chloral, was perhaps now
given very much less than formerly. One drug was not mentioned by Dr. Rayner
at all, and that was the safest and most beneficial, namely, paraldehyde. What he
had said referred to people in an early stage of insanity, or in a condition threaten¬
ing insanity. He would now pass to patients in a very acute state of in¬
sanity. When first he had to treat such patients, there was nothing but morphia
which could be given in cases of acute delirious mania. Often that did not
procure sleep, and if it were pressed the patient was very liable to die of
opium poisoning. He had seen more than one or two die in that way, especially
after the practice of giving the drug by hypodermic injection came into vogue.
On the other hand, in those days many cases of acute mania died from exhaustion
and want of sleep because there was no drug which could be given to produce
it. There was also the question of patients taking such drugs for a long time—
patients who were not in danger of death from want of sleep, but who were in a
somewhat prolonged state of mania or melancholia. In many such cases, if drugs
were given to induce sleep night after night the disease seemed to be prolonged,
and it was frequently better to let the patient get whatever sleep he or she could
without the aid of a narcotic of any kind.

Dr. Savage said he felt so much in accord with what Dr. Blandford had said
that he scarcely knew what to add to those remarks. First, he agreed with him
most distinctly when he said that the symptom of all others that probably he, or
Dr. Blandford, was consulted most frequently about before the persons became
insane was sleeplessness. A person came into one’s consulting room whose chief
complaint was inability to procure sleep ; and if sleep could be induced most of the
cases got better. Of course, the more simply the sleep could be produced the
better. He agreed with Dr. Rayner in saying that narcosis was not that which
was aimed at; what was required was rest under the most suitable conditions.
The cause of the sleeplessness must first of all be cleared up. It was all very well
to say that sleep was associated with some condition of anaemia of the brain.
What was equally certain was that there were certain forms of anaemia of the
brain which were associated with sleeplessness, and which were better treated by a
nightcap of grog and a little food. In the case of many sleepless people, e.g.
those whose systems were loaded with toxic agents already, if the skin and the
bowels were brought into healthy action, sleep would likely be obtained. He had
remarked before at meetings of the Association that it was often forgotten that,
next to the brain, the largest amount of nervous tissue was centred in the skin, and
that a very great deal of good was accomplished by appealing to the skin. Sleep¬
lessness had to be met, and he put it down as a working axiom that when painful
states were present, opiates and narcotics of that kind assisted sleep. There were
many cases in which there was true melancholia, with mental pain and marked

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BY HENRY RAYNER, M.D.

473

sleeplessness; and where the mental pain was extreme he had seen the very best
results follow the administration of large doses of narcotics. That they acted
beneficially, and not to the injury of the individual, was shown by the fact that the
very drugs, such as opium, which caused an upset in the digestion and produced
constipation, had, by means of sleep, brought about an improved state of the digestive
system, and a general improvement in the patient’s condition. One could, of
course, speak at great length on the possible dangers irf the use of such drugs. He
thought of an address given by Sir Samuel Wilks on a similar subject, in which he
said that doctors seemed to have the idea that sleep was to be produced by insensi¬
bility ; in fact, they were gradually inventing what might be called chemical prize¬
fighters. One drug was calculated to knock a man down and render him insensible
for two hours; another would make him insensible for four or five hours. But the
rendering a patient insensible was not the production of sleep, and that the induc¬
tion of insensibility was not treating the patient properly was, he thought, the
object Dr. Rayner had in bringing the subject forward. It was the old subject
over again ; the physician was not treating sleeplessness, but was endeavouring to
treat sleepless patients—endeavouring to cure the condition which led to the sleep¬
lessness. There was a new phase of the use of narcotics, which perhaps would be
more appropriately dealt with in the discussion on Dr. Robert Jones’ paper.
Though he would not like to be looked upon as a supporter of the idea, one had
seen practically the following. In the cases of persons who were absolutely sleep¬
less and extremely destructive, he had seen them poisoned almost to death,
certainly into temporary dementia, and when they had recovered from the drug—
which might be bromide—they had been well; just as it had been found that drug-
takers who had become habitual morphinomaniacs might be given an ounce of
bromide per day for several days, until they became absolutely stupid, and
they came slowly out of the stupor free from the desire for their narcotic, and
practically cured. Thus, though it was a dangerous thing, and a practice which
one would not support, it had been justified by results, and he was sure cases had
been cured by giving them large doses of narcotics. But one would say the same
of narcotics as of restraint. His character was taken away in years gone by
because he declined to altogether bow to the worship of non-restraint. He had
said in reference to that that the kindest thing was to restrain the patient to a
limited extent. So, in like manner, he was persuaded there were certain patients
who were greatly benefited by the judicious use of narcotics. A great deal was
heard at one time about chemical restraint, and it was said that alienists passed
from mechanical into chemical restraint, and that the use of narcotics was simply
carrying out a form of laziness—that one made a desert of the mind and called it
peace. He would conclude by saying he agreed with Dr. Rayner that too much stress
must not be laid upon merely procuring sleep by narcotics, and that there were
many other ways of getting it. But he (Dr. Savage) also agreed with Dr. Bland-
ford that there were many cases in which the production of sleep by one hypnotic
or narcotic was not only good for the patient, but that it could ward off attacks of
insanity.

Dr. Fletcher Beach said he was of opinion, from what he had seen, more
especially in nervous disease—for he had more experience with nervous than with
insane cases—that one did good now and then by giving drugs, especially in cases
of neurasthenia and 11 brain-fag.” Many patients were brought to hospital with
those troubles, and unless sleep could be produced by means of sulphonal or other
like drug, the patient could not be properly treated. Dr. Rayner stated he had no
statistics with regard to sulphonal in connection with nutrition. He (Dr. Beach)
was not aware that there were any such statistics, but he had watched a good
number of patients to whom he had given sulphonal; in fact, he rarely gave
anything but sulphonal to his nerve cases. So far, he had been unable to find any
evidences of emaciation, or of any kind of indigestion likely to lead to emaciation.
Therefore he was of opinion that sulphonal did not produce emaciation, but rather,
by inducing rest, maintained, to a great extent, the natural weight of the body.
With regard to mental cases, he agreed there were patients to whom narcotics
must be given, because if they were not given the patients wbuld die. He was, how¬
ever, of opinion that in many cases if all the bodily functions were attended to recovery
would probably ensue more readily without any narcotic at all, or at all events
with less than the usual doses. Hyoscine had not been mentioned that day. He

XLVIII. 33

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474

SLEEP IN RELATION TO NARCOTICS,

[July,

remembered seeing some time ago a case of hysterical mania to which he
administered injections of hyoscine. He began with ^5 gr. and worked up to
^ gr. In three weeks’ time the patient was cured.

Dr. Hyslop said that it was very important to know what normal sleep was ; he
meant from the clinical and not from the physiological or pathological points of
view. Of late years certain observers, especially German and Russian investigators,
had very carefully estimated the actual depths of sleep, constructing various charts,
pointing out the initial depression into which the person rapidlv sank, followed by
almost complete oblivion. Then there was a period of sfight recoil, which
approached almost up to the activity of the senses. There might also be a
secondary hypnogogic condition, followed by another depression. Then, gradually
that depression healed up, and there ensued, for three or four hours, a period in
which the senses became to some extent active. There were hypnogogic and
dream states, and the investigators on the subject had been inquiring how the
different stages might vary in different individuals. They had also considered the
various peripheral and reflex conditions which might affect the mind after the
initial depression, i. e. just about at that period when, after a heavy dinner, one

awoke with a sense of nausea or diarrhoea. The person then gradually passed to

the hypnogogic state, in which very slight peripheral stimulation was enough to
set up a dream state, and that state was as bad as pure insomnia. Thus it was
most important in all those conditions to differentiate the type of sleep. He had
in his possession the proofs of a paper dealing with a great variety of types of

sleep. Much had been said about the ^effects of fatigue upon the nerve-cell. He

had always felt a little doubtful about those experiments by Hodge. The effect of
an electric current upon the nerve-cell of an insect was comparable to the effect of
a lightning stroke upon a man. Moreover, the amount of preparation which the
cells underwent before being put under the microscope was sufficient to warrant a
certain amount of conjecture that the results were not altogether satisfactory.

He was very glad indeed that Dr. Savage had spoken out on the question of
restraint. If one thing was certain in psychology, it was that there were what
Professor James called “ the grosser emotions,” which were simply due to a reflex
excitation ; and that the grosser emotions themselves were the presentations and
perceptions of that reflex activity. Some people were physical cowards, so that
when they saw the enemy they had a physical condition which led them to run
away, ana an emotion was suffered in consequence of that. Mentally they were
willing to stay, but unfortunately the physical constitution was such that it resented
it. Many of the grosser emotions resulted from the perception of a reflex condition.
In the insane one had seen many cases of agitated melancholia and other types in
which the mental agitation had been the result of excessive agitation in the physical
condition. If the physical expression of an emotion were cut off the emotion itself
was likewise cut off, and it was therefore physiologically sound to cut off a reflex
act, because then it would be found that the excessive emotion tended to die down.
It seemed that alienists might have struck too much in the wrong direction.

He said that in the treatment of insomnia the food question was always
important. One patient could not be done anything with until orders were given
that he should be ted regularly, by the night attendant. It was very important, as
had been said, to appeal to the skin, and at Bethlem the treatment by prolonged
baths had been adopted. There was a system of recording sleep at Bethlem by
means of charts, so that one could see at a glance how much sleep had been
registered during the night. Their experience was that it was possible to diagnose
the condition almost from the sleep chart alone, and that if a patient did not sleep
more than one or two hours at a time, and that continued for more than a month,
he would not get well. Such patients were usually found to be of a type of general
paralysis with excitement, and sometimes with agitated melancholia. Thus the
case was a very critical one as to the future at about the third week. At such a
time every effort should be made, or else there was every likelihood that the patient
would pass into a condition of incurability.

Dr. Claye Shaw said the discussion appeared to have taken an experiential
form, but he had hoped Dr. Rayner’s introduction would have given more scientific
facts, if any existed, with regard to sleep and the action of so-called narcotics and
hypnotics. But from what had been heard it appeared we knew nothing more
about sleep than that it was a condition of unconsciousness; and that little but

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475

what was experiential was known about the action of narcoties. Of course one
would like to do away with narcotics altogether, and his experience had been that
it was possible to do so to a large extent. Still, he agreed with Dr. Blandford that
there were cases of commencing insanity—which possibly was not the condition
Dr. Rayner intended alluding to, the paper having been more concerned with the
treatment of insane states themselves—in which the general opinion was that they
should be treated by means of some kind of sedative. It must be remembered that
sleep was either a nervous or a vascular condition ; that at times it might be the
one, and at times the other. Whether it was more vascular than nervous usually
was difficult to determine. It was known that there were vascular conditions which
prevented sleep absolutely. So also there were nervous conditions, such as worry,
which surely prevented sleep. The question which should be pertinently asked,
therefore, was, “ What is the cause of this person being awake ? Is there some¬
thing wrong with his vascular system, or with his nervous system P ” Having
determined what was at fault, the remedy should be selected accordingly. By a
study of the action of anaesthetics and narcotics it would be seen that they seemed
to act most on the tissue last elaborated and highest developed, namely, in the
upper cerebral centres. No one who had experience of asylums would doubt that
numbers of patients came into those institutions who had already been treated in
hospitals by means of anaesthetics and narcotics. When the action of the drugs on
the higher cells was not known it was safer to avoid giving them at all. He
suggested to the members of the Association that it was possible or probable that
in most cases of insanity the upper brain—that most sensitive to the action of
narcotics—was out of action, and therefore was at rest. In sleep we were familiar
with a state in which we could hear and see things, but were unable to prevent
them or restrain them, because our power of inhibition had gone—there was a
separation of ideation and restraint. There was also a difference between the
perception and the ideation centres. In insanity a person might rave and have
hallucinations or visions in a reflex way, but the upper part of his brain had lost
its power—it was out of action. If that were the case, what could be the use of
poisoning the man, poisoning that part of him which was known to be very suscep¬
tible P People in states of insanity would go without sleep for days, but he would
not say such patients went without rest; he believed the upper parts of their brains
were not functioning. That was shown by the fact that when they recovered their
upper brain came into action, unless it had been severely acted upon by some
narcotic or anaesthetic. Therefore, those physiological conditions were well worthy
of attention and consideration, and in practice, seeing how susceptible the brain was
to narcotics, one should be careful how one used them.

Dr. Percy Smith said that one of the great practical difficulties he had met
with in seeing patients was that the relatives wanted assistance at once; and if the
physician was not prepared to take steps to place the patient under proper care
forthwith, he must deal with the condition as he found it. He was sure that
Dr. Rayner would in such cases consider that some sedative would be absolutely
necessary. He took it that Dr. Rayner did not mean there were no cases in which
a hypnotic or narcotic should be given.

With regard to the points which had already been mentioned, Dr. Beach had
spoken of sulphonal as never, in his experience, giving bad symptoms. Some
years ago, when sulphonal was first introduced, it was given somewhat largely at
Bethlem, and undoubtedly there were cases in which it produced anaemia and
indigestion; in some cases haematoporphyrinuria resulted, and one patient died of
that condition. Therefore there was no question that if sulphonal was still used, it
should be administered with very considerable care; and in his opinion it should
not be given to melancholic patients.

There were also certain questions with regard to patients in asylums. He did
not think that patients always had the opportunity to sleep when they might.
Certain maniacal patients did not get proper sleep at night, but they would, if
allowed, have four or five hours during the day, and then they would do fairly
well. One constantly saw patients who, after dinner, were inclined to sleep, but if
they were at once hurried out into the exercising ground and walked about, they
lost the opportunity of sleep. One had often had people like them put to bed for
three or four hours, and they had slept in the day. It was true that at night they
were restless and had nocturnal exacerbations, disturbing other people, but they

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476

SLEEP IN RELATION TO NARCOTICS,

U uljr,

themselves had obtained a certain amount of sleep. There was a difficulty with
regard to the dormitories. Patients in county asylums often kept others awake,
and they must be treated in some way by a drug for the sake of peace and quiet¬
ness for the others. Regarding prolonged baths, as mentioned by Dr. Hyslop r
they had been used in Bethlem for many years. He had seen manv patients of a
maniacal type placed in a bath and kept there for some hours, and at the end of
that time pass into quiet comfortable sleep, and sleep several hours without any
drug.

Dr. Savage had dealt with the fact that patients were often seen in consultation;
who had been heavily drugged with morphia, which had been given them as the-
only hypnotic. The general practitioner had not perhaps realised that other drugs*
also produced sleep without the very bad or unpleasant after-effects of morphia
consequently dangerous doses of morphia were given, with ill effect. With regard
to the regulation of the dosage of drugs, it was of course most important not to*
continue with a drug without giving the patient an opportunity of seeing whether
he could sleep if it were not administered. It was the constant practice at Bethlem,.
and perhaps elsewhere also, to give drugs on alternate nights to patients who did
not sleep well, and then, as the case improved, to give the medicine every third
night.

Dr. Ernest White said probably all those present had had a considerable
amount of experience in the matter under discussion. Twenty-five years ago
there were any number of cases of chronic mania who were noisy all night, and
created a perfect pandemonium in the institutions. That was the state of affairs,
when he first went to Stone. But, fortunately, for some years past, the quietude-
of the night was not disturbed by a sound, as several of those present could testify.
How had the change been brought about ? Largely by moral influence in the
treatment of the insane. The people'were brought into line, as in school. They
had regular exercises daily, and periodic meals, and they amused themselves at
stated hours. By this regular sequence of events the cases which at first had to
be kept quiet by the administration of drugs now slept naturally without any drugs
whatever. In the induction of sleep the moral side of the question ought to be¬
taken into consideration, but that had not been touched upon in the present dis¬
cussion. Feeding had been dealt with, and that was very important. With regard
to narcotics, he strongly believed there were many forms of melancholia in which
morphia was the sheet-anchor, and he had seen cases recover which he was certain
would not have recovered, or had a chance of doing so, had it not been for the
long-continued use of small doses of morphia with ether. In cases of acute mania,,
for many years past the general exhibition of bromide and chloral had been given,
up at his asylum ; and instead, the patients were got out of bed and taken for an
hour or two’s exercise or a sun bath. Such people were found to gradually fall
into line and sleep naturally, or with only veryfslight assistance from drugs. He was
sure that opium was worse than useless in the treatment of most'forms of mania.

Dr. Bolton said he would like to comment very shortly on the remarks of Dr..
Fletcher Beach and Dr. Percy Smith on the use of sulphonal. He (Dr. Bolton)*
had had considerable clinical and pathological experience of it. Pathologically,
for one case of haematoporphyrinuria he had seen ten of hasmatoporphyrinsemia.
He believed the prolonged use of sulphonal was most pernicious from the point
of view of auto-intoxication. Moreover, the prolonged use of sulphonal frequently
caused marked intestinal catarrh. He thought dysenteric infection frequently
occurred in patients who had had prolonged treatment by sulphonal. From the-
clinical point of view he thought the judicious use of sulphonal was most valuable
in cases of very early insanity. He had seen several cases of insanity similar to
those which had been referred to by Dr. Savage and Dr. Blandford, and those -
patients had derived considerable benefit from small doses of sulphonal, not
repeated more than three or four times. On the other hand, in cases of ordinary
acute insanity, with extreme restlessness and sleeplessness, he was convinced, from;
what he was about to say, that the use of sulphonal, even in moderate doses, was-
injurious. He thought so because in all cases of insanity which developed dementia
—for instance, general paralysis or senile insanity passing on to dementia—the
most rapid way to hurry on that dementia was to give doses of sulphonal extending
over some weeks.

Dr. Weatherly thought that each case should be judged on its own merits..

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BY HENRY RAYNER, M.D.

4 77

*902.]

Though many cases required narcotics, many others did better without them.
Some few years ago, when it was his lot to live for some weeks in a sanatorium, he
was surprised to find that consumptive patients who had had a terrible record of
.sleepless nights were passing splendid nights in that sanatorium. He went to bed
long after the consumptives retired, and was surprised to find perfect silence
instead of a great deal of coughing. It occurred to him that this satisfactory sleep
was largely due to the fact that the patients were constantly breathing the very best
and freshest air, and were subjected to over-feeding. Taking that lesson to
himself, he had found, during the last two or three years, that many of his early
cases of melancholia, and even cases of acute mania, had been enormously benefited
by keeping them out in the open air almost the whole day long, even in windy and
stormy days, protecting them by some shelter, and having the bedrooms most
amply ventilated at night. In his observation dormitory, in which his most restless
patients slept, he had found, that since he had more thoroughly ventilated this
room by specially arranged window flaps, far fewer sleeping draughts had been
.given, and the night record generally was a much better one.

Dr. W. Julius Mickle said he haa not intended to speak, but would briefly respond
to the invitation of the Chairman. To him it seemed that the chief point in the
question of producing sleep by means of narcotics was that the drugs should be

ven with brains. For a necessary preliminary to treatment was that the medical man
should use his brains to make an accurate estimate of the particular patient. Each
patient was a study in himself, and much trouble was entailed in the capacity to
form that estimate, but it was a necessary preliminary to the successful treatment
of insomnia among patients. When the medical man had arrived at what he
considered a correct estimate he would find in many cases that the question of
giving narcotics would not arise. If he came to the conclusion that narcotics were
necessary he should proceed to give such doses as were needed—in some cases
very small ones, in others medium, and in others heroic doses occasionally. A
medical man would not be afraid of giving a heroic dose if it was based upon
a proper judgment of the patient’s condition, physical and mental.

The President said that sleeplessness had to be dealt with in three sets of condi¬
tions: (i) that prior to the actual onset of insanity, (2) acute insanity, and (3)
chronic insanity. With regard to the condition before the onset of insanity—the
neurotic, anaemic patient—he felt that in many of those cases a great deal of harm
was done, either by the patient not getting a sedative at all, or by giving large
doses where small ones would have done. In regard to the cases of acute insanity,
as met with in asylums, in which there was a large amount of motor excitement,
and exhaustion quickly supervening, it was absolutely necessary that sleep should
be produced by a sedative. He feared, however, that in many cases the use of the
sedative was continued too long. With regard to cases of chronic insanity,
sedatives were often given too freely so that the other patients in the asylum
might not be disturbed. If the suggestions of Dr. White were more adopted,
and the diet, and exercise, and fresh air carefully regulated, the chronic sub¬
ject could be treated satisfactorily with much less drugging than was usually
resorted to.

Dr. Rayner, in reply, said he might first refer to Dr. Mickle’s remark as to the
•necessity for the medical attendant to make a careful study of each patient, when
he would often conclude that no narcotic would be required. If he briefly summed
up the views generally expressed that afternoon he thought it would be conceded
they were much in agreement. Dr. Smith had remarked that it was the surround¬
ing conditions which drove one sometimes to employ a narcotic, because there were
no other means at hand to keep the patient quiet and satisfy his friends. But after
all that was quite apart from the question of whether the narcotic was curing the
patient. Regarding Dr. Savage’s remark about relieving bodily pain, that was one
of the conditions in which he, Dr. Rayner, thought a narcotic was always useful.
And he meant to include direct irritation of the brain, not only from the bodv and
the periphery, but from outside, i. e. if the patient had a trouble which he could not
be got away from in any way. Those cases might be relieved by sedatives. Then,
as Dr. Hyslop had pointed out, very often an imaginary trouble seemed so real that
one must try and effect a stirring-up for a time to get rid of it. In all those cases
one must at the same time try to get rid of the causes of the sleeplessness. He had
argued that the narcotic did not get rid of the causes, and that for this purpose

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478

CASES OF MORPHINOMANIA,

[July,

other means of treatment must be resorted to. He was very pleased to hear the
instance mentioned by Dr. Weatherly, where many patients who had suffered
from conditions involving much sleeplessness, were enabled to sleep by the
provision of very simple measures. He was also greatly interested in Dr.
White’s narration of how he cured chronic noisiness by general moral measures.
One might go on, bit by bit, and get any number of illustrations as to the
means by which the disorder of sleeplessness might be removed, not by simply
treating the symptom of sleeplessness, but by treating the bodily condition,
and relieving that on which the fault depended. With regard to the treat¬
ment of acute mania by narcotics, of which Dr. Blandford spoke, his (Dr.
Rayner’s) experience would certainly be that acute mania could be treated, as
Dr. White had said, better without narcotics. He knew that opium had been
regarded as very curative in cases of melancholia. He had tried it himself in his
earlier days, again and again, but was not so impressed with the result as Dr. White
was. He had found the Turkish bath and similar appeals to the skin were more
successful than the giving of opium. The speakers seemed to be fairly in
agreement with him as to the conditions in which narcotics should be given.
In his opinion these conditions were very limited, and he would urge that every-
case and its circumstances should be carefully considered.

Notes on some Cases of Morphinomania. By Robert
Jones, M.D.Lond., B.S., F.R.C.S.Eng.( 1 )

It is a well-known fact that the practice of many physicians
and some alienists includes the treatment of persons who have
brought themselves to the verge of mental or moral ruin by an
indulgence in the use of opium or morphia, the result too
commonly of medical advice. This is probably the most
common origin of the morphia habit, which was called
Morphinomania by Charcot, and Morphinism by Levinstein.
Other methods by which the habit becomes established are
either through friends or persons in the same house imitating
the habit of another, and from curiosity or experiment adopting
it and succumbing to its sway. Others have tried it on the
recommendation or suggestion of friends, and finding they
could not do without it have become victims.

How extensive this habit may be is difficult to determine,
as it is probable that only the repentant sinner visits the
consulting room and seeks for help to overcome the thraldom.
It is suspected, and not without reason, that a large class of
men and women of all social grades, ages, and civil states has
yielded to its sway.

Extension. —Drury,( 9 ) in an interesting paper before the
Academy of Medicine in Ireland, gives a full account of the

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BY ROBERT JONES, M.D.

479

extended use of morphia and opium in individuals and in
races, and he traces this from China westwards into Europe
and America. I must refer the reader interested in these
questions to his paper.

Sex and occupation .—It is stated that doctors ( 8 ) and women
are more often victims than others, and although my experience
is limited to the class received into a county asylum, one was
a medical man, one a journalist, one a pianoforte maker, and
one a coachman, and four (50 per cent.) were women ; two
were journalists, one single and one married, but living apart
from her husband, and two were nurses married. My patients,
eight in number, were thus divided equally as to sex. Four (three
males and one female) contracted the habit from and through
the advice of their unsuspecting medical attendants.

Form taken .—Two out of four males practised the hypo¬
dermic use of morphia, a third took morphia by the mouth
and subcutaneously, the fourth drank opium, and had continued
the practice for four years before admission, taking then four
ounces of laudanum as a dose (about five grains of morphia).
This would have increased had his means allowed it, and it
was the craving for more that caused him to be brought under
treatment; for he could not sleep, he became nervous, irritable,
a depression with suicidal feelings overpowered him, and he
had no energy to work even after the utmost mental effort. Of
the four females, one took morphia by the mouth for many
years. She was a nurse at an asylum where she served for
over twenty years, during most of the time taking morphia,
and finally retired upon a pension. The habit was so secret
that she was not suspected of it. After this she was admitted
under my care. She improved, and was discharged recovered,
but was subsequently readmitted, and died from the exhaustion
of melancholia and senile phthisis. Another took morphia in
the form of chlorodyne, a third took it subcutaneously and by
the mouth ; and in the fourth, owing to marked and unusual
reserve, the method of administration could not be ascertained.

Quantity .—One male patient took 20 grs. of acetate of
morphia daily, which was afterwards increased to 50 grs.
subcutaneously; in another the quantity was not ascertained,
but both arms and his abdomen were much scarred on admis¬
sion from injection with the needle. A third stated he injected
4 grs. at a time, and this was repeated several times a day.

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480 cases of morphinomania, [July,

When received as a patient into Bethlem Hospital prior to his
admission into Claybury, Dr. Stoddart informs me that while
he was in the waiting room of the hospital before being
received he swallowed a packet of morphia, and not knowing
how much it contained, the stomach was washed out at once.
Some clue as to the quantity was revealed by the fact that
30 grs. more were found upon him, and seventeen more papers
of powder labelled 2 drms. The fourth male, as stated,
habitually drank 4 oz. of laudanum for a dose. Of the four
women, one took 4 to 6 grs. as a dose, two drank morphia,
and another chlorodyne, but the quantity was not ascertained.
Further particulars as to the varying quantities of opium and
morphia taken by different individuals in historical and other
records are given in Dr. Drury’s paper already referred to.

Form of insanity .—The depressed form of insanity was the
common accompaniment in these cases of morphia habitues ;
three males were melancholy, and one maniacal; two females
were melancholy, one was suffering from delusional insanity,
and one from mania.

Symptom complex .—The symptoms of morphia taking are
easier detected than diagnosed, that is to say, it is a matter of
suspicion and vigilance on the part of friends rather than
a submission and seeking for assistance by the victim.
There is a moral obliquity as to his conduct and veracity
which is most barefaced, and when the craving is once estab¬
lished this acts as an overwhelming and dominating want,
which at all and every cost must be gratified. Although
morphia is eliminated by the kidneys, it is not readily, easily,
nor certainly discovered in the urine, which adds to the diffi¬
culty of diagnosis. The diagnosis of the habit by means of the
sphygmograph, t\e. plateau, is fully discussed in Jennings’ paper.

During the administration of morphia and opium a pleasure
is imparted to the user, which is like a stimulating vital force.
This pleasure, which is genuine and is exciting, is followed by
the most painful and characteristic symptoms, a restlessness
and a longing which only another dose can appease. Follow¬
ing each dose there recurs a vital and intellectual exuberance
which, compared to the gross and moral enjoyment of alcohol,
is a divine luxury. This general excitement of morphia is
difficult to clothe in words ; De Quincey and others have
attempted it, but it can best be imagined from the world of

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1902.] BY ROBERT JONES, M.D. 481

-dreams. It annihilates the tadium vita , brightens up the
dormant faculties, and awakes any energy the frame is
capable of.

This effect of morphia becomes a fascination, and the
strongest zeal, fervour, or effort of the will fails to resist it; a
passionate anticipation and yearning for this euphoria has be¬
come an all-powerful craving, and the victim realises that gradu¬
ally and unknowingly he has become inextricably involved.

The only remedy is to increase the dose and shorten the
interval, after which a renewed craving of longer duration
succeeds a shorter one of excitation and stimulation, until the
general condition becomes one of fatuous listlessness, ending in
a general wasting emaciation and death. No social grade and
no age is a bar to the insidiousness of this habit. As to the
craving, the wretchedness, misery, poverty, and despair entailed
in its gratification often lead to suicidal impulses, and this was
the case in five (three males, 2 females) out of my eight cases.
In his own words, one patient (Case I preferring to this craving,
stated he was ready to have his hand cut off, or would thrust
it into a furnace if he could only have one injection of morphia
to relieve him, as he was at the time suffering the “ torments
of hell.” On admission he had two hypodermic needles
extracted from under the skin of the right arm and the left
leg. He was drawn, haggard, sallow, and thin ; his teeth were
bad—a very common feature in the morphia habitu£ % He was
suffering severe distress, and was exceedingly restless and
sleepless, and he could only speak with much effort. Upon
his recovery, he wrote saying that after starting the use of the
drug it would be useless for him to dilate upon the futility of
attempting to break with it, as “ the man to perform such a
-deed had yet to be born.”

Another patient (Case 8), describing the effect upon herself,
stated she revelled in sleep full of the most delightful dreams,
compared to which “ fairy-land ” was the merest prose. After
6 grs. of morphia, which she would take in a little champagne,
she saw things “ exactly as I wanted to, and could do any
amount of work.” Finding morphia becoming a habit with
her, she determined to make a stand against it, and for some
time did so successfully.

The general character in morphia-takers changes completely,
anxiety and distrust and depression are depicted in their pallid

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482

CASES OF MORPHINOMANIA,

[July-

and pasty faces. They are restless (the marked restlessness
amounting to an imperious tendency to movement was well
marked in Cases 1 and 2, who could hardly be kept in bed
during the period of craving), shifty, irritable, and unsociable.
There is impotence of will, fitfulness, deception, and lying,
inability to keep engagements, loss of concentration and appli¬
cation to work, neglect, ruin of home and family, and as in all
inebriates a general enfeebled mental capacity, for which the
only suitable place is the lunatic asylum.

Prognosis .—This must depend upon the age, form of opium
or extract, and quantity taken, as also of the prognosis in
mental diseases generally—in so far as heredity, previous
attacks, form, and duration of insanity are concerned. In
asylums the prospect of recovery depends much upon those in
charge of the patient’s treatment—for if all forms of opium
are withheld, and liberal nourishment is pushed, the prognosis
is favourable. I have had no experience in the “ home ”
treatment or the voluntary submission in their own homes of
individuals habituated to the drug, but I can well surmise that
the treatment of persons who in their own homes or other
people’s did not themselves desire or intend to assist in a cure
would be absolutely futile, and even impossible. With power
in the hands of a physician, and where he can know that his
instructions are carried out, as in asylums, a cure is possible
and probable. The length of residence in such cases will
probably on an average be under four months. Exhaustion
has to be guarded against, especially cardiac syncope and
alvine flux, or gastro-enteric catarrh, as many morphino-
maniacs are very susceptible to diarrhoea and vomiting, more
especially during the seven days or so of critical abstinence.
Sleeplessness and restlessness are unfavourable symptoms, so
are syncopal attacks and collapse (especially when the drug is
suddenly withdrawn).

In my eight cases, of the four males three recovered ; one
relapsed, but subsequently again recovered ; and one, a medical
man, died from gummata of the brain ; four females recovered,
but three relapsed, one of whom subsequently recovered, one
died of melancholia with phthisis, and one is still in residence.
The average residence of the recovered cases was about four
months.

Treatment. —i. This resolves itself into (a) preventive and ( 6 )

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BY ROBERT JONES, M.D.

483

actual. As to the former, which relates to such legislative
enactments as the Medicine Stamp Act and the Sale of
Poisons Act, the intention is to make it more difficult for the
rank and file to obtain access to drugs and special stimulants,
thus also deterring the morphia habitues from gratifying too
easily their morbid craving. Too much stress cannot be laid
here upon the great importance of our duty as medical men
in using sedative medicines for the relief of pain. A full
apprehension of our serious responsibility cannot be too
strongly impressed and urged upon us, as carelessness on our
part has too often led to the most grievous results ; for most of
these sad cases can truly trace their downfall to the fascination
exercised upon them by the use, under medical advice, of this
subtle and dangerous remedy. I would almost go so far as
to say that no medical man should ever use the hypodermic
morphia syringe for any female patient suffering from
neuralgia, sciatica, or hysteria, and no medical man should
lightly put the means of indulgence before or within the reach
of any patient.

2. Dr. Sharkey (Nineteenth Century, September, 1887)
called attention to the great danger in respect to the mor¬
phia habit which occurred from the prescriptions of medical
men, and he drew a terrible picture of the extension of
hypodermic injections of morphia among certain classes of the
community, who employed a “ regular arsenal of injecting
instruments,”—the syringe and bottles of women in the well-
to-do classes addicted to the habit being jewelled to conceal
their true significance.

Legal measures of control over the sale of morphia with the
view of controlling druggists have occupied more of the
attention of French physicians than of the medical profession
on this side of the Channel, and druggists, when forbidden to
sell morphia without entering the same in a book for the sale
of poisons, or in prescriptions, too often set up for sale certain
“ specialities ” of their own containing this drug.

The question has often arisen whether the morphia habit
should be looked upon as a pleasure-giving vice, or as a disease
over which the victim was powerless to act, and whether such
an indulgence should be treated by punitive methods ( Lancet ,
1900, vol. ii, p. 1219), or sympathised with as an affliction
caused by some tyranny beyond the control or the power

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CASES OF MORPHINOMANIA,

[July,

of the will. I am inclined to think that a considerable
amount of emotion and pity is wasted over the victims
of self-indulgence of all sorts in these days, and if the
old doctrine of Calvin, viz. “ the expulsive power of a new
affection,” were more freely introduced as a motive to action,
the manhood of our race would doubtless considerably improve ;
as many of these are, I fear, of the class of Kipling’s pleasure-
loving and selfish “ muddied oafs.” No amount of therapeutics
or legislation will make a man good, a drunkard sober, or a
morphinomaniac abstemious, unless he is allowed some credit
for such will-power as he has, or is assisted or compelled to use
this for his own moral reclamation; and to speak of the morphia
habit as a disease, and nothing more, is misguided benevolence
and mawkish sentiment. Many of these cases are fit and suitable
for long detention in inebriate homes. No doubt there are
some in whom a long indulgence has developed and confirmed
a habit which cannot be withstood, but this is by no means
always the case; and where the craving has become a master-
passion which is hated, and over which the power of the will
is unable to offer resistance, and the mind has become diseased,
these are cases which justify asylum care and control, and it is
to these that I direct attention. Much is still wanting in the
way of preventive measures to restrain the drug inebriate—
whether his penchant be for morphia, chloroform, cocaine, or
ether—from getting at his poison ; and it would be hard only to
punish the druggist for the lying, deceitful, and often forged
statements of these self-indulgent persons who themselves
escape unpunished.

The second point involves not only the consideration of the
patient’s surroundings, i. e . whether treatment should be volun¬
tary, either in his own home, or in a “ general home ” where
similar cases reside, or whether compulsory treatment by
detention in special institutions be the most favourable to
effect relief; but also the special treatment necessary for the
acute suffering involved through a compulsory abstention
from morphia. Judging from experience in one of my
patients (Case i) who had voluntarily retired into an in¬
ebriate institution on three occasions, relapsing after each
discharge, I am not in favour of treating several of such
cases together in a home not under special control, i. e. not
under the direct care of a medical attendant, for I believe that to

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BY ROBERT JONES, M.D.

485

associate such cases together is bad, as they talk of their ail¬
ments, plot and practise deception, and utter vigorous false¬
hoods in support of their cunning. I am of opinion that
recovery is impossible in general homes into which some
morphia cases enter through the importunity of friends, unless
they themselves and not their friends alone are willing to assist
in their own cure. Even when the morphia-taker is most
willing and anxious to be cured, but where he still directs
treatment, the cure fails. Coleridge hired men to prevent his
getting opium, and dismissed them for doing their duty. It is
for such reasons as these that I believe no treatment in one's
own home can afford permanent relief. I consider that the
best and most successful treatment of these advanced and long-
continued cases is that which can be carried out only by
compulsory detention in special institutions or asylums, for such
can prevent all introduction of morphia, and they are bright,
cheerful, comfortable, and have special local or Government
inspection. Special hospitals for this class exist in Germany
(Berlin), and also in America (Brooklyn). In such as these,
with attentive, kind, sympathetic, but firm and tactful dealing,
the terrible battle of demorphinisation—as Charcot termed it—
can be fought out; and a serious ordeal it proves, as only those
who have witnessed can know. In the treatment of all the
eight cases recorded in this paper a complete and abrupt with¬
drawal of morphia was effected—after the teaching of Ober-
steiner and Levinstein. This method, to which the terms
sudden* and brusque have been applied, has a train of symptoms
—“ Abstinenz-Symptome”—in its course which may give rise
to much anxiety to the physician, as well as acute suffering and
even torture to the victim. Ball has recorded death as the
result of this brusque and complete withdrawal, and it is
recommended not to employ the method in cases of heart
failure, heart disease, general debility, or in pregnant women*
It is rare for this stage to be endured with silent fortitude, a
restless and most abject despair is more common. In two male
patients (Cases 1 and 2) the abrupt withdrawal caused acute
sleeplessness with restless delirium and suicidal threatenings*
Case 1 was ready to endure any torture in return for a morphia
injection. As an alternative sedative 20 grs. of chloral and
30 grs. of bromide of potassium were administered. Case 2
had serious vomiting with diarrhoea, which threatened to prove

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CASES OF MORPHINOMANIA,

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fatal. These symptoms were much relieved by the administra¬
tion of Pot. Bicarb, in 20-gr. doses, accompanied with Tinct.
Hyoscyam. nixv, and later, Tinct. Nucis Vom. my and Spt.
Ammon. Aromat. v\xv. It is stated that during the period of
morphia injection the alkaloid, as it is secreted by the gastric
and intestinal glands, acts as a sedative, paralysing the glands
and diminishing their secretion, and that the glands over¬
secrete when the morphia is withdrawn, giving rise to vomiting
and diarrhoea. It is also stated that the acid of the gastric
glands is secreted more freely than the peptic material, and
that alkaline remedies (chemical demorphinisation) tend rapidly
to improve the gastro-intestinal irritation. Case 2 was
certainly much relieved by the potash salt Case 3, who dranH
the tincture of opium, and who had commenced to take it for
the relief of neuralgia, was successfully treated with quinine
grs. iij and the tincture of gelsemium v\xv in combination.
The cardiac failure and collapse (which Jennings states is
indicated by a plateau in the sphygmographic tracing shown
here from his work), and which occurred in Case 8, was much
relieved by Ammon. Bromid. gr. xxx and Tinct. Strophanthi
rt\x. A special toxic derivative of morphine called by Marm£
oxydimorphine, and which a further injection of morphine
relieves and neutralises, has been stated to be the cause of this
collapse. In all my cases an abundance of an easily assimilable
fluid dietary was frequently given—milk, concentrated beef tea,
tropon, leguminose, plasmon, with small and occasional doses
of whisky or brandy, and the bed treatment kept up for some
time. The proportion of recoveries was 7 5 per cent, males, and
50 per cent, females, but the number of my cases is too small
to build thereon any theory based upon treatment.

I have no experience of the treatment of cardiac syncope
from the morphia habit by special alkaloids such as sparteine,
digitalin, or nitro-glycerine tabloids, containing nitrite of amyl
and capsicum, as advocated by Jennings, who further recom¬
mends the use of heroin—an opiate derivative—and meco-
narceine, or valerianate of ammonia (used by Coleridge), and
the alkaline bicarbonates—the latter used in the process of what
has already been called “chemical demorphinisation.” Napelline
has been recommended by Pichon and Rodet, but the experience
of Mattison, of Brooklyn, does not support this. To procure
sleep the latter recommends the bromides, codeia, and cannabis

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BY ROBERT JONES, M.D.

487

indica. Clifford Allbutt recommends the use of caffeine in the
treatment of cardiac collapse. Of the use of atropine and
strychnine subcutaneously together with the inhalation of
oxygen, as has been recommended for the treatment of an
overdose of morphia ( Lancet , 1898, vol. ii, pp. 545, 1219, 1392,
1900, vol. ii, p. 1727), I have personally no experience as
remedies for the treatment of morphinomania.

I am fully aware of the recommendations of Erlenmeyer,
who introduced the “ rapid ” method of treatment, diminishing
the doses in from six to twelve days according to the amount
habitually taken by the patient, and so effecting a reduction of
the drug with less of the constitutional disturbances than occur
with the “ sudden ” method. For this reason Clifford Allbutt,
who was formerly an advocate of the sudden or brusque
method, now gives his support to the more tapering. Erlen¬
meyer himself, with experience of both, states that the sudden
method is preferred by patients who have tried the two, and he
compares his own to biting bit by bit a dog’s tail. Apart
from lengthening the period of distress, any method which
sanctions in practice by the medical attendant the use of the
hypodermic syringe tends in my opinion to condone the
offence, if not to encourage the evil. It is, however, an
advantage in cases of serious bodily disease to avoid shock
and this method, recognising the advantage of sleep, directs
that the larger injection should be administered towards evening.

A third method—the gradual or slow suppression carried
out by Braithwaite, and recommended with modifications by
Jennings, who has contributed valuable work to this study—
has been advocated. It extends the cure for many weeks ;
the injections in progressively diminished doses are ad¬
ministered often, with other sedatives if necessary in substitu¬
tion. To demonstrate this method a bottleful of morphia
injection is prepared, and after the first syringeful is used the
bottle is filled with water. Injections are continued indefinitely,
and water repeatedly replaces what has been taken out until
only an infinitesimal dose of morphia remains, which can, it is
stated, be discontinued without discomfort.

Jennings’ method {Lancet, April, 1901) is to practise the
gradual but voluntary suppression of morphia under constant
surveillance, but without restraint, and with tact and encourage¬
ment towards the patient; he has claimed much success from

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CASES OF MORPHINOMANIA,

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his treatment. He divides the period of reduction into three
stages, (i) From the commencement of reduction until 2 grs.
daily are administered subcutaneously. This quantity he
considers to be the minimum vital requirement whatever dose
of morphia has previously been taken. (2) From the time
2 grs. are administered subcutaneously (the greater part of
this being towards night to favour sleep); further quantities of
morphia are given by the mouth or rectum, progressive reduc¬
tion of the subcutaneous injection still proceeding, and (3) the
final progressive diminution ending in complete withdrawal.
He claims for the change in administration—morphia by the
mouth or rectum instead of subcutaneously—a curative effect in
regard to the craving ; but he directs a rational attention to
sleep, to procure which galvanism to the head is used, interest
and occupation are encouraged, and the hot-air bath as a tonic,
a sedative, and an eliminating agent is specially recommended.
Personally I am of opinion that there is only the choice
between the sudden and brusque method of Levinstein and
the gradual or tapering method—also called the rapid method
—of Erlenmeyer; and considering the terrible bondage in¬
volved in the morphia habit, and the overwhelming sway it
holds over those under its thraldom, I am of opinion that
victory should be snatched with the suddenness of the zealous
reformer, and it is for these reasons that I consider the resolute
and absolute withdrawal as entirely the best. In this I am
supported by an authority which will commend itself heartily
to this Association. Dr. Savage, whose experience is extensive
and sound from a great number of morphinomaniacs, states
that after the patients are placed in a reliable home, such
as the house of a medical man—where, he states, there
can be no possible access to the drug by bribery or other
opportunity—for a day or two they are allowed the drug
in the customary dose, but it is suddenly and absolutely
knocked off at once. If there is very serious delirious
excitement Dr. Savage has used chloroform, whilst waiting
for 40—60 grains of sulphonal to take effect, and he has
also tried MacLeod's method of large doses (one drachm
hourly up to one ounce for three days) of bromide of
potassium, relying as a great sheet-anchor upon the plentiful
and generous administration of concentrated foods. It must
not be forgotten that the “ Abstinenz-Symptome ” mean risk,

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BY ROBERT JONES, M.D.

489

and caution is required not only from the inherent danger of
this stage, but also from the suicidal promptings common to
many of these sufferers, who are creatures of impulse, and dis¬
like ordering their lives with method and regularity. As to
relapses, I am of opinion that these are less likely to occur
when the withdrawal has been bold and sudden. The patient
is less likely to feel the break of a habit by the abrupt method
than by the discomfort of decreasing doses of the drug, as
during the whole period of decrease there would be induce¬
ments to repeat the morphia. It is better, if this be possible,
that he should not obtain for the accustomed one the substitu¬
tion of another stimulus. He is better without the (1) narcotic
(2) or stimulant, alternative sedatives, as the surrogates of
morphia have in some cases induced the practice and use of a
new narcotic. If, however, the restlessness together with in¬
somnia continue, bromide and chloral may be given as the least
harmful. It is not easy to ascertain whether relapses are due
to the cravings only or to the irresistible impulse—an over¬
whelming physical yearning—which prompts the best inten-
tioned to succumb to its fascination. I here present sphygmo-
graphic tracings (Figs. 1, 2, 3) of the pulse of a morphia
habitui taken by Jennings, and tracings (Figs. 4, 5) taken

Fig. I.—Pulse of morphia habitat in a state of abstinence. (After Jennings.)

Fig. 2.—Pulse restored by morphia. (After Jennings.)

Fig. 3.—Pulse restored by sparteine. (After Jennings.)

xlviii. 34

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490 CASES OF MORPHINOMANIA, [July,

by myself in a case where a craving for alcohol existed.

Fig. 5.—May P—. Alcoholic neuritis, May 19th, 1902, 3.30 p.m., fifteen
minutes after half an ounce of brandy.

These tracings afford an interesting comparison. Our one great
aim should be to re-educate the dormant will, supply abundant
and generous nourishment, diminish discomfort, avoid fatigue,
and counteract habits of solitude by a well-occupied and full
home life, free from any stimulating temptation. This treat¬
ment should be extended for a period beyond that during
which I have kept my patients under surveillance, and at least
a year of tutelage is urged as an after-cure whenever practi¬
cable. The cases upon which my experience is based are the
following:

Case i. —H. H—, aet. 39, height 5 ft. 10 in., weight 8 st. 2 lbs.,
married, a journalist, was admitted suffering from acute depression with
suicidal tendency. He was restless and fidgety, and had no self-
control. He was irritable, and showed frequent ebullitions of temper.
He was sallow, wretched, and emaciated on admission, and muscularly
much impaired. His pulse, 88, was easily compressible, eyes blue,
pupils reacted to both light and accommodation, he was — 8 myopic, but
the fundus was normal. His knee-jerks were absent, teeth very de¬
fective, urine 1015, acid, no albumen.

His previous history was that at twenty-five years of age he edited
a paper. He drank to excess, and took morphia for three years before
admission. The habit commenced after his mother’s death, which is
stated to have occurred through morphia, taken upon medical advice.
The same doctor who communicated the habit to his mother communi¬
cated it also to him. He found great relief to attacks of asthma from

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BY ROBERT JONES, M.D.

491

1902.]

morphia. His conduct became erratic and uncontrollable, he suffered
from insomnia, neglected his business, and left his wife at home. He
had, on three occasions, desired to be rid of the habit, and voluntarily
entered a “retreat,” but each time he relapsed. Before admission
he was in the habit of taking twenty grains of morphia daily, and
on his admission two hypodermic needles were extracted from under
the skin in right arm and the left leg. He craved intensely for
morphia, and stated he was ready to have his hand cut off, or would
thrust it into a furnace, if only he could receive one injection of
morphia. His father was intemperate from alcohol, and afterwards
became insane; his mother was phthisical.

Two weeks after admission he began to improve mentally and
physically. In two ninths he was brighter, eager for outdoor occupa¬
tion, and went out on the farm. Three months after admission he was
temporarily laid up with a slight attack of asthma, but he was quite
cheerful, and had no wish for morphia. After four months he was
discharged recovered.

Two and a half years later he was readmitted in a dirty, neglected,
miserable state; he was often excited and noisy, refusing all food, which
had to be given to him forcibly; he was exceedingly restless, sleepless,
and in severe distress. He had lived apart from his wife again before
readmission, and he had threatened suicide. He was drawn, haggard,
thin, and sallow. He could only answer questions after some time, and
by using a strong effort He craved for morphia, to relieve “the
torments of hell ” which he suffered. His body presented numerous
small pigmented scars, from the use of the syringe; his forearms and
thighs were also in the same state. He stated he had injected fifty
grains of morphia daily under his skin. Soon after admission he
suffered severely from diarrhoea and vomiting. Chloral and bromides
were given for sleeplessness, and he was fed freely. No morphia
was allowed.

Three weeks after admission he began to improve, and in six weeks
he was useful about the ward. He had occasional but slight attacks
of asthma, which yielded to ordinary treatment. In three months his
improvement was maintained, he had gained much weight (9 st. 8 lbs.),
and in four months he was discharged recovered.

After his recovery he wrote that he was deeply grateful for the
extreme kindness and considerate attention he had received. Referring
to his past use of the drug, he wrote that it was unnecessary for him
to enlarge upon the futility of his efforts to break with it, as the man
to perform such a deed was yet to be bom.

Case 2.—E. C. B—, set. 43, married, a coachman, was admitted
suffering from hypochondriacal delusions in regard to his health. He
was suicidal He thought he was being mercurially poisoned, and had
hallucinations of taste and smell, and was “ fast dying.” The bodily
condition on admission was greatly impaired. He was a brown-haired,
blue-eyed man, with unequal pupils, right larger than left, the sight of
right eye impaired, and there was no reaction to light. His teeth were
decayed. His pulse was 80 and regular. He looked ill and dyspeptic,
his appetite was bad, he complained of “ heartburn,” and his bowels

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were irregular. The skin of both arms and abdomen was much scarred
from hypodermic injection of morphia, which was first given to him by
his doctor for the relief of pain, and he had practised this for twelve
months before admission; he had been very sleepless and ill most of
this time. His family had a history of “ fits ” and paralysis, and he had
a sister who was alcoholic. For some time after admission he
suffered great discomfort and distress, owing to very severe attacks of
gastro-enteritis, which threatened at one time to prove serious. He
complained much of various aches and pains, but no morphia was
allowed to him. Bicarbonate of potassium grs. xx, with tincture
of hyoscyamus rrtxij, gave him much relief, and this was followed by
tincture of nux vomica v\v, and Spt. Ammon. Co. u\xv.

He remained very melancholy for three months, with much depression
when the gastric attacks occurred; after this time he began to mend
gradually for four months, then he was sent out on a month’s trial, and
afterwards discharged recovered.

Case 3.—A. E—, aet. 43, married, a pianoforte maker, height 5 ft.

6 in., weight 8 st. 7 lbs. Admitted suffering from depression with suicidal
tendencies, had aural and visual hallucinations, which confused and
irritated him; was self-neglectful in habits. He felt he had no energy
nor desire to work, and with the utmost mental effort he could not
work; he felt overpowered by depression, and two months before
admission lost his occupation and the means to buy the drug, in
consequence of which he lost heart, became very depressed, and
wandered about half dead. He could not sleep, became very nervous,
irritable, and suffered from a most intense sinking and craving sensation.
His pulse was 120, and the heart-sounds were accentuated. Pupils
were equal, and both reacted to light and accommodation. His tongue
was furred, his bowels constipated, and his teeth were bad, many being
missing. Urine 1020, acid, no albumen. Four years before admission
he commenced taking chlorodyne for toothache; this he found too
expensive, and he changed to laudanum, in small doses at first, until
these increased to 4 oz.

He had a sister insane, and confined in an asylum for seven years.
All opium was disallowed, but he was freely nourished; quinine grs. iij
and tincture of gelseminum were given for the neuralgia, and in two to
three weeks after admission mental improvement began ; in one month he
stated he felt a new man, and was very grateful for his cure. In two
months his improvement continued, he was sent out on trial, and after
three months’ residence was discharged recovered.

Case 4. —J. H. R —, aet. 33, single, a medical man, height 5 ft.
9J in., weight 10 st. 7 lbs., was admitted in a most violent, impulsive,
inattentive, and incoherent condition. It took five men to take him to
his ward. He dashed to break windows, and had to be kept in a
padded room. He was not an epileptic, and never had fits. His certi¬
ficate stated he had visual illusions, he had glimpses of the “ happy
land.” He was noisy, excited, and destructive, voices urged him to
fight, etc. He had dark brown hair, hazel-brown eyes, his reflexes were
increased, and he was of fair muscular development His pulse was-

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BY ROBERT JONES, M.D.

1902.]

493

96, tension normal, his tongue furred and unsteady, and his bowels
constipated.

His previous history, from his mother, recorded that he had slept
badly and had taken morphia to relieve headache. He had been until
recently, and for some period, a patient in Bethlem Hospital, and his
illness had been coming on for thirteen months. Dr. Stoddart kindly
forwarded me the history that, whilst in the reception room, waiting for
admission, he swallowed a packet of morphia, and not knowing how
much was contained in it, the stomach was at once washed out Thirty
grains more were found upon him, and seventeen more packets of
powder, each labelled “Two drachms.” The patient said he used only
to take four grains at a time, and probably his statement was absolutely
and deliberately untrue. Whilst at Bethlem his morphia was suddenly
and completely discontinued, but alternative sedatives, such as chloral,
sulphonal, and hyoscine, were administered, the last, however, having
to be discontinued, as it excited him.

Three months after admission he had a seizure, but there was no
localised paralysis. He rapidly became demented, could not understand
anything, and became exceedingly feeble. After six weeks he had
another seizure and died. Post-mortem examination revealed syphilitic
gummata in the brain.

Case 5.—Esther H—, aet. 56, married, a nurse, was admitted with
grey hair, hazel eyes, pupils irregular but equal, reacting to both light
and accommodation. Her knee reflexes were somewhat increased; her
grip was fair, but she was poorly nourished. Mentally she was melan¬
choly and suicidal on admission, explicitly desirous of ending her life,
and to “ sleep it away.” She was self-accusing, and imagined she had
committed a great crime. She had the idea she would be kept, for her
wickedness, to end her life in the asylum, and she was always reading the
Bible.

Her previous history records she was a nurse in a public asylum for
the insane, where she served twenty years, and obtained a pension.
She is stated to have slept badly, and to have drunk morphia for it for
many years. She was allowed chloral and bromide as night sedatives,
but no morphia, for which she generally sighed and begged and craved.

Two weeks after admission she began to improve, and in three
months was brighter and able to help in the ward. After seven months
she was discharged recovered.

Eight months afterwards she had relapsed, was acutely depressed,
self-accusing, and actively suicidal. There was, however, no history of
morphia taking in connection with this mental relapse. She remained
a patient in the asylum for six years, having become chronically insane,
and she died of pneumonia with senile phthisis, aged sixty-three.
There was marked brain atrophy upon post-mortem examination.

Case 6.—Mary E. K—, set. 47, married, stated she used to be a
nurse; admitted in a restless, incoherent, suspicious mental condition,
having delusions that the police had organised a conspiracy against her,
and also having sexual delusions. On admission she presented many
of the symptoms of the climacteric. She had had irregular floodings for

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CASES OF MORPHINOMANIA.

Duly,

the past six years, she was subject to bad headaches, and talked freely of
persons with improper intentions being in league with the police against
her. She was suspicious, had aural hallucinations, and believed people
accused her of immorality. She had equal pupils, both reacting
normally, but the knee-jerks were absent: her teeth were bad. She was
intemperate, but not a heavy drinker. She had taken morphia, which
began in chlorodyne.

In two weeks she began to improve, in four weeks she was brighter,
intelligent, and useful, taking an interest in her surroundings, and in
two months she was discharged recovered.

Three months later she was readmitted with a furred, tremulous
tongue. She was much excited and persecuted. She was very deficient
in self-control, being alternately sullen and passionate. She threatened
violence if contradicted or thwarted, and she talked ramblingly and
excitedly of vengeance, property, and money. It could not be ascer¬
tained that she had again taken morphia, but she had yielded to
alcoholic intemperance. In two weeks she was more stable, in four
weeks she had lost all her delusions, and was sent out on trial, and
discharged recovered two months after readmission.

Case 7.—Margaret McF—, aet. 30, single, a journalist, of American
nationality, with black hair, dark browfi eyes, height 5 fl 6J in.,
weight 9 st. 10 lbs., and of rather prepossessing appearance and
striking manner, was brought into the asylum, having been found
wandering by the police. She was wretchedly clad in a quasi-
respectable way, and was evidently in want.

She was suffering from egotistical plots, suspicious of mysterious
persecution by the police, talking and writing freely, but communi¬
cating no information about herself, her previous history, or habits in
her’ voluminous correspondence. Her mental condition was that of
delusional insanity. She admitted taking morphia for sleeplessness,
but in what quantity, or how, she refused to state. She was
constantly muttering to herself, and would readily speak about con¬
spiracies, but little real facts could be elicited, any questions, leading
or indirect, being met with reserve and parry.

She was under care for nine months with but little change. She was
then transferred to another London asylum, from whence she was
shortly discharged recovered.

Case 8.—Agnes R—, aet. 43, married, described as a journalist, alsa
a lady dentist. She was admitted in a depressed, confused, exceedingly
nervous, sensitive, and fidgety condition, with suicidal tendencies. She
was very restless and egotistical, talking “fast and big.” She com¬
plained much of lumbar pain and occipital headache, for which she had
taken morphia. Her pulse was 84, soft and regular. Here eyes were
grey, her pupils irregular, the right reacting less freely to light than the
left.

She had been advised in the first instance to try opium cigarettes, but
the result was unsatisfactory, nausea and headache resulting. She subse¬
quently took morphia in the form of draughts, and found that it relieved
her insomnia. The quantity was afterwards increased to 4 grs. for a dose,.

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1902 .] EVOLUTION OF DELUSIONS IN MELANCHOLIA. 495

after which she states she enjoyed sleep full of delightful dreams,
compared to which fairy-land was the merest prose. She increased the
dose to 6 grs., and often took this in champagne, the result being,
to use her own words (in a letter written after mental convalescence),
that she saw things exactly as she wanted to.

She had had a previous attack of insanity, and was treated in a
private asylum.

No morphia or opium was allowed, but she had Ammon. Bromid.
in half-drachm doses, together with Tinct. Strophanthi Ti^x for
cardiac failure, for which she had complained, and which greatly
relieved her.

In three weeks she had greatly improved, and in three months
she was sent out on trial, being discharged recovered after four
months’ residence.

Nearly seven years after her discharge she was readmitted again in a
melancholy mental condition. She had some exaltation, was emotional
and restless, at times excited, and had delusions of electricity. She had
an idea she could write plays for production by the leading actors, and
spent much of her time plotting and writing these. On her readmission
there was some suspicion of general paresis; her pupils were equal, but
they reacted slowly and sluggishly to light. After one year she was sent
out on trial, but was dull and depressed, and had to return. After
two years she remains in the asylum in much the same state.

(*) Prepared for the General Meeting of the Medico-Psychological Association
held in London, May 2ist, 1902.—(*) H. C. Drury, Dublin Journal of Medical
Science , May, 1899.—( 8 ) Medical Temperance Review, October, 1900, stated that
from 6 to 10 per cent, of all medical men suffered from opium and allied drug
habits. It is hoped, however, that this is an exaggerated view of the vice.

The Evolution of Delusions in some Cases of Melancholia.
By Lionel Weatherly, M.D.

Do not expect anything new from this paper. Do not
imagine that I am going to bring forward any startling theory
concerning the origin of delusion, or make any attempt to
unravel the mysteries of the cerebral pathology of any one
class of delusion.

I am simply about to give you a short history of some of
my experiences of the delusions of many melancholiacs, and
draw from this experience the ever-needed lesson of the
necessity for early treatment if a quick recovery is to be hoped
for in these cases.

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496 EVOLUTION OF DELUSIONS IN MELANCHOLIA, [July,

We must all feel a deep and a sympathetic interest in all
melancholiacs, and, I take it, such interest must be greatly
enhanced by the fact that we are dealing with a form of
mental disease which, rightly treated, should show the highest
recovery rate.

In this short paper, however, I want to draw attention only
to those melancholiacs who have delusions which can be
traced back to something real in their immediate past history,
though that reality has become exaggerated, contorted, and
developed with a definite delusion.

Often such reality is so slight and so vague, that without
most careful examination the origin of the delusion cannot be
traced, and, I believe, is frequently overlooked.

We must not forget that in almost all these cases of
melancholia with delusion we have one important factor, viz.
a predisposition to mental trouble.

The slightest worry or anxiety will start in one person
morbid ideas, which, if not quickly set right by healthy reason¬
ing and strong will-power, soon develop into delusion ; while
another may have his life clouded by sorrow and be beset with
constant anxieties and misfortunes, and yet be not affected in
this way. May be such a one has not only no predisposition,
but possesses such a resolute and determined will, that he is
able to battle against any inclination to morbid tendencies.

My own experience of now more than twenty-seven years of
numbers of cases of melancholia leads me to believe that
delusions in this form of mental unsoundness are almost all
of gradual development, and that, if care is taken, they can
most of them be traced back to their origin.

Once accept this, how vitally important is it that these
cases should be recognised in their earliest stages, and by
appropriate treatment the evolution of these delusions be
checked at its very commencement!

Let me now shortly give the outlines of two cases bearing
upon my belief.

I could enumerate many more, but I think these will suffice
to fully explain my contention.

A. B—, aet. 50, a chief inspector of one of our best known banks,
with branches all over the kingdom.

Family history .—Neurotic.

Gradually got out of health; became sleepless; thought change

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BY LIONEL WEATHERLY, M.D.

497

1902.]

would do good, so took country duty and started on a tour of inspec¬
tion. Found work very trying, but still kept on. On arrival at a small
town in west of England, feeling worse, sent for wife, as he said he felt
too ill to continue work, and did not like to be alone. She at once
came down. Found him highly nervous ; blaming himself for not having
done his work properly, and declaring that the bank directors would
make him resign, and he would lose all chance of a pension.

Gradually got worse, and began to imagine that through his inefficiency
grave mistakes had been overlooked.

I was called to see him late one evening. I found him in a terribly
anxious condition, declaring that he had done some crime and feared
the consequences. He was sleepless, very restless, and utterly unable
to occupy himself.

I advised his being placed with a family who had had similar cases
under my care, which was carried out within twenty-four hours. I
•engaged a capable attendant, and mapped out a definite plan of treat¬
ment. He, however, gradually got worse, and now I found his delusions
were of a graver nature. He declared he had absolutely falsified
accounts, that the detectives were after him, and his only chance was to
fly the country. Soon he believed the crime he had committed was one
punishable by death, and the scaffold was ever before him.

In the meantime his general health had been attended to; he had
been kept out in the open air as much as possible, with plenty of long
walks, and, though a difficult matter, he had been fed up with every
kind of easily assimilated nourishment.

He gradually became quieter and more capable of reasoning, and
after some few months of treatment was almost mentally convalescent,
with the one exception, that he could not be made to believe that the
bank would reinstate him in his position. Unfortunately, I could only
obtain evasive letters from the board on this point, and I found his con¬
dition was in statu quo .

After a consultation with Dr. Maudsley, I decided to try an experi¬
ment. I wrote to the bank saying that my patient was now well, that I
felt work would be the best thing for him, and stated that he would
present himself on the following Monday morning at ten o’clock.

With his son he went to town on the Saturday, and an anxious time
the poor boy had of it; but his father, on finding his office, his desk, etc.,
all ready for him, brightened up, started his work, and never again
relapsed.

Here we have an instance of the gradual development of a
delusion, started by the fact that ill-health undoubtedly pre¬
vented him from satisfactorily doing his work as formerly.
This gradually told upon him to such an extent that he soon
became satisfied that his inability would lose him his berth, and
so gradually from this evolved his delusion of criminal conduct
and consequent future punishment.

The clearing up of the final mental doubt was also a most
interesting feature in this case.

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498 EVOLUTION OF DELUSIONS IN MELANCHOLIA, [July,

C. D—, a retired Indian judge, came under my care some nine
years ago.

^Et. 62, bachelor, living in London. A member of two clubs, but
always a retiring, shy, and diffident man, with few hobbies.

Family mental history .—Not good.

He got out of health. Just at this time there had been a well-known,
scandal in London, and he had conversed about this to his valet, an old
and trusted servant.

This scandal was the subject of conversation at the clubs. He began
to shun the society of his few friends. They, noticing this, kept, per¬
haps, rather aloof from him. He construed this into a desire on their
part to break their friendship, and he worried very much as to the
possible cause of this.

Gradually he began to imagine that his valet had been implicating
him in the scandal, and had told the servants of some of the club
members, and that was the reason of their behaviour towards him.

He became more restless, more sleepless, and at last, as his valet told
me, suddenly and secretly disappeared from his rooms in London. He
arrived at Bath, where he had relatives living, who quickly recognised
that he was of unsound mind, and he was placed under my care.

I found him in a state of acute delusional melancholia, pacing up and
down the room, listening for every footstep, and beseeching me not to
let the detectives arrest him.

When questioned as to what crime he had committed, all he could
say was, “ You know—everybody knows ; it’s awful. What will
happen ? ”

After a few days I got from him the fact that he believed definitely
he had been mixed up in this horrid scandal, that all his friends knew
it and had cut him, and that his valet had turned against him and
given information to the police. That he had been for days followed
by detectives, until his life was a perfect misery, and he had had the
greatest difficulty to prevent himself committing suicide.

For some weeks he continued in this state, always making me give
him a promise before he left the house that the attendant would not
allow him to be arrested, and that he would return safely to me.

After a time, seeing nothing happened, he began to gain confidence,,
and seemed to be rapidly improving. As he was fond of hunting, and
had his own horses, I had them down, and his daily rides seemed to
still further improve him. One day when I was out riding with him, he
suddenly started off as hard as he could go across country. Luckily I
was on the best horse, and being, too, the lightest weight, I soon had
him pounded. He was in a most agitated state of mind, and declared
that a gentleman who had passed us on the road was a detective who
had followed him from London.

I tried to assure him of his mistake, and luckily, on our homeward
journey, we met the said gentleman, whom I knew. I introduced my
patient to him, and he soon became much happier in his mind, and on
arriving home said he could not understand how such a foolish idea had
come into his head.

In a few weeks he was convalescent, and after staying as a voluntary
boarder for a short time he was discharged “ recovered.”

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1902.]

BY LIONEL WEATHERLY, M.D,

499

He kept quite well till last year, when I had a message from his
nephew to say that his uncle had broken down again, and was coming
to Bath to be under my care.

On arrival I found him much in the same condition of restless melan¬
cholia, but with rather different delusions.

He declared he was about to be expelled from his London and
provincial clubs; that he was a pauper, as orders, he knew, had been
given to the Indian Government Office to stop his pension.

I discovered these delusions had originated as follows:—He had
again broken down in health and become sleepless, and while in this
state had forgotten to put a friend down at his provincial club for
election as a member. When the date for election came, he dis¬
covered his omission, and was most distressed. He went back to
his sister’s home, and would not leave the house, as he felt certain
he had been guilty of most infamous conduct, and that all his friends
knew it.

He would not write to his friend to apologise for his forgetfulness,
neither would he give the name and address to his sister or his
nephew, so that they might write.

Gradually he became more depressed, restless, and unmanageable,
until his condition had developed as I have described.

In a few weeks he was convalescent, and after again remaining for
a short time as a voluntary boarder, was discharged “ recovered.”

Although these short outlines do not adequately convey the
very gradual development of the delusions in each case, they
are sufficient to point out what I mean ; and though you may
all recognise in my brief description similarities in numbers of
cases which have come under your care, I maintain that in
text-books, and articles on this form of mental disorder, the
gradual evolution of delusion has not been sufficiently empha¬
sised.

These delusions have not had their origin in the imagination
only, but they have been evolved from some definite reality.
A tendency to brood upon these realities gets more and more
rooted. They take full possession, as it were, of the mind, they
overmaster the will, pervert the reason, and gradually develop
into definite delusion.

But, even then, we often see in some of these cases periods
in which the patient’s mind seems to be visited by a gleam of
common sense, and for a moment half realises the absurdity of
its beliefs.

To treat such cases, no half-measures are of value. Tinker¬
ing with such mental states in the early stages only lands your
patient in a condition of definite delusional melancholia, and I

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500 EVOLUTION OF DELUSIONS IN MELANCHOLIA. [July,

am most emphatic in my opinion that the following are the
only right lines upon which successful treatment can be fol¬
lowed out :

1. Cut your patient adrift from his associations, and place
him in an absolutely new environment.

2. Build up his physical health. To do this no system
answers so well with melancholiacs as what we now call the
“ open-air treatment of consumption,” in which fresh air by day
and by night, good wholesome food in abundance, and carefully
regulated exercise form the main features.

3. Occupy his mind by diversified walks and amusement,
never fatiguing him, and yet never allowing him to have time
to think of his miseries.

4. Gain his confidence. Never deceive him, and never allow
those in charge to do so.

5. Never allow your attendants or nurses to attempt to get
their patients to do what they wish by false promises, or by
agreement with them in their insane ideas.

Some years ago I was inclined to believe that these melan¬
choliacs could best be treated in private families, but I have, from
experience of numbers of cases, come to the conclusion that
many of them get quicker well in an institution.

The discipline, so much needed, is general rather than indi¬
vidual, and, consequently, far less irritating.

The mere fact of being sent to an institution pulls them up,
as it were, and makes them realise that there must be something
the matter with them.

As the melancholiac is usually intensely selfish, and, by reason
of his unhappy complaint, he seems unable to think of anyone
but himself, and loves to attract attention to his woes and gain
sympathy, so life in an institution does him good, by the mere
fact that he finds himself surrounded by persons who are, for
the most part, so wrapped up in themselves, that, as Dr.
Clouston points out, “ they do not seem to care a brass farthing
whether he is miserable or not,” and this has a very desirable
effect upon his condition.

Lastly, I have found that such cases have often had a feeling
of security in an institution which has been lacking in a
private house.

I must apologise for having taken up your valuable time by
a recital of such well-known facts, and yet you will, I am sure,

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1902.] PUPILLARY SYMPTOMS IN THE INSANE. SOI

agree with me, that anything which emphasises the necessity of
early and definite treatment in these cases cannot be too often
repeated, for it is only by these means that we can hope to
increase our recovery rate, and in many cases prevent what at
first is only a form of simple depression developing into that
much more serious state of delusional melancholia.

Discussion

At the South-Western Divisional Meeting at Cotford, April 22nd, 1902.

Dr. Aveline, who presided, thanked Dr. Weatherly for his excellent paper, and
for the very lucid manner in which he had described his cases. He said that they
all knew the difficulty there existed in tracing the origin of delusions in cases of
melancholia, and the reason was that the cases were not brought to them at a
sufficiently early stage. It was very important on that account that these cases
should have the advantage of early treatment. He pointed out that the state of
the bodily health had a great deal to do with producing the feeling of depression.
He had no doubt that a great many of the members present had had cases such as
Dr. Weatherly had described, and he hoped they would indicate the results of their
experience.

Dr. Davis said that with regard to the melancholiacs they received in asylums,
they had no opportunity of treating them as suggested by Dr. Weatherly, but be
found by experience that the majority of cases were run down physically, and that
as soon as their nutrition was improved they made marked progress mentally.

Dr. Hungerford said that they could not insist too strongly upon the open-air
treatment. In his experience he had noticed that where a continuous system of
exercise had been indulged in the cases had shown marked improvement, but where
it had been stopped there had been a retrograde movement.

Dr. Macdonald said he had lately had under his care an interesting case of
melancholia, in which the evolution of delusions was the most interesting feature
of the illness. He said he would not restrict the open-air treatment to cases of
melancholia. Every case of mental disease should be treated, when physically
able, in the open air. This is not a new method, and where the patients live in the
fields by day there is no need for a special nursing army by night.

Pupillary Symptoms in the Insane , and their Import .
By T. P. COWEN, M.D.Lond., Assistant Medical Officer,
County Asylum, Lancaster.

Derangements of the motor functions of the iris are
commonly met with in the insane. They are as common in
general paralysis as they are uncommon in all the other forms
of insanity together. Their mechanism and import is not well
understood, and it is in order to elucidate certain points that I
venture to put the following observations before you, and to ask
you to comment on them.

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502

PUPILLARY SYMPTOMS IN THE INSANE, [July,

Motor derangements of the iris are shown by—

1. Size of the pupils.

2. Inequality.

3. Marginal contour.

4. Mobility.

5. Reflex adjustments:

(a) Direct light stimulation.

(< b ) Consensual stimulation.

6. Irido-motor states associated with accommodation and
convergence.

May I remind you of certain points in connection with the
reflex and other adjustments of the pupil ?

The optic nerve is the afferent nerve for the right reflex, the
third nerve the efferent, and the centre for the reflex is situated
in the grey matter beneath the aqueduct of Sylvius, near the
anterior limit of the third nucleus.

The centre for the skin reflex dilatation is supposed by
Salkowski to be situated in the medulla, but on the other hand
Gowers locates it beneath the corpora quadrigemina to outer
side of centre for light reflex.

The path of the afferent impulse varies greatly, and may be
along any cutaneous nerve, spinal or cervical, or by some of the
nerves of special sense. The efferent impulses reach the eye
generally by way of the cervical and upper dorsal spinal cord
(the cilio-spinal centre), the first two dorsal nerves, the
cervical sympathetic, the cavernus plexus branches of fifth
nerve, and the ciliary ganglion. This is, however, not the only
path, as the reaction is retained after complete division of the
cervical sympathetic. It has, I think, been demonstrated that
there are cortical centres for contraction and dilatation of the
pupil also.

It has long been asserted that a special centre exists for the
three associated movements—accommodation, convergence,
and contraction of the pupil; and the old four experiments of
Hensen and Volcker’s in dogs confirm this.

Again, there is some association of pupillary and respiratory
centres, as the pupils dilate with each inspiration and ex¬
piration.

Inequality of the pupils is said to be by no means un¬
common in the insane; Knecht gives 20 per cent, of all cases

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1902.]

BY T. P. COWEN, M.D.

503

as showing this symptom, but apart from general paralysis any
abnormal pupillary symptoms are, in my opinion, decidedly rare.

In cases of insanity we have two classes of pupillary abnor¬
malities : ( a ) inconstant variations ; (< b ) persistent or wholly
progressive impairment. The former are alone met with in
cases other than general paralysis and senile dementia, whereas
both classes of symptoms are present in the latter organic
-diseases.

In acute mania with great excitement one notices, but in¬
frequently, that peculiar condition known as “ hippus,” in which
there is a constant variation in the size of the pupil. This
condition is ascribed to the multitude of sensory impressions
to which the reflex centres are subjected. Occasionally, also, a
wide pupil is seen, but which, nevertheless, preserves its normal
reactions. Later in the disease, when exhaustion tends to reign
supreme, small pupils with a sluggish reaction to light may at
times be seen.

With these exceptions, in the great majority of cases jof acute
mania the pupils are quite normal in size, shape, and reactions.

In acute melancholia there is usually nothing abnormal, but
in a few with marked toxaemic symptoms the pupils tend to
become small, and to react sluggishly to light. In the insanity
of adolescence one often finds a tendency for the pupils to
become wide, but yet to retain their normal reactions.

In epilepsy and insanity the pupils are often wide but active,
yet in the majority of cases, apart from the occurrence of fits,
the pupils are normal in every way. In the chronic cases
of simple insanity there are no pupillary affections. The
pupils in ordinary secondary dements are quite normal as a
general rule, but I have often noticed that as middle age is
reached there is a sluggish reaction to light with a rather small
pupil in many cases.

In senile dementia one occasionally finds unequal pupils,
but usually the only symptom is a small pupil with distinctly
sluggish reaction to light,—apart, of course, from any gross
-defect of the eye.

General Paralysis of the Insane.

The intrinsic muscles of the eyes are affected at some stage
of the disease in almost all cases. The first eye sym-

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504 PUPILLARY SYMPTOMS IN THE INSANE, [July,.

ptom is usually a slight inequality of the pupils, with a
sluggishness on the part of the larger pupil to contract
to a subdued light, accompanied by an absence of the usual
dilatation following cutaneous stimulation, while all the other
reactions are perfectly normal. Later the larger pupil will
be found more sluggish or fixed, and eventually both become
fixed and immobile to light. This is accompanied by an
impairment of consensual activity. Last of all, the power of
contraction associated with acts of accommodation and efforts
of convergence may be impaired, and this may be unilateral or
bilateral.

Mydriasis is a feature of the late stages of general paralysis,
but earlier it may be associated with amaurosis. In other
cases small pupils may be present quite early, and may
persist unchanged during the whole course of the disease
(this I have found in 13 per cent, of cases, but only one fifth,
of these were ataxic or tabetic general paralytic).

Symptoms in Detail .

1. Size .—The pupil is more often dilated, which dilatation
may be unilateral or in both. This condition is found in about
half the cases. Thus, in 2 5 3 consecutive cases of general
paralysis in males, 128 showed dilatation in one or both pupils.
This dilatation is usually moderate in degree, varying from
3 to 4 mm. in diameter. Bechterew explains this dilatation as
an inhibition of the usual light reflex.

2. Inequality .—Bevan Lewis described an early inequality
not associated with impairment of pupillary reflexes, and
probably due to cortical lesion, and a late inequality associated
with absence of reaction to light and other stimulations,
and probably due to advancing spinal and bulbar disease.

B. Lewis, in his book, says that out of 44 cases of general
paralysis the right pupil was the larger in 16, the left pupil
in 11, and pupils of equal size in 17. In 253 cases I found
the right pupil larger in 54, the left pupil larger in 53, and
equal in 146.

B. Lewis says that “ oculo-motor disturbances are greater
on the side of the more deeply implicated hemisphere. The
increase in size of the small pupil indicates a deeper implica¬
tion of the nuclei of one half of the pons, as well as of the

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1902.]

BY T. P. CO WEN, M.D.

505

cerebral hemisphere of the same side. Where unilateral con¬
vulsions or palsy occur the dilated pupil is on the side of
the discharging or paralysing lesion.” This one has often
seen, but I cannot agree with him that a dilated pupil in
late general paralysis has a localising value, as there is no
excess of morbid affection to be seen in the corresponding
hemisphere in these cases.

3. Contour .—One or both pupils may be irregular in
contour; they may be oval above, below, or in both situations,
pyriform or irregular in other ways.

4. Mobility .—An early indication of commencing irido-
plegia is given by focal illumination, for, as shown by B. Lewis,
13*6 per cent., though active to light, show to focal illumination
a most limited range of movement, followed at once by a wide
dilatation. This tendency to dilate during stimulation by light
is the earliest augury of coming paralysis. I have seen this
even more often than the above figures show, and it is often
difficult to make sure that there is even a slight initial con¬
traction, as the pupil dilates up so quickly. One sees, also, in
a few cases a constant oscillation of the pupil resembling that
seen in birds, but this is usually seen in very excited, although
not otherwise very acute general paralytics.

5. Light reflex. —( a ) Bevan Lewis says that in 36 per cent,
both pupils were perfectly immobile ; 18 per cent, show fixity or
sluggish reaction in one or other ; 11 per cent, show sluggish
reaction ; 18 per cent, reacted normally.

I found in my cases, which were rather advanced ones, that
in 3 3 per cent, both pupils were fixed ; in 38 per cent, one or
other was fixed or sluggish ; 23 per cent, showed sluggish re¬
action in both; 3 per cent, were normal ; 2 per cent, showed
a constant oscillation.

(( b ) Consensual reflex is lost (in 43 per cent.—Lewis) when
light reflex is absent in both pupils. Reflex dilatation fails
very early, even before failure of light reflex. Usual order of
events is—(1) loss of reflex dilatation; (2) sluggish reaction
to light and tendency to dilate ; (3) gradually extending
paralytic mydriasis with impairment of consensual activity.

(e) Dilatation of the pupil from cutaneous stimulation is lost
early.

6. Associated movements of contraction of the pupil during
act of accommodation and efforts of convergence are only

xlviii. 35

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506 pupillary symptoms in the insane, [July,

affected very late in the disease. It may be unilateral or bi¬
lateral.

These affections of the pupil are not confined to true pro¬
gressive general paralysis, but one sees quite as definite and
marked symptoms in the cases of alcoholic, syphilitic, and
saturnine pseudo-general paralysis. These latter cases, how¬
ever, nearly always improve, and with the improvement the
abnormal pupillary symptoms disappear and leave not a trace
behind. Yet again, in true general paralysis, remissions
occur, and in these remissions most of the pupillary symptoms
disappear, to return with the onset of fresh activity of the
disease.

There is one exception to this, that of a myotic pupil. I
have seen a fair number of remissions in general paralytics
with pin-point pupils—absent knee-jerks,—but have never seen
improvement in the pupillary symptoms.

Again, one often sees a patient with unequal pupils one day
present equal ones the next, and with often varying degrees of
dilatation.

The improvement in the pupillary symptoms in the above
toxic conditions, which cannot be distinguished from true
general paralysis clinically, has a parallel in the improvement
of symptoms to the remission of true general paralysis. This
accentuates the proposition that these latter cases have a toxic
origin also, and that the symptoms increase or diminish with
the flow and ebb, as it were, of toxicity.

Will you permit me to digress? Can we in any way
bring about a remission of symptoms in general paralysis ?
For several years I have been experimenting with various
antiseptics in the acute insanities and in general paralysis,
under the idea of their toxic origin, in order to try to combat
this toxicity.

Chinosol given in two-grain total daily dose has, in many
cases, brought about a remission of symptoms, and especially
so in general paralysis. This has occurred, I venture to
think, too often to be a mere coincidence. There was a
marked improvement in the pupillary symptoms of general
paralysis, so much so that they had almost normal reactions.
How it acts I cannot say, except it be by an inhibitory action
on the intestinal micro-organisms.

As we shall show later, the nervous system in general

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1902.] BY T. P. COWEN, M.D. 507'

paralysis shows evidences of a primary toxic condition patho¬
logically, so that if any absorption of fresh toxins can be pre¬
vented, even for a time, the damaged but not destroyed ner¬
vous tissues get a chance to recover.

Given, then, these facts of observation, it is apparent that
the diagnostic and prognostic significance of pupillary derange¬
ments by themselves is very doubtful. It can only be in con¬
junction with other symptoms, with a due regard to the progress
of the case, that a just opinion can be formed.

In the acute insanities the pupillary symptoms are so infre¬
quent and variable that one can only look upon them as
evidence of toxicity, which in itself varies so much in degree.
As it is impossible by pupillary symptoms to distinguish the
pseudo- from the true general paralysis, it is rather by the
progress of the case and rate of improvement that one can
make a true diagnosis and prognosis. Again, in general
paralysis itself the affections of the pupil are not at all con¬
stant, and are so variable from day to day that it is often
difficult to make sure of the case.

There is one exception, as I have shown above—the myotic
pupil, which is much more constant, and is of the highest
importance clinically, but this is comparatively rarely seen.
But there is no doubt that any persistent symptom, especially
persistent inequality, is not a good sign, and especially the
occurrence of extreme mydriasis. Mickle says that extreme
myosis followed by marked mydriasis is of bad omen.

In senile cases marked symptoms are unfavourable. The
retinal reflexes are not abolished by lesions above the mesen¬
cephalon, so that one must look for lesions in the lower tracts.

Dr. Orr and the writer found that in the optic and third
nerves, in cases of general paralysis, there was a patchy degenera¬
tion like that described by Vassale in experimental poisons.
Slight changes were found also in the nuclei of origin.
Similar changes are found, however, elsewhere in the nervous
system, and not only in general paralysis.

Impairment of the light and other reflexes seems fully
accounted for by these toxic changes, seen in all parts of the
reflex arcs. The variations in the symptoms vary with the rise
or fall of toxicity.

The mydriasis early in the disease may well be due to
affection of the cortical centres, but is more likely due to irrita-

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PUPILLARY SYMPTOMS IN THE INSANE. ' [July,

S08

tion of the nerves, which inhibit the sphincter action of the iris;
but late mydriasis is probably from paralysis of the sphincter
from profound degeneration.

The loss of direct reflex dilatation has been ascribed to a
paralysis of the cervical sympathetic, or of its centre in the cord.
This condition, the so-called “ spinal pupil,” a moderately con*
tracted one retaining its light reflex, is seen in some early general
paralytics. The Argyll-Robertson pupil, seen in tabetic general
paralytics par excellence , is said to be due to a special affection
of Meynert’s fibres.

Apart from doubtful hypotheses, it seems to me that a
sufficient general explanation is that the toxic agent, apparently
capriciously, picks out here and there certain cells and fibres.
This is probably owing to their less resistent power. The more
delicate and more specialised functions are naturally the first to
become affected. The amount of affection of the internal
muscles of the eye seems to be a very delicate index of the
degree of toxicity.

Discussion at the Northern and Midland Divisional Meeting at
Shaftesbury House, April i6th, 1902.

Dr. Hitchcock said he was personally very much obliged to Dr. Cowen for
giving them a paper on that subject. It was one that had puzzled him very much
in his clinical observations. They had very little information on these symptoms
in the ordinary text-books, which took slight account of them. Any one who
observed a large number of patients must have noticed the varying conditions of
the pupils, which might be of grave importance and much pathological significance.
It was all-important to study the conditions giving rise to the symptoms, and then
one could recognise whether there was a grave condition or something that was-
immaterial. He had been particularly interested in watching one of his own attend¬
ants who had been with him for seven or eight years ; he was of perfectly steady
and quiet habits, he led a temperate life, and there was nothing whatever wrong
with his mental state. He was one of the most suitable and easy-going attendants
that he had. The changes in his case were of no significance. They were per¬
sistent. The pupils contracted to light. Under the stimulus of strong light the
one never became so small as the other.

In one patient he noticed when he was suffering from acute excitement that his
pupils contracted to pin-points. When that was the case it meant that the man
was in a condition or suppressed excitement, and likely to make an impulsive
attack if he had the least provocation. What gave rise to the extraordinary con¬
traction of the pupils under excitement in some cases and not in others was a
matter he knew nothing about. In another case he remembered with grief a
visit of a distinguished friend. He was going round the asylum, and his attentioa
was drawn to a case with marked inequality of pupils. His friend told him it was
a matter of no importance whatever. He was rather struck with that observation,
which was so contrary to his own belief, but he then noticed that his friend’s pupils
were somewhat unequal. Within two years his friend’s death proved that this
condition in his case had had a definite significance.

Dr. Blair said one of his cases was that of a man who was suffering from
melancholia. His pupils, instead of contracting to pin-points, became widely
dilated. The conditions to which Dr. Hitchcock referred would in a normal indi¬
vidual have produced dilatation of the pupils. He agreed with Dr. Hitchcock in.

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1902.] TREATMENT OF ASYLUM DYSENTERY.

509

his appreciation of Dr. Cowen’s paper. One thought that abnormalities of pupils
would be very much commoner in the insane than in the sane. He thought that
the blunted sensibility of the insane simply prevented those pupillary phenomena
which one saw in others. This condition was very much more common amongst
sane nervous people. He was reminded of a patient of his own by what Dr. Cowen
said about pupillary symptoms in cases of general paralysis. This patient had
unequal pupils, but the disease had not progressed in any way.

The Chairman said it seemed a very important thing that they should come to
some decision about abnormalities in the insane, and not jump to hasty conclusions
in diagnosing cases. He frequently received cases of alcoholic insanity which had
been sent into the asylum as suffering from general paralysis. Total abstinence,
fresh air, etc., caused the symptoms to disappear, and the pupils became quite
normal. A neurasthenic patient might get an inequality of the pupil. What was
the pathology of such cases they could hardly say.

Dr. Pierce said the paper was a valuable one, and that he was sorry Dr. Cowen
had left out a good deal of it. He was rather surprised to learn that so little
importance was attached to the condition known as the Argyll*Robertson pupil.
He looked upon it as of considerable importance, not as a direct diagnosis of

f eneral paralysis, but as a sign of tertiary syphilis. He thought this view would
e justified more in the future than it was at present. He remembered a patient
who suffered from melancholia in whom there was complete remission of his
mental symptoms though the pupils remained unequal and did not react properly
to light. He was not, therefore, surprised at the patient relapsing very soon with
maniacal symptoms typical of general paralysis. He considered the inequality of
pupils of less importance in diagnosis than the failure of the pupils to react to light.

Dr. Cowen, replying to the discussion, said he apologised for not reading the
whole of the paper, but he did not wish to bore the members with a mass of
figures. With reference to Dr. Hitchcock’s remarks, he said he had generally
found in cases of acute mania with great excitement that the pupils were dilated.
He looked upon contraction of the pupils in these cases as an evidence of great
toxicity. When remissions occurred in general paralysis, although most of the
pupillary symptoms disappeared, still the pupils did not show quite normal reactions,
but were not far removed from the normal.

He agreed with Dr. Blair that at times inequality of the pupils persisted in
the remissions of general paralysis, but with almost normal reactions otherwise.

In reply to Dr. Pierce, he said that he had not meant to convey the impression
that the Argyll-Robertson pupil had little diagnostic value, as he considered that
the true Argyll-Robertson pupil was of very great import as a symptom. He
referred to the much greater number of cases which showed apparently the Argyll-
Robertson pupil one day, and a dilated, fairly reacting pupil the next. In tabetic

f eneral paralytics, which formed only 28 per cent, of his cases, the myotic Argyll-
Lobertson pupil was present unchanged throughout the whole course of the
•disease.

Dr. Cowen thanked the Chairman and members for their reception of his paper.

The Prophylaxis and Treatment of Asylum Dysentery .
By N. H. Macmillan, M.B.Edin., Asst. Med. Off., London
County Asylum, Claybury.

Dysentery and diarrhceal affections in English asylums
have, for some time past, been attracting considerable attention.

Their well-known prevalence has been considered of sufficient
importance to warrant a passing reference in some of the larger
books on general medicine. Dr. Manson, in his text-book on
Tropical Diseases, refers to it as “that very fatal type of

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510 TREATMENT OF ASYLUM DYSENTERY, [July,

disease which is the scourge and disgrace of more than one of
our English asylums.”

About three years ago, the Asylums Committee of the
London County Council, becoming alarmed at the spread of
the disease in their asylums, appointed Drs. Mott and Durham
to make a special investigation into its causation. As a result
of their study of the disease they handed in a very exhaustive
report, in which they state that in their opinion dysentery is a
highly infectious disease which can be greatly lessened, if not
entirely eradicated, by the adoption of suitable hygienic pre¬
cautions.

The subject has also been taken up by the Commissioners in
Lunacy, who, as a consequence of this report, have recently
issued the order that a register of dysenteric and diarrhoeal
cases be kept in all asylums, similar to the one drawn up by
Dr. Mott, and already in use in the London County Asylums*
They also suggest that at all post-mortem examinations the
intestinal tract should be carefully examined, in order to deter¬
mine the presence or absence of dysenteric lesions.

This is by no means an unnecessary suggestion in view of
the fact that the post-mortem examinations in asylums are not
usually carried out by skilled pathologists.

As Claybury is one of the asylums which has suffered from a
severe epidemic of dysentery, it was suggested to me by Dr.
Jones that it might interest you to hear a few details of the
incidence of the disease and of the measures we are taking to
free the institution from it.

A perusal of the case-books and post-mortem reports shows
that dysentery made its appearance in Claybury very shortly
after the opening of the institution.

The asylum was opened for the reception of patients on
May 16th, 1893. On May 30th, only fourteen days later, a
female patient was admitted suffering from melancholia. On
June 27th she was stated to be suffering from severe diarrhoea,
and on July 6th to have died from the exhaustion of diarrhoea.
No post-mortem was made.

In the autumn of the same year two female patients were
admitted. One of them came directly from a workhouse, and
the other was a transfer from an asylum in the. neighbourhood.
Both these patients died within a few weeks, and both showed
well-marked signs of dysentery on post-mortem examination.

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1902.] BY N. H. MACMILLAN, M.B. SI I

On turning to the male records, I find that on June 24th,
about six weeks after the opening of the asylum, a patient
was admitted with diarrhoea, who, in his previous history, had
suffered from chronic diarrhoea for four years. He died five
days after admission from pneumonia, but unfortunately no
post-mortem was made.

In the following spring the male post-mortem reports show
that two patients died from obvious dysentery.

Dysentery thus made its appearance very early in Claybury,
and by similar importations the disease obtained a footing in
the asylum. During the period of six months—October, 1898,
to March, 1899, it assumed such an acutely epidemic form that
nearly a third of all the patients dying during that term showed
dysenteric lesions of a more or less marked character. About
that time more vigorous prophylactic measures were introduced,
and these shortly afterwards began to have their effect on the
disease.

As to the actual causation of the disease, various opinions are
held by different authorities. One eminent alienist has stated
that " ulcerative colitis ” is primarily due to nerve degeneration,
and is a frequent termination in chronic dementia and in
general paralysis of the insane.

The preponderance of opinion, however, inclines to its being
of an infectious nature. Several observers have shown that
the disease is not confined to any age, and this is the ex¬
perience of all who have noted its spread in Claybury, where
it has attacked patients of all ages, of both sexes, and at all
periods of residence.

That general paralytics are not specially liable to the disease
is shown by the fact that at Claybury Hall, a quarter of a mile
distant from the main asylum, and where a large proportion of
the patients are suffering from general paralysis, dysentery is
non-existent.

In a hundred consecutive deaths from dysentery I find that
the patients suffered from the following mental disorders :

Melancholia .

.28

Mania .

. 25

Dementia

. 34

General Paralysis .

. 9

Epilepsy

. 3

Imbecility

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512 TREATMENT OF ASYLUM DYSENTERY, [July,

The fact, too, that it has been communicated to several of
the nurses and attendants, also supports the contention that
it is of an infectious nature.

The opinion of Drs. Mott and Durham and of many other
authorities, including Dr. Manson, Is that the disease does not
essentially differ from ordinary dysentery.

Numerous bacteria and protozoa have been described in
connection with this disease.

Durham, while working at Claybury, found a minute micro¬
coccus which he separated from the blood, bile, kidney, and
spleen in seven cases of asylum dysentery, but as his investiga¬
tions have not been completed, one can say little about its
connection with the disease.

More recently, however, a bacillus, resembling the bacillus
typhosus , which exhibits pathogenic properties and aggluti¬
nates when added to the blood-serum of persons suffering from
dysentery, has been described by Shiga during an epidemic of
the disease in Japan. This bacillus has been examined by
several bacteriologists in other epidemics, notably by Flexner,
who found that it reacted to the blood-serum of several cases
of the dysentery occurring in the insane wards of the Phila¬
delphia Hospital. The blood-serum of these cases did not
cause agglutination of recent cultures of the bacillus typhosus.

It is impossible, at present, to definitely state more concern¬
ing asylum dysentery than that it is one of the infectious
diseases whose specific organism has not yet been satisfactorily
isolated.

Predisposing causes .—The circumstances which predispose to
the spread of dysentery are those which act by lowering the
general resistance of the patients.

The predisposition of lunatics to dysentery, as to phthisis,
may be associated with their mental condition and their
degraded habits.

Among other causes may be mentioned over-crowding, with
all its attendant evils; also constipation, indigestion, and
catarrhal troubles.

Certain drugs, too, such as croton oil, and sulphonal if long
continued, may, by setting up intestinal irritation, predispose
to the disease.

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1902.]

BY N. H. MACMILLAN, M.B.

513

Prophylaxis.

The great aim we have before us in Claybury, in our
endeavours to combat this disease, is not merely the treatment
of individual cases. Our object is two-fold. In the first
place we are attempting, and with marked success, to limit
the spread of the disease. In the second, we hope to succeed
in decreasing the number of cases in the asylum, until it may
be looked upon* as a sporadic rather than, as in the case at
present, an endemic disease.

Many methods suggested in this paper are at present in use
in the asylum, and experience enables us to continually add to
those at our disposal. It is hardly necessary to mention that
the introduction of an elaborate system of prophylaxis into a
large asylum can only be done gradually, as it is impossible to
at once insure the carrying out of a large number of hygienic
rules by relatively inexperienced nurses and attendants.

Whenever it is suspected that a patient may be suffering
from dysentery the fact is at once reported, and the case placed
in a side room, pending the arrival of the medical officer in
charge of the section, and the suspicious stool is preserved for
his inspection. If dysentery is diagnosed the patient is imme¬
diately transferred to the isolation hospital. All clothing,
edding, and other materials which have been in contact with
the patient are disinfected.

It is highly desirable, too, that patients sleeping near the
case, or who have been in contact with it, should be looked
upon as suspects, and kept under strict observation for at least
a week, and it should be the custom to obtain at least one
report of the condition of their stools with reference to the
presence of loose motions or mucus.

The isolation hospital, to which patients are transferred,
should, in my opinion, be regarded as an emergency ward only,
and the beds contained in it should not be included in the list
of beds available for ordinary patients; in other words, every
patient occupying a bed in the isolation hospital should have
his or her corresponding bed kept vacant in the main asylum.

This method has been carried out with success in at least
one large provincial asylum, from which, by systematic
prophylaxis, the disease has been practically stamped out.
The isolation hospital should possess a separate staff of nurses

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514 TREATMENT OF ASYLUM DYSENTERY, [July,

and attendants, none of whom are allowed to do duty in the
main asylum, excepting in such wards as are largely or entirely
occupied by recovered cases of dysentery.

A striking feature of the type of the disease at present preva¬
lent in Claybury is the frequency with which relapses occur.
On the female side of the asylum I find the relapses have,
during the past two and a half years, occurred in about 20 per
cent, of the cases under treatment. Several of the patients
have suffered from three, and one from as many as five relapses
during this period.

It is consequently not surprising to find in the post-mortem
records that many of the patients, who have apparently re¬
covered from an attack of dysentery, and have later on died
from some other cause, showed chronic dysenteric lesions of
long duration. Not infrequently, also, very chronic dysenteric
lesions have been found in cases who have died from what
appeared to be an acute attack of dysentery of some days’
duration only. It is probable that the majority of such cases
must have suffered occasionally from irregular action of the
bowels, associated with the presence of a certain amount of
mucus.

I am consequently strongly of the opinion that a weekly
examination of the stools of apparently cured cases of dysentery
should be carried out. These facts also show that it is
obviously undesirable for apparently cured cases to be permitted
to return, haphazard, to any ward which may happen to
possess a vacant bed, and, from a general administrational
point of view, be suitable for their reception. Such cases ought,
in my opinion, to be detained in the isolation hospital for a
considerable period of time after all symptoms of the disease
have disappeared.

When ultimately it is necessary to transfer them in order to
create vacancies for recent cases of the disease, such patients
should be sent, at any rate for a time, to wards which are suit¬
able for their reception, and which do not contain recent or
curable cases of insanity.

In these wards should be aggregated all those patients
who are relatively recently convalescent from an attack of
dysentery, and all those cases who have suffered from one or
more relapses.

It is particularly important that all relapsing cases should be

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1902.]

BY N. H. MACMILLAN, M.B.

515

for a time, or even permanently, under special observation. I
think it desirable that they should be placed on a ticket similar
to that in use in the case of suicidal or epileptic patients, in
order that the attention of the nurses and attendants may be
focussed on them. Weekly examinations of the stools of such
patients ought to be made, and the results should be recorded
on the backs of the tickets and initialled by the medical officers.

Any stool which is not entirely normal should be reported to
and inspected by the medical officer in charge of the section.
The bowels of such patients should be kept open by mild
laxatives only. As will be stated later on, I personally prefer
small doses of liquid extract of cascara taken in combination
with Sod. Bicarb, and Spt. Ammon. Aromat., shortly before
meals.

The importance of attention to the bowels during an
epidemic of the disease has long been recognised. Many years
ago Virchow stated that it was noticed during an epidemic of
dysentery at the Charity Hospital, Berlin, that those wards
were rarely affected in which syphilis was treated not by the
administration of mercury, but by a course of medication in
which laxatives were prominent.

It is consequently highly desirable, not only as a general
principle, but especially when any exacerbation of the disease
under consideration should occur, that the bowels of all
patients should be kept thoroughly open.

It would be better to err on the side of laxity than on that
of constipation.

During the summer and autumn, when diarrhoea due to
dietetic irregularities is not uncommon, special attention
should be paid to all patients suffering from gastro-intestinal
irritation.

Considerable difficulty is, in my experience, likely to occur
on the female side during the carrying out of this system,
owing to the frequency with which women suffer from habitual
constipation; but I find it possible to satisfactorily carry it out
when the nurses and attendants sufficiently appreciate its im¬
portance, and work loyally under their medical officer. I make
a practice of treating cases of gastro-intestinal irritation by
mild aperients, followed by tonics rather than by astringents,
and I have obtained excellent results by this method.

I may, perhaps, here refer to the general hygiene of public

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5 l6 TREATMENT OF ASYLUM DYSENTERY, [July,

institutions in which dysentery is endemic. For example, the
water-supply, ventilation, drainage, and especially the question
of over-crowding should all be attended to.

The medical superintendent has wisely given instructions
that the following rules, suggested in the Dysentery Report,
should be posted up in all the ward storerooms :

Directions .—All able patients should be made to wash their
hands before each meal.

All patients who might assist in laying out meals should be
seen to cleanse their hands satisfactorily before being allowed
to handle edibles, etc.

All patients who may be called on to assist in ward duties
(especially cleansing and changing of other patients) should be
seen to cleanse their hands in a sufficient manner.

Systematic disinfection of all things used by or which have
come into contact with patients affected even with slight
diarrhoea only should be carefully and promptly carried out.

Contaminated, or possibly contaminated objects should be
placed in covered receptacles in convenient situations; they
should only be moved from the ward in these receptacles,
wherein they should remain until disinfection is carried out.
The receptacle should itself be subjected to disinfection before
it is returned to the ward.

The disease being contagious, the patient should, therefore,
be isolated at once, and the clothing, linen, bed-linen, mat¬
tresses, used by any colitis case should be scientifically dis¬
infected.

All recovered cases on returning to their wards should be
kept under daily supervision and on a carefully regulated diet.

It is, of course, difficult to insure the keeping of such rules
as the above, owing to the tendency of nurses and attendants
to allow laxity to be gradually introduced, unless the medical
officer is constantly on the watch.

It is probable that many of the local recrudescences which
are continually occurring in different blocks are due largely to
laxity on the part of nurses and attendants.

As regards the source of many of the chronic cases of the
disease which serve as foci of infection, it is probable that
these are largely introduced from without, owing to the fact

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1902.]

BY N. H. MACMILLAN, M.B.

517

that a large number of the patients are admitted after a longer
or shorter period of residence in workhouses and other institu¬
tions where the disease is prevalent.

That cases are certainly introduced from without is proved
by an examination of the post-mortem records, which show
that long-standing dysenteric lesions occasionally exist in
patients who have died within a few months of admission to
the asylum.

It is also highly desirable that all such patients on admission
should for some weeks be looked upon as suspects, and that a
weekly examination of their stools should be made. If irregular
diarrhoea should exist, or if a small quantity of mucus should
occasionally be observed in the stools, such patients must at
once be transferred to the isolation hospital or to appropriate
wards.

If the bacillus of Shiga and Flexner should, in the future,
be found to give a reasonably constant agglutination with the
serum of patients suffering from dysentery, we should have in
our hands a valuable method for the diagnosis of such imported
cases.

Treatment.

The general line of treatment adopted in Claybury in cases of
dysentery is similar to that in common use in the case of
typhoid fever, i. e. expectant and symptomatic.

In our experience the numerous specifics which have been
recommended by different physicians have failed to produce any
marked effect on the disease.

Expectant .—In uncomplicated cases our treatment is ex¬
pectant only. The patient is kept at rest in bed, all unnecessary
movement, such as rising to use the night-commode, or to have
the bedding changed, is avoided, and the patient is generally
made as comfortable as possible.

Little or no food is given during the first day or two, and this
consists entirely of milk, which is given frequently and in small
quantities.

Not uncommonly in these mild cases the patient, on the
second or third day, begins to feel hungry and complains of the
reduced diet. The addition of a little arrowroot frequently
appeases them. This may occasionally be made more palatable
by the addition of a little cochineal and lemon water. Usually

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5 I 8 TREATMENT OF ASYLUM DYSENTERY, [July,

these mild cases rapidly convalesce, but it is well to keep even
the mildest cases in bed for at least a fortnight. I consider
that by this means the liability to relapse is largely averted.

Symptomatic .—If the case be more severe it is generally
desirable to commence the treatment by the administration of
3 ss to ^iss of castor oil, to which, if necessary, a few drops of
laudanum are added. As an alternative—for in some cases
patients object to castor oil—magnesium sulphate in one
moderate or in several smaller doses is exhibited. These drugs
frequently ease the patient from pain and flatulence by
removing irritating matters from the intestinal tract.

When the tongue is much coated, in which case milk is badly
borne, I generally substitute beef-tea containing such additional
proteid as “ tropon."

If the mouth and tongue be dry, the patient should be kept
strictly on milk, and starchy food, owing to the frequency with
which fermentation results from its use, should be avoided.
When the diarrhoea ceases and appetite begins to return,
custard, eggs, and boiled white fish may be given. If, as fre¬
quently happens when the diet is improved, diarrhoea should
reappear, and mucus and blood be found in the stools, pure
milk diet ought again to be returned to.

Prostration and even collapse are frequent in asylum
dysentery. In severe cases they occur early, and immediate
stimulation is then, in my opinion, desirable. If, on the other
hand, prostration occurs later in the disease, the question of
stimulation depends on the general condition of the patient,
and this symptom can often be combated by tonics of a more
general type.

It is, however, my opinion that in the treatment of asylum
dysentery it is a common error to give too little stimulant at
the commencement of the attack, and too much in the later
stages, when either the patient will die whatever treatment
be adopted, or will do better under tonics or more generous
diet.

Dryness of the tongue and failure of the heart not infrequently
follow a sudden fall of the temperature, and indicate the
urgent need of stimulation. Brandy mixed with milk is, as a
rule, less likely to cause sickness than whisky, and it is usually
more agreeable to the patient.

For excessive diarrhoea, especially when this continues after

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1902.] BY N. H. MACMILLAN, M.B. 519

blood has disappeared from the stools, a mixture containing
subnitrate of bismuth and opium is of great value. When
diarrhoea is excessive, patients frequently complain of intense
thirst. This is, as a rule, best relieved by sucking ice or sipping
cold or warm water. Personally I prefer ice to cold water, as
patients not infrequently drink too much of the latter, and are
consequently apt to suffer afterwards from painful contractions
of the colon. Ice is also useful when a patient suffers from
sickness.

Asylum patients, as a rule, do not complain much of pain,
and in this they contrast markedly with sane patients suffering
from dysentery. If pain be present, it is readily relieved by
the application of hot turpentine stupes to the abdomen.

If it takes the form of tenesmus, it, as a rule, readily yields
to small enemata of starch and opium.

During the treatment of asylum dysentery it is necessary to
be always on the watch for the supervention of pneumonia,
which is a frequent and very severe complication.

The treatment of this complication differs only from that of
ordinary pneumonia in the need of early and greater stimula¬
tion.

Cystitis is by no means an infrequent complication, but it
does not, as a rule, give rise to urgent symptoms. It should,
however, be suspected in cases who suffer from frequency of
micturition or griping pains in the lower part of the abdomen.

It is best relieved by injecting a dilute solution of chinosol
into the bladder, the injection being retained by water pressure
for a few minutes.

It is necessary to add a word or two concerning the adminis¬
tration of large enemata. From a theoretical standpoint
such treatment is excellent, and certainly, in many cases, the
patient is much relieved by a large enema of warm boracic
solution slowly administered by means of a rectal tube. My
experience of enemata does not justify me, however, in recom¬
mending it as a routine method of treatment.

During convalescence .—As I stated before, I believe it is desir¬
able to keep convalescent patients in bed for a longer period
than many clinicians consider necessary.

This can do no harm and is to be recommended.

After the patients have been allowed to get up, they are, as
soon as possible, brought out to the fresh air if the weather

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520

TREATMENT OF ASYLUM DYSENTERY, [July,

permits. It is essential, of course, that they should be warmly
clad, and as soon as possible gentle exercise should be allowed.

It is necessary to warn the nurses against allowing such
patients to sit down on the grass or even on the dry ground,
as the slightest chill is prorffe to induce relapse.

The diet requires careful regulating, and all indigestible and
irritating substances should be avoided. The bowels should
be carefully regulated, and this is best carried out by the use
of mild laxatives. As I have already stated, I personally much
prefer a soda—ammonia—cascara mixture given shortly before
meals, and this may, with advantage, be flavoured with pepper¬
mint.

If the dose be carefully regulated by an intelligent nurse or
attendant, healthy motions are induced without either discom¬
fort or intestinal irritation.

Discussion

At the Spring Meeting of the South-Eastern Division at Brookwood Asylum,

April 30th, 1902.

The Chairman said: We have all listened with interest and pleasure to Dr.
Macmillan, and our best thanks are due to him for the very able paper he has read
to us. As we have an authority here on this subject in the person of Dr. Mott,
I am sure that the members would like to hear him discuss this important
contribution.

Dr. Mott said: The paper just read reminded me of the parable of the sower.
At one time I thought that the seed I was sowing was going to fall entirely on stony
ground, and that it would bear no fruit at all—not, however, from the quarter where
most of my work was done ; there they were most anxious to stamp out the disease,
so that my remarks do not apply to Claybury Asylum. Sir William Jenner, in a
lecture I once heard him give on enteric fever, remarked, " The first duty of a
medical man is to prevent disease; failing that, to cure disease; failing that, to
prolong life and relieve suffering.” Dr. Macmillan, in his paper on “ Dysentery in
Asylums,” has followed this important dictum of Jenner. With regard to the
infectivity and prevention of this disease (which I regard as dysentery of the same
nature as was long ago so prevalent in England), when I was appointed pathologist
at Claybury, I was struck with the number of people who died from what
was called colitis. In the wards of the asylum I saw many people suffering
with the disease, and I was so impressed by the ward incidence and the probable
infectious nature of the disease that I asked the late Professor Kanthack to come
down and investigate it with me. This he did in the summer of 1897. He took
away some material with the determination of trying to investigate the specific
cause of the disease, but, unfortunately, he then went to Cambridge and I contracted
typhoid fever in the laboratory; the work was therefore suspended for nearly a
year. Later I met Dr. Durham, who had been for some years working at meat
poisoning due to the bacillus enteritidis. He told me that he had been asked by
a superintendent to investigate an epidemic of an acute and fatal bowel complaint
which had occurred in an asylum. He was unable to associate it with meat
poisoning. After hearing the symptoms which he had noted, I came to the conclu¬
sion that it was the same disease as the dysentery which was then prevalent at
Claybury, and I invited him to come down to the laboratory for the purpose of
endeavouring to find a specific organism. He succeeded in finding minute cocci

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BY N. H. MACMILLAN, M.B.

521

1902.]

In the blood, spleen, and bile of fatal cases, but inasmuch as he was unable to
reproduce the disease in animals, this organism does not fulfil the requirements
necessary for stating that it is the cause of dysentery. Whether Flexner’s bacillus
.dysenteries t which accords with that of Shiga, can be looked upon as the specific
organism I am unable to say; so far experiments made by Dr. Washbourn and
myself on agglutination in cases which have recently occurred at Claybury do not
support this view. Colonel Bruce, at a recent discussion of my paper at the
Epidemiological Society, stated that he had isolated many kinds of colon bacillus
from the cases of dysentery which he had had under his charge at Ladysmith, but
he was unable to find a specific organism. Moreover, he did not consider the
ameeba celt, which Dr. Durham and I were never able to find, as the cause of
•dysentery even tropical, but he looked upon it rather as an epiphenomenon.
Although, therefore, the true nature of dysentery as regards a specific organism is
not yet known, yet the facts which 1 have been able to collect have proved that it
is communicable and infective the same as enteric fever. Many of the most
infectious diseases we know of have not yet had a specific organism proved as a
•cause. The recognition of this disease as communicable and infectious is one of
great importance, for it shows that too much care cannot be taken in isolating
•cases of dysentery, in transferring patients from one ward to another; also in
recognising atypical cases and taking precautions with regard to them. We
brought forward some striking examples of ward incidence in our report. One at
•Colney Hatch was very convincing, because it showed nine people in adjacent
;beds attacked by the disease. Recently at Han well an outbreak occurred in
Ward 20. Investigation of this outbreak showed that first one attendant suffered
with a mild attack, which doubtless he had acquired from an atypical case. A few
more then occurred, and then a young attendant who had only been six months in
the service suffered with a very severe attack of the disease; after this quite a
: number of the patients in this ward suffered with dysentery (altogether 35*5 per
> cent, of the inmates of this ward, whereas the total percentage of dysentery cases
for the whole asylum was only 1*4), many of the cases being severe and fatal. It is
-presumed that a person who can acquire can confer, and I have no doubt in my
own mind that dysentery in this ward was carried from patient to patient. It was
of interest, as showing the similar nature of this dysentery in asylums to dysentery
met with abroad, to have the unbiassed opinion of this attendant, who prior to his

• entry of the service had been a soldier in India, where he had served as an orderly
in the hospital, and had nursed many cases of dysentery. When I asked him
whether he recognised any difference between the dysentery he had seen in India
and the dysentery of which he had had practical experience in England, he replied,
none, except that the asylum dysentery was more severe. We were able to collect
a number of instances of attendants, workers on the farm, and other sane indi¬
viduals who were affected with the disease; even doctors and the higher officials

• (such as the matron at Hanwell) have suffered with severe attacks of dysentery.
Moreover, an instructive case of its communicability has recently been afforded.
A laundrymaid at Hanwell in April of last year suffered with an attack of dysentery
during a slight epidemic of the disease; she was isolated, and recovered. At the
end of November she suffered with a recurrence, and another laundrymaid who
slept in the same two-bedded room was off duty a week with a mild attack of the
•disease. I cannot therefore agree with those who believe that it is a disease
peculiar to lunatics, although they, from their habits and on account of their being
crowded together in large institutions, are more liable to become infected. I do
not find that the disease affects one class of lunatics more than another, although
the old, infirm, demented, and bedridden are subjected to more chances of infec¬
tion, and are more liable to suffer with a severe form of the disease on account of
their low vitality. A few observations I have made do not support the views put
forward by Dr. Claye-Shaw that the disease is due to degeneration of the nerves
supplying the bowel. The recommendations which we gave in our report would, I
am sure, if carried out, prevent dysentery ever assuming a serious epidemic form.

.Sporadic cases in these large institutions will always be liable to crop up, and too
much care cannot be exercised in making transferences from ward to ward, or from
one asylum to another; and especially should care be taken, in opening a new
asylum, not to introduce cases of chronic dysentery, which, owing to its liability to
.intermission of symptoms and then recurrence, may so easily be overlooked, but
XLVIII. 36

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522

TREATMENT OF ASYLUM DYSENTERY, [Julyv

yet act as a focus in the production of an epidemic. The matter of sewage farms
and the disposal of sewage, especially when there is an epidemic in the asylum, is
of very great epidemiological importance, as was long ago pointed out by Dr.
Clouston. My experience would lead me to believe that cases arise not so much*
from exhalations as from contamination of vegetables, which are eaten uncooked,
and by pollution of the hands of workers on the farm, who on returning from their
labours do not wash. In fact, the matter of washing of hands bpr patients before
sitting down to their meals is a very important one in the prevention of the spread
of this disease.

Dr. Robert Jones. —The opening remarks of Dr. Macmillan—minatory as
regards myself—have turned out to be a much-appreciated compliment, for we*
have all accepted his paper as being a full and up-to-date account of this disease,
with which we at Claybury, and possibly others in this room, have had too much
experience. Since this disease was so fully investigated by Drs. Mott and Durham,
who have done a public service by bringing forward their report, there has been no¬
contribution to the clinical and therapeutic aspects of this disease more practical
and more full of excellent suggestions than Dr. Macmillan’s paper to-day, and I
gladly accept any responsibility that I have undertaken in asking Dr. Macmillan^
to bring forward his experience before this division of the Association.

Whatever views have been favoured and advanced by other recent writers as to
the neurotic or nervous origin of this disease, there is possibly no one in this room'
who does not accept the theory, founded upon an extensive and convincing record,
that colitis or dysentery is an infectious disease. Unfortunately, so long ago as
the first year of opening of the Claybury Asylum, and in July, 1893, when
only 291 patients (147 males and 144 females) were in residence, I reporterf
diarrhoea of an unusual type, and began to suspect that the water tanks may
have had something to do with it. The water was examined by the chemist to*
the London County Council, but no definite cause was discovered. Several
cases occurred during the winter, and I feared that the system of ventilation,,
which was then unsatisfactory and not under proper control, was at fault. In the
following spring an epidemic, more or less, made its appearance, and was marked
by great headache, and in some cases by extreme collapse and vomiting. The
symptoms in one fatal case resembled those of acute metallic poisoning, and my
previous experience had met with nothing similar to this. I sent the vomit to the
Councils chemist, as also milk, water, bread, some tins, etc. No less than 129'
patients and some of the staff suffered from this; one nurse, who developed pneu¬
monia, succumbed to the exhaustion. Careful analysis of the food, drink, etc.,
failed to give us any information. The epidemic, however, abated, but cases kept
cropping up frequently from time to time. In the autumn of this year, the second
year of opening, another outbreak occurred, and I suspected the subways, which
afterwards were carefully concreted in leaking spots, and channelled for water to
run out. In December of this year I met with several fulminating cases of
diarrhoea, death occurring in twelve hours after the onset in one case. The follow¬
ing year I had again to report an outbreak, and the Medical Officer of Health for
London, Mr. Shirley Murphy, was summoned. The inspection made through the-
infirmaries, the subways, and the whole place generally, by the Medical Officer of
Health and myself, revealed no definite cause, and the Medical Officer was shown
various pathological conditions of inflamed and ulcerated intestines in fatal cases.
The symptoms accompanying these were mdrked collapse, a bloody and slimy alvine
flux, and severe vomiting, with a temperature of about 104°. During 1895, as is re¬
corded in my published annual report for that year, no less than 280 cases of diarrhoea
occurred, and in a number of those who got well this was followed by an epidemic
of general acute eczema. I began to suspect the infectiousness of this disease, and
in the third year of the opening of the asylum, 1896, we commenced to isolate
cases in the isolation hospital. In May of this year I became uneasy again, and'
Dr. Shirley Murphy was summoned to our assistance, and inspected the day-rooms,
dormitories, subways, and stores. The symptoms of the disease in July were
reported by me to have been a high temperature, 105°, often sickness, great
collapse, a dry tongue, and slime and blood in the stools. Dr. Hamer, Mr.
Shirley Murphy’s assistant, was summoned to our assistance in the autumn,
and he visited and saw cases of diarrhoea under treatment. In my published
annual report of this year I stated that thirteen males and nine females ha<L

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1902.]

BY N. H. MACMILLAN, M.B.

523

died from diarrhoea caused by colitis. In the following year and in the autumn
of 1897 we had several cases of typhoid, and the serious attention of the
asylums’ engineer and myself was directed to the general sanitary condition of
this new asylum. We examined closely the subways, the water tanks in the roofs,
the outlets and inlets of the ventilating system, and the drain-pipes before these
issued into the sewers, and after they had received the soil from the upright soil
pipes. We found that liquid sludge had deposited in the glazed earthenware
drains at the foot of the main soil pipes, but there was no block, and this was per¬
fectly ventilated. No smell could thus issue into the w.c. annexe where typhoid
cases occurred, unless syphonage had taken place. This system, however, was
entirely removed. Later on one of the Medical Officers of Health for London again
visited and investigated the recent cases of typhoid. He also went into the water-
supply, drainage, and system of subways with myself. In the annual report for this
year, published 1897, it was reported that twenty-one deaths (seventeen males, four
females) were caused by diarrhoea, which was confined mostly to patients, and the
incidence was believed to be more particularly during spring and autumn. In
cases that proved fatal there was much collapse, acute pain, haemorrhage, and an
almost constant alvine flux. Post-mortem examination revealed the most acute
colitis, and cultures of the bacillus coli communis were obtained after death even
from the blood of the brain.

In the following year, 1898, eighteen deaths (seven males, eleven females)
occurred, but it is possible, as I have stated elsewhere, that post-mortem examina¬
tion may reveal the disease where during life it was not suspected, or where the
patient died from some other more evident disease, and in this way there may be
a higher record in the post-mortem notes than in the annual statistical tables.

In 1899 thirty-five deaths occurred (fourteen males, twenty-one females). The
whole of the glazed earthenware pipes round annexes were relaid and trapped, and
further, a commencement was made to relay the whole of the drainage system on
a bed of concrete covered again with six inches more concrete, no section being
passed as satisfactory until it had answered the hydrostatic pressure test and been
seen by myself and a representative of the asylums’ engineer. In 1900 there were
further thirty-five deaths, but the incidence became now more marked on the
female side, only seven males, but twenty-eight females dying from the disease.
In 1901 the drains were finished completely; a reduction of 100 was made in the
number of patients, which became 2400 instead of 2500—the asylum was built
for 2050 patients,—and very strict isolation of all cases of diarrhoea was carried
out. In oonsequence of these variations the deaths were reduced to twenty-five
(nine males, sixteen females), and this year, up to April, 1902, there have been no
male deaths, but twelve females.

So far as I have been able to ascertain from the medical journals, case-books,
and other records, the dysentery since the opening of the asylum has been as

follows:

1893

Males.

Females.

1894

106

1895

1896

1897

1898

1899

104

1900

142

1901

*53

1902 1
Up to April j

Such is the history of the progress of this disease in one asylum only, and it will
be evident to every one in this room how personally I welcome Dr. Mott’s very
great assistance.

As to its origin, Dr. Mott has already referred to its introduction from other
asylums or workhouses; and once admit the infectivity, it is not difficult to account
for its spread when a typical case has been admitted. Although this disease is
probably not caused by overcrowding, it is favoured and aggravated by such a
condition.

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524

TREATMENT OF ASYLUM DYSENTERY. [July

As to treatment, I agree that it is in the main preventive, but my experience of
actual cases has been in accordance with Dr. Macmillan’s account, and I agree
as to the futility of rectal injections. I have tried large rectal injections of boracic,
and if my late colleague, Dr. Spicer, had been here to-day as he expected, you
would have heard more of the detail in this regard. I have used from one to six
pints, and I do not think you can disinfect the bowel. I have used salol, resorcin,
iodine, carbolic acid, and chinosol as internal antiseptics. Purgatives in the early
stages are certainly useful, and if the disease be due to a special micro-organism
this must be in the bowel, and obtain access through the abraded mucous membrane,
possibly from a stercoral ulcer caused through constipation, and we all know how
much women among the insane suffer from this. Rest in bed from the beginning,
with farinaceous food as dietaiy, is the most suitable, as Dr. Macmillan has already
stated. The ticket which Dr. Macmillan suggests; and to keep the infected person
under suitable supervision I consider to be a most excellent and important sug¬
gestion ; but I would venture to add a further one, and that is that the superficial
area should be marked in clear plain numbers upon a panel of the door of every
dormitory in the asylum, so that the number of patients allowed upon the scale of
the Lunacy Commissioners’ rules may be easily seen, and overcrowding remedied
where this can possibly be done.

As to something which has been said in regard to working with sewage, I
should like to make it quite clear that the sewage of Claybury goes into the local
sanitary system, but it has the possibility of being intercepted in one place and
turned on a part of the land. This, however, has only been done on about four or five
occasions in the history of the asylum during nine years, and then only in a summer
drought. The sewage of Claybury Hall, where the private patients are fed on a more
liberal scale, and where the total number of beds has not exceeded sixty, is dealt
with upon the Dibdin bacteriological method, the effluent flowing into a local course.

I cannot help thinking that the majority of cases of colitis occur among the
more demented; at any rate, it occurs among non-workers rather than the workers
in the asylum, which points to the more feeble and helpless; but no single class is
free, and I have known quite young acute mental cases ill with it, but the habits of
these are difficult to control. It is absolutely impossible to get the insane to be
chemically and bacteriologically pure, and the suggestions of Dr. Mott, and in the
paper read to us, are most valuable and necessary.

As to the disease, it certainly has of late years become more recognised. In
1897 the Lunacy Commissioners reported a death-rate of 2 \ per cent. Five years
later their statistics record a death-rate of 6 per cent. Taking the deaths that have
occurred in Claybury, there appears to be an increase, although only a slight one,
during March and April, also during August and September. This has certainly
been so the last two years since a more accurate record has been kept of all cases
of diarrhoea. Of the cases of diarrhoea and dysentery which prove fatal, the pro¬
portion has been variously estimated, from one fourth downwards, and I have
estimated that 168 cases (63 males, 105 females) have died from the disease in
Claybury since its opening in nine years, and in a population under treatment of
nearly 8000 persons. For the reasons I have previously stated, this may not be in
accordance with the number as ascertained upon post-mortem examination.

As to relapses, these are not uncommon after longer than a year’s recovery, and
once a dysenteric probably always a dysenteric; at any rate, more or less certainly,
it may be so for three years. As to the age of the patient, I am inclined to believe
that the older are more liable; the greatest number of patients are attacked
between 50 and 59 years. In my statistics the senile cases appear to be the more
numerous, as many as thirty or forty being between 70 and 79.

Dr. Bolton. —The average age at death has been 57 years.

Dr. Jones. —This goes to confirm what I say, for if the paralytic dements are
considered, they being of the earlier decades tend to lower the average ages.
Mr. President and gentlemen, our thanks are due in a high and special degree to
Dr. Macmillan for his very full, suggestive, and critical paper from actual experience,
and whether we agree with his theory of infectivity or not, I venture to think that
in this room there are no dissentients. He has contributed, summarised, and
classified a most interesting addition to our knowledge of a disease that apparently
presents some diversified phenomena, and a disease which has certainly been the
subject of much recent scientific inquiry.

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1902.] PSYCHIATRIC WARDS IN COPENHAGEN HOSPITAL. 525

Dr. Bolton. — I should like to draw your attention to the fact that one third to
one half of the total deaths are due to general paralysis, whereas only about 11 per
cent, of any series of deaths from dysentery are general paralytics, therefore
dysentery is not more common in general paralytics than in other varieties of
mental disease. With reference to the question of the infectivity of the disease,
some six or seven years ago I myself suffered from it at Rainhill. At Claybury
the post-mortem porter has suffered from dysentery; the present chief nurse at
the isolation hospital and also the past chief nurse have suffered from it, and
several of the attendants. This alone is quite sufficient to show that the disease
is infectious. I quite endorse what Dr. Macmillan has said. The suggestions he
has made have been largely carried out at Rainhill, and were instrumental in
stamping out the disease in that asylum. The treatment he has suggested is that
which I have myself used in this disease with successful results.

Dr. White. —This is no new disease. When I was an assistant medical officer
in 1872 we had several cases. 1 made post-mortem examinations on the
cases and carefully investigated them. During my career I have seen several
cases of an endemic type at the City of London Asylum. These cases were treated
in our hospital with the other hospital cases, and the disease did not become
epidemic. We had during the autumn of last year a certain amount of acute
diarrhoea, but it was caused, in my opinion, by the patients eating a large amount
of stone fruit. I think there is no doubt this disease is sporadic. It is brought on
sometimes by defective sanitary conditions, defective ventilation, defective sewage
disposal, etc., and very often from defective drainage and overcrowding.

Dr. Mott, in answer to questions put by Drs. Hyslop and Taylor, said that
chronic cases of dysentery might occur without diarrhoea; generally at the post¬
mortem it would be found that the bowel was blocked with scybalous masses. He
wished particularly to emphasise the fact that acute cases might die before the
characteristic stools had had time to occur. Patients like epileptics and general
paralytics often ushered in the onset of the disease with continued fits, and
naturally, if a post-mortem had not been made, would have been said to have died
in “ status epilepticus." Again, Dr. Mott referred to cases occasionally dying in a
few days, and at the post-mortem the large and the lower part of the small bowel
might be found filled with blood and slime, and yet no ulceration to account for it,
only the acute inflammatory congestion.

In answer to questions put by Dr. Boycott, Dr. Mott said that he considered the
sporadic cases of so-called ulcerative colitis which one occasionally finds in hospital
and private practice were really sporadic cases of dysentery. With regard to Dr.
Boycott’s question about care in sterilising enema apparatus, this had been called
attention to by the French physicians as a cause of the spread of dysentery, and he
had some time ago pointed this out to the medical officers and attendants at the
asylums, although it was not specifically stated in the recommendations of the
report.

The Psychiatric Wards in the Copenhagen Hospital\

By Professor Knud Pontoppidon.

The Commune Hospital was built in 1863 for the recep¬
tion of poor patients of all classes from the city of Copenhagen.
It was therefore necessary to provide a ward for the treatment
of the insane. For this special purpose a pavilion was erected
simultaneously with the main building, within the grounds of
the hospital. It was arranged on the corridor plan, with single
rooms only. The pavilion cost between £3000 and £4000.

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526 PSYCHIATRIC WARDS IN COPENHAGEN HOSPITAL, [July,

It was forty-two yards long, and had twenty-two single rooms,
on two flats, besides a special room in the basement for the recep¬
tion of patients suffering from delirium tremens. It was by
no means intended to provide the city with a regular fully-
equipped hospital for the continuous treatment and nursing of
the insane. The pavilion was designed to serve as a recep¬
tion-house, and those patients who did not show signs of im¬
provement within a short time were removed to one of the
country asylums. Besides ordinary insane persons, the
pavilion was also to receive patients whose condition
necessitated isolation, e . g ; suicidal cases, epileptics, and severe
cases of alcoholic poisoning. Later on, when the physician in
charge was appointed Physician of the Court of Justice, all
criminals suspected of insanity were sent to the pavilion for
observation.

In view of the continual increase in the number of patients,
the usefulness of the pavilion was soon proved, and the rapid
growth of the population of Copenhagen rendered it necessary
to enlarge the building in the years 1886—8. A sym¬
metrical wing was added to each end of the pavilion, thereby
giving it a length of sixty-four yards. Each wing had its
entrance by stone stairs leading up to both stories of the
building. The rebuilding cost between £5000 and ^6000,
furnishings included, and gave room for fifty-four patients in
all, which is still the present capacity of the building, Copen¬
hagen having a total population of 235,000. It is situated
in the west corner of the Commune Hospital grounds, facing
south-east like the main buildings of the hospital, and it is
surrounded by a garden, which is isolated by a fence, and
divided for the two sexes. The fifty-four beds are arranged
in the different rooms in the following manner:—Twenty
rooms have one bed each, three rooms two beds, four rooms
four, and two have each six beds. Besides these rooms, the
building contains a common sitting-room, lecture-room, bath¬
rooms, apartments for the attendants, kitchen, etc. The windows
in the rooms all face the south-east. The doors open into a
corridor three yards wide, running through the whole length of
the building. The system of heating and ventilation is about
to be improved.

In rebuilding the pavilion the original small elevated
windows have been enlarged, and lowered to breast height.

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1902-]

BY PROF. KNUD PONTOPPIDON.

527

Inside, they are provided with shutters which can be securely
closed without darkening the room, as part of the shutters are
fitted with wire gratings. Both shutters and doors are fitted
with a special kind of safety lock. The male patients are on
the ground-floor, the female on the first floor, and the trouble¬
some patients are all kept in one end of each floor, separated
by a wall from the others. For the further protection of the
-quiet patients a third section has been introduced, separating
the two ends, for those patients whose condition ranges between
the two extremes.

In spite of this enlargement, and although the average
duration of treatment (calculated in decennial periods) has not
been prolonged beyond twenty-three days for each, the capacity
of the pavilion has again proved insufficient, so that at pre¬
sent further additions are under consideration.

In providing common rooms the principle of isolation
adopted in the original building was abandoned. Since the
enlargement in 1888 the use of seclusion by means of locked
-doors, formerly adopted as the appropriate treatment for
troublesome patients, has gradually been abandoned, while
the open-door system has been carried out completely.

This change has been coincident with the introduction of an
absolute non-restraint treatment, while medical restraint—quiet¬
ing the patient by narcotics—is also very seldom used. It has
rather been tried to quiet patients by means more harmless
and humane ; as, for instance, rest in bed, hydropathic packs,
and prolonged hot baths. Only as an immediate resource
-during a paroxysm of violence, and consequent danger to the
other patients or to the attendants, narcotics have occasionally
been used. It has also been necessary in special cases, such as
patients suffering from surgical lesions, to take precautions so
as to prevent them from getting out of bed. In these
cases a broad belt or strap has been used, fastened to the
bed, thereby preventing the patient from rising, while the limbs
are left free.

A very important step, adding greatly to the progress in
treatment in a modern direction, was taken when a reform of
the nursing system took place in the year 1888. In earlier
years the nursing had been managed by women who not only
lacked training in this kind of work, but also education and
refinement. In the pavilion, as in the main hospital, these

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528 PSYCHIATRIC WARDS IN COPENHAGEN HOSPITAL. [Jill y r

women were replaced by trained and educated nurses of higher
social rank. The change was carried through easily and
quietly, and the success was so complete that the section for men
has also been served by female nurses, day and night, ever since
that time. Only in the unruly part of the men's division male
attendants are kept for assistance, especially in cases of delirium
tremens. But it is often seen that violent patients become
excited and want to fight the male attendants, while a kind
and firm nurse can easily quiet them. It was feared that
obscene tendencies in the male patients would make it impos¬
sible to have female nurses. But this fear proved groundless*
the said tendency, as is well known, being found more fre¬
quently among female than among male insane patients.
Everything considered, this reform has been a great blessing
and an immense advance, both in respect of the medical nurs¬
ing and the general condition of the patients concerned.

The pavilion has been of high importance as a place of
training in clinical psychiatry for medical students and doctors.
During the last twenty years the chief physician, who is also
Professor in Clinical Psychiatry at the University, has given
regular lectures on clinical material available, and for years
these have been compulsory, so that students cannot pass the
final medical examination without having attended one term
of these lectures. Besides, the assistant house physicians of
the Commune Hospital are in turn obliged to serve for a certain
time in the pavilion.

It is of great importance in this training to have a continu¬
ously changing set of patients, as doctors later on in the course
of practice will usually meet with similar acute cases. It
must also be considered very profitable for study because the
pavilion receives criminals suspected of insanity, thereby offer¬
ing the student an opportunity to appreciate the mental con¬
dition and responsibility of such individuals.

It has been of great advantage for the hospital to have an
insane pavilion to which can be sent all cases of psychoses
occurring during treatment for other diseases; because such
patients, when the psychoses are cured, can return to their
former ward and treatment. This applies especially to alco¬
holic patients. On the other hand, it has often been seen that
patients in the insane ward call for treatment in other wards,—
as, for instance, in the surgical or in the neurological, the latter

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CLINICAL NOTES AND CASES.

1902 .]

529

being nearly connected with the psychiatric pavilion, and under
the care of the same physician.

The pavilion seems, in fact, to have been a benefit, because
asylums still inspire a great many people with horror and fear,
while patients and relatives, as well as doctors, seldom hesitate
to make use of the insane ward of the Commune Hospital,
in the hope that the patient will soon recover, knowing that
he will here at once be placed under rational treatment, which
so often greatly improves the prognosis.

The adding of the pavilion as an integral part of a hospital
for general somatic diseases has influenced public opinion in
modem and scientific direction, and done away with much of
the mysticism which too often, in the public mind, clings to
mental disorders. The usefulness and saving of time for
students and doctors in having the pavilion within the grounds
of the hospital will be apparent to all.

On the whole, this system may be said to have secured these
several evident advantages to the public of Copenhagen, without
any apparent disadvantages to the hospital as a whole, during
the thirty-nine years of its existence.

No doubt a small institution annexed to a general hospital
cannot command the same accommodation as a large asylum
designed for the treatment of the insane in every direction. And,
of course, the clinical material does not represent the whole
complex of insanity, so that cases have to be followed out to
their termination in the asylums of the country. On the other
hand, many forms of insanity, constantly changing or evanescent,
are brought under notice in a way that is otherwise impossible,
and, as has been said, of the highest value to the medical
profession and the public generally.

Clinical Notes and Cases.

Calcification of the Pericardium. By Francis O.
Simpson, L.R.C.P.Lond., M.R.C.S.Eng., Senior Assistant
Medical Officer, Rainhill Asylum^ 1 )

ADVANCED calcification of the pericardium is a condition
that is rarely met with in autopsies conducted upon the insane.

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CLINICAL NOTES AND CASES.

530

Duly,

and some points in the following case seem to render it worthy
of being recorded.

The patient was a male set 61, by occupation a gardener, and the
mental condition was of twelve months’ duration. He was admitted to
Rainhill Asylum on May 13th, 1898, suffering from acute melancholia,
and the cause of his attack was business troubles. His habits were
said to have been temperate, but he was subject to attacks of vomiting
in the morning, beyond which there was nothing special in the
history.

He cut his throat before coming to Rainhill, and upon reception was
profoundly depressed and actively suicidal. He was the subject of
auditory hallucinations, and thought he could hear people telling him to
prepare for burial, as it was his last day; he also imagined that he had
been brought to the asylum to be shot. There was a recent self-inflicted
wound of the throat which healed rapidly, and, his mental condition
likewise improving, he was fit to be allowed to work in the garden by
July 17 th, 1898.

Exactly a week later (July 24th) he relapsed suddenly, and again
attempted suicide by driving an iron spike into his forehead. He held
the point of the spike against the skin and hit the blunt end against a
wall with his cranium. Only superficial wounds were inflicted, and they
were practically all healed by July 31st.

From this time until September 13th, 1899, he remained in much the
same depressed and unhappy state, retaining all his delusions of
persecution and auditory hallucinations. During the latter months of
this period he was noticed to be deteriorating physically, and upon
examination was found to be suffering from advanced cardiac hyper¬
trophy and dilatation with a mitral regurgitant bruit, the sounds being
faint and distant at the apex and inaudible elsewhere. He was also
noticed to have an enlarged lymphatic gland in the left groin, which in
some respects simulated a small hernia of the omentum.

During the last two days of his life he had a return of the vomiting
noted prior to his admission, and the question of rupture was then
raised, but fortunately was enabled to be negatived. The idea of an
exploratory operation under an anaesthetic was discussed, but was
thought to be contra-indicated on account of the heart trouble. He
died on September 26th, 1899, fr° m heart failure.

Post-mortem .—An autopsy was performed forty hours after death, the
weather being cool and wet. An enlarged lymphatic gland was present
in the left inguinal region, the increase being apparently due to simple
adenitis. The costal cartilages were every 7 where ossified. The left pleura
was universally adherent to the chest wall and considerably thickened.
Both lungs were congested posteriorly; the right weighed 15 and the left
16 oz. The pericardial sac was entirely obliterated and the membrane
enormously thickened. The heart weighed 19^ oz. with its adherent
pericardium, and it w r as impossible to open it in the ordinary way from
the presence of thick and very calcareous plates which had been formed
in the pericardium. By means of a large pair of bone forceps an entry
was at length effected, when the myocardium was found to be every-

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1902 .]

CLINICAL NOTES AND CASES.

531

where in a state of advanced fatty degeneration, and the organ much
hypertrophied with all its cavities dilated. The right side contained
much ante - and post-mortem clot, and the whole of the valves were
markedly incompetent. Those of the pulmonary artery and aorta were
greatly thickened and calcified, the tricuspid and mitral thickened and
very rough. The mitral orifice admitted five fingers with ease, and the
tricuspid four fingers. The aorta was in an advanced condition of
atheroma. The liver weighed 40 oz. and was rather congested,
and the spleen appeared fairly normal, scaling oz. The right
kidney was 5$ and the left 6 oz. in weight; they seemed fairly healthy.
The brain weighed 1500 grms., and there were some adhesions
between the dura and pia-arachnoid over the right motor area. The
cerebral substance was soft and cedematous, but with the exception of
cystic degeneration of the choroid plexuses, and some granulations of the
ependyma in the left lateral ventricle, there was nothing worthy of note.

All the text-books agree as to the infrequency of calcification
of the pericardium, and in connection with the present case the
following points seem deserving of special note, viz.:

1. The extensive affection of the organ, which had occurred,
as far as could be ascertained, without any serious illness being
noted by his relatives, or his occupation as a gardener being
interrupted. The condition was of very old standing, and it
could not have originated during his sixteen months* residence
in the asylum.

2. The presence of vomiting during the last stage in associa¬
tion with a tumour of the left groin, in some respects simulating
an omental hernia.

3. The great difficulty amongst insane patients suffering
from cardiac disease in selecting suitable cases for operation,
the physical signs being often much obscured and their
histories faulty and unreliable. In this case the administration
of an anaesthetic would almost certainly have proved fatal.

(*) Read at the Northern and Midland Divisional Meeting at Shaftesbury House,'
April 16th, 1902.

Hczmatoma of the Cerebral Dura Mater {Pachymenin¬
gitis Interna Hamorrhagica) associated with Hcemor-
rhage from the Colon. By Stephen G. Longworth,
L.R.C.P.Irel., Senior Assistant Medical Officer of the
Suffolk County Asylum.

An unmarried female, set. 56, was admitted into the
Suffolk County Asylum on February 24th, 1902. Owing to

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532

CLINICAL NOTES AND CASES.

[July,

circumstances at the time no very complete examination into
the mental condition was made, but the case appeared to be
one of dementia of quite an ordinary type, characterised by
dulness, stupidity, inability to sustain a connected conversation,
although able to give replies to simple questions, loss of
memory, tendency to wander aimlessly about, and negligence
in habits. Nothing of any particular note could be ascertained
in the previous history of the case, which was evidently of
some months’ duration, although the mental condition did not
necessitate removal to an asylum until a week or so before
admission.

On admission she was physically rather feeble, and presented con¬
siderably more than usual pigmentation of the skin generally, more
especially in the exposed situations. There was no evidence of any
gross organic disease beyond possibly some degeneration of the myo¬
cardium as suggested by the cardiac sounds, but no murmurs were
present. The pulse averaged about 98, was regular, and the arteries
were not unduly sclerosed for her years; the blood-pressure equalled
98 mm. Hg. (Hill and Barnard). The tongue was inclined to be dry
and somewhat coated, the appetite was poor, and the bowels confined.
Her temperature was subnormal. The urine was of high sp. gr., and
free from albumen and sugar.

March 7th (ten days after admission).—Appetite is now much
better, and bowels are acting fairly regularly, but she is confined to bed,
owing to extreme negligence in habits. The temperature continues
subnormal.

12th.—She has not been nearly so well for the past three days,
and has gradually lapsed into a dazed, drowsy state. She lies in bed in
whatever position she is placed. All passive movements of the limbs
are at first resisted, but when the initial resistance is overcome (such as
straightening a flexed forearm) no further resistance is offered. Nourish¬
ment is taken fairly well when placed in her mouth, but she makes no
effort to feed herself. The knee-jerks and reactions of the pupils are
doubtful. The heart-sounds are weaker, and pulse shows signs of
failing. The temperature since yesterday has risen to ioo° F., and
there is present an erythematous cutaneous inflammation involving the
right foot. This morning she passed a motion, otherwise normal, con¬
taining a considerable quantity of dark red blood-clots.

13th.—Is much more drowsy, and cardiac weakness increasing, but
she continues to take a fair amount of nourishment. A similar motion
to that of yesterday was passed this morning, containing about quarter of
a pint of clots. The morning temperature was ioo° F., and the evening
98 *6° F.; the pulse was 108, and the blood-pressure 100 mm. Hg.
Towards midnight the pulse failed entirely at the wrist, and another
motion, consisting almost entirely of blood-clots, was passed.

14th.—Patient died at 1.15 a.m.

Autopsy (eleven hours after death). — Cranium .—External surface

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OCCASIONAL NOTES.

533

1902.]

of the dura mater was normal; on removal, a thin, irregular
shreddy layer of blood-clot was found between it and the
arachnoid, and -slightly adherent to both. It 'commenced over
both occipital lobes, and extended downwards over the entire surface
of the cerebellum; the whole of the base of the brain was also
involved in a similar condition. There was more than usual fulness of
the cortical veins, and the brain as a whole was unusually firm. No
further macroscopic changes of any note were evident. The basal
vessels appeared to be fairly normal.

Thorax .—Lungs showed considerable emphysema; heart presented
a white opacity in pericardium covering anterior surface ; no hypertrophy
or dilatation, and very slight atheroma of the aorta.

Abdomen .—Liver presented signs of old extensive perihepatitis.
Kidneys showed slight fibro-fatty changes. Large intestine: on
opening up from the rectum to the caecum it was found to contain a
quantity of scybala mixed with blood-clots, which were more or less
adherent to the mucous membrane. The blood ceased abruptly at
the level of the hepatic flexure of the colon, where for an area of
about three square inches the mucous membrane presented a purplish
discoloration due to engorgement of the veins and extravasation of
blood into the coats of the bowel, but there was no apparent breach
of the surface. This was evidently the site from which the haemor¬
rhage took place. There was no ulceration in any part of the
intestinal tract, nor were there any haemorrhoids.

This case appears to be worthy of record, owing to the
associated haemorrhagic conditions. Although I have been
unable to find any reference to cases presenting similar
features, I believe one was recorded some few years back in
which there was an associatied vesical haemorrhage. Points to
which attention might be drawn in the above case are
the low blood-pressure, the fairly healthy condition of the
kidneys, and the absence of any marked arterio-sclerosis.
The hepatic condition found post mortem may be suggestive
of alcohol as a factor in the causation, but this was denied in
the previous history of the case.

Occasional Notes.

Insanity and Toxaemia.

The Scottish Division entered upon an important discussion
at their spring meeting. It has been evident for some time

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534

OCCASIONAL NOTES.

[Jul Y,

that the trend of opinion in the advanced school of pathology
has been towards a theory of toxic causation of insanity.
Indeed, it is inevitable that the extension of such a theory,
pushed to its furthest limits, should permeate all departments
of medicine and find enthusiastic supporters in our own
specialty. Toxic causes, established in such diseases as diph¬
theria and tuberculosis, have eluded observation in cancerous
affections, although the search has been skilful and prolonged.
A poisoning of the system, which we now call toxaemia, has
been recognised in the domain of psychiatry for many years.
Schroeder van der Kolk was so assured of his opinion that he
based his treatment of insanity upon the theory of a common
causation in the overloaded, disordered condition of the great
intestine; and, even at the dawn of medical science, the toxic
effects of black bile were denominated melancholia, and
described at interminable length. At any rate, these
theoretical ideas were useful in drawing attention to the
physical basis of mind, and in offering indications for the
treatment of its disorders. Of late years, however, there has
been a remarkable advance in the strictly scientific knowledge
of the physiology and pathology of living organisms. The
science of biology has been rapidly evolved, and it is a real
struggle to keep pace with the more important conclusions
formulated by the great army of workers. In our own
particular sphere of interest, we could not but expect the
moment when the toxaemic stalking-horse should be advanced
to occupy territory hitherto held strongly by the old guard of
a less materialistic psychology. Therefore the battle-field at
Glasgow could occasion no surprise—it was as inevitable as
the great Boer war. Not that the Old Guard were inactive in
defending the positions in which they have been so long
entrenched, or that they have entirely lost their scalps in the
fray. It would rather seem as if they were ready to establish
a zone of neutral territory—ground common to both, which
may yet be extended by diligent sapping and mining on the
part of the aggressors. So the day ended.

We have no doubt that the report of the discussion, as
printed on page 434, will be carefully read and considered.

Dr. Clouston, desirous of arriving at adequate results, left
no point of moment unmarked—except that perhaps, in the
arena so familiar to every true-born Scot, he devoted none

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1902 .]

OCCASIONAL NOTES.

535

of his gladiatorial skill to the abiding question of free-will.
He will not have it that mind is a mere secretion of brain ; but
is he not responsible for the story of the man who found salva¬
tion after the administration of a brisk purgative ? The fact
remains that we are in constant touch with the unknowable,
and that we may safely content ourselves with invincible
ignorance of the unsolvable.

Is there so great a practical difference between Dr. Clouston
and Dr. Ford Robertson as mere words would indicate?
Myxcedema was, quite recently, an incurable disease. By
extension of knowledge, it is now a commonplace of medicine
to treat it to recovery. We may unite in hoping that further
research will afford us similar results in the management of
other forms of mental disorder. There is no difference
between the parties in reference to this practical side of the
discussion. So far as we understand the difference, it refers to
a question of territory—how far can the toxic theory be
pushed ? Dr. Ford Robertson gives it a wide application in
saying that he would claim that all forms of insanity occurring
in normally developed personalities are toxic in origin, the
toxaemia being generally established before the mental cata¬
clysm occurred, the nutrition of the cell having been altered
by a breakdown in the first line of defence in the organism—
in the gastro-intestinal tract and the bone marrow especially.
That, of course, brings insanity into a line with tuberculosis—
there is no hereditary consumption, only an hereditary weakness
of defence against the tubercle bacillus. We can thus think
more precisely. If these toxins can be demonstrated, more
especially if the antitoxins can be beneficially applied, Dr. Ford
Robertson’s theory will be established ; and it seems to us
that it is, if not a more hopeful attitude, at least a more
satisfactory method of approaching the subject. But much
remains to be proved ; has anyone accumulated a sufficient
body of evidence to show that the first line of defence has
broken down before mental disorder is apparent ? Dr. Bruce
indicates several observations on that point, and we hope that
trustworthy records will be exhumed from case-books in order
to establish the facts one way or another. All this does not
induce us to repudiate the empirical treatment at present
generally adopted. Our whole efforts are directed towards
physical and mental hygiene. No one could suppose that

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536

OCCASIONAL NOTES.

[July,

Dr. Ford Robertson in dealing with a case of simple melan¬
cholia would advise the continuance of mental worry and over¬
strain, or an environment of morbid psychical influences. We
would place no great stress on Dr. Clouston’s reference to the
characteristics of periods of age—just as little as on the
religious manifestations of the insane. They are naturally
tinged by the colour of the surroundings, just as they come up
to date with delusions regarding the Rontgen rays.

It would appear to us that the weakness of Dr. Ford
Robertson’s position lies in his absolute denial of any causative
force in manifestations of functional activity, and that the
strength of Dr. Clouston’s position lies in the opposing idea.
The latter finds his chain of evidence in primary morbid weak¬
ness, a stimulus, a nutritional disturbance, and then, after all,
a toxin. The toxins of fatigue have been already recognised,
and the various forms of trades’ paralysis have been described
over and over again. Will Dr. Ford Robertson object to our
assigning a blacksmith’s paralysis to his daily occupation as a
cause in the complex of causes ? It would be an imperfect
description of the case which would omit such a relevant fact,
as it would be impracticable in treatment to ignore it. We
know that, in such a case, nutritional changes precede the
disease; and on that analogy Dr. Clouston might maintain his
position. In the affairs of daily life, however, we have not to
determine whether the egg or the hen occurred first, and until
the toxaemists accumulate more evidence we do well to with¬
hold a final deliverance.

The Cathcart Case .

After a period of more than ten years justice and mercy
have met in this case, some features of which are very interest¬
ing and may one day form the basis of a paper on medico¬
legal relationships.

The early history of Mrs. Cathcart’s illness was dealt with
at considerable length in the Journal of Mental Science for
October, 1891.

Many of our readers doubtless recollect that in the July of

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OCCASIONAL NOTES.

537

1902 .]

that year a very prolonged inquiry into her state of mind was
held before a Master in Lunacy, and that the jury decided that
she w r as of sound mind and fit to manage herself and her
affairs. The finding of the jury evoked much comment at
the time, and a contributor to one of the medical journals
expressed the view that was then prevalent when he stated :
4 * If it is the fact that she is now sane, all we can say is that the
case affords the most striking and conclusive evidence of the
benefits of asylum treatment ever publicly demonstrated, for
that up to a few months ago she was insane was put beyond
all question by her letters and actions, as was acknowledged
by the eminent specialist who was called on her behalf.”

Unhappily Mrs. Cathcart’s conduct, when she was discharged
from care, followed only too closely the course that was
predicted by those medical men who had carefully studied her
case. During the ensuing years—in fact, up till the date of
her imprisonment in May, 1901—she was almost incessantly
before the law courts. She changed her legal advisers a
dozen times, and in many cases declined till compelled to
pay their reasonable fees.

Saturated with suspicion, she trusted no one for long, and
became the prey of designing and unscrupulous men. She
employed detectives to watch her agents, and then instructed
a second set of detectives to watch the former ones. Some
of the solicitors into whose hands she fell were of the lowest
class, and this was brought out in the recent inquisition when
the judge commented on the number of those who had been
•employed by Mrs. Cathcart and had been struck off the Rolls.

In May, 1901, she had to appear before Mr. Justice Farwell;
she then refused to produce certain documents in her posses¬
sion, and was committed for contempt of court.

She was sent to Holloway Prison, where she spent a year.
Nothing would persuade her to purge her contempt. The
Treasury eventually decided to apply for an inquiry into her
mental state. Mrs. Cathcart, with characteristic conduct, at
first declined to have legal advisers, and then, having obtained
counsel, at the last moment declined to continue them in her
employment or to be responsible for their fees. She was
visited by Drs. Maudsley and Savage on behalf of the Treasury,
and she had the opportunity of consulting specialists of her
own selection, but declined at first to see any.

xlviii. 37

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538 occasional notes. [July,

The inquisition was held before Mr. Justice Grantham in¬
stead of a Master in Lunacy.

Mrs. Cathcart is a typical example of the disorder in which
cunning and suspicion are equally blended, associated with
organised delusions and with hallucinations. She is deaf, and
has very clearly marked hallucinations of hearing. A prominent
feature in her case is that she sees hidden meanings in every
movement and action of those about her. When examined by
the medical men who visited her in prison, she at one time
imitated their actions, and at another resented their supposed
interference. Even during the inquiry she imitated the actions
of some of the witnesses, and before leaving the court she
resented her own lawyer touching her, which he did when
calling her attention to some fact.

The whole case was fairly laid before the jury, who unani¬
mously decided that Mrs. Cathcart was of unsound mind, and
unfit to manage herself and her affairs.

An attempt was made by her counsel to ensure that an
order for the custody of her property only would be made,
while she would be allowed to have her liberty; but it was
pointed out that such a course would be certain to fail, as she
was so readily influenced by designing people.

The evidence of the prison medical officer (Dr. Scott) was
convincing, but that given by the female warders probably
influenced the jury more than did the evidence of the experts.
The evidence given by the medical men who were called on
behalf of Mrs. Cathcart told rather against her than in her
favour.

Now, fortunately, this lady will be, for the remainder of her
life, protected from scoundrels, and more or less at peace with
herself and the world. The end is satisfactory, but the mode
of reaching it could not be more unsatisfactory from a legal
point of view; whilst from the social aspect, the neglect of the
individual and the welfare of society by their special and most
eminent guardians is appalling to contemplate.

This unfortunate lady, for nine long years, was permitted week
by week to demonstrate her insanity before many of our judges.
The suffering inflicted on her relatives and friends was glaringly
obvious, the squandering of money only too palpable, whilst
the waste of public funds and the delay of justice to others by
her occupying the time of the judges was notorious. The

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1902 .]

OCCASIONAL NOTES.

539

absurd proceedings thus gravely dealt with constituted a
contempt of court of a far more serious character than that
for which the unfortunate lady was at last committed to prison.
Finally, this lady, suffering from insanity and utterly irrespon¬
sible, was imprisoned for an obviously insane act, and for a
whole year lay untreated in prison before her insanity was
brought to a test.

A magistrate, if informed that an insane person exists in his

district, is enjoined by the law to take steps for ensuring
proper treatment.

Is it not even more clearly the duty of judges, if not moved
by pity or feelings of humanity, at least to protect their courts
from being occupied by insane persons, who furnish amusing
paragraphs to the evening papers, or supply pitiful prey for
legal scavenger sharks ? If such a duty on the part of our
judges becomes recognised as a result of this case, this unhappy
lady and her friends will not have suffered in vain ; but that
such will be the result is, we fear, utopian.

Justice and mercy have met at last; but all this suffering
and scandal might have been avoided ten years ago by a
union between common sense and law.

The Bayigoiir Asylum .

Dr. Clouston, in a letter to the ‘Scotsman’ (May 5th),
strenuously urges on the Edinburgh Parish Council the
desirability of making a receiving hospital near the town, as a
part of their scheme for providing for the treatment of the
insane.

He advises that the incipient insane should be treated in the
Royal Infirmary (as recently proposed), the acute insane in
this hospital, and the prolonged and chronic cases at Bangour.

The hospital, he suggests, should not be built on the palatial
system, but on one that would not involve a cost of more than
£200 per bed, and should be named in such a manner that
the patients should not consider they had been in an asylum.

These suggestions, if carried out thoroughly in conjunction
with hospital out-patient departments, would constitute a very
considerable advance in the systematic treatment of mental

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540

OCCASIONAL NOTES.

[July,

disease, and would yield to Edinburgh the honour of being the
pioneer in this country of the reception hospital system, which
has worked so satisfactorily in Australia and in Copenhagen.
An account of the latter from the pen of Dr. Pontoppidon
appears in this number. The London County Council nearly
adopted this system, but has unfortunately relapsed to im¬
proved workhouse infirmary wards, officered by infirmary
superintendents.

The prediction may be safely hazarded that if this system is
established Edinburgh will not be rewarded by honour only,
but will soon show statistically that benefit has resulted to
both population and purse.

Incidentally, too, it would tend to reduce the outlay on
architectural display to which insane benevolence has so
largely tended of late, and Bangour might still be built at
something approaching the cost of Alt Scherbitz.

In Scotland, as in England, it seems difficult to persuade
the benevolent builders of asylums and their architects that
insanity is not treated by palaces, but by physicians ; not by
bricks, but by brains.

The Association of Asylum Workers.

The annual meeting of this association, held on May 22nd,
under the presidency of Sir James Crichton-Browne, gave
ample evidence of the great progress this association is making,
and of the useful work performed by it.

The increase of membership from 2868 in 1900 to 4116 in
1901 is indicative of the rapid spread of its influence, while a
striking proof of its usefulness was given in the distribution of
medals for long and meritorious service.

Gold medals were given to Mr. W. Hope, inspector of
Colney Hatch Asylum (thirty-six and a half years' service),
and to Miss M. Riches, head nurse at Heigham Hall, Norwich
(thirty-five and a half years' service). Two silver and twenty-
eight bronze medals were also awarded. The importance of
the encouragement to faithful service thus given is too obvious
to need comment.

The President gave an interesting, instructive, and stimu-

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OCCASIONAL NOTES.

1902 .]

541

lating address in his usual admirable and effective manner,
adding greatly to the success of the meeting.

Lunacy Legislation .

The Session of Parliament has so far advanced without the
introduction of a Lunacy Bill, that no expectation of such an
event can now be indulged. Bills, unlike other offspring, are
sometimes the better for a protracted gestation, and the Lunacy
Bill, when the Lord Chancellor is at length brought to the
woolsack, ought to be of exceptional merit.

The Lord Chancellor, in considering the pension clauses,
should give full attention to the strong argument reiterated by
Sir J. Crichton-Browne in his address to the asylum workers,
of the increased efficiency of asylum staffs resulting from re¬
taining trained attendants by the inducement of pensions.

Another argument in favour of liberal pensions to asylum
superintendents has not been so generally recognised, and
that is the fact that owing to the law against the establish¬
ment of private asylums, retired superintendents are prevented
in a large measure from using their professional experience.
Many pensioned asylum superintendents would be able, and
would be specially qualified, to treat a few patients with
advantage both to themselves and the community. In the
existing state of the law they are subjected to disability in
this respect, being permitted to take only one patient.

This disability is not only a great injustice to the retired
asylum physician, but is a great wrong to the public, which is
thus debarred from obtaining the services of men of the very
largest experience of insanity. Whenever lunacy law makers
recover from their serious attack of prejudice against alienist
medicine, one of the first reforms will be, not only to license
“ houses,” but also to license “ physicians ” with special experi¬
ence, to treat the insane. Asylum medical officers would then
retire much earlier, and consequently need smaller pensions.

The existing injustice, so long as it continues, constitutes a
most important claim on the part of the asylum medical
officers to liberal pensions.

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542

OCCASIONAL NOTES.

[July,

Physical Culture in America.

A bill has been recently introduced into the Senate of the
United States providing for the creation of a department of
physical culture, whose head is to be “ a member of the
Cabinet.” Each State, moreover, is to have “ a Commissioner
of Physical Culture ” at a salary of £>800 , whose duties will
comprise the preparation of plans for playgrounds, gymnasia,
parks, public baths, and other facilities for physical culture, and
who will have general charge of all such matters within the
State limits.

If the war just concluded has inculcated any great truth, it
certainly is that of the vast national importance of physical
health and development. It has demonstrated that national
wealth or intellectual culture are useless in war unless associated
with physical vigour, and there can be little doubt that what is
true of the struggle of war is equally true of the competition
of peace. Nothing probably is or can be of greater im¬
portance to the nation than this question of physical develop¬
ment, brought home to us as it has been by the enormous
number of rejections of recruits in some districts during
the war.

The member of our Legislature, however, who would venture
to introduce such a proposal as the above would run the risk
of being spoken of as the member for Bedlam. The bill,
if it becomes law, should have an important influence on the
mental health of the population of the United States, and
demonstrate again the truth contained in “ mens sana in corpore
sano”

Epidemic Irrationality : an American City of Unreason .

“ Leaves of Healing,” which the Lancet describes as “ a very
curious sheet,” gives information of the foundation of “ Zion
City,” already possessing a population of several thousands
(medical men being excluded), a mayor with corporation,
subordinated to a Theocratic committee, itself dominated by
the Rev. J. A. Dowie. “Theocracy” must now, therefore, be
added to the list of the forms of government.

All disease in the new city is to be treated by prayer, the

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recorded results of which are reported to be wonderful. The
alienists of the United States, however, do not seem to be
alive to their opportunities, or the inhabitants of their asylums
would ere this have been sent to the new city for cure.
Perhaps this has already been done to some extent.

We would also suggest that the sanitary authorities might,
with advantage, send a few cases of smallpox to be treated
by the Zionists.

Irrational associations have long ceased to attract much
attention beyond a feeling of compassion or amusement.
This community, however, is so large, and is the outcome of
such an extensive outburst of irrationality, that it really calls
for grave consideration, and raises the question whether there
is not something seriously wrong in the modern systems of
education : for it can scarcely be believed that all these
afflicted persons are really examples of degeneracy.

The sufferers, in a large majority of instances, are of the
so-called “ educated class ; ” that is, a class who have been
much taught and have read a great deal. Many of them
remember a large amount of what they have been taught and
of their reading, and are consequently spoken of as “ highly
cultured,” “ intellectual,” etc. It is a question indeed whether
the condition is not one in which the memory has been highly
developed, whilst the judgment has been utterly neglected and
consequently deteriorated.

Zion City must afford unlimited opportunity for the study
of this form of brain stunting, and we hope that the American
Congress will appoint a scientific commission to investigate the
causes and nature of the epidemic.

Part II— Reviews.

A Text-book of Insanity . By Charles Mercier, M.B., M.R.C.P.

London : Swan Sonnenschein & Co., Ltd., 1902. Pp. 222, sm.

8vo. Price 6 s. net.

Dr. Mercier is indefatigable. Hardly has his magnum opus been
discussed in these pages, when, lo ! a little text-book appears. This
time, however, it is milk for babes, not the hard tack of a few months
ago. He has been moved to publish a text-book of such dimensions

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and of such a nature as he considers suitable for medical students who
have to assimilate vast masses of material during their brief curriculum.
By the omission of illustrative cases and the rigorous avoidance of dis¬
cursiveness, directness of statement is attained—and the student must
skip nothing from cover to cover. The personal note dominant in a
book designed on this plan reveals the teacher grounding his pupils in
the institutes of insanity, and reviewing its various forms and varieties
discussed as types. No doubt Dr. Mercier, in the more important
clinical instruction to which formal lectures are but introductory,
softens his dogmatic tone, and more fully indicates the difficulties
which await the young practitioner in dealing with individual patients.
In the first instance, it is evident that Dr. Mercier’s introduction to the
study of mental diseases will be highly appreciated by the over¬
burdened student, because he will find in this book a lucid account of
the subject, leading him to a due understanding of problems which he
cannot evade in professional life.

In planning a text-book on insanity the main difficulty is to arrange
the mass of knowledge regarding mental disorders on a logical method.
Dr. Mercier, continuing his established practice, divides his subject
into three parts. The first deals with conduct, mind, certifiability, and
the causes of insanity. Thus the student finds the way cleared for the
second part, which describes the forms and varieties of insanity, before
passing to the third part, which is concerned with the legal relations of
insanity.

We need not refer at length to the contents of the first division of
the book, which are a resumt of Dr. Mercier’s opinions already familiar
to our readers, and should be followed out by those desirous of further
specialising, in his other works—especially Sanity and Insanity , and his
article on “ Vice, Crime, and Insanity ” in Clifford Allbutt’s System of
Medicine.

The chief interest of the present text-book lies in the second part,
and we therefore briefly indicate - Dr. Herder’s position. By a form
of insanity he means a certain aggregate of symptoms that a case of
insanity presents at one time ; by a variety he means a specific course
that a case may run from beginning to end, usually combined with an
assignable cause. He rightly insists that every case of insanity is a
form of weak-mindedness, and shows that the same form of insanity
may be exhibited by different varieties, thus treating the forms of in¬
sanity as symptoms, and the varieties as diseases. In this way general
paralysis is regarded as a variety, while exaltation and depression,
either of which may be characteristic of that variety, are described as
forms of insanity. Dr. Mercier classifies the forms of insanity as
follows : (a) weak-mindedness, (b) stupor, (c) depression, (< I) excitement,
(e) exaltation, (/) suspicion, (g) systematised delusion, (h) obsession
and impulsiveness, {k) moral perversion; and the varieties of insanity
as follows : (i) idiocy and imbecility, (2) dementia, (3) stupor, (4) acute
delirious mania, (5) acute insanity, (6) fixed delusion, (7) paranoia,
(8) folie circulaire, (9) insanity of reproduction, (10) insanity of times
of life, (11) insanity of alcohol, (12) general paralysis, (13) insanity of
epilepsy, (14) insanity of bodily disease. This method is convenient
for the purposes of clinical teaching, and is, perhaps, as good a pro-

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visional scheme as can be devised, pending the results of pathological
researches, for which, indeed, a teacher cannot wait. The student is
thus led on from the elementary study of mind and conduct, through
the symptomatic characteristics, to the groups which have been
differentiated for practical purposes. No doubt, if Dr. Mercier had
been writing a more elaborate treatise he would have modified some of
his statements at the risk of discursiveness and uncertainty. For
instance, in speaking of recurrent insanity, he says that recovery
becomes less and less complete until a definite state of dementia takes its
place in the cycle. Our experience is that the slight degree of dementia
in fully established cases of folic circulaire is astonishing, after the
severity and number of maniacal attacks. Again, in referring to general
paralysis associated with syphilis, he says antisyphilitic remedies have
never proved useful; whereas successful cases have been recorded from
time to time, and should encourage further trials on the same line.
No doubt, consideration of such points would have rendered the text¬
book more unwieldy than desirable, so we must be content with the
limitations within which Dr. Mercier has confined his work.

The publishers have done their part in turning out the book in a
handy readable form. We note a mistake here and there which
should be corrected in future editions, e . g. “ sesophagial ” for “ oeso¬
phageal ; ” and surely “ melancholiacs ” is to be preferred to “ melan¬
cholics.”

Encyclopedia Medica , under the general editorship of Chalmers
Watson, M.B., M.R.C.P.E. Large 8vo, illustrated ; vols. i to
iii. Edinburgh: William Green and Sons, 1899 et seq. Price
20 s. net each volume.

The first three volumes of this notable work are now before us, and
we heartily congratulate Dr. Chalmers Watson upon the assured success
of his great undertaking. It was projected to furnish medical men with
a work w r hich, differing from all existing ones, w'ould be a medical and
surgical library in itself—complete, concise, authoritative, and easily
referred to. The cost is moderate, considering the great array of names
of authors and the space which has been placed at their disposal. We
believe that the editor has hit a happy medium in all the difficulties of
allocating space to the w r ell-known physicians and surgeons whom he
has induced to support him in the production of an encyclopaedia which
is thoroughly practical and up-to-date. There is, of course, an inevi¬
table tendency to repetition and to lack of unity in presentation of so
many facts and opinions; but, on the other hand, the monographs are
generally the wwk of specialists on the various subjects, and what may
be contradictory is not much in evidence nor relative to points of great
importance. The advantage of such a work as this, accessible as it is
to every one wdio is interested in the details of his professional life, and
eager to learn the latest pronouncements of science in reference to his
daily difficulties, lies in the admirable arrangement of its parts and the
full information it affords. The Encyclopedia Medica is not an affair
of snippets, nor is it discursive and wearisome in consultation. Nothing

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can be more vexatious than to take from the shelf a book of reference
which fails in the matter of relevant details, or which deters a reader by
the multiplicity of outworn opinions written round the subject on hand.
In order to attain symmetry of treatment in the presentation of know¬
ledge, Dr. Chalmers Watson has arranged for a synopsis, or index, at
the beginning of each important subject. By this method he has
attained something of French precision and form, which one seeks for
in vain in certain other works of this kind—especially in those of
German origin. There is also a brief, useful appendix to each article,
giving the literature which may further be consulted. Thus the reader
is led on to the study of what may be interesting to him or vital to his
purposes.

We do not profess to have read the whole of these bulky volumes,
but we have perused with careful attention those articles which are
more nearly related to the work of psychiatrists, and we find them
satisfactory in form and intention. Taking the first of these, Acromegaly ,
by Professor Dreschfield, we have in it a succinct account of all that is
known on the subject, down to the year of publication. Or turning to
the last, on Food\ which is to be read with others on Diet and Invalid
Feeding , we have a resumk of practical importance—with a description of
the characteristics of good meat, and the characteristics of unsoundness ;
a brief summary in regard to milk and milk products; and lastly, a
chapter on the effects of eating impure food.

The Brain is approached from the point of view of Physiology, by
Dr. A. Bruce; the Vessels, by Dr. James Taylor; Tumours, by Dr.
Risien Russell; Atrophy, by Dr. R. A. Fleming; and Surgery, by Mr.
Cotterrill. But in addition to these main articles such special diseases
as Aphasia , by Dr. Byrom Bramwell, and Epilepsy (including Epileptic
Colonies) y by Dr. Aldren Turner, are very fully considered in all their
bearings. We note, too, that the Cerebellum is separately treated by
Dr. Risien Russell, who begins with an account of the relative experi¬
mental physiology, and then passes on to describe the effects of
haemorrhage, softening, tumours, atrophy, and ataxy, with the diagnosis,
prognosis, and treatment appropriate to each. Equilibrium is sepa¬
rately dealt with, so that the whole of the relative physiology and
pathology is appropriately summed up. These studies have required
adequate illustrations, and the publishers have not withheld these in the
endeavour to make the text readily understood. A very important
article on Bloody by Dr. T. H. Milroy, also commands our attention.

Coming to Mental diseases, we find that the editor has been fortunate
in securing the services of authors well entitled to be considered repre¬
sentative. Dr. Clouston treats of Adolescent Insanity , Alcoholism has
been the work of Dr. G. Wilson, Climacteric Insanity is described by
Dr. Urquhart, and Cretinism by Dr. John Thomson.

The articles on Civil Incapacity and Criminal Responsibility are
rather meagre from the medical point of view\ They could have been
improved had the advocate-author written them in collaboration with a
medical expert. In this connection, however, we would draw special
attention to the article on Aphasia by Dr. Byrom Bramwell, where the
difficulties in regard to civil capacity are fully and most judiciously
considered.

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We need not continue these brief notes of this important work; our
aim has been to indicate the results of our study of it; and our hope is
that it will find a place in asylum libraries as most useful for reference
in regard to many subjects of interest, designed to bring asylum physi¬
cians into touch with allied departments of medicine and surgery.

Recherches Cliniques et ThPrapeutiques sur rApikpsic^ PHystcrie, el
PIdiotie [Clinical and Therapeutical Researches on Epilepsy,
Hysteria, and Idiocy]. By Dr. Bourneville, with the collabora¬
tion of MM. Crouzon, Dionis du Sejour, Izard, Laurens, Paul
Boncour, Philippe, and Oberthur. Paris: aux Bureaux du
Progrte Medical, and Felix Alcan. Large 8vo, pp. 236 (with
11 plates and 19 illustrations in text). Price 6 f.

In this annual volume Dr. Bourneville and his coadjutors record

their experience, not only in the routine work of the departments for
imbecile and epileptic children at the Bicetre and Fondation Vallee,
but in several lines of research arising therefrom. The usual institution
statistics appear in the opening section, showing that there were at the
beginning of 1900 at the Bicetre 449 male patients, and at the
Fondation Vallee 199 female patients of the class named above. Six¬
teen deaths were recorded at the Bicetre, and eight at the Fondation
Vallee during the year. The discharges and transfers were respectively
eighty-six and forty. Some interesting details of classification and of
individual improvement noted in some of the younger cases are also
given in this section.

A chapter is next devoted to the advocacy of the establishment
of special classes for backward children, in connection with the Com¬
munal Schools of Paris, and a rcsuml of what has been done in this
direction in Italy, Holland, and Berlin (following a communication
printed in a former report as to special instruction in England, Belgium,
Prussia, and Switzerland) is given in the form of a memorandum to the
Commission of Supervision of the Asylums for the Department of the
Seine. In spite of Bourneville’s persevering advocacy, no steps have
yet been taken by the school authorities for the formation of special
classes in Paris, though he points out that in view of the increasing
demand for institution treatment for defective children, much in excess
of the 1068 beds available, it is desirable to adopt all feasible means for
the amelioration of such as are fit to remain in their own homes. A
scheme of domiciliary aid with medical supervision for cases of slight
mental defect, for mild epileptics, and for adolescents discharged from
Bicetre to their own homes—a species of outdoor relief which need
not cost more than a franc or franc and a half a day—is spoken of with
approval, though Bourneville would evidently prefer a colony plan if
practicable.

In the second portion of the Recherches we find clinical, therapeutical,
and pathological observations all well worked out, and some of consider¬
able interest. One is of family spastic infantile diplegia existing in two
brothers, with an account of the autopsy of one which disclosed atrophy

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of the cerebellum as well as of the pons and peduncles. The thyroid treat¬
ment of a case of “ myxcedematous idiocy ” is related in minute detail
in another essay. Marked improvement in a case of profound idiocy
after four years’ treatment, medico-pedagogical and hydrotherapeutical, is
chronicled in another section. The statistics of the influence of consan¬
guineous marriages in the production of epilepsy, hysteria, idiocy, and
imbecility are discussed, Dr. Boumeville’s conclusion being that consan¬
guinity of parents (shown in 3*23 per cent, of his cases) is, per se f an
insignificant factor apart from morbid heredity. An interesting and im¬
portant collection of microcephalic cases, illustrated by photographs of
living patients who were shown at the International Medical Congress
in Paris, forms the subject of another chapter, in which it is shown that
even in this class considerable amelioration may be effected by perse¬
vering educational efforts. MM. Philippe and Oberthur contribute
some particulars of histological examinations in hydrocephalic idiocy,
in idiocy following meningo-encephalitis, in cases with atrophic sclerosis
of the frontal lobes, in epileptic and hemiplegic idiocy consecutive to
parental alcoholism, and in idiocy with cerebral atrophy, pachymenin¬
gitis, and cyst of dura mater. The lesions observed have evidently been
carefully studied and recorded. Minuteness of detail indeed character¬
ises in a special manner these Recherches, which, illustrated as they are
by a number of large photographs and drawings of brains, worthily
continue the series of annual volumes for which the Children’s Section
of Bicetre has so long been renowned. G. E. Shuttle worth.

The Treatment of Neurasthenia. By A. Proust and Gilbert Ballet.
Translated by Peter Campbell Smith. London: Henry Kimpton,
1902. Foolscap 8vo, pp. 213. Price 5 s. net.

Dr. Smith has made a useful present to English-speaking medical
men. Neurasthenia, a plant of American growth, has not taken deep
root in Britain. An eminent physician wrote to me not long ago that
he saw no sufficient reason to accept neurasthenia as a special disease.
The differentiation of new diseases is like the engravings which contain
a hidden figure of a man or a cow or some other creature which can be
made out after a little scrutiny. If one will not take the trouble to
look for the tracing, the figure will not be descried. Doubtless this
experienced physician had seen many cases of neurasthenia, but he
arranged them under different forms.

On the Continent this disease gets wider recogniton. There are at
least three separate books recently published in Germany on neuras¬
thenia, and a host of articles in medical journal^. The work under
review is the joint product of two well-known professors of the medical
faculty of Paris. They begin by observing, “ We cannot help thinking
that in some circumstances neurasthenia is commoner than it was sixty
years ago. In any case we recognise it better and give it a name when
we meet it.” The authors devote the first eighty-eight pages to a
description of the nature and causes of neurasthenia, and then pass on
to the prophylaxis. Here the authors observe, “ The modern concep-

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tion which accords to heredity a power at least equal to that ascribed
by ancient poets to fate is assuredly excessive.” Most frequently
hereditary influence does not produce irresistible outbreaks in the
progeny. It is then that education may intervene to give birth to
artificial instincts capable of balancing the hereditary instincts.

We have chapters upon psychotherapy, diet, climate, and hydro¬
therapeutics. The authors justly observe that experience has shown
that the best treatment of neurasthenia consists in a wise regulation
of the patient’s hygiene. In this, which is often no easy matter,
the patient needs the advice of the physician, who may derive help
from a work like this. There are some formulated methods of treat¬
ment which receive a well-considered appreciation. The causes of
nerve exhaustion nowadays are many and various, and different cases
require special treatment. The book is written with that clearness
and preciseness which is characteristic of French writers, and with
unusual felicity of expression. Dr. Smith has succeeded in putting it
into an English dress exempt from stiffness, and has added some
useful notes. William W. Ireland.

Li Audition. Par Pierre Bonnier. Paris: Doin, 1901. Pp. 275,

8vo. Price 4 f.

This volume belongs to a new “ International Series of Experimental
Psychology, Normal and Pathological,” edited by Dr. Toulouse, phy¬
sician at the Asylum of Villejuif and director of the Laboratory of
Experimental Psychology at the Paris Ecole des Hautes-Etudes,
well known also as the author of numerous works in various branches
of psychology and psychiatry. He has planned the series with his
customary energy and thoroughness; it is to comprise fifty volumes,
dealing, it would seem, with nearly every subject which can be included
under psychology. The contributors, while mainly French, have also
been recruited from Russia, Italy, Belgium, England (Professor Stout,
who will deal with metaphysics), America, and Roumania. German
and Austrian psychologists are, however, alike absent. The enterprise,
it will be seen, is a somewhat daring one ; it is the most aggressive
attempt which has yet been made by experimental psychology to take
a recognised place in the intellectual world, and to claim the support of
a large body of the intelligent public. It is to be hoped that Dr.
Toulouse will be able to carry out his enterprise with complete success.

The present volume, on the sense of hearing, is not nominally the
first of the series (that is to be by the editor and his assistant, Dr.
Vaschide, and will be devoted to “ The Examination of Subjects”),
but appears as the twelfth on the list. Dr. Bonnier is a specialist in
his subject; he devoted his attention to it even before he wrote his
Paris thesis, and he is the author, not only of a work on the ear in
four volumes, but of a long series of special memoirs on various
auditory subjects. In the present book, avoiding elaborate detail, he
discusses the conditions of hearing, the anatomy of the ear and its
functions, and the theory of hearing. Organic lesions are not dealt

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with, although various functional forms of deafness are described. A
considerable part of the volume is controversial, for the author has a
theory of his own which, while to some extent agreeing with Hurst’s,
is opposed alike to those of Helmholtz and Gelle. He believes that
the theory of hearing must be taken out of the region of acoustics into
that of hydrodynamics, and he insists that the ear is not a resonator
but a registering apparatus. This view he defends with much skill.
The theory of hearing, however, like the theory of colours, is one con¬
cerning which even the most competent authorities differ, and it would
be impertinent to express here any opinion on the merits of the case.

It may be added that the volume is well illustrated, but there is no
index, a defect to be noted also in most of the other volumes of the
series which have yet appeared. Havelock Ellis.

Les Emotions . Par G. Sergi, Biblioth&que Internationale de Psycho¬
logic Experimentale. Paris: Doin, 1901. Pp. 460, 8vo.
Price 4 f.

Professor Sergi, although he speaks with most authority as an anthro¬
pologist, has long taken a keen interest in psychology. In the present
volume—first published some years ago in Italian under the title of
Pleasure and Pain —he appears as the champion of the James-Lange
theory of the emotions, sometimes called the physiological theory, and
by Sergi the peripheral theory, since, as he considers, that term best
expresses its “opposition to the old theory according to which the
emotions, like intellectual phenomena, are of central and cerebral
origin; in our theory these phenomena develop primarily in the organs
of nutritive life, which, in relation to the brain, are peripheral.”

Sergi’s new contribution to the James-Lange theory is an attempt
to apply it to the aesthetic emotions. James had restricted the theory,
somewhat unreasonably, to the “coarser” emotions, excluding the
“ subtler ” emotions. Sergi seeks to show that such a distinction is not
required. How far he has succeeded the reader must judge for him¬
self. It cannot be said that either the truth or the falsity of this theory
has yet been conclusively demonstrated. Clinical facts and experi¬
mental demonstrations have been brought forward on one side and the
other. But emotional phenomena are so elusive and all-pervading that
it is extremely difficult to isolate them, and so far each party has had
little difficulty in showing that the evidence brought forward on the
other side is not absolutely conclusive. Every one adopts—and is
doubtless justified in adopting—that theory which best fits into his own
psychological system. On a question on which such judicious
authorities as Wundt and Ribot take opposite sides there is ample room
for difference of opinion.

This book has been well translated by M. Petrucci, and has been
revised by the author, who has written a new preface, and added a
final chapter in which he discusses the most recent objections and
criticisms. It is an attractively written monograph.

Havelock Ellis.

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La Morale . Par G. L. Duprat, Bibliotheque Internationale de

Psychologie Experimental. Paris : Doin. Pp. 400, 8vo. Price

4f.

This book is an attempt to state “ the psycho-sociological founda¬
tions of rational conduct,” and in the preface the author seeks to justify
the inclusion of a book on this subject in a series devoted to experi¬
mental psychology. In the past morals has been closely connected with
metaphysics. That is no longer possible ; we have, the author admits,
to content ourselves with a humbler task, but one which rests on a far
surer foundation. “ We have to vindicate for psychology, with which
we must associate sociology, the exclusive right to furnish the moralist
with the basis of his ethical doctrine. . . He who desires to show

men the best way of living must be a savant before he can be a moralist;
he must at least be inspired by all the scientific data which individual
and social psychology are in a position to give him.”

Dr. Duprat is well equipped for the task he has approached. It was
pointed out, in a review of the author’s previous book, LInstability
Mentale , in this Journal, that the value of that work was scarcely com¬
mensurate with the author’s varied accomplishments and training. In
the present work he has a more congenial task, and is able to make
much better use of his equipment. It is true that the results he
reaches are somewhat vague, but in outlining a new subject any undue
precision would have been out of place, and this sketch of morality, on
a scientific basis, will be found full of suggestive indications.

The work is divided into four parts. The first deals with method,
and the author sets forth the proposition that, though morals must
have a scientific foundation, it is not, properly speaking, a science, but,
at the most, applied science. Morals is, in the strict sense, a technical
matter—a craft. It is here compared to medicine, and the parallel
drawn between the moralist and the doctor.

The second part, entitled “ The Psychological Ideal,” covers a con¬
siderable amount of ground, and discusses heredity, determinism, and
the scope that is left for the individual; a chapter is devoted to the
criminal and unbalanced classes. The third part, “ The Social
Ideal,” deals with morality as affected by the state, with the part that
ought to be played by the state, and with marriage and the family.
One chapter presents a clear and unprejudiced sketch of the doctrines
of Tolstoy and Nietzsche, regarded as representing the two most
opposed ethical doctrines—the gospel of love and the gospel of struggle,
—and the author concludes that, while there are sound elements in
each, we cannot accept either without qualification; renunciation for
the sake of renunciation, and virility for the sake of virility, are alike
irrational. The concluding part deals with “ The Struggle against
Immorality.”

It may be added that an English edition of this book is announced
to appear, with a preface by Professor Stout. Havelock Ellis.

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La Mimoire . Par J. J. van Biervliet, Bibliotheque Internationale
de Psychologie Experimentale. Paris: Doin, 1902. Pp. 352, 8vo.
Price 4 f.

The name of Professor van Biervliet, of Ghent, is a guarantee of
careful and competent work, though not usually of a very brilliant or
original character. In the present volume he returns to a subject with
which he has dealt before, and presents us with a useful, concise, and
well-arranged summary of the experimental work bearing on memory
produced during the past fifteen years.

The book is divided into three parts. The first deals with rqental
retention, or what Richet has termed “ memory of fixation.” Here are
discussed the seat of memory, the types of memory, and the intensity
of mental fixation, including the amnesias. This important section
occupies half the volume. The second part deals with “ memory of
reproduction,” including its disorders, such as the amnesias due to
traumatism, disease, and intoxication (alcohol and tobacco), together
with those connected with various forms of insanity ; the experimental
investigations dealing with the association of images, emotions, and
ideas, are also summarised, and the nature of the bond uniting them
discussed. The last part is concerned with “ memory of identification,”
or with recognition and localisation in time. Various forms of par¬
amnesia are here considered, and more especially the inability to
recognise and identify. There is finally a short and rather slight
chapter on experimental methods ; this is the weakest part of the book,
which can scarcely be recommended as a guide to those who propose
to carry out investigations for themselves.

In following out his plan the author has not attempted to cover the
ground exhaustively, but has selected what seem to him the most
important investigations, whether carried out in Europe or America.
Full justice is done to American psychologists—Jastrow, Miinsterberg,
Scripture, Stetson, Miss Calkins, etc.,—and summaries are given of
Toulouse’s elaborate experiments on Zola, and of Binet’s on Diomandi.
Altogether the book will be found a very convenient compendium of
the experimental results lately reached in what is now a somewhat
large and complete field of work. Havelock Ellis.

L'Annee Psychologiqae. Publiee par A. Binet. Seventh year. Paris :

Schleicher. Pp. 854, large 8vo. Price 18 f.

The latest issue of this valuable annual is marked by the different
proportions in which the elements that constitute it now appear. The
original memoirs occupy considerably more than half the volume,
pp. 538, leaving less than pp. 150 for the analysis of current psychologi¬
cal literature, which bulked so largely in the early issues. The remainder
of the volume is devoted, as usual, to the bibliography, which this year
includes 2627 items.

Not only do the original memoirs this year constitute a larger portion
of the volume, but they are shorter than usual, so that their number

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extends to twenty-four. The first, of some length, is of biological
character, and embodies a minute study of the habits of one of the
most interesting of the wasps ( Bembex ) by Professor Bonnier. This is
followed by a series of papers by Dr. F 6 re, presenting the results of his
recent investigations concerning the variations in excitability and in
amount of work done under the influence of fatigue, and of various
jpleasant and unpleasant stimuli; the results of most of these inquiries
have already been noted in this Journal. These papers are followed
;by Mile. Joteyko and others, who deal with the relations of muscular
fatigue to the nervous centres. Professor Claviere investigates the
results of mental work and dynamometrical effort in schoolboys, and
finds that intense and prolonged mental work during two hours leads to
a notable and proportional diminution of muscular force as measured by
the dynamometer, that moderate mental work produces no appreciable
diminution of muscular power, while there is increase of muscular power
in the total absence of mental work. Dr. Claparede discusses the
question as to whether we possess specific sensations of the position of
the limbs, and defends the use of the term “ muscular sense,” the word
“ sense ” being an ancient term which it is impossible to attempt to
confine within narrow technical limits. Larguier des Bancels deals
with the estimation of coloured surfaces, showing how judgments of the
extent of a coloured surface largely depend on the particular colour.

Dr. Binet, the editor of the Year-book , contributes an important series
of five memoirs dealing with the measurement of the head in living
subjects, more especially school children. Binet observes that investi¬
gations of this and allied anthropological character are being pursued by
psychologists at the present time with much energy in various countries.
He has consequently set himself to acquire a technical knowledge of
anthropometrical methods, and the first of this series of memoirs
describes at length his own recent education in this matter; he
incidentally refers to various minor points in which the leading French
anthropologists, like Manouvier and Deniker, differ from each other;
his own methods appear to approach most closely to Deniker’s. In the
succeeding memoirs he proceeds to describe his study of the head
measurements of children in schools near Paris, carried out with a view
to ascertain how, if at all, intelligent children differ from unintelligent
children in head and face measurements. The subjects were, so far as
possible, racially homogeneous, belonging to the same region of France,
and all pathological subjects, including all “ defectives,” were excluded
from the inquiry. When the intelligent group was then compared with
the unintelligent group it was found that there was an advantage, on
the average, on the side of the former, but the advantage was very
slight. After much fruitless manipulation of these results, in the
hope of bringing out clearer conclusions, Binet resolved to compare
the two extremes, the very intelligent and the very unintelligent, omitting
those in the middle, and, as before, all abnormal cases. Much more
pronounced results were now reached. On the whole, it was found, the
intelligent children have slightly larger heads than the unintelligent,
the chief advantage possessed by the former being in greater maximum,
transverse, and also biauricular diameters. Nearly all the transverse
measurements are, however, greater in the intelligent, this applying to
XLVIII. 38

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the zygomas, and even to the lower jaws. Antero-posterior measure¬
ments show very little advantage to the intelligent, and vertical
measurements none at all. One measurement, indeed, and only one,
shows an advantage in favour of the unintelligent: the measurement
from the nostrils to the chin (inclusive of latter), thus including the
greater part of the masticatory region. The frontal region plays a very
small part in these differences ; it is very slightly broader in the intelli¬
gent, but only, it would appear, because the parietal region is broader.
Extreme variations were found chiefly among the unintelligent.

A related series of memoirs, but dealing with the weak-minded
and imbecile children at the Colony of Vaucluse, is furnished by
Dr. Simon. He finds that extreme variations, over and under the
average, are very marked, and much more so in idiots than in the
feeble-minded. Especially notable, apart from the general reduction of
the cranial vault and the constriction at base, was the tendency to
unequal development of the anterior and posterior portions of the
skull, the chief defect being in the posterior region. In the psycho¬
logical and anthropometrical study of idiots and the weak-minded we
have a field of research of great interest and wide-reaching significance^
and it is much to be regretted that it is not more frequently explored
with Dr. Simon’s thoroughness and care. Havelock Ellis.

Jahresbericht der Neurologic und Psychiatric [ Year-book of Neurology
and Psychiatry]. Vol. iv. For the year 1900. Berlin : S. Karger,
1901. 8vo, pp. 1100. Price not stated.

This volume, massive in size and highly important and instructive in
contents, would require a small volume to itself were justice to be done
in reviewing it. But as space does not permit this, and as many of the
papers summarised in it have already been noticed in this Journal, it
will be sufficient to draw attention in a general way to its contents.

Such a volume is of the greatest usefulness to any one who
endeavours to keep in touch with the progress which is being made
from year to year in this most interesting branch of medicine. It is
quite an impossibility for a busy man to read all the papers bearing on
neurology and psychiatry, and a general summary, such as the
Jahresbericht furnishes, is therefore most useful in enabling every one
to ascertain, with the least amount of trouble and expenditure of time,
what advances are being made in these important departments of
medicine. The names of those associated with the editors, Dr. Flatau,
of Warsaw, and Professor Mendel and Dr. Jacobsohn, of Berlin, are, in
most instances, already known over the whole world as masters in their
speciality. Such names as von Bechterew, Ewald, Jolly, von Leyden,
Lugaro, Obersteiner, Pick, Schlesinger, Verwom, and Ziehen are a
guarantee, if any were needed, that the work is carefully done, and that
the summaries of papers are written by men thoroughly acquainted with
their subject.

The book is arranged in sections, which are divided primarily into-

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REVIEWS.

55S

those dealing with neurology and with psychiatry; the former are further
subdivided into methods, anatomy, physiology, pathological anatomy,
pathology, and treatment. The latter also contains six sections, viz.
psychology, general aetiology, symptoms and diagnosis of mental
diseases, special forms of insanity, criminal anthropology, forensic
psychiatry, and treatment. Each of these is further divided into
smaller sections, so that no part of the subject escapes notice, and any
one can be readily referred to. There are, altogether, no less than
sixty-two different sections. There is an index of subjects and of
authors, so that it is easy to find any reference which one desires. At
the beginning of each section there is a complete bibliography,
and the total number of the papers and books included in these
lists amounts to no less than 6400. This of itself shows how com¬
plete the compilation is, and at the same time demonstrates the im¬
possibility of giving more than a general notice of the book. We have
tested its accuracy in the case of a number of short papers published
in some of the smaller medical journals, and have found them all
included. Most of the papers mentioned in the bibliographical list are
summarised in the immediately subsequent pages. These rhutnis are
clear and accurate, though necessarily not critical. There are, unfor¬
tunately, numerous printing errors, especially in the names. This is
perhaps excusable, and is the only fault that can be found with an
admirable and thoroughly useful book. Jas. Middlemass.

Zur Lehre von der Blutzirkulation in der Schddelhdhle des Menschen
namentlich unter den Emfluss von Medikame?iten. Experimentelle
Untersuchungen von Dr. Hans Berger, Hausarzt d. Psychiat.,
Klinik zu Jena. Jena : Gustav Fischer, 1901.

Much the larger part of this instructive monograph is devoted to a
review of previous literature on the subject, beginning with a general
historical introduction which occupies nearly half the book. This is
well done upon the whole, and will be useful to future workers, though
it is not quite complete, there being no mention, for instance, of
Cavazzani’s important contribution to the subject, while Robertson’s
views as to the functions of the dural perivascular canals are not noticed.
In general, however, the work of the British school has justice done to
it. The conclusion on page 36, that “the circulation in the closed
cranium must take place under the same conditions as in the rest of the
body,” can scarcely be regarded as proved ; and we notice an error on
page 54, where it is stated that Gulland failed to find nerves in the
walls of the cerebral blood-vessels.

The author’s own observations were made partly on animals; but the
most noteworthy are those on a patient with a considerable cranial
defect, the method used being chiefly that of Mosso, and plethysmo-
graphic tracings from the arm being taken simultaneously. A good
deal of the work covers old ground, including a study of the circulatory,
respiratory, and vaso-motor movements of the brain, and touches on
many points of interest. For instance, the author supports the view of

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REVIEWS.

[July,

Mosso that the vaso-motor waves are of two kinds, passive and active,
the latter (clearly shown in one of the curves) implying the existence of
vaso-motor nerves. The danger of mistakes from the marked effect
produced upon the curves by slight changes of position, respiration, etc.,
is an important point strongly insisted on.

The most generally interesting section of the book, however, is that
which deals with the effect of drugs on the cerebral circulation. It
includes, besides a review of the literature, a number of original obser¬
vations on amyl nitrite, camphor, digitoxin, caffein, cocain, ergotin,
morphin, and hyoscin. Amyl nitrite was found to exercise a specific
dilating action on the human cerebral vessels, as on those of animals.
Digitoxin and ergotin increase the cerebral blood-supply, both, probably,
by augmenting the general arterial pressure. On the other hand,
morphm and hyoscin lessen the supply of blood to the brain, the
latter by actual con traction, of the cerebral vessels, so. that it should be
used with caution where cortical malnutrition is suspected. Camphor
and caffein seemed to have no effect whatever, and cocain, strange to
say, actually reduced the height of the cerebral pulse-waves, an import¬
ant observation showing that increased chemical change (as manifested by
rise of temperature and subjective and objective phenomena) is not
necessarily accompanied by increased blood-supply. It is right to say,
however, that some of these statements are apparently based on single
experiments. The facts taken together tend to show that the drugs act
for the most part directly upon the nerve-cells. The monograph is
liberally illustrated with curves. W. R. Dawson.

Reports of the Cambridge Anthropological Expedition to Torres Straits .
Vol. II, ‘Physiology and Psychology;' Part i, “Introduction and
Vision.” Cambridge : University Press, 1901. Pp. 140, 4to.
Price 9 s.

The straits between Australia and New Guinea, named after the great
Spanish navigator whose pioneering discoveries in these regions are
only now beginning to receive the credit due to them, have long served
to indicate one of the main southern trade routes, but have seldom
attracted scientific investigators. Some fourteen years ago, however,
Dr. Haddon was in that region exploring its marine zoology. While
studying the fauna, by a natural transition he became interested in the
people. The final result of the visit, indeed, was that Dr. Haddon
abandoned zoology and devoted his great and versatile energies entirely
to anthropology ; at the present time he is the President of the
Anthropological Institute of Great Britain. His interest in the
peoples of Torres Straits still continues, and a few years ago he was
enabled to carry out a cherished plan for a thorough scientific and
methodical investigation of the district, anthropological and psycho¬
logical. The Cambridge Expedition, conducted by Dr. Haddon,
including many able specialists, especially Dr. Rivers in psychology,
and well equipped with scientific instruments, is notable as the first
considerable scientific expedition which has ever been sent out to study

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1902.]

REVIEWS.

557

anthropological and psychological phenomena. The results of the
expedition will be published in some six volumes, of which the present
part—for which Dr. Rivers is mainly responsible—is the first portion to
appear.

Dr. Rivers’ investigation of the vision of the natives mainly falls into
three divisions: (i) visual acuity; (2) colour-vision; (3) visual spatial
perception.

Visual acuity was tested according to several methods, of which the
most satisfactory was found to be Snellen’s method, by which the letter
E is held in various positions. There was found to be no marked
difference between the visual acuity of the European and the Torres

Straits Islander, such difference as was found being to the advantage of
the latter. Visual acuity declines at an earlier age than in Europe.
Myopia was rare ; astigmatism was occasionally found. There was
some reason to believe that the natives could see better in the dark
than Europeans, and Dr. Rivers would explain this by greater abundance
of pigment and more rapid formation of visual purple. With regard to
the slight difference in visual acuity between the European and the
Torres Straits Islanders, Dr. Rivers is in agreement with those who
attribute the visual feats of savages to greater practice in observation.

The investigation of colour-vision was carried out chiefly with
Holmgren’s wools and Lovibond’s tintometer, and due care was taken
to avoid fallacies. Not one case of red-green colour-blindness was
found among 152 natives of Torres Straits and the Fly River District,
but there was some reason to suspect the presence of the rare condition
of yellow-blue blindness. Confusion between green and blue was very
common, also between blue and violet, while red was always well
discriminated. Colour nomenclature and the derivation of colour
names were also carefully investigated ; as in other parts of the world,
the common name for red was found to be derived from blood, and of
green from gall. The colour words for red and yellow were found to
be the most definite and best established. The interest of Dr. Rivers’
report is greatly increased by the constant reference to the results
reached by previous investigators of primitive peoples. These references
are full and accurate, though at one point—in reference to colour-vision
—the previous state of the problem seems not quite accurately repre¬
sented. Magnus is classed among those who have based a belief in
primitive defectiveness of colour-vision on the evidence of nomenclature
alone. It is true that in his first book Magnus ranged himself with
Geiger, but, unlike Geiger, he was an ophthalmologist, not a philologist,
and in his two subsequent pamphlets on this subject he clearly stated
that philological evidence is not adequate to prove the defective
colour-vision of primitive peoples. And he not merely “ argued ” that
defects in colour-vision have a probable physiological basis, he attacked
the question directly. With the advice and aid of Dr. Pechuel-Loesche,
an eminent traveller and ethnographer, he set on foot inquiries among
many different races in various parts of the world, besides col¬
lecting such existing evidence as he could find, and he reached the
conclusion that among primitive peoples there not only must be, but
actually is, a tendency to defective perception of blue and green. Al¬
though he could not command the facilities at the disposal of the later

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558

[July,

investigator, his position twenty years ago was exactly the same as that
of Dr. Rivers to-day.

In making observations on visual spatial perception there appeared
reason to believe that the natives showed less sensitiveness to optical
illusions than Europeans.

On the whole, this first instalment of the results of the Cambridge
Expedition fully demonstrates the great value and interest of the results
that have been reached. Havelock Ellis.

Trattato di Psichiatria . Del Prof. Bianchi Leonardo. Napoli: 1902.

Part II, pp. 171 to 377. Price 1 . 6.

As already indicated in the notice of the first part of Professor
Bianchi’s text-book {Journal of Mental Science , October, 1901, p. 786),
this second instalment deals with the elementary symptoms of mental
disorder, and is intended to form an introduction to the clinical study
of insanity. It consists of seven chapters, in which the physiology and
pathology of perception, of attention, memory, ideation, the emotions
and sentiments, the will and consciousness are successively considered.
It is virtually a succinct treatise upon normal and pathological
psychology. It is coloured throughout by the strong individuality of
the author, who has beyond question given a masterly exposition of this
difficult subject. In view, however, of the fact that a translation is in
preparation, and as, in ordinary course, the complete work in its English
dress will be reviewed in this Journal by some one fully competent
for the task of duly estimating the value of new contributions to
psychological literature, it will, perhaps, suffice for the present to have
indicated the general scope of this second part. As the third part is
already in the press, it may be hoped that the complete work will soon
be available to the English reader. W. Ford Robertson.

Parole Pronunciate dal Prof. Clodomiro Bonfigli , Presidente della Lega
Nazionale per la Protezione dei Fanciulli Deficient /, il'24 Aprile ,
1901, nelF Innaugurazione Ufficiale dell 1 Istituto-Medico-Pedagogico
della Lega [Inaugural Address of Professor Bonfigli on the
Opening of the Institution for Mentally Deficient Children at Rome\.

Prof Doit. G. C. Ferrari: Istituzione della Lega Nazionale per la
Protezione dei Fanciulli Deficienti [Dr. Ferrari on the League for
the Protection of Deficient Children J.

A. Gianelli: Sulla Educazione dei Fanciulli Deficienti [On the
Education of Deficient Children ]. Passegna Internazionale , 1

Marzo , 1902.

Resoconto Finanziario della Lega Nazionale , 1899—1901.

Relazione Finanziaria de FIs tituto Medico-Pedagogico. Rome , 1902.

{Financial Statements of the said Institution.)

Towards the end of last March, along with Dr. Alexander Robertson,

I visited Rome, when I had the honour of being shown through the

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1902.]

great asylum of Santa Maria della Pietk by the superintendent, Dr.
Clodomiro Bonfigli. How much pleasure did it give me to converse
with this distinguished professor, and to be introduced to his brilliant
staff of young physicians and pathologists! The survey of the
numerous buildings presented many novel features. The library, the
offices, the wards, with some unwonted types of insanity, the grounds
gay with early flowers and the trees and shrubs of a warmer sun, and,
lastly, the commanding view from the summit of Janiculum, with the
Alban hills on one side, the Vatican and the Eternal City on others,
filled my mind with a crowd of images which it would be vain to
endeavour to record. I shall, therefore, content myself with the
account of a visit which I made on the afternoon of the same day to
the new training school for imbecile boys in the Via Pietro Cossa on
the right bank of the Tiber, near the Ponte Cavour.

The first school for imbeciles in Italy was begun by the Senator
Vincenzo Tommasini on the Janiculum in 1884.

The first approach towards the present institution was made by
Professor Bonfigli in the Chamber of Deputies about five years ago.
He urged the necessity of taking Italy out of its inferior position, com¬
pared with other civilised nations, in the education of deficient children.
The Minister of the Interior, while admitting the desirability of the
-object, declared that the State was not prepared to assume such a
charge. Turning his hopes upon private charity, Bonfigli founded in
1898 the League for the Protection of Deficient Children, which re¬
ceived the adhesion of the principal scientific and political men of
Italy. Doctoress Montessori undertook to lay this object before the
public, which she eloquently advocated through the principal towns
of Italy. Enthusiasm was kindled, and local committees were formed
to collect subscriptions. Professor Bonfigli began by instituting a
preparatory school for the training of teachers in this special branch of
education. Those who had already acquired a certificate of teaching
for the primary schools were instructed in the elements of biology,
hygiene, and the ordinary symptoms of deficient mental power, as well
as the methods and art acquired in the special teaching of the deaf and
blind. The present training school for imbeciles was begun a year ago
in a conventual building. In time, no doubt, more suitable quarters
will be obtained in a less inhabited neighbourhood. At present it gives
instruction to fifty-six boys. Fifty of these were sent from the asylum
by Dr. Bonfigli, their cost being defrayed by the provinces; six are
private boarders. All the children I examined seemed educable, save
perhaps one, a microcephale. The circumference of his head was 37 c.
They seemed in good health, and had every sign of being well cared for.
The institution is under the direction of Dr. Montesano, with a
secretary. The staff of teachers is liberal, allowing suitable division of
•classes in small schoolrooms. There is a matron and five governesses,
and male teachers of music, gymnastics, and language. They have the
services of eminent medical men in special diseases. The school
material is ample and varied. There were some appliances of Italian
device for testing sight and touch which I had never seen before.
Evidently every means are used to awaken a dull apprehension and
hold the attention of the pupils. The symptoms of the inmates, their

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560

EPITOME.

[July,

grades of intelligence, and their progress are carefully noted, and, in
time, observations important to psychology may be expected to come
from Dr. Montesano’s institution. Here I had the good fortune to
meet Professor Tamburini, of Reggio Emilia, and Dr. Virgilio, of
Aversa. These distinguished physicians were in Rome for a few days
to prepare for the Government a report upon the asylums of Italy. I
accompanied them through all the rooms, and saw everything. A
chamber had been set apart for scenic exhibitions, which was darkened,
and on the little stage a pantomime was performed by three of the
pupils. One of the governesses explained the meaning to the rest as
the acting went on. In the Rassegna Professor Gianella explains in a
popular way the need and use of instruction for the imbecile, and the
methods which have been proved for conveying it. The paper is
illustrated with some woodcuts. His information seems almost wholly
derived from French sources; but these are so ample that nothing of
moment is omitted.

From the financial statements it appears that the daily cost to each
pupil comes to 1 . 0*55 ; the monthly board to 1 . 30, /. e. about
£18 8s. 4 d. a year. The diet roll is given. During the hot months
the inmates are rusticated to the heights of Rocca di Papa. The
income of the institution, about 1 . 20,000, is derived from payments
through the asylum from the several communes, a subsidy of 1 . 1000
from the Minister of Public Instruction, payments for private boarders,
and charitable contributions. The money seems to be carefully spent.
The salaries of the teachers, 1 . 750 a year, are less than those of the
primary communal schools, and we share in the hopes that the funds
will soon allow a more generous retribution to these painstaking and
devoted women, who have made an apostolate of this work of benefi¬
cence to a helpless class. William W. Ireland.

Part III—Epitome of Current Literature.

i. Anthropology.

The Finger-prints of Normal and Insane Persons \Le impronti digitali
deifanciulli normal^ frenastenici sordomuti]. (Atti della Soc. Rom .
di Antropol ., vol. viii, fasc. ii, 1901.) Sanctis , S. de, and Toscano , P.

The authors examined the finger-prints of forty boys in an elementary
school in Rome, forty boys in an establishment for the weak-minded
(not including cases of extreme idiocy), and twenty-three deaf-mute
boys; the ages varied between six and fourteen.

Three types of imprint are described as normal, three others,
simpler in character, as abnormal. The weak-minded and deaf-mute
boys showed greater frequency of the abnormal types of imprint than
the normal boys. The weak-minded and deaf mutes presented, how-

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1902 .]

NEUROLOGY.

56l

ever, no truly specific asymmetries, the same asymmetries occurring in
all groups of subjects. It is noted, at the same time, that the weak-
minded and deaf mutes present a greater tendency to uniformity of
pattern in the same individual than do the normal subjects; what is
here called “ the uniform-anomalous type ” prevails among the weak-
minded, and especially among the deaf mutes. Simplicity may thus be
said to be the special degenerative characteristic of the finger-prints of
the weak-minded and the deaf mutes. But the anomalies found by the
authors among these two groups of subjects are not so marked, they note,
as other authors have found among idiots, epileptics, and criminals. The
authors regard it as, perhaps, significant that the most exceptional
anomaly, whether in normal or abnormal groups of subjects, occurs
only in the index finger, “ the finger of most advanced physiological
evolution.” The paper is illustrated and furnished with tables.

Havelock Ellis.

3. Neurology.

Cases illustrative of the Localisation of the Mental Faculties in the Left
Prefrontal Lobe . ( Amer . Journ. of the Med . Sci., April\ 1902.)

Phelps, C.

The first part of this article consists of an interesting history of many
attempts made to localise the mind in the human body before and
since that made by Gall in the first decade of the nineteenth century.
After mentioning the work done by Bouillaud, Flourens, and others,
the author states that no further advance was made for twenty years or
more, until Broca, in 1861, localised the centre for articulate speech.
He then describes the experiments in cerebral localisation made by
Fritsch and Hitzig in 1870, closely followed by those of Ferrier,
Horsley, Schafer, and many others, resulting in the determination of
centres of control for nearly or quite all the groups of voluntary
muscles, for general sensation, and for the more important special
sensations of sight and hearing.

He points out that on the question of control of the intellectual and
moral faculties Ferrier and Hughlings Jackson arrived at conclusions
which were radically different. The latter, together with all those who
believe that there are higher centres which form the substrata for the
higher mental operations, placed them in the frontal lobes. The
author believes that if mental control be resident in the frontal lobes at
all it must be localised in their prefrontal region, the posterior portion
of the frontal convolutions having been demonstrated to control special
motor functions, including the co-ordination of muscles of articulation.
He is led to the conclusion, by an analysis of a considerable number
of cases, in which injury has been essentially limited to one or both
frontal lobes, that not only does such control probably reside in the
prefrontal region, but that it lies in the left to the exclusion of the
right lobe.

In his first series of cases, published in 1894, out of 225 necropsies

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EPITOME.

562

[July,

he excludes, owing to an early fatal issue, primary and permanent un¬
consciousness, etc., all but twenty-eight cases, in which the attendant
conditions permitted an estimate of the direct results of frontal lesion.
He added eleven more cases in the second edition of the same work,
and still later cases increased the number of his personal observations
of frontal lesion, verified by necropsy, to forty-six. The whole number
of these more recent cases, together with those included in the second
series, and previously unpublished, are then described in detail.

He makes three generalisations from an analysis of his first series of
•cases, e. g,:

1. In every instance but two in which consciousness was retained or
regained, and the mental faculties were not perverted by general
delirium, laceration involving the left frontal lobe was attended by
default of intellectual control, and the lesion was usually, if not always,
of the prefrontal region, and implicated either its superior or inferior
surface. Subcortical disintegration, or deep or extensive laceration of
the cortex, was specially characterised by abrogation of mental power
and superficial laceration by aberration in its manifestations. In one of
the two exceptional instances referred to in which laceration of the left
frontal lobes was not attended by default of intellectual control, the
supervention of final coma within two hours was so nearly immediate
as to practically withdraw it from the class of cases under consideration.
The other case seems to have been made exceptional by reason of
the mental condition having been regarded as normal on the one day
only in which the patient emerged from a general condition of stupor.
In the first series of cases the inferior surface of the lobe was the
more frequently implicated, but in the second it was the superior; and
the abrogation of mental power seemed to be proportionate to
the extent of the lesion rather than to its situation in the prefrontal
region.

2. In every instance in which laceration was confined to the right lobe
the mental faculties were unaffected, except as they were obscured by
stupor or delirium occasioned by coincident general lesion.

3. Compression or contusion of the left lobe only exceptionally pro¬
duced specific intellectual disturbance.

, This generalisation is based upon an examination of an entire series
of 295 cases in which the history was supplemented by necropsy.
He questions, however, whether in recovering cases the lesion may
not often be contusion, either limited to, or especially pronounced in,
the left frontal lobe.

The author is of opinion that the large number of cases cited, with
the analysis of their symptoms and lesions, are probably sufficient in
themselves to form a basis for conclusions. They represent the
personal observation and record of 800 cases of intra-cranial traumatism,
of which more than 300 were subjected to either operative or post¬
mortem inspection. Excluding those cases in which death had been
preceded by primary and permanent unconsciousness, they were all
germane to the present inquiry as showing either the presence of left
frontal lesion where mental symptoms had been noted, or the absence
of such symptoms where the lesion was situated in any other region of
the brain. In many excluded, because unverified cases, the coincidence

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*902.] PHYSIOLOGICAL PSYCHOLOGY. 563

of predominating symptoms of a mental disorder with external
indications pointing to a left frontal lesion afforded at least a corrobora¬
tion of the inferences which the post-mortem examination of the other
cases proved to be well founded. A. W. Wilcox.

The Action of Santonin on the Colour-sense, especially the Dichromatic
Colour-sense [ Ueber die Wirkung des Santonins auf den Farbensinn ,
insbesotidere den dichromatischen Farbensinn ]. (Zeit. f Psych ., Heft
4, 1901.) Nagel\ IV. A.

Prof. Nagel, who is partially colour-blind (green blindness), has been
^experimenting on himself with santonin. The rather puzzling action of
this drug on colour perception has long been known, and many experi¬
ments have been made by previous observers. As, however, with some
other similar drugs, there is great variation in individual reaction, and
the unpleasant results that are liable to occur also stand in the way of
experiment. Nagel’s observations were chiefly made with Helmholtz’s
colour-mixture apparatus. Violet and blue appeared absolutely un¬
changed at all stages of santonin poisoning. At the other end of the
spectrum, on the contrary—from yellow-green to red—the colours
appeared pale or greyish from the first, and were finally seen only as
white. The colour-system was not, however, thus rendered mono¬
chromatic, for though the spectral colours were affected, pigments,
coloured glass or paper retained their vivid colours. These results
correspond, on the whole, with those reached by some previous
observers. Nagel’s explanation is that the effects are produced not by
the temporary falling out of one of the components of the dichromatic
colour-sense, but, on the contrary, by the special stimulation of the blue
or violet component. He remarks that, apart from santonin, strong
stimulation of the retina with diffused white light produces increase of
blue sensation, and he has also found that brief stimulation with strong
sunlight produces, under certain circumstances, a blue after-image, and
also that, with pupils dilated by atropine, small black objects on a
bright ground are seen as blue. In this w r ay he would explain the
action of santonin, not as paralysing one element of colour-vision, but
as abnormally stimulating another.

The other symptoms noted were a peculiar odour, nausea, and a
high degree of nervous restlessness. At some points Nagel’s observa¬
tions recall the effects of mescal, although the chief feature of the
latter—the visions—is entirely absent. Havelock Ellis.

3. Physiological Psychology.

On Dreams [Le rive], {Rev. Scient., June 8th , 1901.) Bergson.

This is the subject of a lecture delivered before the Institut Psycho-
logique. The part played in dreams by visual sensations of internal
and external origin is all-important, but auditory sensations as well often
determine the character of certain dreams. And so with sensations of
touch. The author mentions interesting observations illustrating these

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EPITOME.

[July,

points. One must remember that in what we call natural sleep our
senses continue to work. Although they work with less precision they
receive numerous impressions, which, while they would attract no notice
during the waking period, may be vivid during sleep. The colours,
the changing forms, which appear when our eyes are closed, constitute
the material of our dreams; they do not produce them, because they
are vague and ill-defined. Memory forms our dreams. Recollections
of objects perceived more or less clearly, more or less difficult to recall
during the waking state ; these give shape to our dreams, although we
cannot always recognise this. A conjunction of the two factors,
memory and sensation, constitutes the dream. The author also examines
the question of the psychological characteristic of sleep, the real or
essential difference between perceiving and dreaming. It is not aboli¬
tion of reasoning. To sleep is to be disinterested. In dreaming the
same faculties are exercised as during the waking state, but they are
in a state of relaxation, not in a state of tension. We hear a dog
barking during sleep; we dream in consequence of an assembly mur¬
muring, shouting, etc.; no effort is required. To associate the noise with
the barking of a dog requires a positive effort. This force the dreamer
lacks, and herein he differs from the subject awake. Other differences
might be deduced from this essential difference. The author mentions
especially three points : the incoherence of dreams, the abolition of
the sense of duration which dreams often appear to manifest, and the
order in which recollections appear before the dreamer, to fit in with,
the sensations actually present. H. J. Macevoy.

Contribution to the Semeiology of Dreams [Contribution a la skmeiologie
du reve\ (Gaz . des I/bp., May 23 rd 9 1901.) Vaschide et Pieron .

A brief account is given of thirteen observations, carefully analysed,
in which symptoms of illness followed upon characteristic dreams on
an average forty-eight hours later, e.g. (1) a little girl, set. 3I years,
dreams that she is asleep in a closed copper bed, and that a carpenter
who looks like her doctor fixes a vice by her bedside and squeezes her
head in it. She shortly after developed a febrile illness which proved
to be meningitis. (2) A lady, set. 41 years, dreamt that her neigh¬
bour came to see her with a serpent coiled about her neck, which
entered her (the lady’s) mouth and tried to come out by the ear. In
order to protect her own child, which she thought was lying by her
side, she compressed her own ear to keep in the serpent. She was
bitten by it, and could hear the hissing of the infuriated reptile. Three
days later she had a purulent discharge from the ear.

In other cases, membranous sore throat, typhoid fever, bronchitis,
etc., respectively followed, at intervals varying from a few hours to twa
days, dreams in which the subjects experienced painful sensations
referred to the throat—sensations of thirst, of suffocation, etc. etc. On
the other hand, the authors have observed cases in which dreams of
this character were not followed by anything untoward. Still, cases like
the above they consider to be useful contributions to the study of the
manifestations of pathological changes in the “ subconscious ” mind.

H. J. Macevoy.

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1902.]

PHYSIOLOGICAL PSYCHOLOGY.

S6S

The Mental Condition of Saint-Simon [DPtat mental de Saint-Simon],
(Rev. Phil., Jan., March, April, 1902.) Dumas, G.

Saint-Simon, the philosopher, the precursor and teacher of Auguste
-Comte, is an interesting figure from the psychiatric point of view, and
Dr. Dumas has here given a somewhat elaborate account of his life.
Bom in 1760, he was the oldest of seven children, and belonged to an
ancient and noble family, traditionally said to have descended from
Charlemagne; the author of the famous memoirs belonged to one
branch of the family. In the early part of his career, before he adopted
socialistic views, the philosopher was wont to insist on his noble
•descent, and to say that all great men—Bacon, Galileo, Newton, etc.—
were gentlemen. At an early age he showed characteristic self-confi¬
dence, energy, and independence; at thirteen refused to take his first
communion, and when, in consequence, confined, he wounded his
keeper and escaped. At fifteen he already began to gain a vague idea
of his mission in life, but his education was conducted in a methodless
way, though he used to congratulate himself that d’Alembert had been
one of his masters. He was an enthusiastic admirer of Rousseau, and
went to visit him. At sixteen he was in the army, and in 1779 was
fighting in America under the orders of Washington, but was much
more interested in political science than in military matters, and he soon
left the army, “ to study,” as he said, “ the progress of the human mind,
and to work at the perfecting of civilisation.” At the same time he
still remained eager to take part in all sorts of adventures. When the
Revolution broke out he took the popular side at first, and renounced
his title of count, but he soon withdrew from the whirlpool, for he had
no love of mere destruction. He speculated unscrupulously, however,
with national property, acquired wealth, and, arousing the suspicions of
the ruling party, he was imprisoned for a time. In prison, exalted by
his ideas of scientific and social reform, he had a hallucination : Charle¬
magne appeared to him, and declared that his glory in philosophy would
equal Charlemagne’s in other fields. On leaving prison he began to
study mathematics and medicine, and, being now rich, kept open
house, all men of science being welcome. His receptions were pre¬
sided over by a series of mistresses, and in 1801, when he married, by
his wife. Very soon, however, he read the books of Madame de Stael,
and realised that she was the collaborator whom fate had destined to
share with him his great task. He succeeded in obtaining a divorce
from his wife, though it was only with much grief that he could leave
her. He had, however, neglected to consult Madame de Stael—a
characteristic instance of his sanguine and impulsive tendencies,—and
when he proceeded to Coppet to set forth his plans for social regenera¬
tion his reception was frigid. He retired to Geneva, and consoled him¬
self (1803) by writing his first book, a somewhat fantastic production,
but already containing the germs of some of his greatest and most
fruitful ideas. He there plans an “ Introduction to the Science of the
Nineteenth Century,” but, feeling that his knowledge must first be en¬
larged, he travelled in England and Germany. Then, his funds being
exhausted, he was compelled to find employment as a clerk, but his

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EPITOME.

[July,

health brpke down, and he began to spit blood. But a saviour
appeared in the form of an old servant of the family, one Diard, wha
placed himself and his house at Saint-Simon’s disposal. The philosopher
accepted, and lived in peace until Diard’s death in 1810. In the mean¬
while he endeavoured to thrust his projects before Napoleon and
influential persons in the scientific world, but with no result, and he
began to think that he was being persecuted; he definitely accused
Laplace of “ poisoning ten years of his life.” From the height of his
pride he dealt out contempt to the great astronomer, but Laplace took
no notice. On Diard’s death Saint-Simon was again reduced to
misery, and, overcome by privations and anxieties, he had a severe ill¬
ness, with delirium. On recovering, his family granted him a small
pension, and he proceeded to develop his philosophic and scientific
ideas, one of the chief being that the science of man must be placed
on the same basis, and conducted by the same sound methods, as the
physical sciences, instead of, as had hitherto been the case, on a meta¬
physical or theological basis. His efforts to attract attention and get
his books printed proving vain, he again fell ill, and we find him for a
short time in an asylum. Concerning his disorder nothing, unfortu¬
nately, is known, save that he suffered much from insomnia. On leav¬
ing the asylum he brought forward his scheme for the union of England
and France (he had a great admiration for England), as a nucleus for
the future unification of the whole of Europe. Again reduced to
despair by want and neglect, he resolved on suicide, and, having spent
his last moments in philosophic meditation, he shot himself. The only
result was, however, that he lost the sight of one eye. Gradually
friends and admirers, including Comte, came around him, and he died
in 1825, full, to the last moment, with the thought of his works and of
his dreams for the happiness of mankind.

Was he insane ? Dumas inclines to think not. He was an abnormal
man certainly, and a neuropath, but he must be classed, Dumas
believes, with the group of messiahs—the men with a mission. The
whole of his life was consistently arranged, almost systematised, around
his great mission ; to that everything was subservient, and, in spite of all
incoherences and extravagances, he was justified by the fact that some
of his main ideas are now embodied in human thought. Outside his
messianic character, Dumas points out, he was a man with the ordinary
simple, commonplace, human emotions. Havelock Ellis.

The Value and Limits of Psychological Investigation in Psychiatry and
Criminal Anthropology [ Valore e limiti delP indagine psichologica
negli studiipsichiatrici e di anthropologia criminally {II Manicomio r
anno xvii, No, 3, 1901.) Del Greco,

In this critical essay del Greco, developing views which he has put
forward in earlier papers, argues against what would appear to be a
current tendency in Italy to minimise the rdle of psychological inquiry-
in the study of insanity and crime.

The reaction from the old metaphysical psychology has brought in an

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.ETIOLOGY OF INSANITY.

1902.]

567

extreme mechanical positivism, which views consciousness as a mere
epiphenomenon, a grouping of sensations reflecting a grouping of vibra¬
tions in the brain-cells; in this doctrine the psychical factor becomes
almost a quantite negligeable.

When, however, we attempt to apply this artificial associationism in
clinical inquiry, it at once proves itself inadequate; instead of the
conditions which this psychic atomism would suppose, it is the fact of an
active individuality, round which the complex mental phenomena
cluster, that imposes itself on the observer.

Tracing this psychical formation to its simplest expression, the author
finds it, with Fouill^e. in instinct—appetite. As the biological indi¬
viduality becomes defined in the struggle with the environment, the ego
appears “ in the form of the impulsive psyche rising to the volitional
and rational psyche.” The ego is always experienced as an activity; it
is a dynamic whole which operates on each impression by combined
disintegrations and integrations.

Followed back in the individual to the obscure facts of temperament,
in the zoological line to the organisms without distinct nervous
structures, the two series—material and psychical—reach a point where
they seem to merge in impulse—tendency. But it is impossible to
reduce one series to the other; they must be regarded as two aspects of
the somato-psychic personality. It is necessary to study them together
“ in the unity of the somato-psychic individual.”

The neglect of this synthetic view, leading, as it does, to the adoption
of a crude doctrine of somatism, has been responsible for such
absurdities as the attempts to define localised psychic centres. In
criminal anthropology the same doctrine presents even greater dangers
to the future development of that science. W. C. Sullivan.

4. /Etiology of Insanity.

On the Heredity of Endogenous Psychoses in Relation to Classification
\Ueber die Vererbung endogener Psychosen in Beziehungzur Classifi¬
cation ]. ( Monats . f Psychiat. u. Neurol ., April and May , 1901.)
Vorster .

In this paper the author endeavours to demonstrate the unsoundness
of the prevailing opinion of polymorphism in the heredity of mental
disease. He quotes Kirchhoff, Scholtz, and others, who hold the view
that a child of parents mentally afflicted may, to a certain extent,
be expected to suffer from some functional, nervous, or mental disorder;;
but that that child is not to be expected to suffer necessarily from the same
form of mental disorder as its parents. Sioli believes that mania,
melancholia, and circular insanity mutually replace one another in
heredity. Kraepelin and Harbolla believe that the form of psychosis
in the descendants is, in the majority of cases, similar to that observed
in the ancestors.

With these conflicting statements before him, the author has investi¬
gated the question of polymorphism in heredity by a study of twenty-

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EPITOME.

i68

[July,

three families, which he has been able to investigate at his asylum at
Stephansfeld.

He found nine families liable to suffer from mania depressiva ,
eight from dementia prcecox, six from “ reconstructive psychoses ”
(adolescent, climacteric insanities, etc.).

Taking the nine families whose ancestors suffered from mania de¬
press iv a ^ he finds that 80 per cent . of the mentally afflicted descendants
suffered from the same form of insanity. In the case of the eight
families whose ancestors suffered from dementia prcecox , 77 per cent
of the mentally afflicted descendants suffered also from dementia prcecox .

In twenty-nine instances of brothers and sisters coming under the
author’s care, the form of insanity was similar in twenty-six of the
families.

The author, in conclusion, believes that a more careful investigation
of the family history will help in prognosis; that is to say, that the
physician should, in hereditary cases, always endeavour to find out
whether the family suffers from a curable or incurable form of insanity.

W. H. B. Stoddart.

Nervous Diseases and Pregnancy [Nervenerkrankungen und Schwan-
gerschaft ]. {Allgem. Zeitschr.f Psychiat ., B. xxxviii, H. 5.) Mongeri.

He observes that the character of women is altered during pregnancy,
and often in a pathological direction. He is of opinion that it has a
favourable influence in hysteria when it is not complicated with some
other affection of the nervous system. Marriage not only satisfies the
sexual instinct, but it gives them some one on whom they can expend
their tender feelings, and gains for them some one who will care for
them and protect them. “ I have known,” he says, “ and treated several
very hysterical young girls who are now married, and show no trace of
nervous disease. Some of them have no longer the desire to satisfy the
sexual feeling, and are averse to such intercourse, although they love
their husbands and live happily with them. The physician need not
hesitate to recommend hysterical women to marry if the other party
have a healthy constitution, and is free from predisposition to nervous
disease. On the other hand, he should never advise a woman to marry
who has come through a severe attack of insanity, not only on account
of the danger to the children, but because of the danger of relapse, often
in an aggravated form.”

Dr. Mongeri discusses at some length the cause of chorea gravidarum,
and cites the experiments of Pianese, who has advanced the idea that
chorea is the symptom of a disease of an infective character. This, he
holds, is indicated by the lesions found, to wit, small haemorrhages, peri¬
vascular inflamed spots scattered over the central nervous system, con¬
gestion of the liver with increase of pigment, necroses and extravasations
in Bowman’s capsules and other parts of the kidneys. He was able to
withdraw from the spinal canal of a choreic patient a special bacillus,
which, being inoculated into dogs, cats, and rabbits, gave positive results
in the brain, the medulla, and the nerves. In no other organs did
changes appear. Pianese obtained cultures of these bacilli, and found
them in the blood of living choreic patients. Triboulet succeeded in

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ETIOLOGY OF INSANITY.

1902.]

569

communicating chorea from one dog to another ; but he failed to detect
a special bacillus in the blood of choreic patients. Dr. Mongeri thinks
that auto-intoxication furnishes the best explanation of the origin of
chorea during pregnancy.

Dr. Mongeri concludes that pregnancy favours the production of an
auto-intoxication and gives a predisposition to eclampsia. A current
insanity is aggravated through pregnancy or rendered chronic, though
an accidental mental derangement may derive benefit from it.

William W. Ireland.

Consanguine Marriages and their Consequences [Consanguinitat in der
Ehe und seinen Folgen]. {Allgem. Zeitschr . f Psychiat., B. Iviii',
H 5.) Peipers.

Mr. Felix Peipers has taken much pains to gather all the published
reports bearing on the question of consanguine marriages, and his
collection, though additions could be made, is pretty complete. In
handling statistical literature of this kind one generally meets some
contributions which show a controversial bias; Mr. Peipers especially
remarks that three authors have published figures which are so far out
of line with those of other inquirers in the same field that they may be
treated as palpably incorrect, and the question occurs, Are they not to
be rejected as untrustworthy? As these papers all support the old
notion that close marriages entail something prejudicial to the offspring,
it is possible that if they w r ere summarily rejected, the remaining
advocates of this view w^ould consider that the question had been
prejudged. Probably the authors in question had begun with the
assumption that such .marriages were prejudicial, and had collected
supposed facts with too little scrutiny. If one were content to take the
statistics of the last thirty years only, it w ? ould appear that the great
preponderance of evidence is in favour of those who consider that
consanguine marriages, per se, have no unhealthy effects; and if statis¬
tical inquiry continues to realise the same result, the older array of
figures on the opposite side will, in comparison, shrink more and more.
The author has himself made some extensive inquiries in special insti¬
tutions, especially amongst the epileptics in Bielefeld, and in various
asylums and schools for deaf mutes and idiots, as w r ell as from private
sources. He has arrived at the conclusion that a degenerative tendency
in the offspring of the union of consanguine relations has, as yet, not
been proved.

Mr. Peipers is still anxious to carry on the inquiry, and will be thank¬
ful if answers to his form of questions bearing on this subject are sent
to him. William W. Ireland.

Statistical Note on the Role of Consanguinity in the aE tiology of Epilepsy,
Hysteria , Idiocy, and Imbecility [Note statistique sur le rdle de la
consanguinite dans Pitiologie de Pipilepsie, de Phystirie , de Pidiotie , et
de Pimbecillite]. {Prog. Mid., May 4 th, 1901.) Bourneville.

In 2784 defective children observed at the Bic£tre and in the
Fondation Vallee from 1879 to 1900, Bourneville has found only 91
•cases (3*23 per cent.) in which the parents were of near kin—cousins-
XLVIII. 39

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570

EPITOME.

[July,

german in 49 cases, cousins farther removed in 36 cases, other or
undefined relationships in 6 cases. In all the 91 cases some degree of
neuropathic heredity could be traced. These figures thus confirm the
view that parental consanguinity is, per se, insignificant as a cause of
degeneracy in the offspring. W. C. Sullivan.

5. Clinical Neurology and Psychiatry.

Argyll-Robertson Pupil , its Clinical Value and its Relation to Syphilis
[Le signe pupillaire dArgyll-Robertson ; sa valeur semeilogique;
ses relations avec la syphilis\ ( Gaz . des Hdp ., Dec . 28th, 1901.)
Cestan et Dupay-Dutemps.

Argyll-Robertson pupil is an acknowledged sign of tabes and of
general paralysis, both of which diseases have a close relation to
syphilis. The authors have set themselves the task of determining
whether this sign, when it occurs in cases other than tabetics or general
paralytics, has any relation to previous syphilis in the patients.

In their investigation they have been careful to examine all patients
in a dark room, and to throw a beam of strong light on to the macula
of the eye under examination; and they have rejected all cases in
which there was the slightest sign of contraction to light, or in which
there was any failure to contract on accommodation. In cases of
myosis in which it was difficult to ascertain whether the pupil con¬
tracted, they adopted the ingenious plan of dilating the pupil with
cocaine before examination. No cases of tabes or general paralysis
are considered in this paper.

To facilitate the discussion, the patients are divided into three
classes. In the first class are placed those cases in which syphilis was
certain or extremely probable. There were ten such cases. In four
of these reflex iridoplegia was the only symptom or sign, five were cases
of hemiplegia; there were two cases of myelitis, one was a case of
haematomyelia, one amyotrophic lateral sclerosis, and one Friedreich's
disease.

In the second class are placed cases in which it was practically
certain that the patients had not had syphilis. Under this heading
there is a discussion of certain cases of multiple neuritis in which the
pupils did not re^ct to light; but it is demonstrated that these are not
true cases of Argyll-Robertson pupil, the sign being, in these cases, due
to scotomata, retro-bulbar neuritis, etc. The authors here also quote
two cases from the literature of syringomyelia, in which the Argyll-
Robertson pupil occurred, and in which there was no history of
syphilis.

The third class might have been omitted from the paper, since it
includes only cases in which there was not any reflex iridoplegia.

Recognising that the light reflex is always tested in the insane, the
authors then looked up the statistics of some asylum physicians..

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57i

1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

Siemerling and Mignot have both reported that the Argyll-Robertson
pupil occurs rarely in the insane apart from general paralysis and tabes.
Marandon de Montyel, however, appears to have made the extra¬
ordinary statement that one quarter of all cases of insanity present
this symptom. With such divergence of opinion, the authors very
naturally sought to investigate the matter for themselves at Salpetri&re.
They failed to find a case of Argyll-Robertson pupil there apart from
general paralysis and tabes. The authors very properly observe that it is
no easy matter to test the pupils in the insane as accurately as in other
cases. The conclusion arrived at from this research is that, if subsequent
investigation should confirm the above observations, in the insane just
as in cases of organic disease of the nervous system, the Argyll-
Robertson pupil means syphilis.

The paper concludes with rather too pessimistic a discussion of our
ignorance of the course of the fibres along which the light reflex travels.
The authors are evidently unfamiliar with the experimental work which
has been done in this country in connection with the Argyll-Robertson
pupil. W. H. B. Stoddart.

On the Symptomatology of Tabes Dorsalis in the Pre-ataxic Stage , and on
the Influence of Optic Atrophy on the Course of the Disease [Zur
Symptomatologie der Tabes Dorsalis im praeataktischen Stadium ,
und iiber den Einfluss des Optischatrophie auf den Gang der Krank-
heit\ (Mofiat, f Psychiat. u. Neurol.^ July and August , 1900.)
Forster .

This is an analysis of twenty-seven cases of tabes in the pre-ataxic
stage. They do not appear to be all undoubted cases of tabes. For
example, the diagnosis of Case 18 is made solely on the fact that the
patient has had syphilis and now has optic atrophy; and the author
rather begs the question in the second half of his paper by asking,
“What would become of diagnosis if there existed a genuine non¬
tabetic optic atrophy ? ”

The cases are tabulated under the heading of twenty individual sym¬
ptoms, and it is pointed out that no one of these symptoms existed in
every case.

Although an inspection of the table is not convincing, the author,
in the conclusions which he draws from it, is in agreement with the
usually accepted view that other symptoms of tabes do not progress
when optic atrophy has set in ; and he quotes cases in which the signs
and symptoms have even retrogressed (return of knee-jerks, etc.). He
does not attempt to explain this improvement of the ataxic symptoms
in such cases. W. H. B. Stoddart.

On Objective Signs of Disturbed Sensation in Cases of Traumatic
Neurosis—so called [Ueber objective Symptome der Storungen der
Sensibilitdt bei den sogen traumatischen Neurosen\ ( Monais . f
Psychiat. u. Neurol^ February , 1901.) Bechtereiv.

In cases of traumatic neurosis we are often called upon to decide
whether complaints by patients of disturbed sensibility are well founded
or due to malingering. In the present paper Bechterew draws attention

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572

EPITOME.

[July,

to the importance in such cases of observing the objective signs of
disturbed sensation—anaesthesia, hyperaesthesia, paraesthesia, or pain.
Though first described by Mannkopf, the author claims priority in
establishing the importance of these signs.

The signs to which the author refers are as follows :

1. There is diminution of the cutaneous reflexes in anaesthetic areas,
and corresponding increase in hyperaesthetic areas. In the case of
hemianaesthesia there is diminution of the cutaneous reflexes (e. g.
plantars) on the anaesthetic side. If this be due to organic brain
disease, there is also inequality of the tendon reflexes on the two
sides; but if due to functional disease, there is no inequality of the
tendon reflexes.

2. If an electrical wire brush be applied to a normal area of skin, there
is disturbance of respiration and pulse; if it be applied to an
anaesthetic area, this disturbance is less marked ; if to a hyperaesthetic
area, it is more marked.

3. Dilatation of the pupils should be noted when the wire brush is
applied to a normal area, a supposed hyperaesthetic area, or a supposed
anaesthetic area.

4. There may be vaso-motor spasm on stimulation of an anaesthetic
area, or undue vaso-motor dilatation in a hyperaesthetic area.

5. The vascular reaction to stimuli may be shortened or delayed in
the area of disturbed sensation.

6. There may be local alterations in the surface temperature.

7. The author quotes cases in which convulsive twitchings, occasional
giddiness, and swaying of the body occurred on irritation of a hyper¬
aesthetic area.

He further points out that pains are sometimes associated with local
vaso-motor symptoms, e. g. abnormal redness, cyanotic discoloration,
demography, etc. The parts principally affected by skin hyperaemia
appear to be the face, throat, neck, and upper part of the chest.

W. H. B. Stoddart.

The Sense of Smell in General Paralysis [Recherches expirimentales sur
la sensibilite olfactive dans la paralysie gen/rale]. {Rev. de
Psychiat., February , 1802.) Toulouse and Vaschide.

It has long been known that there is a tendency to loss of the sense
of smell in general paralytics. A. Voisin, indeed, regarded this as one
of the earliest signs, and therefore of diagnostic value. The present
investigation was carried out at Villejuif, on twenty-eight women in
various stages of the disease. The method was one which has been
frequently used by Dr. Toulouse in previous investigations, and consists
essentially in a graduated series of solutions of camphor, various
precautions being taken to avoid fallacies. The difficulties in the
present case were very great, and to avoid error the experiments were
repeated many times.

' It was found that complete loss of smell does not tend to appear at a
very early stage (contrary to Voisin’s opinion), and that it increases
progressively with the course of the disease. Of the twenty-eight
subjects, eight, or about one third, were absolutely anosmic, or quite
without sense of smell, while among normal subjects only one in thirteen

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 573

is found to be in this condition. None of the anosmic individuals
belonged to those in the early stage of the disease.

The authors also investigated what they term the “ tactile olfactive
sensibility ” of their subjects; in other words, the reaction of the
olfactory region to ammoniacal stimulation, using graduated solutions,
as with the camphor. This kind of sensibility, or rather organic irrita¬
bility, is very fundamental, and it is not surprising that it usually
persisted in spite of the decay of the true olfactory apparatus. In
most cases, however, although a painful sensation was perceived, the
subject could not (as most normal persons can) detect the nature of the
stimulus.

It was noted that perception is lost much sooner than sensation,—that
is to say, that while the subject was vaguely conscious of some olfactory
sensation when the camphor was applied, and could distinguish it
from water, she was often unable to recognise the nature of the
odour, even at an early stage of the disease. It is interesting to
remark, the authors observe, that in a disease which is the very type
of dementia, of intellectual weakness, the most delicate form of mental
activity, perception, should be the first to go. Havelock Ellis.

Statistical Contribution to the Etiology and Symptoms of General
Paralysis [Statischer Beitrag zur Aetiologie und Sympiofnatologie
der progressiven Paralysie\ (Arch. Psychiat ., B. xxxv, H. 2.)
Raecke.

Dr. Raecke has made an elaborate study of 136 patients suffering
from general paralysis. Of these, twenty-nine men and three women
were followed to the end, the others being transferred to various asylums.
His inquiries confirm the results of previous observers. The evidence
of the great part played by syphilis in the causation of the malady is
powerful. The previous existence of lues was found to be certain in
57 per ce?it. of the cases, to be probable in 20*9 per cent ., unknown in
10 per cent., and denied in n*8 per cent. Only fifteen of the sixty-three
had been under medical care for venereal disease prior to the onset of
nervous disease. Antispecific treatment was practised on twenty-eight
patients with little success. Immobility of the pupil to light in both
eyes was found in fifty-four patients, and on one side only in ten; slow
reaction of the pupil in thirty-eight, prompt in eight, i. e. the reaction
was impaired in 92 per cent. In only one case was there a return of
pupil activity. In above half the cases the patellar reflex was increased.
Dr. Raecke found that the paralysis of the pupil and exaggerated
patellar reflex frequently go together, though he does not consider that
impairment of the pupillary reaction indicates affection of the posterior
column of the spinal cord, as Gaupp has maintained. Tremor of the
tongue appears to be about the most constant symptom. It was present
in ninety-five cases; deviation of the tongue to one side in twenty-four.
He found the duration of general paralysis to be two years and
three months. Sprengeler, from an observation of 337 cases in
Gottingen, found the mean duration to be two years and six months for
men, and three years five months and a half for women.

William W. Ireland.

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574 EPITOME. [July,

On the Early Symptoms of General Paralysis [ Ueber die Fruhsymptome
derprogressiven Paralysie ]. ( Allgem . Zeitschr . fur Psychiat., B. Iviii ,
H Moravesik

Amongst the early symptoms of general paralysis are mentioned dis¬
orders of digestion, wandering neuralgic pains, a diminution in mental
activity, a feeling of tightness orbeating within the orbits, flashes before
the eye, sounds in the ear, with pulsation in the arteries of the neck and
temples. The reproduction of ideas becomes sluggish. He cannot hit
upon the right word, and has to use less appropriate expressions. His
memory begins to fail him. Sometimes, on the other hand, the intensity
of intellectual power seems increased, even while the patient is suffering
from the troubles of digestion, loss of flesh, sleeplessness, inequality of
the pupils, and heightened patellar reflex, and he is able to work as well
or even better than usual. At an early date the patient becomes
more emotional, and shows a sentimental distress at anything pathetic
or unpleasant. He has paleness of the face and a blue ring around the
eyes. There is often a rise of temperature during the night and an
increased secretion of saliva.

Dr. Moravesik confirms the observation of Mendel that the type of
general paralysis has altered during late years, returning to the old
classical demented form, and that remissions of the symptoms are more
considerable and more frequent. He also thinks that now the initial
symptoms of paralysis are more liable to be confounded with other
forms of insanity, especially paranoia, while the characteristics of the
malady at a later date become more accentuated.

William W. Ireland.

Cerebral Syphilis simulating General Paralysis [Syphilis cerlbrale
simulant une paralysie genirale\ (Le Prog. Med. y Jan. i&th,
1902.) Brissaud et Vichin.

This is a case in which the diagnosis was for some time uncertain,
and in which at one time the condition was almost characteristic of
general paralysis. A man aet. 43 years, in a responsible position, had
syphilis in 1897, and was treated. In 1898 he began to suffer from head¬
aches on the left side, especially localised in the temporal and posterior
parietal regions. On July 22nd he noticed that he had dimness of vision,
scintillating scotoma, and developed an attack of Jacksonian epilepsy.
The headache disappeared for a while, only to recur again, and on
September 18th he had a right brachial aura, “ mirror writing ” was
noticed by him, and ten minutes later he had a second epileptiform
attack. He was ordered to Egypt. On November 10th, after temporary
motor aphasia, he had a third fit. For the next four months he was
pretty well (he was under treatment). On March 23rd, 1899, recurrence
of temporary motor aphasia and a fourth fit. June 1st, auditory
hallucinations followed by a fifth fit. After this he did not regain
health as usual, disorder of speech persisted, and on July 10th he had
a sixth fit. He returned to Paris, and four days later (July 14th) had a
seventh fit. Ballet and Brissaud then saw him. His speech, twitching
of the lips, trembling of the tongue, altered handwriting, unequal pupils—
all strongly suggested general paralysis. On July 22nd paresis of the

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575

1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

right upper limb occurred. Intra-muscular injections oi biniodide of
mercury were prescribed; the fits did not recur, and now supervened
ocular troubles, which enabled his medical advisers to exclude once
for all the diagnosis of general paralysis. Diplopia was followed by
strabismus, and on October 15 th there was complete paralysis of the
sixth nerve on the right side, with slight ptosis of the upper lid and
mydriasis. Partial paralysis of the third nerve was also present.
There was also noticed right-sided twitching of the eye, slight facial
paralysis, and deviation of the uvula to the left. The diagnosis ap¬
peared to be clearly cerebral syphilis: arteritis at the base, especially
in the circle of Willis, associated with bulbo-pontine lesions.

In spite of some improvement under treatment, the prognosis given
was grave, for the diffuse lesions suggested rather syphilitic arteritis
than a gumma. However, the result was more favourable than could be
expected, for the patient gradually resumed his occupation, and in
November, 1901, he seemed to be as well as if he had had no cerebral
disorder. H. J. Macevo^.

Two Cases of Idiocy with Diplegia [Diplcgie et Idiotie chez deux freres ].

(. Prog . Med., April 27///, 1901.) Bourneville and Crouton .

Dr. Bourneville has added to his numerous contributions to the
pathology of idiocy a description of two brothers admitted to the
Bicetre in 1897. They were both helpless idiots, and were aged thirteen
and ten respectively. The limbs had become rigid; neither of them
could stand. The family history is given at some length, and shows
nervous diseases among the collaterals, but the grandparents, father and
mother, seemed to have been healthy. The eldest began to walk, when
he had the measles at eighteen months, which is said to have had a back¬
ward effect upon him. The younger had never walked ; he had some
convulsions when eighteen months old. They could use the hands so
far as to grasp objects and put them to their mouths. Both had
strabismus, one convergent, the other divergent. The eldest died in
December, 1899. Nothing seems to have been found in the brain to
explain the idiocy. The cerebellum was found to be atrophied, all its
parts were diminished in value, the pons Varolii was also less than usual.

As the authors remark, atrophy of the cerebellum is a rare affection,
and was insufficient to explain the symptoms. The authors do not
think themselves entitled to affirm that a similar atrophy will be found
in the cerebellum of the other brother. A microscopic examination of
the brain was made, and a diminution of the fibres of the anterior
column of the pyramids was observed. William W. Ireland.

Mental Cofidition in Aphasia \Etat mental des aphasiques\ {Rev. de
Psychiat.,Jan ., 1902, No. 1.) Vigouroux.

The question to be determined is how far organic aphasia, on account
of the alteration of internal speech, determines mental enfeeblement
tending more or less to dementia. Vigouroux reviews the various
opinions that have been held, e. g. that of Trousseau, who thought that
in aphasics there was intellectual impairment; that of Charcot and
Ballet, who considered that this impairment varied with the type of

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576

EPITOME.

[July,

mind affected, that is, according as the individual is visual, auditory,
etc. The appreciation of the intellectual ability is often a difficulty;
there are a number of observations, for instance, in which sensorial
aphasia with paraphasia may simulate dementia. Charpentier believes
that among old chronic patients in asylums with apparent incoherence
are a certain number of cases of paraphasia not understanding what
they say, but well knowing what they wish to say.

The general conclusion of the author after a study of the question
is that, while it is clear that a certain number of aphasic patients have
been in full possession of their intellectual faculties in spite of their
disorders of speech, yet the majority show intellectual enfeeblement
and easily become demented. H. J. Macevoy.

Definition of Hysteria [.Definition de PhystMe]. {Rev. de fhyp. y Jan. y
1902.) Babinski.

In spite of the large number of works dealing with the subject of
hysteria, there is a great divergence of opinion concerning the nature of
this neurosis. Babinski attributes this to the lack of a good definition.
In the search for some characters which are common to all
hysterical manifestations, and yet confined to hysteria, he draws special
attention to these: the possibility of their being reproduced by sugges¬
tion with exactness in certain subjects, and that of their disappearance
through the exclusive influence of persuasion. The word suggestion
here used itself needs accurate definition. It must imply that the idea
which one tries to insinuate to the hysterical patient is unreasonable,
and should not be used in the sense of being synonymous with per¬
suasion. The typical manifestations of hysteria major, the varieties of
paralyses, contractures, anaesthesias, etc., are all of this kind; they can
be exactly created by experimental suggestion. In addition they are
all susceptible of disappearing under the exclusive influence of per¬
suasion. On the other hand, the latter characteristic is not met with
in other conditions. There is not another nervous affection, well
defined and outside the limits of hysteria, which psychotherapy alone
will cure ; it may be of use, but not all-sufficient; the proof is that in
cases of this kind persuasion does not lead to an immediate cure. The
above relates to what Babinski calls primitive symptoms, which may
occur without being preceded by other manifestations of hysteria. But
he holds it legitimate to call also hysterical those disorders which,
without exhibiting the characters of primitive symptoms, are yet closely
allied to, and subordinate to them; but one must add to these the
epithet secondary. The muscular atrophy of hysteria is a type of
this kind. The definition proposed is—Hysteria is a psychical condition
which renders the subject of it prone to auto-suggestion; it manifests
itself principally by primitive symptoms and accessorily by certain
secondary symptoms. That which characterises the primary symptoms
is that it is possible to reproduce them in certain subjects by sug¬
gestion with rigorous exactitude, and to cause them to disappear by the
exclusive influence of persuasion. That which characterises secondary
symptoms is that they are closely subordinate to the primary symptoms.

Incidentally, Babinski refers to the subject of hypnotism, which he
holds to be closely related to hysteria, and which he thus defines:

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

577

—Hypnotism is a psychical condition rendering the subject of it sus¬
ceptible to adopt the suggestion of another; it manifests itself by
phenomena, which suggestion creates, which persuasion causes to
disappear, and which are identical with hysterical manifestations.

To the objection that may be raised that in certain hysterical cases
we may meet with some symptom rebellious to treatment by persuasion,
Babinksi replies that the characteristic of hysterical manifestations is
that they are susceptible of cure by this means, they are pithiatic
(wciBut, larus )—a more accurate word, the author suggests, than the
vague one hysterical. Restricting hysteria within the limits above
defined, Babinski holds that such symptoms as exaggeration of the
knee-jerks, the big toe phenomenon (Babinski’s sign), pupillary
immobility, paralysis limited to the distribution of one nerve, etc.,
cannot be classified among hysterical manifestations.

H. J. Macevoy.

Hysterical Psychosis arid Myoclonus [.Psichosi isterica e mioclonia\ (II
Manicomioy anno xvii, No. 3, 1901.) Mondio.

The patient was a woman aet. 24, with alcoholic and neuropathic
taint in ancestry; she suffered in childhood from general choreiform
tremors, which gradually disappeared before puberty. Always odd in
disposition, as she grew older she appeared more unstable and eccentric ;
she developed homosexual tendencies, and became addicted to drinking.
At twenty-three years of age she came under treatment for persecutory
delirium, with suicidal ideas and refusal of food. After a short period
of improvement she was readmitted with the same mental symptoms,
which were associated with ordinary hysterical stigmata. She now
presented, in addition, anomalous muscular phenomena combining the
characters of myoclonus, electrical chorea, convulsive tic (Charcot), and
fibrillary chorea (Morvan). She remained huddled up in a state of
general flexion ; the upper limbs and right leg were agitated by constant,
rapid, synchronous tremors ; the shoulders were jerked up and down in
movements of wider range ; from time to time rapid fibrillar contrac¬
tions ran along some of the larger muscles; occasionally one or more
muscles passed into tetanoid spasm. The muscles of the face showed
no clonic movements, they were occasionally contracted in a grin of
pain. Emotion and effort increased the spasmodic symptoms ; they
ceased during sleep.

After persisting without much change for two months the myoclonic
condition disappeared gradually in the right leg and left arm ; the
mental state remained about the same. At the date of the last note,
three months later, the clonic spasms were limited to the right forearm
and hand ; the patient remained obstinately mute, and appeared to be
dominated by persecutory delusions.

Discussing the case, the author points out that the association in an
hysterical patient of myoclonic phenomena with symptoms resembling
other spasmodic affections—electric chorea, convulsive tic, etc.—sup¬
ports Raymond’s view that all these conditions are to be regarded not
as distinct diseases, but merely as syndromes developing on a basis of
neuropathic degeneration. W. C. Sullivan.

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578 EPITOME. [July,

Symptomatic Value of Dreams as regards the Mental State in a Patient
suffering from Circular Insanity [ Valeur symptomatique du reve au
point de vue de Petat mental de la veille chez une circulaire\. ( Gaz.
des Hop., August 20th, 1901.) Vaschide and Pieron .

This case, of Mrs. B—, aet. 42 years, was under observation for over
three years. She early showed a curious disposition to be influenced
by meteorological variations. She was sent to the asylum at the age of
thirty-two years, where she remained for over eight years. Suffering
with circular insanity, at first her lucid periods were much in excess of
the periods of excitement, but the former became shorter, and the latter
proportionately longer, as time went on. One feature of the patient’s
disposition was her keen observation of her dreams, which she was fond
of interpreting. The authors, as the result of many experiments, were
satisfied that her interpretation was often correct, and of useful import
in prognosis. The nature of the indicating dreams varied according as
they announced a period of excitement, one of depression, or a period
of calm. (1) With dreams announcing a period of excitement, this condi¬
tion usually came on suddenly not less than thirty-six hours after it had
been foretold. The dream was usually in character like a nightmare,
with feelings of being choked, strangled, violently handled. (2) In
the case of dreams announcing a period of depression, the patient
thought she did not exist, that she was a child, that her senses were
restricted, that she was unable to move, etc. Her awakening was
slow, and followed by some hours (eighteen to thirty-two) of in¬
decision, when the period of depression began. (3) As regards dreams
foretelling a period of calm, a correct result was less frequent, in six
only out of fourteen of observations; the dreams were less character¬
istic. In a fourth set of observations the patient exhibited dreams fore¬
telling a continuance of her then present mental condition—the
particular period in her circular insanity being prolonged beyond its
usual duration.

This case is important in connection with the question of prevision
through dreams. The authors think that it is a possibility, while
fully recognising that a mass of worthless evidence has been produced
in favour of this view. H. J. Macevoy.

Paroxysms of Anguish—Epilepsy and Hysteria [Paroxysmes dangoisses
—epilepsie et hystdrie]. (Rev. de PHyp., Jan., 1902.) Raymond.

Cases shown at the Clinique of the Salpetrtere.

1. Man aet. 52, engineer. Suffered for eight years from fits
which have become worse. After some general tremors, objects begin
to appear more distant, then a shock at the heart is felt, palpitations,
and loss of consciousness. This is followed by an imperative desire to
sleep for seven or eight hours. No involuntary micturition, no biting
of the tongue. Occasionally a keen desire to eat constitutes the crisis.
Epileptic attacks of this kind, coming in late, are often of grave
import, being related to arterio-sclerosis.

In the former history of the patient one notes that he inherits melan¬
cholia from his mother, and has had obsessions, continually puzzling his
mind about final causes, the nature of man, the reason of his sojourn on

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY. 579

earth, etc. Raymond, in addition to the administration of bromide in
such a case, recommends moral treatment.

2. A boy aet. 13 \ years, also subject to attacks, but of a different
kind. He has been to school since the age of five years. Six months
ago, after being locked up by a schoolfellow in the water-closet, and
apparently as the result of fright, he became giddy on returning home,
slept badly the following night, and dreamt a good deal. Since then he
has had daily fits, which begin with a kind of aura, beating in the temples,
hissing in the ears, vertigo, thumping of the heart; then he falls to the
ground, becomes stiff, and struggles. At the onset there was no loss
of consciousness, but now it is the rule. The attacks last two
minutes; he gets up tired, cries, but does not feel an irresistible desire
to sleep. It is difficult in some cases to diagnose hysteria from epilepsy.
On one occasion the boy had involuntary micturition during a fit, but
this may be seen in hysteria. He has bitten his tongue sometimes ; this
is in favour of epilepsy. There is, at times, some weakness on the left
side; this does not help much in diagnosis. But there are disorders of
sensation. On the left one notes absolute anaesthesia limited to the
upper third of the arm, and close to this hyperaesthesia ; this points
almost certainly to hysteria. Moreover, in the post-paroxysmal stage,
instead of being drowsy and sleepy the boy cries for a while, and,
recovering himself, becomes cheerful again. This confirms the diagnosis
of hysteria. The treatment here recommended is by persuasion (“ sug¬
gestion ”)—the attention must be exalted, and sensation restored.
If necessary hypnotism may be required to annul the memory of the
emotion which seemed to give rise to the morbid phenomena.

H. J. Macevoy.

Psychical Disorders in Malaria [Les troubles psychiques dans le palu-
disme\ (Le Prog. Med., Sept. 28th, 1901.) Cardamatis.

After reviewing the historical aspect of this question from the time of
Hippocrates down to our days, the author gives the results of his
clinical experience. He classifies clinically the intellectual disorders
which are associated with, or due to, malaria into— (a) those which
accompany the febrile attacks; (b) those which occur during the
intervals, as well as during the attacks, of chronic malaria; ( c) those
which are observed in the course of intermittent fevers and pernicious
attacks; (d) disorders which appear during the malarial cachexia.
Great stress is laid upon the predisposing causes as compared with
the immediate or exciting cause—the poison; the malarial parasite
provokes simple hypenemias; other pathological alterations beyond
this are, according to the author, related to the predisposition of the
organism. The close relation to alcoholic toxaemia is emphasised.
Among the general conclusions are—(a) malaria lights up morbid pre¬
dispositions (neurasthenia, hysteria, psychoses), or a general or local
disorder present in a latent state; it may aggravate disorders already
active ; (b) the delusional state of malaria is provoked by hallucinations;
(c) according to the degree of excitability of the individual, the con¬
dition of predisposition, and the activity of the malarial poison, four
degrees of malarial toxaemia may be distinguished: (1) excitement, (2)
anaesthesia, (3) coma, (4) paralysis; (d) acute forms of insanity occur

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EPITOME.

580

[July,

but rarely in malaria; (e) beyond the melancholic type and the
maniacal type there is a third type of insanity, often seen following
upon a febrile attack—the mixed depressive and excited type; (/)
psychical disorders in the course of chronic malaria are rare, while the
occurrence of psychoses, which are said to appear some time after the
disappearance of malaria, is doubtful. H. J. Macevoy.

Case of Acute Delirious Mania [Sur un cas de dilire aigu]. ( Gaz . des
Hop.) Jan. 14 thy 1902.) Buvat.

This is a case, apparently, of endogenous toxic origin, immediately
arising after a violent emotion of sorrow, which caused sudden sup¬
pression of the menses. J. C—, $, was admitted into Villejuif
Asylum, May 1st, with certificates stating that she was acutely maniacal
and violent, and that she also presented signs of mental enfeeblement
and alcoholism. She was restless, incoherent, violent, and slightly
feverish. The onset of her illness dated from the beginning of her
child’s illness; she became sad, irritable, and ate but little. The
child dying, her menstruation ceased after twenty-four hours’ duration,
and she began to have delusions. A few days later she became acutely
maniacal. May 2nd, restless, incoherent, destructive, scarcely heeds
questions; has to be fed with stomach-pump; temperature 37*8° C.
Between May 3rd and May 12th temperature varied between 39*4° C.
and 38*2° C., and the acutely maniacal condition persisted. No sign of
typhoid, etc. Wasting rapidly. This went on, more or less, till
June 6th, when the patient became quieter; her temperature fell to
normal, and her tongue became cleaner. After June 14th, although
there was no fever and the acute delirious condition did not recur, the
patient remained maniacal until the end of August—restless, incoherent,
sleeping badly, mistaking identities, etc.

On August 30th a sudden emotion apparently brought aboqt con¬
valescence. One of five patients with whom she was bathing made an
attempt to drown one of the attendants, thereupon J. C— rushed to
the alarm bell and fled naked from the bath-room, shouting for help. A
few minutes later she gave a sensible connected account of what
occurred in the bath-room, although she was incoherent and maniacal
when she was being undressed. From that time she rapidly improved,
gained weight, and was discharged October 10th.

Dr. Buvat believes that the copious injections of serum (with
chlorides and bromides in solution) he gave had a beneficial effect on
the course of the illness. H. J. Macevoy.

On a Special Form of Negation of Memory [Sopra una forma speciale di
negativismo mnemonico]. (II Manicomio , anno xvii, No. 3, 1901.)
Angiolella.

The patient was a man set. 40 years, with nothing special in his
family history. His first mental symptoms—apparently of an acute
confusional type—occurred in 1899, following an attack of some
infective fever, probably typhoid, in Brazil. After treatment in an
asylum he returned to Italy in April, 1900, when he presented no other
mental symptoms except the peculiar disorder of memory described in

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1902 .] CLINICAL NEUROLOGY AND PSYCHIATRY. 581

this paper. Up to the date of the paper (October, 1901) this disorder
has persisted unchanged.

Questioned even on the simplest subject—whether he is married or
single, how many children he has, how long he has been in the asylum,
whether he has had his dinner, etc.—he answers that he does not
remember, that he is “no good at remembering from one day to
another.” If told anything as a fact and then asked about it, he
replies, “ If you say so, it must be so.” When asked if he is well, or if
he is cold, he answers, “ I am so-so, not very ill and not very well,” or
“ I am not precisely cold and not precisely hot.” At times he plays
cards with other patients and acquits himself very fairly. On one
occasion the experiment was tried of giving him no dinner ; some time
after, asked if he had dined, he replied that it was not yet the hour;
told that the hour was passed and that he had dined, he accepted
the statement. He has to be guided to his bed every night; if the
effort is made to compel him to choose his place in the dormitory
without help, he insists on his lack of memory and becomes excited.
At no time, however, does he exhibit symptoms of angoisse. He asks
for nothing, and appears generally apathetic.

Discussing the case, Angiolella rejects at once the hypothesis of
simulation; it is negatived by the absence of motive, the long duration
of the symptoms, and the fact that the patient is not a degenerate. On
the other hand, it is difficult to imagine that so profound a loss of
memory should not be associated with other evidence of advanced
dementia. Moreover, the patient’s attitude of ignorance refers not only
to the past but to the present. The inference is, therefore, that the
case is allied to the folie du doute —the patient will not venture to affirm
anything, or to deny anything, for denial is also an assertion of certainty ;
he simply denies that he can affirm anything.

Angiolella discusses acutely, and at considerable length, the relation¬
ship of this peculiar condition to the obsessional folie du doute , and to the
delirium of negation. His conclusion is that it depends on a special
and limited defect in cerebral function, consisting in a weakening of
the power of perception and retention. Impressions, accordingly, do
not fix themselves firmly in the patient’s consciousness, and thus do
not furnish the elements of sure judgment. Out of this state of
doubt and uncertainty is formed the conviction in the patient’s mind
that he has lost his memory, and this idea acquires the character of a
fixed delusion. W. C. Sullivan.

The Mental State of the Subjects of Tics [Lietat mental des liqueurs].

{Prog. Med., Sept, yth, 1901.) Meige and Fein del.

The fact that tics only occur in individuals of the degenerate class
has been recognised by most writers on these affections. The aim of
the present paper is to describe more fully the special mental state
which accompanies the tic. The authors find the most constant
features of that state in a weakness and instability of the will and the
emotions, recalling conditions which are normal in childhood. This
state of psychic infantilistn is expressed in an inconstancy and variability
of ideas, to which corresponds a similar variability of tic movements.
Tics localised to particular muscles or groups of muscles similarly have

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582

EPITOME.

[July,

their counterpart in such psychic abnormalities as fixed ideas, obsessions,
etc. A tic may thus arise from an obsession if the besetting idea
provokes a motor reaction; or, inversely, a tic may engender an
obsession. The mental basis is similar in the two cases, and it is not
rare to see obsessions and tics alternate or coincide in the same indi¬
vidual. The different varieties of phobia, the dilire du toucher , hypo¬
chondriacal doubts, etc., are mentioned as forms of obsession, common
in the subjects of tic. The authors urge that it is important to dis¬
tinguish the tics which belong to the fundamental state of psychic
infantilism from those which are related to these secondary mental
disorders. In the latter, which are harder to eradicate, it is necessary
to direct treatment specially to the mental condition.

W. C. Sullivan.

Differential diagnosis between Hysteria and Katatony [Beitrage zur
differential Diagnose der Hysterie und Katatonie], ( Allgem . Zeitsch .
f Psychiat., B. Iviii, H 5 and 6.) Kaiser , O.

He describes at considerable length two patients in the Asylum of
Alt-Scherbitz, one, which he calls a typical case of katatony, becoming
finally dementia prcecox; the other, a young student with hysterical con¬
vulsive attacks and hallucinatory states and delirium. Kaiser regards
hysteria as an abnormal mental susceptibility of the nervous system, by
which it becomes prone to yield either to outward suggestions or to
fanciful notions formed within the mind of the patient. Through this
hyper-suggestibility, whole association systems are diverted from their
functions, and the activity of others heightened. The differential dia¬
gnosis between katatony and aggravated hysteria is stated to be, that in
the former there is a childish mental weakness, a state of depression
with few ideas, passing into dementia, which contrasts with the selfish
caprice, cunning, and persisterice of purpose in the hysterical patient.

In my opinion, katatony is a formal distinction into which it is
difficult to squeeze a sufficient number of cases of insanity. To find
katatony one must hold Kahlbaum’s description in mind, and step into
the asylum to seek for examples. It is like looking for faces in the fire.

William W. Ireland.

6. Pathology of Insanity.

Changes in the Cerebellar Neuroglia in Progressive Paralysis [Die
Gliaverdnderungen im Kleinhim bei den progressiven Paralyse].
( Arch./\ Psychiai. u. Nervenkr ., B. xxxiv, H. 2,/. 5 23.) Raecke , Dr.

Fifteen cases in which the changes in the cerebellar neuroglia were
specially studied are given in some detail. The results correspond
generally to those of Weigert. In the molecular layer, Bergman’s fibres
are increased in numbers, but unevenly. Most of the new fibres run
vertically, but some obliquely or transversely, the last often forming
bands at two levels, viz. along the outer margin of the cortex and at the

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PATHOLOGY OF INSANITY.

583

1902 .]

boundary of the granular layer. In the latter position they form
basketworks enclosing Purkinje’s cells. The transverse fibres are
mostly delicate, but a number of large spider-cells at the border of the
granule layer give off coarse fibres, running to the surface. The
largest collection of glia-nuclei is in the same situation. In the granule
layer also the changes are of unequal degree. They consist in loss of
granules, the place of which is taken by hypertrophied neuroglia fibre
and nuclei. In the medulla the hypertrophy is rarely of great extent,
and appears to prefer the immediate neighbourhood of the vessels,
where large, coarse-fibred spider-cells are also found. Fibres and
nests of glia-nuclei occur, however, between the nerve-bundles. In
general, the rule is that in progressive paralysis the molecular layer is
most involved, then the granule layer, more in spots, and last and least
the medulla. Hence it is the dendrites of Purkinje’s cells which
appear to be chiefly affected in this disease, and their bodies also
vanish in advanced cases. The morbid process thus seems to
advance from without inwards. Little clinical value is claimed for
these results, owing to the irregular distribution and frequently slight
degree of the foci of disease; but it may be supposed that the changes
contribute to the ataxy and incoordination. The paralytic seizures are
more likely, from these cases, to be connected with diseased foci in the
thalamus. No relation could be detected between the cerebellar
changes and absence or increase of the reflexes.

W. R. Dawson.

The Topography of Degeneration in the Cortex 0/ Paralytics in 7 ‘elation
to Flechsifs Association Centres \Die Topographie der paralytischen
Rinden Dege?ieration und deren Verhdltjiiss zu F/echsigs Associa¬
tions- Centren], (Near. Cbl ’., No. 2, 1902.) Schaffer, Karl.

Dr. Karl Schaffer, of Budapest, gives the results of his examination of
the brains of three general paralytics. His paper is illustrated with
five lithographs, showing sections of brain stained by Weigerts-Wolter’s
method. The degenerated parts take on the stain poorly. Schaffer
finds the most degenerated parts in general paralysis to be the anterior
and basal portions of the frontal lobes, the whole parietal lobes, the
posterior median convolutions, the insula, and the temporal gyri, and
the occipital lobes and the upper surface of the cerebellum. Less
affected were the anterior median gyrus, the margins of the calcarine
fissure, and the inferior occipito-gyri. This showed that degenerative
process most affected the association centres of Flechsig, his sensory
spheres being very much less touched. Schaffer holds that the degenera¬
tion of the cortex in general paralysis is not haphazard but selective. He
upholds Flechsig’s views, and considers that they have been confirmed
by the recent researches of Ramon y Cajal, who has made an original
study of the nerve-tissues in the foetus and in the newly-born child.
The latter describes a specific plexus of centripetal nerve-fibres, which
terminate in the motor area of the cortex, in the sphere of bodily
sensibility, and in the visual area. It is significant that this plexus does
not pass into Flechsig’s association centres, confirming Schaffer’s
observation of the posterior median convolution being, in general
paralysis, much more degenerated than the anterior. These considera-

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EPITOME.

584

[July,

tions induce Schaffer to think that the posterior median gyrus belongs
rather to the association centres than to the sensory areas.

Cajal confirms the observations of Flechsig that the fibres of the
association centres become mature later, and shows that these centres
in the new-born child, as well as in some small mammalia (the mouse,
the rabbit), have no exogenous terminal fibres; while, at the same time,
the pyramidal cells and the nerve-cells of the zonal layer have a special
appearance in the embryonic development. He largely agrees with
Flechsig’s views, and considers his anatomical and physiological dualism
in the cortex as rational a priori , but he differs in regarding the
association centres as wanting a specific terminal plexus, and not pro¬
jection fibres. Cajal also holds, as against Flechsig, that the associa¬
tion centres occur not only in the anthropoid apes, but also in the
smooth-brained animals. William W. Ireland.

7. Sociology.

Judicial Condemnations of Unrecognised Lunatics [Les alients devant les
tribunaux ]. {Rev. de Psychiat^ March, 1902.) Pactet.

In this critical review the author, by reference to some of the recent
literature on the subject, illustrates the frequency with which persons
suffering from mental disease are committed to prison for criminal acts.
A number of personal observations (referring chiefly to general paralytics)
are quoted to the same effect. To prevent such miscarriages of justice
the author suggests that all persons accused of criminal offences
should be submitted to examination by an alienist; and he quotes the
opinion of Dr. Paul Gamier—an exceptionally competent judge in the
matter—as to the practicability of such a plan, at all events in large
centres of population. The author also advocates the Belgian system
of frequent examinations of prisoners by alienist inspectors, and
recommends certain modifications in the French procedure of expertise
in criminal cases. W. C. Sullivan.

Criminal Asylums and Sections for the Insane in Prisons \Manicomii
criminali e sezioni per fol/i ne/le case di pena\ {Riv. mens . di
Psychiat. forense, Feb., 1902.) Penta.

In Italy, as in most other countries where such institutions exist,- the
admissions to criminal lunatic asylums have increased enormously in
recent years. Thus, in spite of the opening of two new asylums of the
same class, the original criminal asylum of A versa, which in 1876 con¬
tained nineteen patients, in 1898 contained 209. This increase Penta
ascribes, in part, to a real increase in lunacy, but much more to wider
knowledge of the nature of insanity, and more particularly of the close
connection between mental disease and crime. In face of this condi¬
tion of things, the future of the criminal lunatic asylum becomes an
urgent problem. Penta’s opinion is that a multiplication of these in¬
stitutions is undesirable. He thinks that they should be reserved for
incorrigible degenerates who, with or without co-existing insanity of

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SOCIOLOGY.

585

1902.]

thought, are insanely criminal in conduct. Curable or less dangerous
cases he would send to ordinary asylums, or would treat them in special
annexes to prisons. The creation of such annexes, after the model of
the section for insane criminals in the Moabit Prison at Berlin, he
regards as the most effectual way of dealing with the problem.

W. C. Sullivan.

On Diminished Responsibility [Sulla responsabilita diminuita ], (Riv.
mens . di Psychiat. forense,Jan ., 1902.) Penta .

The doctrine of the partial responsibility of the insane for criminal
acts is taken, Penta points out, in a different sense by lawyers and by
alienists. The former interpret it as meaning that an insane person, no
matter how insane he may be, is to be held in some measure account¬
able for his conduct unless it can be shown to depend logically on his
delusions. The alienists, on the other hand, would apply the doctrine
to cases of slight or early insanity, putting forward the mental condition
as a plea in mitigation of punishment. In either sense the doctrine is
fallacious. The mind is a unity, a synthesis, and not a mere aggregate,
and the idea of spheres of mind, one sane and the other diseased, is
quite untenable. And further, the fallacy is a very mischievous one.
It would combine the maximum of harm to the insane person with the
minimum of protection to society; the degree and not the nature of the
social reaction would be changed, so that the insane culprit would be
subjected to penal discipline instead of to medical treatment; and his
time of restraint would be shortened so that he would have increased
opportunities for wrongdoing. The doctrine is, in fact, a feeble and
useless compromise in the struggle between tradition and science. In
the present state of that struggle the proper attitude of the alienist is to
confine himself to indicating the mental condition of the criminal with¬
out entering into the metaphysical question of “responsibility.” If
forced to deal with that question he will do wisely to hold fast to the
choice between absolute responsibility and absolute irresponsibility.

W. C. Sullivan.

Abnormalities of the Circle of Willis in Criminals , in relatio 7 i with
Alterations in the Brain and Heart [A noma lie del poligono arterioso
del Willis nei delinquenti in rapporto con alterazioni del cervello e
del cuore]. {Arch, di Psychiat., vol . xxii,fasc. 1, 1902.) Parnisetti.

In a series of eighty-seven post-mortem examinations of criminals, the
author found that the circle of Willis presehted abnormalities of origin,
development, or direction in 65*5 percent, of the cases, the majority (32*18
per cetit .) occurring on the left side. In 73*56 per cent, of the cases
the weight of the brain was below the average, and the inferiority of
weight coincided in 51*72 per cent, of the subjects with the existence
of such vascular anomalies. Morbid changes in the vessels, membranes,
and brain-substance were unusually abundant. The weight of the heart
was below the average in 75*86 per cent, of the criminals examined, and
in 49*42 per cent, this condition was associated with abnormalities of
the circle of Willis. Among the cases with these latter abnormalities
heart lesions were particularly frequent.

XLVIII. 40

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586 NOTES AND NEWS. [July,

The paper is accompanied by a plate showing the arrangement of the
vessels at the base of the brain in nine of the cases.

No information is given as to the age or stature of the subjects.

W. C. Sullivan.

Contribution to the Medico-legal Study of Prostitution and Vagrancy in
Imbeciles [ Contribution dietude midico-legale des imbeciles prostitutes
et vagabondes\ ( Gaz . des H 6 p.,July 30/A, 1901). Gamier and
Wahl :

The authors record three medico-legal observations of imbecile
prostitutes. The subjects all presented numerous stigmata of degene¬
racy, and displayed extremely perverse instincts. Attention is drawn
to the large proportion of congenitally weakminded persons to be found
amongst prostitutes and vagrants, and measures of special restraint for
individuals of that class are recommended. W. C. Sullivan.

Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

A Council and General Meeting of the Association were held on May 21st,
1902, at No. 11, Chandos Street, Cavendish Square, W. Dr. Oscar T. Woods
presided.

The Council was attended by Drs. Oscar T. Woods, L. A. Weatherly, Fletcher
Beach, Alfred Miller, C. Mercier, H. H. Newington, P. W. Macdonald, H. Rayner,
James M. Moody, T. Stewart Adair, C. H. Hitchcock, Theo. B. Hyslop, C. H.
Bond, G. Stanley Elliot, R. Percy Smith, J. B. Spence, A. N. Boycott, H. A.
Kidd, and Robert Jones.

Apologies for non-attendance were received from Drs. A. R. Urquhart, J.
Wiglesworth, and H. T. S. Aveline.

The following members attended the General Meeting: — Members : Drs.
Oscar T. Woods, P. W. Macdonald, H. Rayner, L. A. Weatherly, F. Beach,
C. K. Hitchcock, R. D. Hotchkis, J. M. Moody, G. S. Elliot, C. H. Bond, H. H.
Newington, C. Mercier, T. B. Hyslop, T. S. Adair, H. A. Kidd, A. Boycott, C. S.
Morrison, E. W. White, J. C. Johnstone, W. Kingdon, J. W. Evans, J. Benson
Cooke, J. G. Soutar, W. J. Mickle, H. E. Haynes, J. H. Edwards, J. F. Bland*
ford, H. Barnett, T. C. Shaw, J. Middlemass, G. E. Mould, F. A. Elkins, C.
Clapham, G. H. Savage, H. Corner, R. H. Cole, E. Powell, W. E. Jones, J. M.
Ahern, G. H. Johnston, E. B. Whitcombe, D. Bower, J. Chambers, G. E. Shuttle-
worth, R. Langdon-Down, A. Helen Boyle, R. P. Smith, F. Edridge-Green,
W. Douglas, H. F. Winslow, E. S. Pasmore, C. T. Ewart, D. H. Macmillan, J. S.
Bolton, A. J. Alliott, H. C. MacBryan, J. P. Richards, R. Baker, J. B. Spence,
T. O. Wood, W. H. Haslett, James Stewart, and Robert Jones.

Visitors: Dr. Osswald Hofhain, Mr. C. B. Lockwood, and Major C. W.
Johnson, R.A.M.C.

The President said that, as the minutes had appeared in the Journal, it would
save time if the members would consent to their being taken as read. This was
agreed to.

Dr. Hayes Newington mentioned that two days ago he heard from the late
Registrar of the Association, Mr. Benham, who requested him to place before the
members an expression of Mr. Benham’s hearty appreciation of the kindness and
courtesy which had always been extended to him, especially during his illness.

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1902 .]

NOTES AND NEWS.

587

Dr. Newington had much pleasure in mentioning the matter, and in stating that
Dr. Benham was much better, and hoped soon to be amongst them again as well
as ever.

The following candidates were elected as ordinary members: Dudgeon, Herbert
William, M.D.Durham, M.B., B.S.Lond., Horndean, Mowbray Road, Upper Nor¬
wood, S.E., Medical Officer to the Egyptian Asylum, Abassieh, Cairo, Egypt (pro¬
posed by G. H. Savage, James M. Moody, and H. Hayes Newington); Forshaw,
W. H., M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, London County
Asylum, Claybury, Woodford Bridge, Essex (proposed by Robert Jones, C. T.
Ewart, and J. S. Bolton); Forsyth, John Glen, M.B., C.M.E d.. Assistant Medical
Officer, Cumberland and Westmorland Asylum, Garlands, Carlisle (proposed by
W. F. Farquharson, Geo. A. Rorie, and John Findlay); Kerr, Neil Thomson,
M.B., C.M.Ed., Medical Superintendent, Lanark District Asylum, Hartwood,
Shotts (proposed by J. Carlyle Johnstone, T. C. Clouston, and W. Ford Robert¬
son) ; Round, John, L.R.C.P., L.R.C.S., L.F.P.S.Glasgow, 34, Huntingdon Street,
Barnsbury, N. (proposed by T. Claye Shaw, H. Hayes Newington, and Robert
Jones); Rows, R. G., M.D.Lond., M.R.C.S., L.R.C.P., Pathologist, County Asylum,
Lancaster (proposed by David Orr, J. S. Bolton, and Robert Jones).

The President referred to the loss of members during the past year by death,
Viz. Dr. Strange, Dr. Boddington, and Dr. Bonville Fox. He was sure every one
in the room deeply regretted their removal. It was usual at the annual meeting to
mention those losses, and he merely referred to them now in order to express his
own deep sympathy with the friends of those gentlemen.

Report of Tuberculosis Committee.

The President said that the report of the Tuberculosis Committee came before
the Council Meeting that day, and in order to have the matter formally placed
before the present meeting he would call upon Dr. Weatherly.

Dr. Weatherly said it was his pleasure to simply bring before the meeting in a
formal way the report of the Tuberculosis Committee. The report had been
printed, was in the hands of the Council, and would be in the hands of every
member before the next Annual Meeting, when he would be glad to move its
adoption.

The President said that at the Annual Meeting an opportunity would be afforded
of discussing this report. He thought members would agree to the suggestion of
Dr. Weatherly that the report should be laid on the table. Agreed.

Dr. Henry Rayner opened a discussion on “ Sleep in relation to Narcotics in
the Treatment of Mental Diseases” (see p. 460).

Dr. T. Claye Shaw read a paper entitled “The Surgical Treatment of Delu¬
sional Insanity based upon its Physiological Study” (see p. 450).

Dr. Robert Jones’ paper, " Notes on the Treatment of Morphinomania,” was
not read owing to the advanced hour of the afternoon. It appears in this number
of the Journal (see p. 478).

Members afterwards dined together at the Caf£ Royal, Regent Street.

SCOTTISH DIVISION.

A meeting of the Scottish Division was held in the Central Hotel, Glasgow, on
March 28th.

Present: Drs. Clouston, Carlyle Johnstone, Carswell, Ford Robertson, Graham,
Havelock, R. D. Hotchkis, Hamilton Marr, John Keay, Macdonald, McRae,
Maxtone Thom, Mitchell, Oswald, W. A. Parker, Rorie, G. M. Robertson, A. R.
Turnbull, Urquhart, W. R. Watson, Yellowlees, and Dr. Lewis C. Bruce, Divi¬
sional Secretary for Scotland. On the motion of Dr. Turnbull, Dr. Graham was
called upon to preside.

The minutes of last meeting were read, approved, and signed.

Election of Members.

The following candidates were elected Ordinary Members of the Association :—
Dr. Kenneth D. C. McRae, Assistant Physician, District Asylum, Inverness; Dr.

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588

NOTES AND NEWS.

[July,

Eric M. Thomson, Assistant Medical Officer, James Murray’s Royal Asylum,
Perth; Dr. Leonard D. H. Baugh, Assistant Medical Officer, Stirling District
Asylum, Larbert; and Dr. Frederick Watson, Assistant Medical Superintendent,
District Asylum, Ayr.

Dr. Bruce proposed, and Dr. Yellowlees seconded, the nomination of Dr_
Carlyle Johnstone to the Examinership for the Nursing Certificate.

Dr. Urquhart proposed, and Dr. Parker seconded, the nomination of Dr.
Carswell as Examiner for the Medical Certificate of the Association.

After some discussion these proposals were adopted by the meeting.

Nominations for Elections to the Council.

Dr. Turnbull said that he understood that the Assistant Medical Officer repre¬
senting Scotland now retired, and proposed Dr. McRae as his successor.

Dr. Carlyle Johnstone suggested that whoever was named as a member of
Council ought to engage to attend the meetings.

Dr. Oswald moved that Dr. Macdonald, Senior Physician at Hawkhead Asylum,
be nominated, as he would undertake to attend the meetings in London.

Dr. Parker said he had much pleasure in seconding the motion.

After some discussion as to the importance of attending the Council Meetings,
especially that one usually held in May, the Chairman announced that the feeling
of the meeting was evidently in favour of Dr. Macdonald’s nomination, and this was
agreed to item, con .

Plans of Villa at Perth Royal Asylum.

Dr. Urquhart apologised for bringing such a very slight affair before the meet¬
ing. It was only of interest to those who were dealing with private patients, and
more especially with those paying the higher rates of board. The lower part was
to be built of stone, with a verandah to the south, and the upper part of brick, half
timbered. The main feature was a central hall, large enough to be used for
billiards. The patients’ parlours were grouped round this central hall, with glass-
panelled doors for the purpose of intimate supervision. Private patients were not,
as a rule, willing to have attendants sitting beside them at all times. The attendant
was, therefore, usually relegated to the corridor, in a most uncomfortable position.
Otherwise the domestic arrangements were of the usual villa type, minus kitchen
premises. These two villas were placed to the north of the main asylum, one on
either side of the chapel, the basement of which was to form stores, and a subway
to be continued to the central kitchen. The important point now to be determined
is the question whether these houses should be quite detached, or connected by some-
kind or corridor. He had therefore endeavoured to ascertain from the patients
themselves what their preference would be, and had consulted with Dr. Clouston as
to the results of his experience. The upshot was that it had appeared to him that
the Murray had as much entirely separate accommodation as was desirable in
present circumstances, and that the majority of patients were strongly in favour of
an attached house, so that they might live in the main current of life m the asylum
without any difficulty in moving about the establishment on winter evenings, etc.

The Chairman said that the erection of such a convenient residence for the
patients who were able to afford it was a very interesting subject, where they might
be supervised in a convenient, unobtrusive, and effective manner. It might be too
much to expect that a thorough examination of the plans could be made in a
cursory manner round the table, and perhaps Dr. Urquhart might see his way to
give a fuller account of the building when convenient.

Dr. Clouston thanked Dr. Urquhart for having brought these plans before them.
One could not express an opinion merely by glancing at the plans, but they all
knew that these houses would be tasteful outside and in, and if there was as much
comfort as they had at Craig House, he would have very great satisfaction in
having these houses attached to his institution. He thought, however, that there
ought to be two staircases. He doubted if it was a proper thing to fill up the space
on the first floor over the hall by box-room accommodation, and thought it better
to place the cupboards round about.

Dr. Carlyle Johnstone seconded the vote of thanks, and said that the plans
showed an amount of artistic skill which was generally absent from asylum,
buildings.

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NOTES AND NEWS.

1902.]

589

Dr. Urquhart, in reply, said that with regard to the single staircase, it ought to
be stated that the villa was really a small house, as there were only eight bedrooms
on the first floor. The height of the ceilings downstairs was 11 feet 6 inches, and the
windows were all to open casement fashion. There was no use of having small rooms
with fourteen-foot ceilings, as at Gartnavel, and he did not think that any cupboard
should be any higher than they could reach comfortably from the floor, and modem
libraries were now constructed in the fashion adopted. The whole of the roof over
these cupboards was a glass canopy, and the first-floor rooms would not be in use
by day. With regard to the cost, if that house were built for State-supported
patients there would be space in it for seventeen. As it was, they expected to
accommodate from seven to nine, depending upon the rates paid. The contract
price, exclusive of foundations, which would cost about £ 80, came to ^1604, so
that would be about ^100 a bed on the ordinary calculation, which he thought
sufficient even for patients paying ^200 or /300 a year. The finish of the inside
was somewhat elaborate, but he thought that they would be able to complete the
house at the price indicated. Perhaps the best way of describing the villa in detail
would be on the occasion of a visit of the Scottish Division to Perth.

Dr. Clouston opened a discussion on “ Toxaemia in the Etiology of Insanity M
(see page 434).

A vote of thanks was accorded to Dr. Graham for his conduct in the chair.

NORTHERN AND MIDLAND DIVISION.

A meeting of the Northern and Midland Division of the Medico-Psychological
Association was held on Wednesday, April 16th, at Shaftesbury House, Formby.

Members present: Drs. Blair, T. P. Cowen, S. Edgerley, Stanley A. Gill, C. H.
Gwynn, C. K. Hitchcock, R. Legge, Alfred Miller, Bedford Pierce, H. A. Robin¬
son. F. O. Simpson, A. Simpson, J. B. Tighe. Visitors : Drs. Drury, E. H. Gill,
A. C. Blackney.

Dr. Stanley Gill having been voted to the chair, Dr. Hitchcock read the minutes
of the last meeting, and stated that he and Dr. Miller had attended the Council
Meeting in London. He reported the result of the representations that had been
made regarding nominations by the Northern and Midland Divisions to fill
vacancies in the Council.

The minutes were then adopted, after which the Chairman announced that there
were one or two strangers present, whom they welcomed.

The Election of Secretary.

Dr. Pierce proposed that Dr. Hitchcock be re-elected. This was seconded by
Dr. Miller, and unanimously agreed to.

Dr. Hitchcock said he would be glad to take the office for another year. He
did not think, however, that one man should continue in the office year after year,
because it added to the interest of a society when members took office in rotation.
If, however, the Society wished him to accept office he would be glad to do so.

Place of Next Meeting.

An invitation from Dr. Pope to hold the Autumn Meeting of the division at
Middlesbrough was unanimously accepted.

The following candidate was elected as an Ordinary Member:—A. Mair
Rattray, M.B., C.M.Edin., Senior Assistant Medical Officer, City Asylum, Gosforth,
Newcastle (proposed by Drs. Callcott, T. W. McDowall, and Robert Smith).

Dr. F. O. Simpson read a paper entitled “Calcification of the Pericardium”
(see page 529).

Dr. T. P. Cowen read a paper entitled “ Pupillary Symptoms in the Insane and
their Import” (see page 501).

A vote of thanks was accorded to the Chairman at the close of the meeting.

Previous to the business meeting Dr. Gill entertained the Division at luncheon.
Those members who were able to remain spent a very pleasant evening as his guests.

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590

NOTES AND NEWS.

[July,

SOUTH-WESTERN DIVISION.

The Spring Meeting was held on Tuesday, April 22nd, 1902, at Cotford
Asylum, near Taunton, under the chairmanship of Dr. Aveline.

Present: Drs. Braine-Hartnell, H. T. S. Aveline, Laing, Sproat, Davis,
MacBryan, Morton, Weatherley, Willis, Hungerford, Findlay, Beale-Brown, P. W.
MacDonald (Hon. Sea.), and one visitor.

The Hon. Sec. read the minutes of the last meeting, which were adopted.

The following were elected ordinary members :—Thomas Richard Beale-Brown,
M.R.C.S., L.R.C.P.Lond., A.M.O., Cotford Asylum, Taunton; Arthur Charles
King-Turner, M.B., C.M.Edin., The Retreat, F airford; and William Frederick
Willis, M.R.C.S. and L.R.C.P.Lond., A.M.O., County Asylum, Exminster, Devon.

Dr. Weatherly said that he had very much pleasure, on behalf of the members
of this Division, in asking Dr. MacDonald to carry on the secretarial duties again.
They recognised his work and all he had done for the Association, and they would
feel grateful if he would again accept the position. (Hear, hear.)

Dr. MacBryan seconded the proposition, which was put to the meeting and
carried unanimously.

On the proposition of Dr. Davis, seconded by Dr. MacBryan, it was decided to
submit the name of Dr. Braine-Hartnell for the consideration of the Council when
nominating members to fill vacancies.

Dr. J. V. Blackford and Dr. Goodall were elected to the vacancies on the Com¬
mittee of Management.

The Chairman said that the next business was the selection of the date and
place of the next meeting. Dr. Davis had been kind enough to invite them to
Exminster, and he proposed that the invitation be accepted, which was unanimously
adopted.

Dr. Macdonald read a letter from the Hon. Mrs. Wade, widow of the late Dr.
Law Wade, of Wells, dated October 27th, 1901, in which she thanked the members
for the vote of sympathy extended to her in her great loss.

Dr. Weatherly read a paper entitled “The Evolution of Delusions in some
Cases of Melancholia ” (see p. 495).

Dr. Sproat read a paper entitled “ The Care of Idiots and Imbeciles." The
publication of this paper has been unavoidably postponed.

Vote of Sympathy.

The Chairman said that they all regretted that owing to illness Dr. Benham
had been obliged to give up work. He had six months’ leave granted him, and he
(the Chairman) had seen him before he went away, and again about a month ago,
and he was ^lad to inform them that he was very much better. They all expressed
sympathy with him.

Dr. Weatherly endorsed the Chairman’s remarks, and said that they all recog¬
nised the work Dr. Benham had done, and the Association generally trusted he
would soon be with them again.

The Chairman proposed a vote of sympathy and condolence with the widow of
the late Dr. Bonville Fox, of Brislington House, and said he remembered when he
first joined the society what a lot of work Dr. Fox had done for it.

Dr. Macdonald said that he had known Dr. Fox for a great many years, and
he was sure they all felt that by his death they had lost a very able member of the
profession. In days gone by he had taken a very active and important part in the
work of that Association. He had heard Dr. Fox’s voice on many memorable
occasions, and he was sure it was the wish of the members that a most cordial vote
of sympathy and condolence should be passed.

Mr. Davis proposed a vote of thanks to Dr. Aveline for his hospitality, and said
that the members had looked forward with interest to an inspection of the extensive
and modern asylum at Cotford, and no doubt many of them had learnt a great
deal from it.

Mr. Braine-Hartnell seconded the proposition, which was carried unani¬
mously.

The members afterwards dined together at the Station Hotel.

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591

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South-Eastern Division was held, by the courtesy of

Dr. Barton, at the Surrey County Asylum, Brookwood, on April 30th, 1902.

Present: Drs. Barton, Bolton, Bower, Chambers, P. Campbell, Cappe, H.
Corner, W. I. Donaldson, C. Edwards, F. H. Edwards, C. Stanley Elliott, Lieut.-
Col. J. W. Evans, Drs. Edridge-Green, France, Fee, Gayton, Gardiner Hill,
Haynes, Hyslop, Robert Jones, Kerr, Moody, Mott, Macmillan, A. S. Newington,
Peeke Richards, Steen, Shuttleworth, Grimmond Smith, Stoddart, R. J. Stilwell,
F. R. P. Taylor, E. W. White, and Boycott (Hon. Sec.).

After luncheon a meeting of the Divisional Committee was held. During the
morning the grounds and asylum buildings were inspected, and at 2.45 p.m. the
General Meeting of the Division took place, Dr. Barton being voted to the chair.

The minutes of the last meeting were read and confirmed.

The following gentlemen were elected ordinary members of the Association:—
Frederick Cairns Blakiston, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Herts County Asylum, Hill End, St. Albans (proposed by Drs. Boycott,
Grimmond Smith, and McConaghey); Percival L. Langdon-Down, M.B., B.C.
Cantab., Normansfield, Hampton Wick (proposed by Drs.T. S. Tuke, R. Langdon-
Down, and Boycott); Robert Serjeant, M.R.C.S.Eng., L.R.C.P.Lond., Assistant
Medical Officer, Camberwell House (proposed by Drs. Edwards, Lavers, and
Boycott.

Official Recommendations.

Dr. A. Norman Boycott was nominated as Honorary Secretary to the Division
for 1902-3.

Drs. Everett, Gardiner Hill, and T. S. Tuke retired by rotation from the Divi¬
sional Committee, and Drs. Wolseley Lewis, Amsden, and F. H. Edwards were
elected in their places.

The name of Dr. Mott was suggested to the Council to fill the vacancy on that
body at the next Annual Meeting.

Next Meeting.

An invitation from the Drs. Tuke to hold the Autumn Meeting of the Division
at Chiswick House in October, 1902, was unanimously accepted.

Dr. N. H. Macmillan read a paper on “ The Treatment of Colitis” (see page 509).

At the close of the discussion on this paper the following resolution, proposed
by Dr. E. W. White and seconded by Dr. Mott, was unanimously carried :

“ That this Division of the Medico-Psychological Association approves of the
register for recording cases of dysentery and diarrhoea in asylums, and will do its
utmost to further the carrying out of the same.”

The Chairman regretted that time did not permit Dr. H. Corner to read his paper
on “ Melancholia as the Expression of Physical Disorder.”

A hearty vote of thanks was accorded to Dr. Barton for entertaining the
Division at Brookwood, and also for presiding in the chair.

The members afterwards dined together at the Cafe Monico, Regent Street.

RECENT MEDICO-LEGAL CASES.

Reported by Dr. Mercier.

[The Editors request that members will oblige by sending full newspaper reports
of all cases of interest as published by the local press at the time of the assizes.]

Welsh v. Duckworth and others .

This was a remarkable action brought to recover damages for conspiracy and
false imprisonment. The plaintiff was sergeant in the Liverpool Police Force, and
the defendants are superior officers in the same service. As far back as 1891
plaintiff was employed at the docks, and it was admitted that while so employed

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he had on various occasions obtained sacks of corn-sweepings, bundles of cigars,
and perhaps other things of small value for the defendants, Chief Inspector
Strettell and Chief Clerk Sperrin, under whose orders he was. He had never got
anything for the defendant Duckworth. It was proved that the corn-sweepings were
often given away at the docks for nothing as worthless, and that on some occasions
the plaintiff had been paid ios. per sack for these sweepings. It was admitted that
the two officers had occasionally received cigars from the plaintiff, but as to a
number of other articles alleged by the plaintiff to have been procured for them
the defendants denied all knowledge, and the plaintiff adduced no corroboration of
his statement, though he said he had had a large number of letters, which he had
destroyed, with respect to them. Of all the letters he had kept but three, and these
dealt with corn-sweepings, cigars, and tobacco only. As far as can be judged from
the evidence, the plaintiff had on various occasions, from nine to eleven years ago,
obtained from ships’ stewards and such people small quantities of tobacco and
cigars, which he had given to the defendants Sperrin and Strettell, and that seems
to have been the full extent of these dealings, of which a very great point was made
at the trial.

It appears from the evidence that the plaintiff was not liked in the force, that he
was charged with being addicted to drink, and that he was a man of intensely
suspicious nature. He frequently complained that as an Irishman and a Catholic
he could not get justice, that his nationality and religion retarded his promotion
and excited prejudice against him; and in this he persisted, although there are
many Irish Catholics in the Liverpool Police Force, and although, in order to abolish
his grievance, he was actually transferred to the section of an inspector who was an
Irish Catholic. When he was reprimanded for drinking and for small faults, he would
get very excited, and suggest that there were plots against him. He declared that
he could never get fair play; he talked mysteriously or the misdeeds of his superiors,
and of the conspiracy against him until the matter came to the ears of the vratch
committee, and they investigated his complaints. He was called before them,
and submitted a written statement to them, on which he was examined. The
examination seems to have been patient and thorough, and the committee came to
the conclusion that plaintiff’s charges were baseless, a conclusion in which they
were confirmed by a written statement by the plaintiff himself that he had no
charges to make. The upshot of the investigation was that the committee decided
to obtain medical opinion upon the state of the plaintiff’s mind, so that if it were
disordered, as they evidently suspected, they might award him a pension. Other¬
wise he must have been dismissed. On the instruction of the committee, the head
constable had the plaintiff examined by the police surgeon, Dr. Dawson, whose
evidence was that the plaintiff complained of insomnia, indigestion, general
nervousness, and breakdown, caused, as he said, by the persecution and tyranny of
his superior officers. Asked if he could give any reason for, or show any proof of
this persecution, he said he could not. He said that even the tramway officials
were set to spy upon him and to see that he paid his fare.

Dr. Lownaes, another police surgeon, also examined the plaintiff, who complained
that he was being persecuted because he was an Irishman and a Catholic.

Dr. Wiglesworth also examined the plaintiff, who complained of being persecuted
by practically all the members of the force. He did not single out any officer or
any two officers as his persecutors; it was a general charge against practically the
whole of the Liverpool Police, that they were conspiring to deprive him of justice.
Witness pointed out the improbability of his statements, and said that at any rate
the chief constable would do him justice. Plaintiff said that the chief constable
was as bad as the rest. Witness pointed out how incredible it seemed that a gentle¬
man in the position of the chief constable should be banded together with all the
other officers of the force for the purpose of injuring plaintiff, and asked for proofs,
but could get no mention of any proof whatever. 41 1 consider,” added Dr. Wigles¬
worth, “ that he was absolutely unfit to continue duty as a police officer, that he was
suffering from delusions of suspicion and persecution, that he was insane, that he
might develop dangerous tendencies, and that he ought to be placed under care
and control.”

Upon the reports of these three medical men, the plaintiff was arrested as a
dangerous lunatic, taken to the workhouse, and placed in a padded room. This
was the false imprisonment complained of. Here he was examined by Mr. Stewart,

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1902.]

the stipendiary magistrate, by Mr. Henry Peet, J.P., and by Drs. Smart, Alexander,
Bickersteth, and Barnard, the result of their examinations being that he was dis¬
charged. Of these, all but Mr. Stewart gave evidence at the trial, and stated that
in their examinations of the plaintiff he made allegations against Strettell and
Sperrin only, and these allegations he supported by showing the letters from them
which have already been referred to, asking him to procure certain articles for them.
The grounds that they hack to go upon were therefore quite different from those
upon which Drs. Dawson, Lowndes, and Wiglesworth formed their opinions.

The judge summed up the case with the care and impartiality to which we are
accustomed from Mr. Justice Wills, the gist of his charge, as it concerns readers of
this Journal, being as follows:—His lordship impressed upon the jury that they
were not trying whether the doctors arrived at a right conclusion or not as to the
plaintiff’s mental condition, but were trying whether their action, erroneous though
it might be, was brought about by the fraudulent and wicked malpractices of the
three defendants. In his opinion it seemed quite clear that the responsibility for
the removal of Welsh to the workhouse rested upon the chief constable, who did
not attempt to shirk the responsibility. The question was whether or not the pro¬
ceedings were within the statute. There he thought the defendants were in con¬
siderable difficulty, and a verdict against them on this part of the case would not
involve any kind of imputation upon them. If the chief constable had acted
wrongly, the officers who acted upon his directions were not protected by his orders.
It was a cardinal principle in English law, and a very good one, that an order given
by a superior, which he had no right to give, did not protect his inferior. There¬
fore, if the chief constable had no right to send plaintiff to the workhouse, the
defendants were not protected by having acted under him. His lordship proceeded
to deal with Sections 13 and 20 of the Lunacy Act, 1900, and pointed out that
** under proper care and control” must be such care and control as would be proper
if a man were a lunatic, or the Act would have no meaning. He would ask them
whether Welsh was under proper care and control. But there was another question,
which constituted the real difficulty of the defendants upon this part of the case.
He agreed with counsel for the plaintiff that the meaning of the words “ if a con¬
stable is satisfied that it is necessary for the public safety or for the welfare of the
alleged lunatic that he should be placed under control ” then steps might be taken,
was that a constable must exercise some independent judgment, and not shelter
himself by simply saying that he had no responsibility in the matter—simply
adopted whatever the doctors said. Did the chief constable honestly satisfy him¬
self that the plaintiff ought to be kept under care and control ? It went without
saying that he honestly believed that he was doing right and was fulfilling his duties
under the section. It was for the jury to say whether that was done according to
the view of the law that he had explained. In a subsequent discussion between his
lordship and counsel on the legal question, the judge repeated his ruling that it
would not do for a constable simply to make himself the mouthpiece of a doctor
without exercising any judgment of his own. If he had the opinions of doctors
and honestly came to the conclusion in his own mind, that would be honest satis¬
faction ; but if he exercised no judgment at all, and simply sheltered himself behind
the doctors, that would not do.

The questions left to the jury were, first: Was there a conspiracy to procure the
dismissal of the plaintiff and his imprisonment as a lunatic? To this the jury
answered, “ No.” The other questions were: Was the chief constable honestly
satisfied, when he gave the order to remove the plaintiff to the workhouse, that it
was necessary for the public safety or for the welfare of the plaintiff that he should
be forthwith placed under care and control ? and, Was the plaintiff under proper
care and control ? As to these questions, it does not appear whether they were
categorically answered, but upon the written reply of the jury being handed to the
judge, his lordship said, “On the question which relates to false imprisonment you
find in favour of the plaintiff?” To which the foreman answered in the affirmative.
4t Then,” said his lordship, who does not seem to have been prepared for this
result, “you have to say what damages.” These were assessed at £200. Counsel
for the defendants asked for a stay of judgment, to which the judge assented,
remarking that he was very anxious to get this Act of Parliament definitely con¬
strued.—Liverpool Assizes, Mr. Justice Wills .—Liverpool Courier, May 10th, 12th,
13th, 14th, 15th, and 16th.

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[July,

The sections of the Lunacy Act, 1890, to which the judge referred were as
follows:—“ Every constable . . . who has knowledge that any person within

the district ... is deemed to be a lunatic, and is not under proper care and
control, . . . shall within three days after obtaining such knowledge give
information upon oath to a justice (Sect. 13).

“ If a constable ... is satisfied that it is necessary for the public safety or
the welfare of an alleged lunatic with regard to whom it is his duty to take any
proceedings under this Act, that the alleged lunatic should, before any such pro¬
ceedings can be taken, be placed under care and control, the constable . . .

may remove the alleged lunatic to the workhouse. . . .” (Sect. ao).

These proceedings are parallel to those of the judicial reception order, and of the
urgency order in private cases, but no actual documentary order is required for
the immediate removal of the alleged lunatic to the workhouse, nor is any state*
ment required of the reasons for this step, such as is required in the case of the
urgency order. The trial turned upon the point whether the chief constable, who
was not a party to the action, was satisfied that this step was necessary. If he
were so satisfied, his subordinates were justified in acting upon his orders, which in
that case were legal, and the action would not lie. If he were not so satisfied,
then the judge ruled that his order to remove the patient was illegal, the defendants
were not protected by it, and the plaintiff must have his verdict upon this part of
the case. The evidence upon which the chief constable acted was made up of
(<*) his own observation of the plaintiff, ( 5 ) the reports of his subordinate officers,
and (c) the reports of Drs. Dawson, Lowndes, and Wiglesworth, who testified that
the plaintiff was a lunatic who might develop dangerous tendencies, and that he
ought to be placed under care and control. It is unfortunate that the actual terms
of the certificates or rather reports, for they were not, and did not need to be, cer¬
tificates in the form prescribed by the Act, are not given in the report of the trial,
but the purport of them is given in the evidence. As described, they do not state
that the plaintiff was a dangerous lunatic at the time of the examination, but that
he might develop dangerous tendencies ; and there does not appear to be sufficient
warrant in this statement for the instant arrest of the plaintiff, his removal forth¬
with to the workhouse, and his incarceration in a padded room. If the chief con¬
stable were satisfied of the necessity of this action, it must have been from the
evidence (a) and ( b ), and not from the medical reports. Dr. Wiglesworth explicitly
stated in court that the confinement of the plaintiff in a padded room was unjusti¬
fiable, and therefore there could have been nothing in his report to justify this. It
should be stated that this step was taken on the order by telephone of the work-
house medical officer, who had received information by telephone that a dangerous
lunatic had been admitted. Examination of the evidence of the chief constable
and of his subordinate officers does not reveal any act or threat on the part of the
plaintiff that indicates the necessity for such instant action, and it is probable that
this was the ground upon which the jury arrived at the conclusion that the chief
constable was not “satisfied” within the meaning of the Act that such action was
necessary. The case has been reported at length because it is one of considerable
importance, and indicates how very necessary it is that the terms of the Act should
be observed in the letter and in the spirit.

Rex v. Simmons.

Edward George Simmons, 36, was indicted for the murder of Hettie Stephens at
Melcombe Regis, on March 27th.

Prisoner was steward of a club, opposite to which was the bar at which deceased
served. Prisoner was a married man, but had paid great attention to the girl, and
had given her presents. Shortly before the murder he had told the employer of the
deceased that she was robbing him and that she drank. The employer, both at the
time and at the trial, scouted the accusations as absurd. On the evening in
question prisoner went into the bar and had some private conversation with the
deceased over the counter. Deceased was heard to say, “ I don’t want anything
more to say to you, Mr. Simmons;” and to some other observation of the prisoner,
“ No, not after what you said about me.” Prisoner then fired three shots at the
girl with a revolver, killing her on the spot, and a fourth shot into his own mouth,
which gave him but a slight wound. A man who was in the bar seized the

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1902 .]

prisoner, on which the latter said, " Don’t hold me, Purden, let me go and look
after the girl. Look after the girl. I know I did it. I meant to do it.” To the
police he said, “ I did it. 1 lost my temper. She did not treat me as she ought to
have done a married man. I shot her. That is all I have to say.” It was proved
that the prisoner had bought the revolver two days before, and that on the same
day he bought a butcher’s knife, saying, what was manifestly untrue, that he wanted
it to kill pigs with.

For the defence, the plea of insanity was raised, and in establishing this plea a
degree of latitude was allowed to the defence which is rare even in these humani¬
tarian days. The prisoner’s eldest brother and many other witnesses were called,
and gave the prisoner’s history from infancy. As a child he was excitable and
delicate. At school he was given special privileges on account of his health. He
walked in his sleep. In 1883 a companion of his went to prisoner’s home, and
informed his father that prisoner had been at his rooms all the evening; that he
could make nothing of prisoner, and had left him in charge of a friend. When his
friends went for him prisoner seemed dazed, and could not walk properly, though he
was not in drink. On the way home he revived, but talked rubbish. In July of the
same year he disappeared, he was advertised for, and answered from Ramsgate,
after being away for four days. Some time after that he again disappeared and
enlisted. He served from 1886 to 1894, and left as sergeant. His certificate of
discharge was, “ Exemplary. A very good clerk. A thoroughly trustworthy and
smart non-commissioned officer.” After he left the service he became steward of
a club in Manchester. Here he became excitable, restless, and sleepless, and com¬
plained that the committee were against him, which was not the fact. Before his
escapade to Ramsgate he had complained that the foreman in the business in
which he was employed was against him. While employed at this club he would
frequently go about the premises and sit on the doorstep in the early morning
in his pyjamas. He used to be very much worried and make a great fuss over
trifles, and make troubles out of nothing. A week or two before the murder
he had been worse. He complained of severe pains in the top of his head.
He complained repeatedly that the top of his head was coming off, and begged his
wife to press on it, which she did. He then consulted Dr. Wetherall, who treated
him for alcoholic gastritis and spoke positively to the strong alcoholic odour of
his breath, though other witnesses denied that the prisoner drank. On March
25th he was in a highly-wrought excitable state. A stranger who witnessed the
purchase of the revolver remarked that he did not seem to be in his right mind. A
day or two before, he had come home in a most excited state because a stranger had
spoken to him without being introduced, and on another occasion because he had
seen a man with a bracelet on his wrist.

Dr. Weatherly, called for the defence, was asked, “ Have you formed an opinion
of the prisoner’s mental condition at the time of this act ? ” Prosecution objected to
the question as being the question which would have to be answered by the jury.

The Judge : “ No; only partially. I shall tell the jury that prisoner may not have
been in a well-balanced state, and may even have had partial delusions, but that of
itself would not be enough. But I cannot disallow this question.”

Dr. Weatherly was of opinion that the prisoner suffered from petit mal without
convulsion. He believed that the prisoner meant to kill himself, that he acted
under the influence of morbid delusive fear, that he imagined that his whole life
would be ruined if his wife knew that he had given a few presents to this girl, and
that this produced the irresistible impulse to kill the girl.

The judge here put some very significant questions to this witness. ” Have you
ever,” he said, “ found this to be the fact—that a person suffering from mental
disease, unhinged from some cause or other, would suddenly take a violent dislike
to a person with whom up to that moment he had been on terms of intimate
friendship of a perfectly proper nature, and proceed to make charges against that
person, and then as suddenly agree to their being cast to the wind ? ” And, when
this question had been answered in the affirmative he said, M Would there not be
the same relative want of control in the charge made by the person as there would
be want of control in an act done afterwards ? would you not come to the conclusion
that the whole thing was due to mental want of control ? ”

Dr. W. B. Morton gave evidence in the same sense.

In summing up, his lordship is reported to have said that there was a fine

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NOTES AND NEWS.

[July,

dividing line between the healthy, vigorous mind and the dilapidated mind of the
insane; but though the mind of a man might not be healthily disposed, he might
be responsible for his acts. Counsel for the defence asked them to say that there
was overwhelming proof of a diseased mind. But it was not enough that he had a
diseased mind. The jury must find that in consequence of that diseased mind
prisoner had not at that particular time a full appreciation of the nature of the act
which he committed. In other words, that his mind was a blank, or that he was
under the uncontrollable impulse of a madman. Guilty, but insane.—Dorchester
Assizes, Mr. Justice Bucknill. — Dorchester Telegram , June ioth.

It is certain that a few years ago this merciful verdict could not have been
delivered in such a case as this. The evidence of deliberate intention was strong,
as was the evidence of previous animosity. The prisoner had already attempted to
injure the girl—to get her dismissed from her situation—by officiously representing
to her employer that she was neither honest nor sober. He purchased both a
revolver and a butcher’s knife. He shot her dead at the first shot, and fired twice
into her lifeless body. Immediately after he said, “ 1 know I did it, I meant to do
it.” Subsequently he mitigated this statement by saying, “ I lost my temper.” In
the act itself there is not only no trace of insanity in the legal sense, but there is
ample evidence of intention and deliberation. The whole of the evidence of
insanity was derived from the previous history of the prisoner, and it is precisely
this class of evidence which many judges have rigorously excluded from the con¬
sideration of the jury. The whole of the prisoner’s life, from infancy down to the
time of the trial, was scrutinised with the utmost vigilance, and everything that
could suggest that he was—I will not say insane, but different from the average
ordinary man was adduced and dwelt upon. The experts called for the defence
were not only allowed the widest possible latitude, but the judge himself went out
of his way to suggest an exonerating hypothesis which had not occurred to them.
Dr. Weatherly’s opinion that the prisoner suffered from petit mal must have been
founded upon facts which were not reported at the trial, and supposing it to be
valid, it applies only to corroborate the hypothesis of the prisoner’s general mental
deterioration; for it is quite certain that the murder itself was not done in a period
of post-epileptic automatism. The judge told the jury that he never recollected a
case so fully charged with difficulties, and certainly the difficulties are very great.
The first, and one of the greatest, is that of discerning an adequate motive for the
crime. The prosecution suggested that the prisoner was in love with the girl, that
he desired to possess her, that she refused, that he then tried to get her dismissed
from her place in order that she might be more fully in his power, and that failing
this, he shot hef. It is proverbially dangerous to attribute motives. As has been
before remarked in these pages, if we knew the full history and circumstances of
the actors, the motives of most of the crimes that we call motiveless would be clear
enough. Had the trial taken place in a neighbouring country, the agitation and
excitement that the prisoner evinced on the two or three days preceding the murder
would have been attributed to the resolution that he had then formed to commit
the murder, and this hypothesis would have been as probable as that advanced by
the prosecution. Certain it is that the circumstances of the crime alone lent no
support to the plea of insanity. This was established solely by reference to the
prisoner’s previous life, and after this case it will be impossible even for Dr.
Weatherly to assert that our legal procedure presses with undue severity upon
prisoners of unsound mind, or that any difficulty is placed in the way of establishing
the plea of insanity.

Rex v. Burden .

Frank Burden, 31, gardener, was indicted for the murder of his wife. Prisoner
had spinal disease, and when his wife became pregnant he was convinced that she
had been unfaithful, as he believed himself to be impotent and incapable therefore
of being the father of the child. They had many quarrels on the subject, and after
one of these the prisoner murdered his wife with a knife and a razor, which he then
hid under the mattress of the bed. He subsequently tried to drown himself. Dr.
Macdonald deposed that several relatives of both the father and the mother of the
prisoner were insane, and that the prisoner suffered from the two fixed delusions
that he was himself impotent and that his wife was unfaithful. Prisoner described

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1902.]

a visit that he had had from the devil in the night. Dr. Weatherly gave similar
evidence. On the other hand, Dr. Good, the surgeon to Dorchester Prison, who
had had the prisoner under observation for four months, could detect no insanity
in him. The judge here asked the jury whether they were satisfied that the
prisoner was insane at the time that he committed the offence; and the jury, after
some hesitation, replied that they were. His lordship said that he agreed. It
would be too terrible, after what they had heard, to come to any other conclusion.
Guilty, but insane.—Dorchester Assizes, Mr. Justice Bucknill .—Dorchester Tele¬
gram, June 10th.

It will be observed that there was no certain proof that the conviction of the
prisoner that he was impotent and not the agent of his wife’s pregnancy was a
delusion. The deceased seems to have been a modest, well-conducted woman, and
the strong probability is that the belief was a delusion ; but its delusive nature was
not susceptible of certain proof, and Dr. Good, who had the best opportunity of
acquainting himself with the prisoner’s state of mind, did not regard it as a delu¬
sion. Even if the belief was erroneous and the woman innocent, it by no means
follows that the belief was a delusion. It may have been a sane mistake. But the
judge took a strong course, and practically directed the jury to find a verdict
of insanity. The verdict was probably right, but the evidence upon which it was
founded was so slender as to justify fully the conclusion of the Committee of this
Association that in practice the law does not press hardly upon prisoners with
respect to whom the plea of insanity is raised.

LABORATORY OF THE SCOTTISH ASYLUMS.

The pathologist, in the Fifth Annual Report, gives in an appendix the following
list of publications (continued from the Fourth Annual Report) containing records
of researches carried out in the Laboratory, or in association with it :

W. Ford Robertson and James H. Macdonald; “Methods of rendering Golgi-
sublimate Preparations Permanent by Platinum Substitution.”— Journal of Mental
Science, April, 1901.

Chalmers Watson: “ A Contribution to our Knowledge of Disease of the
Nervous System in Horses.”— Veterinary Journal, March, 1901. “ On Disease in

the Nervous System of Horses.’’— Veterinary Journal, June, 1901. “ The Patho¬

genesis of Tabes and Allied Conditions in the Cord.”— British Medical Journal,
June 1st, 1901.

Lewis C. Bruce: “Clinical and Experimental Observations upon General
Paralysis.”— British Medical Journal, June 29th, 1901 ; and Trans, of the Medico -
Chirurgical Society, Edinburgh, 1900-01.

W. Ford Robertson: “Observations bearing upon the Question of the Patho¬
genesis of General Paralysis of the Insane.”— British Medical Journal, June 29th,
1901; and Trans, of the Medico-Chirurgical Society, Edinburgh, 1900-01. “The
Role of Toxic Action in the Pathogenesis of Insanity.”— British Medical Journal ,
October 26th, 1901. “ Platinum Method for the Central Nervous System.”— Pro¬

ceedings of the Scottish Microscopical Society, vol. iii, No. 2, 1901.

A. R. Urquhart and W. Ford Robertson : “ A case of Epilepsy following Trau¬
matic Lesion of Pre-frontal Lobe.’’— Journal of Mental Science, January, 1902.

Sir John Batty Tuke and W. Ford Robertson : “The Pathology of Insanity.”—
Quoin’s Dictionary of Medicine, 3rd edit., 1902.

W. Ford Robertson and J. S. Fowler: “ Researches on the Channels by which
the Cerebro-spinal Fluid escapes from the Intra-cranial Cavity, by the late Dr.
George Elder.”— Journal of Pathology and Bacteriology.

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[July,

CORRESPONDENCE.

From Dr. D. G. Thomson, Norfolk County Asylum, Thorpe, Norwich.

Hospital Ideals in the Care of the Insane.

I am sure few papers dealing with the practical side of asylum work have been
read by most of us with such interest as that by Dr. Robertson, of Larbert, on the
nursing of asylum patients, reported in the April number of the Journal of
Mental Science, and I hope that others like myself who were not present when the
paper was read will, either at future meetings or by letters to this Journal, con¬
tribute their views on this important subject.

Dr. Robertson's conclusions and practice are based on one fundamental belief
or premise, which is that the more closely we follow not only the hospital ideal
but hospital methods, the more perfect will our asylum nursing become. I, for one,
emphatically urge and protest that this belief or premise is unsound ; I believe that
while theoretically diseases of the mind may be diseases of the body as much as
tubercle and typhoid, yet in any case they demand an utterly different machinery
and environment for their management and treatment from that which obtains for
ordinary bodily disorders in a general hospital.

I am quite aware that from a medical point of view every inmate of an asylum
is a patient, but to assert that the hospital ideal is to be aimed at and striven for
in the care and management of the ordinary asylum inmate is absurd. I am sure
we have run after this ignis fatuus “ hospital ideal " long enough and far enough.
Moreover, we have in vain called asylums hospitals. One we have called Bethlem
Hospital for centuries; the public, who won’t be humbugged, call it Bedlam.
Another we have for a few years called Graylingswell Hospital, although by law it
is a county lunatic asylum, and thereby try to deceive ourselves and the public,
but only deceive the former. We have dressed our female attendants in hospital
nurse’s uniform and called them nurses; I do so myself, indeed we have, in our
zeal for hospital appearances, a comical ostrich-like way of ignoring the male
division in showing strangers round our asylums, because somehow it is not so
consonant with our hospital ideals as the female division. Further, I am con¬
stantly dinning into the ears of the friends of patients that this Norfolk County
Asylum is a hospital, knowing all the time that this is only a sop or comfort to
their feelings, and that it is no more a hospital than a hospital is an asylum.

Let us set aside all this prejudice in favour of hospital ideals, and certainly let
us disabuse our minds of the idea that the hospital nurse is the ideal woman, and
review the situation and examine the matter de novo.

As Dr. Robertson’s paper refers chiefly to the “ nursing ” of male insane persons
by women, I will confine my remarks to male patients. There are in this asylum
360 male patients who may be classified shortly as follows: 50 epileptics, 50
infirm, 5 recent melancholic or maniacal cases, and 255 “ chronics ’’ in good
health.

I presume no one with any sense of the fitness of things would suggest that the
255 “chronics ” should have women in charge of them. With very few exceptions
•the fifty epileptics could not be managed by women, and certainly my five recent
cases, not epileptic or infirm, admitted during the past thirty days, could also not
be managed by women ; so there remain only my fifty sick and infirm cases who
might be managed by women.

To hear the current talk about hospital ideals in asylums one would imagine that
there was any amount of acute or chronic bodily and psycho-physical sickness in
asylums demanding the specially trained hospital nurse, but we asylum doctors—
perhaps I should have said we hospital physicians—know this is all nonsense. I go
my rounds on the male division to-day, and I find out of my 360 patients eight
men in bed; in winter perhaps a dozen, in summer perhaps none at all. Of the
eight I find to-day, two are in bed for acute maniacal excitement, women could not
“ nurse ” them; one is in advanced general paralysis, and as he is no longer
obscene, blasphemous, and excited withal, but only demented, helpless, and filthy
in habits, he might be nursed by a woman ; one has an ulcer on his leg; another
has bronchial catarrh; and three others are suffering from senile debility. The six
Jatter might be “ nursed ” by women as capably as by men, although the three

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senile cases were sent here from workhouse infirmaries, where, forsooth, they were
said to be unmanageable, under unfavourable conditions I admit, by trained women
nurses there.

Therefore, so far as I can see, the only considerable number of male cases which
could be managed by women are the forty to fifty infirm cases. Analysing these
cases one finds them to be mostly more or less feeble old men able to go through
the ordinary performances of life—eating, sleeping, exercising, dressing, and
undressing—provided all facilities are given them for this, and all difficulties of
initiative smoothed away; that is to say men who require attendance. But surely
this is not nursing unless an unwarrantable use or misuse is made of the term, and
this attendance can be as well given by men as women.

Dr. Robertson admits that bathing and other sanitary requirements have to be
fulfilled in the case of his women-nursed male patients by male attendants. I think
such an admission damns his whole scheme; anything more unsatisfactory or sub¬
versive of proper discipline and methods than this handing over of male patients
at one time to the care of women and at another to men is difficult to conceive. A
nurse in a hospital will do anything and everything for a male patient so long as
he is in bed helpless, but as soon as he gets up and about he attends to his toilet,
bathing, and calls of nature himself; and this, of course, an asylum patient cannot
or should not do in privacy. One knows that on rare occasions a male asylum patient
will do things, such as take food, for a woman when he will not do so for a
man, and vice versA ; and, acting on this knowledge, I have on such rare occasions
employed a female asylum nurse to help in the nursing of a male case. It may be
that we do not sufficiently keep in view the occasional great benefit which might
be derived from a slight extension of such a principle, but this is far from either the
general practice Dr. Robertson recommends or the principle on which he bases
his practice.

A minor premise of Dr. Robertson’s is his contention that men are not naturally
nurses by inclination or instinct.

I have shown above that, firstly, there is really very little nursing to do, using the
term in its hospital sense, and I now say that what little there is to do can be
equally well done by men. A priori perhaps one would not expect men to turn to
or take up nursing as women do, yet when they do do so they do it equally well, if
not better, than women ; just as although not naturally or aboriginally cooks, dress¬
makers, etc., those who take up these callings excel women therein. Who of
us among his staff of male attendants has not a few admirable nurses ? I have
several whom I would not replace by the best women asylum-trained nurses, far
less by hospital nurses. That female nurses would consent to, and even prefer to
nurse on the male division is quite beside the mark, and the reasons plain. Firstly
and chiefly, the intinctive natural preference of one sex for the other, and secondly,
that the male insane are at least twice as easily managed as the female insane.

There are many other matters of interest touched upon in Dr. Robertson’s paper ;
indeed, it teems with topics for controversy, to which I should like to refer, but
your valuable space I fancy forbids. I must, however, enter my protest against
his scheme of having a hospital-trained nurse as the principal official in a female
ward and calling her a new creation, which scheme, apart from its being unneces¬
sary, reduces our on the whole admirable and daily improving asylum nurses to the
position practically of wardmaids. I submit the same arguments against this as I
have adduced against the hospital female nursing of male patients. The advan¬
tages of having two or three hospital-trained nurses available for special bodily
illnesses are manifest in any asylum, or for the matter of that, in a school or any
similar institution. One of my two assistant matrons has had hospital training,
and her special nursing knowledge is at times of great value, but to appoint a
hospital-trained nurse, as such, over the charge nurse of a ward would be as much
a misapplication of a specially and specifically educated product as to place a
doctor as foreman in a chemist’s shop; the nurse would have little or no nursing,
and the doctor little or no doctoring.

Does Dr. Robertson not credit our male and female attendants with any senti¬
ment, aspiration, or ambition above the pay and limited promotion to which he
refers on page 279 ? Were I a fully asylum-trained certificated charge nurse and
a hospital-trained nurse were put in authority over me, not as an officer, but as a
fellow nurse, I would most certainly resent it, just as I would were I a fully quali-

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tied and asylum-trained assistant medical officer if a gynaecologist, operating
surgeon, or even a general hospital physician were appointed as my medical chief.

Dr. Robertson suggests that the hospital-trained nurse would never be guilty of
the ill-treatment of patients. Of course, 1 cannot possibly admit this; hospital
training does not eliminate the “ black-sheep ” that exist amongst us, whether we
be asylum doctors or hospital doctors, asylum nurses or hospital nurses.

I heartily join Dr. Clouston and the other speakers in the discussion on the
paper in their admiration of Dr. Robertson’s enthusiasm. 1 would even go further
than they, in believing that with his enthusiasm he could make the converse of his
methods a success, viz. that male attendants should nurse female patients. It is
better, however, to have enthusiasm and a trial of new methods of management,
than a dead-level red-tape conservatism ; but the enthusiast must expect criticism,
and I trust that he will acquit me, in this somewhat forcibly-worded letter, of any
other intent than to fairly examine the methods he suggests and practises.

To the Editors of the Journal of Mental Science.

Gentlemen, —There is sufficient internal evidence in the letter addressed to you
by 44 Resartor ” to warrant the belief that his strictures on my last review of the
Commissioners’ Blue Book are the result of certain carefully collaborated objections
against the manner and the matter of these reviews.

He accuses me, in the first place, of 44 shakiness in inferences and conclusions ”—
a sweeping condemnation, but one hardly justified by the instances he quotes.
He declares that I am 44 much exercised by the manner of taking the annual census
of the insane as on December 31st of each year,” but he continues 44 everyone
knows that this process is not accurate.” So far, then, I am not 44 shaky.” What
he distinctly objects to is that I should presume to suggest that the average
residence of the year should be taken 44 as a more accurate basis.” This is a direct
misrepresentation, a statement which I meet by a flat contradiction. May I,
through you, request 44 Resartor ” to read my review more carefully P I suggested
nothing of the sort. At the top of page 77 in the January number of your Journal
he will find that the suggested comparison between the totals of the average number
resident was meant merely to give the Lord Chancellor, to whom the report is
addressed, a better estimate of the amount of work the Commissioners have to do
annually; it was not put forth as 44 a more accurate basis ” of statistical computation.
A tyro in arithmetical reasoning could see that such a summation could
not possibly be taken as a basis fpr working out ratios and proportions, and that
fact alone should have made 44 Resartor ” pause before citing this, his own, assump¬
tion of my meaning in the forefront of his accusation. Ignoring, however, the
simple arithmetical rule that actual numerical computation and not estimated
summaries must form the groundwork of every statistical argument, he amusingly
nails his ignorance to the mast by occupying nearly half a page of your valuable
Journal in an attempt to prove to you and your readers by columns of figures
(which I spare him from criticising) how sadly I have erred—the labour of which
calculation he might easily have saved himself had he taken more than a passing
glance at the wording of my article, and adhered to the elements of statistical
computation.

Secondly, he objects to my request for an analysis-table to show the reasons for,
the results of, the antecedent residence of, and the nature of each case of transfer.
Why ? Does 44 Resartor ” ever read the lunacy reports of other countries, or is he
so insular as to believe that the Blue Book, by reason of the Association’s early
responsibility in the matter of its statistical tabulations, cannot be improved upon ?
Does he know that in some foreign reports every case of admission and discharge,
to say nought of transfers, is carefully analysed P There was nothing so pre¬
posterous, therefore, in making this innocent and quite unoriginal proposal, and it
seems to me a mere laborious effort to pick holes in my criticism so pointedly to
object to such a suggestion. For all that 44 Resartor ” may say to the contrary, I
maintain that alienist physicians are not truly appreciative of the practical utility
of transfer as a mode of treatment, for unless under actual compulsion, either
official or administrative, cases are seldom transferred from one asylum to another
for curative reasons only.

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Thirdly, he declares that I am “ mixed on the subject of recovery ratios," and
bases this assertion on a single sentence, with a complete disregard of its context.
In my critique I am at pains to prove that the actual recovery rate may be assumed
to be somewhat greater than the numerical estimate furnished by an admission
ratio or a daily average ratio. “ Resartor," however, disregards the argument, and
prefers to pick to pieces a comment by which I am tending to the conclusion of
my proposition. In so doing he appears to display not critical ability but
animus, and it would be right to ignore such an assumption of error; but I am
perfectly willing to meet him even on the small of strip ground he has marked out
for himself, to maintain once more that he shows defective acquaintance with statis¬
tical reasoning and a simple disregard of plain English when he declares that by what
he quotes I am “ mixed on the subject of recovery ratios.” The sentence he dwells
upon and criticises is this : " We go further, however, and maintain that, consider¬
ing the magnitude of the yearly aggregate increase in non-recoverable cases, and
the merely fractional diminution in the recovery rate, the inference that asylums
show no improvement in their recoveries is altogether a false one.” This sentence
in my critique followed a quotation from the report showing the existing dis¬
crepancies between admission and daily average recovery ratios. “ Resartor ” says
that he can find no such inference in the Blue Book. I did not say it was in the
Blue Book—it is a natural and popular inference and not a stated one. He then
makes the following observation : “ Returning to the sentence quoted above, if he,
in using the term recovery rate, refers to that which is calculated on admissions,
he is doing that which is not lawful to a statistical expert by considering it in rela¬
tion to yearly aggregate increase. On the other hand, if he is meaning the recovery
rate in proportion to daily average numbers he is clearly wrong in talking of its
diminution as fractional, etc.” [the italics are my own]. Now my sentence makes
no attempt whatever to consider the recovery rate calculated on admissions “ in
relation to yearly aggregate increase.” This is “ Resartor’s ” own erroneous deduc¬
tion. I merely desired to emphasise the fact—a simple fact which any unbiassed mind
at once can grasp—that such a yearly aggregate increase must in some measure affect
the calculation, be it the average number resident or the admission rate which may
be chosen. A simple calculation will prove this even to the biassed. The word
“considering” is also, I believe, capable of more meanings than one. Again, the
diminution must certainly be fractional, in a comparative sense, considering how
great is the yearly aggregate increase in non-recoverable cases; if “Resartor”
does not credit this, it can easily be demonstrated to him by a few examples in
elementary division. Then he objects to the suggestion I offer to have a quin¬
quennial analysis of all admissions, and once more his superficial reading of my
meaning leads him to unwarranted criticism. There is nothing so “ disastrous ” in
the idea of tracing out the fates of every admission every five years as “ Resartor ”
would have you believe. He makes a mountain out of a molehill, and apparently
strives to misinterpret my proposal. I cannot weary you with a detailed explana¬
tion of what, after all, was but a passing suggestion, but anyone possessed
of a fair mind can, by perusing the review and “ Resartor’s ” letter side by side,
discover that it is not merely an ultra-conscientious objection to my statistics that
has provoked this ex cathedrd indictment of my work.

Fourthly, “ Resartor ” declares that “ the fact is patent that in spite of increase in
numbers of all patients there are absolutely less ” suffering from general paralysis
than formerly. How does he know this P His “ patent fact ” is a mere bit of guess¬
work, a gratuitous and unwarrantable assumption, coming ill from one urging the
doctrine of exactitude. Because the Commissioners show statistically that there
are fewer general paralytics in asylums, does “ Resartor ” imagine there to be fewer
cases in the community P He must be a very optimistic being if he does.

Fifthly, he does not like my objections to the causation table supplied by the
Commissioners, he thinks its infallibility established because it was the outcome of
the recommendation of a strong committee of the Association 1 A valuable and
uncontrovertible argument forsooth, one utterly beyond the pale of criticism I

And lastly, he ndicules me for being pleased at the disappearance from the
report of the table of causes of general paralysis, and he says, “ Why P ” Will he
trouble himself to cast his eye over that table in the Commissioners’ Report for
1900 or any previous year, and declare his complete satisfaction with every item
therein P Will he tell us how “ old age,” “ previous attacks,” “ puberty,” and many
XLVIII. 41

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other “ causes ” there enumerated can have been factors in the production of this
essentially organic disease ? And he inquires if I am wedded to the belief that
syphilis is a sole factor in any given case—it is a trivial matter, but if he is so
interested in my beliefs 1 may assure him that I am. In an article on “ The
Probable Etiology of General Paralysis,” published nine years ago, I suggested, on
clinical grounds alone, syphilis as the prime factor in every case of this disease,
and recent pathological evidence of an irrefutable character has certainly not
shaken my conviction.

These, gentlemen, are all the points of evidence in “ Resartor's” indictment, by
which he seeks to establish my “ shakiness in inferences and conclusions.” As to
his criticism of my literary manner, which he regards as “too vigorous,” it surely
is a subject ot regret that during the eleven years in which I have reviewed these
reports no other Daniel has come to judgment, nor until now has one arisen to
urge this trenchant objection to my style, for I would willingly have clothed my
contentions in more sober, though I believe less effective, utterances, to avoid
offence to the susceptibilities of some of your readers.

During the time that I have, under you and your predecessors in the editorial
chair, reviewed these reports for the Journal, I flatter myself that I have, acci¬
dentally perhaps, been the means of introducing alterations into the official
statistical summaries, as well as of modifying the views previously held by the
Commissioners as to the alleged increase of insanity—at all events emendations
have directly followed the suggestions I ventured to offer,—and it seems late in the
day to be taxed with charges of unfairness of comment and inaccuracies of deduction,
not one of which 11 Resartor” has, save in his own judgment, established.

But all this may perhaps be regarded by those of your readers who are hyper-
critically disposed as “ pointing to the value of the reviewer,” and with your per¬
mission I shall follow the example set me and similarly hide my identity.—I am,
yours truly, F. S. S.

OBITUARY.

Bonville Bradley Fox.

We had long known that Dr. Bonville Fox was in a grave state of ill-health,
and so his death at the early age of 49, which occurred on April 2nd, 1902, though
most deeply regretted, came to us all as no surprise. It was a long and a painful
illness, and borne by him with the greatest patience and fortitude.

Dr. Bonville Fox was the son of the late Dr. Francis Kerr Fox, the well-known
proprietor of Brislington House Private Asylum ; the nephew of the present Dean
of Westminster, and the half-brother to the late Dr. Edward Jay Fox, of Clifton,
Ex-President of the British Medical Association, who pre-deceased him only by a
few days.

He was educated at Dr. Hudson’s School, Manilla Hall, Clifton, and at Marl¬
borough College, and afterwards took his degree of B.A. at Christ Church College,
Oxford, in 1876.

He studied medicine at St. George’s Hospital, taking his M.R.C.S. in 1878.
After this he acted as Assistant Medical Officer at Bethlem Hospital for a period
of six months. In 1879 he took his M.B. degree at Oxford, and in 1882 his M.D.
After his work at Bethlem he became Assistant Resident Medical Officer at Bris¬
lington House, his father’s well-known private asylum, which has always stood in
the forefront of similar institutions in this country.

At the death of his father he became joint proprietor with his brother, Dr.
Charles Fox, and sole proprietor on the retirement of the latter some few years
ago.

Dr. Bonville Fox married the daughter of the late Mr. Tom Danger, who for
many years was Clerk of the Peace for the City of Bristol. He leaves a family of
two sons and one daughter.

In addition to his professional work, of which we shall presently speak, Dr.
Bonville Fox was a zealous member of the Keynsham Board of Guardians, and
was for a considerable time the vice-chairman of that body.

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In politics he was a staunch conservative, and an active worker on the Brislington
District Conservative Committee. Always having a great liking for agriculture,
he became a most useful member of the North-East Somerset Farmers’ Association.
He was a capital shot, an enthusiastic cricketer, and a man who endeared himself
to a large circle of friends and neighbours.

His loss is greatly felt in the district, and it was with feelings of deep regret at
his early death, and of heart-felt sympathy for his wife and his children, that large
numbers of those who had known him assembled at the quiet private cemetery of
Brislington House on April 5th, when his body was laid to rest.

In the west of England he held a high position as a mental consultant, and his
great experience and his sound judgment made his advice in this branch of
medicine frequently sought and most highly valued.

By the members of the Medico-Psychological Association he will be much
missed. For years he was a regular attendant at the quarterly meetings, and he
had been elected a member of the Council several times. His thoughtful and
scholarly mind was appreciated by all who knew him, and whenever he rose to
speak he commanded immediate attention and respect, for it was always recognised
that he seldom brought forward an opinion which had not been carefully weighed
and logically reasoned.

He contributed an article to Tuke’s Dictionary of Psychological Medicine , and
several papers to the Journal of Mental Science. Many will remember his capital
paper on “ Exaltation in Chronic Alcoholism,” and the interesting discussion which
followed; while those of the Association who were fortunate to be his guests at the
meeting held at Brislington House on May 1st, 1891, will have happy recollections
of that pleasant day ana his kind and generous hospitality.

His death causes a gap in our Association not easily filled, and we mourn with
many the loss of a kind heart, a scholarly mind, and an ever thoughtful courtesy.

Lionel Weatherly.

Arthur Strange.

11 Arthur Strange, Med. Supt. Salop and Montgomery County Asylum, Bicton
Heath, Shrewsbury, M.D.Edin., 1867.”

Such is the description of the subject of this notice given in the Medical Directory ,
and it is eminently characteristic of the man. There is no parade of titles, of
appointments held in other places, of attachments to learned societies, of papers
written, or work done. Simply a plain statement that he was qualified in a certain
way and was carrying on a definite appointment in a certain part of the country.
It reads almost like an inscription on a monument, and, indeed, to those who knew
him no more appropriate legend could be engraved on the walls of the building in
which he worked and where he died than the simple facts drawn up in his own
words.

Dr. Strange, who was 58 years of age at the time of his death, was appointed to
the charge of the county asylum at Bicton Heath in the year 1872, previous to
which time he had held various degrees of assistant medical officership at the
Chester, Gloucester, Leavesden, and Colney Hatch Asylums. The immediate
cause of his death was meningitis, and he died literally in harness, for he was only
off duty for three weeks before his death. About seven years ago he had a severe
illness, erysipelas and sequelaj, and was off duty for three months. He was buried
in Oxon Churchyard, Shrewsbury, and he has left a widow and seven children to
mourn his loss. Descended from families honourably associated with the treat¬
ment of insanity—his father was the superintendent of the asylum at Powick, and
by his mother’s side he was related to the Skaes—he successfully carried on the
traditions of his ancestors, imbued from an early age with those advanced and
sound principles which later on he carried into effect. It is difficult to convey to
others a real estimate of his character, because he was essentially a man who had
to be known to be fully appreciated. Not that he was reserved in conversation, or
that he hesitated to ventilate his opinions ; on the contrary, he was free and ready
of speech, and often expressed himself with a force and fearlessness that could
only arise from a man of strong convictions, obtained by familiarity with the sub¬
ject he was discussing; but he was essentially of a practical mould, obstinate
perhaps, but impatient of listening to the discussion of matters^Rbout which he had
already formed strong opinions. He was opposed to irrelevancy of any kind, and

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not being a man of wide reading or of scientific trend, he preferred to spend his
energy in attending to the wants and the comfort of his dependents. Strange
was a man of thought and action, but not in a public sense. He never spoke in
debate, nor did he write except when officially obliged to do, and yet he was not a
nervous man, nor was his a mere humdrum intellect. It was sufficient for him
that a duty had to be carried out in as careful and complete a manner as he could
do it, and his time and energies were devoted to making his asylum as safe and
up-to-date as lay in his power. Of course this meant that he moved to a large
extent in a groove, but discursiveness was anathema to him, and he probably best
recognised the way in which he could be most useful.

The writer, who was intimately associated in work with him for some time, can
speak of him as the embodiment of truth, loyalty, and devotion to principle, whilst
his rugged honesty and individuality were reflected in an exterior forcible and
unconventional. To us who are left behind Arthur Strange is both an example
and a warning; an example in the devotion of his life to duty, in his unswerving
fidelity to his friends, in his knock-down denunciation of humbug in any form, and
in his uncompromising manner of dealing with deceit or malice ; a warning in that
he stayed too much in his immediate surroundings, and thus failed to expand to
the degree that he was really capable of, and this not from mere inertia or idleness,
but from a too keen sensitiveness to criticism, and partly perhaps from the
restricted conditions under which the work of a conscientious medical superinten¬
dent is carried on, conditions which, during the early and subsequent parts of his
career, were of a narrower and more restricted kind than they are nowadays.

To most of the younger members of this Association Dr. Strange must be
unknown both in appearance and character; to those who have spent many years
in the specialty he will be remembered in the manner which would have been most
agreeable to him, as one who by his practice and example endeavoured to do the
right thing, and who did it with all his might.

George Fowler Bodington.

We greatly regret to have to record the death, in his seventy-third year, of Dr.
George Fowler Bodington, which occurred recently in Paris. He was the eldest
son of Mr. George Bodington, surgeon, of Sutton Coldfield, of whose work as a
pioneer in the outdoor treatment of tuberculosis Sir Walter Foster has recently
reminded us, and was educated for the medical profession at Queen’s College,
Birmingham.

After taking the Membership of the Royal College of Surgeons, and holding the
post of House Surgeon at Queen’s Hospital, Birmingham, he visited as a snip’s
surgeon Natal and India. He spent some time practising his profession in the
back settlements of Pietermaritzburg, where his fees were paid him in elephants'
tusks, of which he brought away some hundreds of pounds’ worth as the fruits of
about eight months’ work. He returned to England, married, and settled in
practice at Kenilworth in partnership with the late William Bodington, F.R.C.S.,
his uncle. In 1866 he moved to Middlesbrough-on-Tees and to Saltburn, where he
remained until called to take the management of a prosperous private asylum
established by his father at Sutton Coldfield, near Birmingham. He bore a leading
part in establishing the Birmingham Medical Institute, of which he was one of the
early Presidents; and he was also President of the Birmingham and Midland
Counties Branch of the British Medical Association in 1876.

He at this time associated himself with the late Mr. Dalrymple in the movement
to obtain legislation for the care and control of inebriates. But meanwhile two
events happened of considerable importance; he lost his first wife and married
again; the asylum, owing to the falling in of the lease, had to be transferred to
Ashwood House, Kingswinford, in Staffordshire. Unfortunately, the second Mrs.
Bodington never enjoyed good health at Kingswinford, and Dr. Bodington decided
to sell the asylum ana seek elsewhere, in a more congenial climate, a home for his
family. After wandering for a year or two he settled eventually in British
Columbia, where he purchased a farm and carried on medical practice, but it is
doubtful whether these ventures were altogether successful. The advance of
civilisation in these western regions rendered a large lunatic asylum a necessity of
the province, and of this Dr. Bodington was appointed Medical Superintendent in

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605

1895. His success in this work is well attested by the following extract from the
report of his successor :

“It was apparent that to bring about the required changes would entail an
immense amount of work, and Dr. Bodington felt constrained, through the advance
of years, to relinquish the labour to younger hands, and seek well-earned rest and
retirement in the land of his birth, surrounded by the members of his family and his
friends. In this connection I can truthfully testify that no greater general sorrow
has been witnessed throughout the institution than that occasioned by the departure
of the one who had taken the helm at a very trying time, and had safely piloted the
hospital through some difficult passages, giving to it his best energy and utmost
attention, though never in robust health, and having already arrived at that period
of life when men hope to be able to forget labour and worry. Dr. Bodington’s
resignation was accepted by the Government, who voted him a retiring allowance
for his faithful services, which terminated on February 28th, after six years of most
arduous toil, during the greater part of which he was alone in the charge of the
institution.”

He came to England last year to visit his relations and to renew acquaintance
with old friends, and he eventually settled in Paris. His death occurred after a
very short illness, but his state of health had not been satisfactory for some time
past.

Dr. Bodington was a man of magnificent physique and fine presence, a delightful
companion, and an enthusiastic man of letters. He was for many years a member
of this Association; he resigned on going to British Columbia, and was re-elected
in 1895.—From the British Medical Journal .

NOTICES BY THE REGISTRAR.

Examination for thb Nursing Certificate.

Five hundred and fortv-three candidates applied for admission to the May
examination for this certificate. Of this number 179 failed to satisfy the examiners,
twelve withdrew, and the following were successful:

ENGLAND.

Three Counties , Hitchin. —Females: Edith Folkes, Beatrice Florence Rainbow,
Lucy Devereux, Minnie Winter, Maud Rainbow. Males: Charles Michel, Isaac
Bottomley.

Bucks County. —Females: Violetta Peck, Emily Hutchins, Emily Hughes, Agnes
Louisa Smith, Ada May Johnson, Agnes Louisa Walton, Mary Kinsella. Male:
Christopher Hicks.

Cumberland and Westmorland.— Female : Sarah Heron. Males : John Stewart,
Richard Lambert.

Devon County.— Females: Ada Trenerry, Annie Elizabeth Harris, Bessie Marley,
Mary Ellen Ley. Males: William Henry Ponsford, John Tuplin, Edwin Leach.

Kent County , Maidstone. —Females: Eugenie Emily Bishop, Ellen Lavinia
Morris. Male : Charles Thomas Worsel.

Kent County , Chartham. —Male: Harry Percival Hastings.

Lancaster County, Rainhill .—Females: Bessie Case, Nellie Trusler, Edith
Maud Alford, Alice Mansefield Caley, Lilian Riley, Annie Moss, Edith J. Poulton,
Ada Foster, Sarah Smith, May Hughes, Jessie Hollingworth, Hannah Drabble,
Beatrix Ethel Hudson, Emma Smith, Rachel Crilly, Alice Mary Lamb, Mary
Mason, Catherine Lamb. Males: James Renshaw, William Leonard Gill, James
Everitt, William Stones, Archibald Osman Wynne, Harry Harding, William
Charles Boddy, Leonard Roberts Kingdom, Walter Hague.

London County , Bexley. —Females : Annie Berry, Alice Musto. Males : Arthur
Watson, Edwin Robert Blackman, Ernest Gordon Clark, Alfred Williams, Thomas
Foster.

London County , Cane Hill .—Females: Lily Annie Ashby, Esther New, Eliza¬
beth Rees. Males: John McKeown, George Griffith.

London County, Claybury. — Females: Amy Louisa Lelliott, Catherine Helen

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NOTES AND NEWS.

[July.

Henson, Alma Augusta Annie Holtzhansen, Alice Mary Ayres, Bertha Skinner,
Ethel Ellis, Clara Charlotte Webb, Beatrice Ida Shirley. Male: Walter Harry
Dew.

Middlesex County. —Females : Annie Berry, Ida Caroline Reakes, Annie Max¬
well, Alice Rebecca Mawson, Anastasia Maria McDonald, Harriet Almma Spurling.
Males : William Hemy Russell, George Sharpe, George Bowmer, Arthur Thomas
Boxall.

Warneford Asylum , Oxford. —Females: Kate Alice Wilkins, Agnes Thomson.

Surrey County, Brookwood. —Females: Harriet Annie Baker, Frances Brodribb,
Edith Frances Crouch, Emeline Ada Driver, Amy Elizabeth Platt, Maud Rosaline
Griffin, Margarat Walters. Males: Henry Lowe, Charles Arthur Woodcock,
Thomas Betteridge.

Warwick County, Hatton. —Females: Frances Rudge, Elizabeth Hinsley, Nancy
Woosnam. Males: Harry Frederick Latham, George Matthews.

Isle of Wight. —Males : William Edwards, William Henry Sneath.

North Riding , Yorks. — Female: Catherine Emeline Jackson. Males: John
Robert Peckitt, Thomas Dunn Bertram.

Menston, Yorks. — Females: Isabel Patchett, Annie Ford, Mary Greenall
Molyneux. Males: Joseph Craven Thornton, James Holmes.

South Riding , Wadsley. —Female : Mary Jane Batty. Males: John Richard
Reynolds, Charles Robert Lincoln.

City of Birmingham, Winson Green. —Female : Alice Lees. Males: William
Edward Barry, Arthur Walton.

City (f Birmingham, Rubery Hilt .—Females: Florence Gwendoline Wright,
Ada Collins, Harriet Ada Stringer, Annie Maria Ellis, Ellen Roberts, Harriet
Cotton, Florence Clews. Male: Arthur Thomas Horton.

Bristol City.— Female : Edith Mary Yeoman.

Hull City .—Females: Mary Emma Clark, Ada Learoyd, Kate Harrison,
Annie Louisa Credland, Kathleen Winifred McCardle. Male: George Herbert.

Newcastle City. —Females: Margaret Wilson Smith, Deborah Elizabeth
Haynes, Marian Aldis, Isabella Bulman, Mary Jane Law. Male: Walter
Phillips.

Nottingham City .—Females: Mary Ellen Rawson. Males: John Henry
Stapleton, William Loach, Frank Law, Mark Tomlinson, George William Frow.

Plymouth Borough. —Females: Evelyn Hodge, Florence Ada Harper.

Portsmouth Borough. —None.

Sunderland Borough. —Females: Louise Slaney Page, Elizabeth Ann Smith.
Males: John Charles Young, William Lewis Willcock, William Allen, David
Hume.

West Ham Borough.— Females : Charity Filby, Louisa Mary Maud Griffin, Jane
Waite Robinson. Males: Walter Wilkinson Hollis, James Hunt, Joseph Jennings,
William Charles Peat, George Edwin Sparkes, Samuel Frederick Robinson.

Darenth. —Female: Edith Jane Henderston.

Leavesden. —Males : Robert Watson, Stephen John Constable.

Friend's Retreat, York. —Females: Jessie Maria Pearson, Margaret Gibbon,
Christian William Gordon, Sara Christine Hearder, Edith Emily Parker, Lucy
Foster Swain, Dora Cole, Eleanor Alice Wood, Annie Eliza Naylor, Hannah Mary
Iveson.

Camberwell House. —Females : Elizabeth E. Brazebridge, Florence Jessie Cheal,
Alice C. Graham, Minnie A. Vinicombe. Males : John Henry Moore, John Lewis,
Sam Hedgland Blake.

Holloway Sanatorium. —Females: Millicent Hannah Strong, Emily Lonsdale
Me Master.

Redlands. —Male : Adolphus William Pulman.

St. Luke's Hospital. —Females: Violetta Bidgood, Elizabeth Potter. Males:
John Barnard, William Heslop.

HaydoCk Lodge .—Male : William Waterhouse Cromack.

WALES.

Abergavenny County. —Females: Mary Hannah Davies, Nellie Oakley, Edith
Price, Eleanor Williams, Margaret Ann Williams. Males: Michael Doolan,

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NOTES AND NEWS.

1902.]

607

William Henry Jones, John Preece, Alfred Price, George Richard William Rosser
Edward Williams.

Glamorgan County. —Females: Elizabeth James, Clara May Jones, Edith
Maud Poyntz, Martha Ann Rowlands, Mary Ann Waldin, Hannah Elizabeth
Wherritt, Elizabeth Tarr. Males : Rees John Davies, John Edmunds, William
Hopkins, John Bcvan Preece, David Price, William R. Rogers, George Perry, John
Thomas.

SCOTLAND.

Argyle and Bute District. —Female : Nellie Sherrie.

Aberdeen Royal Asylum. —Females: Elsie Carr Wilson, Helen Wilson, Bella
Valentine McDonald, Georgina Black. Males : Peter Duncan, George Skene.

Dundee Royal. —Females: Margaret Crocket McKenzie, Jane Hay.

Edinburgh Royal Asylum. — Females: Annie McLarty, Maggie Campbell, Isa¬
bella Nicol, Janet Smith, Margaret McDonald, Jane Malcolm Ashton.

Gartnavel Royal. —Females: Ellen Mary Hawkins, Elizabeth Meams, Isa Craig
Brown, Mary Bissett. Males: William Ingram, William Duncan.

Gartloch Asylum. —Females: Marie Walker, Grace Thomson, Annie McBride,
Elizabeth Eleanor McPhillips, Martha Henry, Anne Clare Brennan. Males: James
Gibson, John Findlay.

Inverness District Asylum. —Females : Ella Munro, Katherine Shaw Mackay
Cecilia Elizabeth Curran. Male : Alexander Macquarrie.

Lanark District. —Females: Fanny Dawson, Marjory Lindsay, Elizabeth H.
Lowe, Mary Bleakley, Agnes S. Murray, Mabel N. Mathcson, Lizzie Tait, Mary
S. Muir. Males: Thomas Johnston, Hector MacPhail, Andrew Adam.

James Murrays Royal. —Females: Margaret Sutherland, Elizabeth Corbett.
Male: James Forbes Stalker.

Perth District Asylum. —Females: Thomasina Cramb, Annie Thomson.

Roxburgh District Asylum. —Female: Elizabeth Anne Telfer. Males: Alexander
Cameron Grant, James Marr.

Smithston Asylum. —Female: Sara Morrison. Males: James M'Kaig, John
Frew, David Skelton.

Stirling District Asylum. —Female: Mary Elizabeth Smith.

Woodilee Lenmie Asylum.— Females: Isa Allen Stewart, Anna Elizabeth Hay,
Elizabeth Stevenson MacIntyre, Bessie Dick Marshall, Mary Barnwell Young, Jane
Gemmell Brennan. Male: George Watt.

IRELAND.

Armagh District Asylum. —Females: Bridget McMahon, Sarah Mullan,
Adelaide Hewitt, Ellen Hughes. Males: John McMahon, John Molloy, Robert
Baird, James Devlin, John O’Farrell.

Cork District. —Females: Kate Coghlan, Hester Murphy, Marv Rearden, Kate
Walsh, Maud Leyne, Katherine M. Reynolds. Males: John O’Callaghan, Cornelius
Reardon.

Clonmel District. —Male: William O’Gorman.

Down District. —Females: Mary Harkin, Elizabeth Wilson. Males: William
John McComb, William Conway.

Limerick District. —Female : Helena McEvoy. Males: Joseph Slattery, Richard
Galligan.

Londonderry District. —Female: Matilda McConnell. Males: James Kyle,
Hugh Henry, Hugh Margay.

Richmond District Asylum. —Females: Ellen Kelly, Teresa Pollock, Kate
Kinsella, Bridget Rowan, Bridget Connell, Julia Howell, Annie Elizabeth Doran,
Elizabeth R. McGee, Lizzie Johnston, Susette Edith Herd, Bridget Boland, Lizzie
Mary Higgins, Emily Alice Fogartey, Margaret Owens, Margaret Lynch, Mary
Jane Qooney. Males : James Napier, Peter Donnelly, Peter O’Loughlin, Thomas
Parry, Stephen Maher.

Waterford District.- —Females : Kate Quinlan, Mary Burke.

St. Patrick's Hospital , Dublin. —Female: Agnes Bailey. Males: John Joseph
Piggott, Patrick John Fagan, John O’Neill. .

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6o8

NOTES AND NEWS.

[July,

St. Edmunsbury. —Females: Dorothy Kent, Mary Bridget Pender.

Dr. Dawson's, Maryville. — Females: Jennie Hewitt, Margaret Vaughan, Margaret
Cullen.

ENGLAND.

Somerset and Bath. —Females: Louisa Ivy Hancock, Annie Bickell. Male:
William Charles Hawkins.

City of London. —Males : Edward James Thorp, Walter John Figg.

West Sussex. —Males: James Hayward Strudwick, James F. Cragg, Arthur
Turner.

London County , Claybury. —Female: Jennie Anderson King.

The following is a list of the questions which appeared on the paper : i. What
do you understand by fresh air ? What is its composition P What impurities
are found in air which has been respired ? 2. What is the pelvis P Name the

bones forming it. What organs does it contain ? What are their relative posi¬
tions ? 3. What should be noted about the urine of patients ? What are the
different conditions which may lead to incompetence of the bladder P 4. In
what cases may suicidal attempts be made ? What are the most frequent modes
in which patients attempt suicide, and how do you guard against it P 5. To what
special risks of injury are epileptic patients liable P How would you guard against
these risks ? 6. How are bedsores caused ? In what cases are they liable to occur ?
How would you prevent their occurrence P 7. How would you treat an attack of (a)
apoplexy; (b) syncope (fainting); (c) choking ? 8. What are the special points

to be attended to in feeding paralytic and helpless patients P 9. State briefly how
you would guard against and discover escapes; what precautions would you take
aganist homicidal impulses; and what do you understand by special observation.
10. Into how many classes may poisons be roughly divided ? Name them, give
examples of each, and state what steps you would take in cases of suspected
poisoning directly the doctor had been called, but before his arrival.

Examination for Nursing Certificate.

The next examination will be held on Monday, November 3rd, 1902.

Note. —As the names of some of the persons to whom the Nursing Certificate has
been granted have been removed from the register, employers are requested to
refer to the Registrar in order to ascertain if a particular name is still on the roll of
the Association. In all inquiries the number of the certificate should be given.

Examination for the Professional Certificate.

The next examination for the Certificate in Psychological Medicine will be held
on Thursday, July 17th, 1902.

Gaskbll Prize.

The next examination for the Gaskell Prize will be held on Friday, July 18th,
1902.

NOTICES OF MEETINGS.

Medico-Psychological Association.

The Sixty-first Annual Meeting of the Association will be held at the Medical
Institution, Hope Street (corner of Mount Pleasant), Liverpool, on Thursday and
Friday, July 24th and 25th, 1902, under the Presidency of Dr. J. Wiglesworth.
There will be a meeting of Committees as follows on Thursday, July 24th, before
the Annual Meeting : Educational Committee 9 a.m., Rules Committee 9.30 a.m.,
Parliamentary Committee 945 a.m., Council Meeting 10 a.m.

The Annual Meeting commences at 11 a.m. on Thursday, when the usual business
of the Association will be transacted.

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1902.]

NOTES AND NEWS.

609

2 p.m.—The President’s Address.

About 3.15 p.m.—Mr. Damer Harrison will read a paper upon ** Some Remarks
upon the Surgical Treatment of Insanity.”

About 4 p.m.—Dr. Mercier will propose the following resolution, upon which
Mr. Percy Becher, Solicitor, of Bedford Row, London, and others will
speak:— 11 That in the opinion of this Association further legislative measures
are needed to protect the property of those who, without being certlfiably
insane, are yet, by reason of disorder of mind, unable to administer their
affairs with ordinary prudence.”

Friday, July 25th, 1902, 10 a.m.—F. W. Mott, M.D., F.R.S., will read a paper
entitled “ Stimulus in Relation to Decay and Repair of the Nervous System.”
The paper will be illustrated by lantern slides and diagrams. Professor
Sherrington, F.R.S., Dr. W. B. Warrington, and others will take part in
the discussion. A. W. Campbell, M.D., will give a lantern demonstration
on the “ Medullated Nerve-fibres of the Cerebal Cortex.” David Orr, M.D.,
will give a lantern demonstration on “ Nerve-cell and Medullated Fibre
Changes in Acute Insanity.”

2 p.m.—T. S. Clouston, M.D., will introduce a discussion upon ” The Possibility
of providing Suitable Means of Treatment for Incipient and Transient Mental
Diseases in our Great General Hospitals.” The President, Sir John
Sibbald, Lewis C. Bruce, T. B. Hyslop, T. W. MacDowall, C. Mercier,
H. Hayes Newington, N. Raw, H. Rayner, G. M. Robertson, G. H
Savage, Percy Smith, Urquhart, Yellowlees, and others will take part
in the discussion ; after which the following papers will be read : Hubert C.
Bond, M.D., “ Medico-Psychological Statistics—the Desirability of Correlation
with a View to Collective Study.” A. R. Urquhart, M.D., and G. Ford
Robertson, M.D., will read a “ Clinical Report on a Case of Epilepsy.” W. R.
Dawson, M.D., will read ” Notes on the Pathology of Diabetic Insanity.”

The Annual Dinner will take place at the Adelphi Hotel, Liverpool, on Thursday,
July 24th, at 7 o’clock; tickets £1 is. each.

The President, Dr. J. Wiglesworth, and Mrs. Wiglesworth, invite members
to a Garden Party on Saturday, July 26th, at the Rainhill Asylum, near Liverpool.

Belgium .—An International Congress for the care of the Insane will be held at
Anvers from the 1st till the 7th of September, 1902.

South-Eastern Division .—The Autumn Meeting will be held at Chiswick House
in October.

South-Western Division .—The Autumn Meeting will be held at the Devon
County Asylum, near Exeter, about the end of October.

Northern and Midland Division .—The Autumn Meeting will be held at Clevedon
County and Borough Asylum, near Middlesbrough, on Wednesday, October 8th
1902.

APPOINTMENTS.

Browne, T. R. Beale, M.R.C.S., L.R.C.P., appointed Junior Assistant Medical
Officer to the Northampton County Asylum.

Cassells, A.H., M.B., Ch.B.GIasg., appointed Assistant Medical Superintendent
of the Sunnyside Asyhim, Montrose.

Dodgson, H., M.B.. Ch.B.Edin., appointed Senior Assistant Medical Officer to
the Cumberland and Westmorland Asylum.

Easterbrook, C. C., M.A., M.D., M.fc.C.P.Edin., appointed Medical Superinten¬
dent to the Ayr District Asylum.

Elder, J. B., M.D., Ch.B.Aberd., appointed Junior Assistant Medical Officer to
the Cumberland and Westmorland Asylum.

Harding, Norman, E., M.B., Ch.B.Edin., appointed locum Assistant Medical
Officer to the Durham County Asylum.

Heffernan, P., L.R.C.P., L.R.C.S.Edin., appointed Assistant Medical Officer to
the Clonmel Asylum.

XLVIII. 42

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6lO NOTES AND NEWS. [July, 1902.

Hunter, Miss Jessie. S.B., M.B., appointed Assistant Medical Officer of the
Lawn Hospital for Insane, Lincoln.

Jones, W. E., M.R.C.S., L.R.C.P., appointed Medical Superintendent to Brecon
ana Radnor Joint Counties Asylum.

McCutchan, William A., L.R.C.P. and S.Edin., appointed Assistant Medical
Officer to the Cambridgeshire Asylum.

Pasmore, Edwin Stephen, M.D.Lond., appointed Medical Superintendent to the
Croydon Borough Lunatic Asylum, Warlingham.

Reid, W. H., M.B., Ch.M.Syd., appointed junior Medical Officer in the Department
of Lunacy of New South Wales.

Baba, M. Singh Sodhi, M.B., Ch.B., Edin., Junior Assistant Medical Officer,
appointed Senior Assistant Medical Officer, Portsmouth Asylum.

Stuart, F. J., M.R.C.S., L.R.C.P.Lond., appointed Senior Assistant Medical
Officer to the Northampton County Asylum.

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THE

JOURNAL OF MENTAL SCIENCE

[.Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland ’ ]

No. 203 [To’faT] OCTOBER, 1902. Vol. XLVIII.

Part I.—Original Articles.

The Presidential Address , delivered at the Sixty-first
Annual Meeting of the Medico-Psychological Associa¬
tion , held at Liverpool on July 24 th, 1902. By J.
Wiglesworth, M.D., F.R.C.P.Lond.

The honourable position which your courtesy rather than
any merit on my part has placed me in, carries with it the
privilege of addressing you, and in offering you a few remarks
on some of the problems of heredity, more especially with
reference to their bearing upon insanity and allied conditions, I
am fully conscious how inadequate my knowledge is to treat with
satisfaction so important a theme. I venture to hope, however,
that a few facts and theories bearing on this subject may not
be devoid of interest, and may possibly serve as a stimulus to
additional inquiries in this direction.

The activity of biological research, more particularly during
the past two decades, into the intimate nature of the processes
involved in the act of fertilisation has resulted in many im¬
portant additions to our knowledge, and in what may almost
be described as a revolution in our views with respect to the
essential meaning of this process. It used to be thought that
the respective shares which the sperm-cell and the germ-cell
contributed to the act of fertilisation were of a different order,
the germ-cell furnishing the matter, and the sperm-cell supply-

XLVIII. 43

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PRESIDENTIAL ADDRESS,

[Oct.,

ing the force which animated that matter, and started it upon
its career of development. But this view can no longer be
held in the light of modern research. We now know that by
far the greater portion of the germ-cell with its relatively large
mass takes no part whatever in the construction of the offspring,
but that the portion of matter which is to develop into the
offspring—the hereditary substance—is entirely confined to the
nucleus of the cell; and it is to the union of the nucleus of this
germ-cell with the nucleus of the sperm-cell that the develop¬
ment of the new individual is solely due, the two nuclei
contributing equal shares to the process. It would appear,
indeed, that not even the whole of the nucleus is of importance
in this respect, but that the chromatin rods contained within
the nucleus are the only essential elements ; and it is these
which we must regard as constituting the actual hereditary
substance which contains within itself all the qualities which
go to make up the new individual. Furthermore, there is
every reason to believe that this chromatin substance is itself
composed of innumerable minute particles, which are the actual
bearers of the qualities of the cells which constitute the organism,
and control their development. It matters not whether, following
Darwin, we call these particles “ gemmules,” or, in the language
of de Vries, style them “ pangenes,” or, adopting the nomenclature
of Weismann, label them “ biophorsthere seems no escape from
the conclusion that the actual germ substance is composed of an
enormous number of minute material particles, which, singly or in
groups, control the development of every portion of the organism.
Very remarkable changes are undergone by this chromatin
substance in the course of its development preparatory to the
process of fertilisation. The nuclear chromatin rods are in the
first place doubled, and then are divided into halves by two
successive processes of division, so that the final result is that
the nucleus of each egg-cell comes to contain exactly one half
the number of chromatin rods which were contained in the
original egg-cell. The chromatin substance which is separated
off in these processes of division is expelled from the egg-cell,
and forms the so-called “ polar bodies.” Precisely analogous
changes also occur in the process of development of the
spermatozoon, the number of chromatin rods in the nucleus of
the primitive sperm-cell being first doubled and then halved
twice over, so that the nuclei of the sperm-cells come to contain

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1902.] BY J. WIGLESWORTH, M.D. 613

exactly one half the number of chromatin rods contained in the
nucleus of the primitive sperm-cell ; the chief difference between
this process and that which goes on in the egg-cell being, that
whereas in the latter case the separated nuclear rods are
expelled from the cell in the form of “ polar bodies,” in the case
of the former they are retained in the daughter- and grand-
daughter-cells formed by the subdivision of the primitive
sperm-cell. Although the precise interpretation of the different
steps of this process is still obscure, the final result of these
“ reducing divisions,” as they are called, is obviously to diminish
by one half the chromatin substance contained both in the
germ-cell and in the sperm-cell. And it seems clear that the
chief object of this process is to prevent indefinite increase in
the mass of nuclear substance. If the nuclear rods of the
primitive egg-cell simply united with the corresponding rods of
the primitive sperm-cell without going through any process of
reduction, the result of course would be to double the
number of these rods ; in other words, to double the mass
of germ substance, and as the same process would be gone
through at each fertilisation, the resulting mass would soon
become altogether unwieldy. But the preliminary reduction of
the nuclear rods by one half previous to the union of the germ-
and sperm-cells, prevents such an increase, and preserves
uniformity in the mass of nuclear substance. But the “reducing
division ” is not merely a process for keeping the mass of
nuclear substance uniform in size. This result might clearly
have been attained without any previous increase. As already
indicated, however, prior to the operation of the “ reducing
divisions,” the nuclear rods are doubled by a process of longi¬
tudinal splitting, the object of which is not immediately
apparent. Weismann/ 1 ) whose monumental work has done so
much to illumine the intricate problems of heredity, believes
that the object of this primary doubling of the nuclear rods is
to increase the possible number of combinations of the germ
plasm ; and he has calculated that in the case, say, of an
organism, the germ-cells of which contain eight nuclear rods,
this number would, without any preliminary doubling, produce
seventy different combinations of germ plasm which, if multi¬
plied by the same possible number of combinations from the
sperm-cell, would produce no less than 4900 possible varieties
or combinations of germ plasm in the fertilised ovum ; whilst

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[Oct.,

with the preliminary doubling the number of possible com¬
binations would be vastly greater (266 x 266). But
whether Weismann be right or wrong in his interpretation
of the meaning of the preliminary doubling of the nuclear rods,
there can be no doubt that one object, and that probably the
chief one, of the union of two somewhat different elements, the
germ-cell and the sperm-cell, which takes place in bisexual
reproduction, is to produce the above result. This is clearly a
factor of immense importance in phyletic development.
Natural selection acts always and everywhere by seizing upon
and fixing favourable varieties, and the greater the number of
variations which it has to work upon, the greater is the chance
of a type being developed adapted to any particular environ¬
ment. There can be no doubt that only a fraction of the
countless variations which are being continually produced become
permanently fixed, the remainder being silently quenched by
the operation of this great natural law. Hence the vast
importance of obtaining the greatest possible diversity in the
minute structure of the germ plasm, as furnishing an abundant
material for natural selection to work upon. Amphimixis is
the term employed by Weismann to signify the mingling of the
two parental idioplasms in the process of fertilisation, and the
term is a convenient one to adopt.

With these few prefatory remarks, which may serve to direct
attention to the enormous complexity of the ultimate nature of
the problems awaiting solution, I turn to the main subject of
this address.

Although much work has been done and a vast number of
facts have been accumulated bearing on the question of the
hereditary transmission of qualities, we are still very much in
the dark as regards the laws which govern the processes of
heredity, and the subject is one which is very far indeed from
having attained to the dignity of an exact science. The
subject is of interest to everybody, but to us, as psychologists,,
the interest is peculiarly great, for in our daily work we are
continually reminded that mental qualities, no less than
physical ones, descend from parent to child, and that the
aberrant mental traits of one generation are the logical
sequence of the mental abnormalities of preceding generations,,
following the one from the other in accordance with natural
laws, which indubitably exist, however much they may have

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1902.]

BY J. WIGLESWORTH, M.D.

6i 5

hitherto eluded our ken. And how many problems crowd
upon us when we come to consider this question! What pro¬
portion of our patients owe their insanity to definite hereditary
taint, and in how many can the insanity be said, in the
strictest sense, to have been acquired in the course of the in¬
dividual life ? Is one sex more prone to hereditary insanity
than the other ? Is one parent more potent than the other in
transmitting the disease to his or her descendants ; and are
the male and female children affected in different numerical
proportions, according as their insanity is derived from the
father or the mother? Do the different forms of insanity
differ from one another in the degree with which they tend to
be inherited ? Can any character or disease acquired by a
parent in the course of his or her individual life be handed on
to the offspring, and appear in them as one of the manifold
manifestations of the insane diathesis ? Is there any condition
or diathesis other than insanity occurring in one parent which,
when associated with the insane diathesis innate in the other
parent, might tend to neutralise the latter, so that the offspring
might escape unharmed ? and, conversely, is there any dia¬
thesis which tends to reinforce the insane one, and to add
therefore to the dangers ? These are but a few of the
questions with which we are confronted, and many of them
are far from being the most complicated ones. Yet I fear
that even to the most simple of these it is not yet possible to
give definite and exact replies. It is not, indeed, that no
attention has been paid to these matters. Many observers
have already interested themselves in these and allied
problems, and have published the results of their investigations;
but the conclusions drawn from their statistics do not always
harmonise with one another, and hence scientific precision is
far from having been attained to. I have thought, therefore,
that an inquiry into the family histories of a series of cases
of insanity which I have had under my care might present
some points of interest, and serve as a small contribution to a
subject for the full elucidation of which a vastly greater
amount of material is required. It would obviously take me
far beyond the limits of this address to attempt a detailed
analysis of all the literature of the subject, but I shall quote a
few of the more important publications. My statistics deal
with a series of 3445 insane patients who have been admitted

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PRESIDENTIAL ADDRESS,

[Oct.,

into Rainhill Asylum under my care during a period of twelve
years, 1693 of these patients being males and 1752 females.
It has not been practicable to include all cases that have
passed through the asylum in the course of that period, as
many patients come in of whose antecedents it is impossible
to obtain any trace, but every patient has been included of
whose family history any details whatever were obtainable. In
not a few cases, indeed, the information supplied has been
meagre, and doubtless in many cases fuller information would
have resulted in the transfer of the case from the negative to
the positive side, but I have thought it best to take all cases
without selection, whether the information supplied has been
full or the reverse; this course, at any rate, avoiding the
possibility of overstating the case as regards heredity. I have
also thought it advisable to exclude from the returns cases
which exhibited an hereditary taint in cousins only. These
have been included by many observers, and there can be no
doubt that they do in many cases afford valuable evidence of
the existence of a tainted family stock. Nevertheless it is
clear that there is an equal chance of such taint having been
introduced by marriage from an entirely different family, and
we have, I think, no right to assume without further proof that
such taint belonged to the family of any individual patient. I
think, therefore, that for the purposes of statistics it is wiser to
exclude them altogether, and this has been done in the
statistics which follow. I have, however, in some cases
worked out a series of comparative figures, in one of which
cousins were included and in the other left out, and I do not
find that their inclusion or the reverse in any way affects the
general results, though naturally, when added to the general
total, a slightly higher percentage of hereditary taint is
obtained. Brothers and sisters have, however, been included,
as the occurrence of insanity in more than one of these
members of a family is strong presumptive proof of a faulty
family stock, although even here the evidence is not wholly
free from objection, for both brothers and sisters may owe
their insanity to like causes of an acquired character.
Although occasionally a more remote ancestor has been in¬
cluded, the inquiry has practically resolved itself into finding
evidence of insanity in the grandparents, parents, uncles and
aunts and brothers and sisters of the patient. Out of the

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1902.]

BY J. WIGLESWORTH, M.D.

617

whole series of 3445 patients, a definite hereditary taint of
insanity, epilepsy, or a marked degree of eccentricity or
peculiarity, either direct or collateral, was found in 965 cases,
a percentage on the whole number of 28*01. This figure is
somewhat below that which has been obtained by many
observers, and there can be no doubt that it errs on the side
of deficiency, for we all know how difficult it is to get trust¬
worthy information as to the family history of our patients,
especially when they belong to the pauper class, from which
class the patients dealt with in my statistics have almost ex¬
clusively been drawn; this is particularly the case when
dealing with the more remote ancestry of the patients, the
history of whom it is comparatively seldom possible to obtain
in any detail. Farquharson,( s ) a recent observer, dealing with a
large number of patients of a similar class to my own, obtained
a percentage of hereditary taint of 30*7. Statistics drawn
from private institutions usually give appreciably higher
results; thus Grainger Stewart ( 8 ) found a percentage of 49*6
amongst the patients admitted into the Crichton Institution.
Scarcely any two observers, however, agree precisely as to
what they include under the term “hereditary taint,” and
hence the statistics they give are not exactly comparable. The
percentage from my own cases, of 28*01, which I have just
given, of course refers to the whole series of cases, males and
females combined. But when we come to separate the two
sexes we find a distinct difference. Thus, of the total number
of patients, 965, showing heredity, 419 were males and 546
females ; which figures, calculated on the total number of cases
treated of, give a percentage of hereditary taint of 24*74 for
the male patients, and 31*16 for the females. This is a
striking difference, and its interest is enhanced by the fact
that it harmonises with the records of previous investigators.
Almost all observers have found a higher percentage of
hereditary taint amongst the female patients than amongst the
male. To name a few of the records, Thumam ( 4 ) gives a
percentage of 32*82 for the males and '35*48 for the females ;
Grainger Stewart ( 8 ) 48*56 for males and 51*05 for females.
Farquharson’s ( f ) figures are respectively 27*4 and 34*16. The
conclusion has hence been drawn that the female sex has a
greater liability to suffer from hereditary insanity than the
male, and the figures given certainly seem to bear out that

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618

PRESIDENTIAL ADDRESS,

[Oct.,

opinion. The reason for this is not at first sight very evident,
but an explanation may perhaps be found, as suggested by
Turner,( e ) in the fact that the female organisation is less
resistive to stress than the male, and that the physiological
crises through which the female sex has mostly to pass con¬
stitute periods of danger which the male sex may be said to
be free from after the period of puberty is past. It would
appear, however, as I shall show later on, that certain forms of
insanity are more often acquired in the lifetime of the in¬
dividual in the male sex than in the female, and when these
are excluded the difference between the sexes as regards the
hereditary incidence of insanity is not so marked.

The question as to the greater potency of one or other
parent in transmitting what we may briefly style the insane
diathesis is one of much interest, but one on which, unfortu¬
nately, the observations of different investigators are not alto¬
gether in accord. The opinion of Esquirol that insanity
derived from the mother was more liable to be transmitted tc
the offspring than that coming from the father, has been con¬
firmed by Baillarger ( 5 ) and others, and has very generally been
assumed to be correct. The statistics of the Crichton cases,
however, given by Grainger Stewart ( 8 ) point in the opposite
direction, whilst other observers have found the proportion of
the paternal and maternal influence nearly equal. Thurnam ( 4 )
found that, calculated on the total number of cases treated
of, insanity inherited through the father amounted to 8*3 per
cent., and that through the mother to 8*5 per cent. Grainger
Stewart found in his cases that the paternal influence was
9*1 per cent., and the maternal 7*5 per cent. Turner’s ( 6 )
cases show a greater preponderance of the maternal element.
Farquharson,( 2 ) from a large series of cases, gives a percentage
of 8*i for the paternal and 8*2 for the maternal, which may be
regarded as equal. My own statistics closely correspond with
those of Farquharson. Thus, in 620 cases out of the total
number treated of, in which the relative influence of the two
sexes was ascertained with some approach to exactness, I
find that in 306 the paternal element predominated, and
in 314 the maternal; which figures, calculated on the total
number of cases (3445), give for the former a percentage of
8*88 and for the latter one of 9*11. This difference, *23 per
cent., is so small, especially having regard to the comparatively

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1902.] BY J. WIGLESWORTH, M.D. 619

large number of cases treated of, that I hardly think that
any importance can be attached to it. If, indeed, we take
insane fathers and mothers only, excluding all collateral and
reversional cases, unless these were associated with insanity
in the father or mother, my figures give an actual prepon¬
derance of the paternal element. Thus, out of 350 insane
patients in which this point was worked out, I find that the
father was insane in 185 instances and the mother in 165.
I incline, therefore, to the opinion that the female sex, as such,
has little if any greater power of transmitting insanity than
the male, but that the relative potency of either parent in
handing down the insane diathesis is governed by the same
laws as those which regulate prepotency in general, laws of
which we are still profoundly ignorant, and which stand in
urgent need of elucidation.

Another point of great interest is whether the insanity of the
parent bears any relation to the sex of the child,—that is to say,
whether either parent has a greater tendency to transmit the
disease to the children of his or her own sex. Here, again,
statistics are unfortunately somewhat at variance. The older
writers, e.g ,., Baillarger,( 6 ) asserted that the father’s insanity was
somewhat more liable to be transmitted to the sons, whilst the
mother showed a markedly greater tendency to hand the
disease on to her daughters ; and the statistics of Thurnam,( 4 )
Brigham,( 7 ) Grainger Stewart,( 8 ) and Farquharson,(*) all point
in this direction. Turner,( e ) however, found that whichever
parent was insane, the daughters were more often affected,
though they were attacked in a considerably higher pro¬
portion when the mother was insane rather than the father.
Thus, in 186 cases where the father was insane, the male
insane children numbered 117 and the female 138; whilst
from 236 insane mothers 295 insane children were born,
of whom 113 were males and 182 females. My own
statistics harmonise with those of Turner in the fact that
the female children were more numerously affected which¬
ever parent or parental relative was insane, though a pro¬
portionately greater number were attacked when the mother
was insane than when the father was so. Thus in my cases,
out of a total number of 306 in which the paternal influence
was paramount, 130 of the patients were males and 176
females; whilst in 314 instances in which the maternal

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620

PRESIDENTIAL ADDRESS,

[Oct.,

influence was paramount the males numbered only 124 and
the females 190. I have thrown these figures into percentages
calculated on the total number of cases treated of, and have
tabulated them in a similar manner to those of the other
observers indicated, so as to enable them to be compared at a
glance. Turner’s cases do not permit of being presented in

similar form.

•

i 1

1 Paternal influence.

j Maternal influence.

| Author.

' ' ' |
! Males.

Females.

Males.

Females.

1 Thurnam . . ■<

19 !

8‘5 per cent. |

8*1 per cent.

7 6 per cent.

97 per cent.

J Brigham . . i

42 j

7*07 per cent.

6 3 per cent.

5 9 per cent.

5 *>

9*5 per cent. 1

! Stewart . . . *[

j L

49 i

9 4 per cent. |

87 per cent.

37 !

7‘i per cent.

31 j

8 *i per cent. J

| Farquharson . , |

170 j

8*4 per cent.

147

7 7 per cent.

136

6 7 per cent.

185

9 8 per cent. j

j Wiglesworth . . j

130

7*6 per cent.

176

10 0 per cent.

124

7 3 per cent. !

190

10 8 per cent, j

It will be seen from the above statement that whilst
observers are somewhat divided as to whether the paternal
influence acts more powerfully on the male children of the
family than on the female, there is a unanimous consensus of
opinion as to the greater influence of the mother in trans¬
mitting insanity to the daughters rather than the sons, the
excess of female members of the family affected from the
maternal influence as compared with male members varying
from 1 per cent, in Grainger Stewart’s cases up to as much as
3 5 per cent, in my own. It would seem, therefore, to be an
actual fact that the mother has a greater tendency to transmit
insanity to her female rather than to her male offspring, and
this fact is not only one of considerable scientific interest, but
it has a practical bearing of some value. The varying
statistics as to the relative potency of the paternal influence
upon the children of the respective sexes do not at present
permit us to draw any definite conclusions on this point.
Turner( e ) has suggested that the relative influence of either

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1902.]

BY J. WIGLESWORTH, M.D.

621

parent upon the children of the corresponding sex could be
best ascertained by putting on one side all cases of insanity
commencing in adult life, and confining our inquiries to con-
genitals and adolescents only, so as to eliminate as far as
practicable all extraneous causes of the disease ; and he
found when this was done in his cases that more imbecile sons
than daughters were born to insane fathers, and more imbecile
daughters than sons to insane mothers. If the inquiry were
confined to congenital cases only, it would have still more
weight, and the point is worth the attention of those who are
connected with our large idiot establishments, whence alone
could sufficient material be collected to justify an authoritative
pronouncement. It would of course be necessary to carefully
exclude all cases, such as might be styled “ accidental idiots/*
in which the idiocy has been the result of difficulties or accident
associated with the process of parturition, etc.

Do the different forms of insanity differ from one another
in the degree with which they tend to be inherited ? Put in
this way, the question is a very difficult one to answer, as it is
comparatively seldom possible to obtain with the required
precision the exact nature of the mental disorder from which
a progenitor has suffered, and hence sufficient data are not
available to enable a definite conclusion to be drawn. We
know, however, that though the form of insanity occurring in the
child may in some cases be identical with that in the parent,
there is no necessary connection of this kind between them, but
that the insane diathesis may manifest itself in very different
ways in different generations. An allied question, however,
as to the relative incidence of the different forms of mental
disorder in those who have inherited a predisposition to insanity
is one which several investigators have endeavoured to answer,
and different percentages have been given, showing the relative
frequency of occurrence of mania, melancholia, dementia, and
so forth. But before we can get results of value from such an
inquiry we must first of all satisfy ourselves that our classifi¬
cation is a correct one, and that none but cases of a like
character are included under one head. I fear, however, that
the charmingly simple system of classification which has so
long received official sanction, and upon which so many of our
returns are founded, is one that from this point of view will
not stapd the test of criticism. For, whilst it is an undoubted

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622

PRESIDENTIAL ADDRESS,

[Oct.,

fact that many cases of melancholia, as also of mania, are as
well-defined clinical entities as any diseases we are ever called
upon to treat, there is, I think, equally little doubt that other
forms of insanity, many of which are somewhat vague and
ill-defined, are included under the above heads which assuredly
have no strict claim to be so designated ; hence these terms
come to include a somewhat heterogeneous assemblage of
cases which hang together by a very elastic thread. In fact,
the different forms of mental disorder are forced to fit the
classification, instead of the classification adapting itself to the
manifold manifestations of the disorder. To take but a single
example. To include, as has often been done, under the
general term “ mania ” such a thoroughly distinct group of
symptoms as that which goes to make up the affection known
as 44 monomania of persecution ” is at once to vitiate any
comparative statistics founded thereupon. Moreover the terms
are not mutually exclusive, as the same case might be classified
under different headings, according to the stage it has reached
when first observed. Instead, therefore, of attempting to work
out the hereditary frequency of the different forms of mental
disorder as set forth in the time-honoured classification already
quoted, I shall content myself, for the purposes of this inquiry,
with simply dividing all forms of insanity into congenital cases
(idiocy and imbecility) and non-congenital cases, and after
dividing off from the latter the two clearly defined sections of
epilepsy and general paralysis, I shall group together all
remaining forms of insanity under one head.

The number of cases of congenital insanity admitted into
Rainhill Asylum is a small one, due in part to the fact that, the
asylum having been overcrowded for many years past, a restric¬
tion has been put upon the admission of this class of cases. In
all only 68 congenital cases, with or without epilepsy, are
included in the 3445 cases treated of, and these were nearly
equally divided between the two sexes, 3 5 of them being males
and 33 females. * A definite hereditary taint was traced in no
less than 30 of these cages, a percentage on the total number
of congenital cases of 44*11. As in the whole series of cases
treated of, the proportion of hereditary taint is appreciably
higher amongst the females than the males ; thus the percentage
of the male congenitals (13 cases) works out at 37*14, and that
of the females (17 cases) at 51*51. These cases have, however,

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1902.]

BY J. WIGLESWORTH, M.D.

623

been taken indiscriminately, and no endeavour has been made to
exclude “ accidental ” idiots from the list, whose idiocy may
have been occasioned by accidents occurring during the process
of birth. On account of the superior size of the male head, it
is probable that there are more cases of this class amongst
males than amongst females, and if all these cases (in which
one might expect an absence of hereditary taint) were ex¬
cluded, it would tend to make the difference between the
two sexes somewhat less pronounced.

Insanity associated with epilepsy furnishes a well-defined
group of cases which lends itself to statistical examination.
Excluding all cases associated with idiocy or imbecility (which
have been treated of in the previous class), the number of cases
of epileptic insanity which I have collected amounts to 120, of
which number 77 were males and 43 females. The proportion
of these cases showing hereditary taint works out at 31 *66 per
cent, of the total number; but there is a remarkable difference
between the sexes as regards the relative incidence of the
heredity—the male epileptics with heredity, 15 in number,
giving a percentage of only 19 48, whilst in the females,
23 cases, the percentage works out at 53*48. One cannot but
think that this great difference must in part be due to accidental
causes, and that if larger numbers were taken, the real disparity
would be found not so great. Still, the figures certainly lead
one to suppose that epilepsy in the male is far more of an
acquired affection than it is in the female.

I now come to general paralysis, which is in some respects
the most satisfactory of all mental diseases to treat of statisti¬
cally, on account of the clearly defined character of the affection,
and the improbability of many cases being erroneously included
under this heading, such errors of diagnosis as may creep in
being too small to affect the general result when large numbers
are considered.

Great difference of opinion has existed as to the extent to
which this disease is hereditary, some observers saying that the
number of cases showing hereditary taint is so small that the
disease may be removed out of the hereditary category alto¬
gether; whilst others regard it as almost as hereditary as
ordinary insanity. Thus a recent observer—Revington( 8 )—
found that out of 145 male general paralytics there was a
family history of drink or insanity in 51 per cent. Excluding

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624

PRESIDENTIAL ADDRESS,

[Oct.,

the alcoholic factor when this occurred by itself, and taking a
history of insanity only (which in my opinion is the more
correct way of regarding the question), the percentage of
hereditary taint in Revington's cases still works out at the
comparatively high figure of 317, and this, be it observed, in
male general paralytics only. On the other hand, Farquharson ( 2 )
found in 231 cases of this disease, males and females combined,
a percentage of hereditary cases of 18*6 only. My own
statistics, based on a larger number of cases, closely agree with
those of Farquharson. There are included in my figures 433
cases of general paralysis, 363 of which were males and 70
females, and out of these 82 (60 males and 22 females) showed
a definite family history of insanity, which gives a percentage
on the total number of 18*93. The incidence of heredity is,
however, very unequally divided between the two sexes, the
female cases being nearly twice as hereditary as the male ; thus
the percentage of the female cases works out at 31*42, and that
of the male cases at 16*52 only. It would appear, therefore,
from these figures that general paralysis is less hereditary than
other forms of insanity, but that hereditary tendency is never¬
theless a factor of considerable importance in the disease. Or,
to put the matter in another form, general paralysis is a disease
which is to a large extent acquired, but that its exciting causes
are distinctly more prone to eventuate in the disease when the
cerebral resistive capacity to morbific agencies is lowered by an
inherited weakness. The different incidence of heredity in the
two sexes points to the disease being much more of an acquired
affection in men than in women, and is of interest in connection
with syphilitic infection, which we now regard as such an
important factor in the production of the disease.

I pass now to the remaining forms of insanity other than
congenital, epileptics and general paralytics being deducted.
This class embraces all forms of ordinary insanity—mania,
melancholia, dementia, and so forth,—for the inclusion of which
under one head I have already given my reasons. The total
number of cases included under this head amounts to 2824, of
which 1218 were males and 1606 females. Out of this total
the number showing hereditary taint amounted to 815, which
gives a percentage of hereditary cases on the total number of
28*85. Separating the sexes, we find that the males (331
cases) give a percentage of heredity of 27*17 and the females

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1902.] BY J. WIGLESWORTH, M.D. 625

(484 cases) one of 30*13. It is interesting to compare
these figures with those obtained by the analysis of the whole
series of cases treated of, for whilst the percentage of hereditary
taint is only slightly higher (*84 per cent.) when insanity is
considered from the above-named more restricted standpoint
than when the calculation is made on the total number of cases,
the difference between the sexes as regards the incidence of
heredity is very much less, this difference amounting to only
2*96 per cent, when ordinary insanity (as above defined) is
considered, as against a difference of no less than 6*42 per
cent, when all cases are taken. This result is mainly due to
the exclusion of epileptics and general paralytics, which,
according to my figures, as already pointed out, are much less
hereditary in the male than in the female.

The foregoing results are shown at a glance in the following
table:

Form of insanity.

Number of cases.

Number of J
these showing
heredity. j

Percentage of heredi¬
tary cases on total
numbers.

Tl.

T'.j

Tl.

Congenital insanity (id¬
iocy and imbecility)
with or without epi¬
lepsy

Epileptic insanity
General paralysis
Ordinary insanity (non-
congenital) — mania,
melancholia, demen¬

30 j

37*14

51*51

4411

363

1218

1606

120

433

2824

331

484

815 J

19*48

16*52

27*17

53*48

31*42

3013

3**66

1 8*93
28*85

tia, etc. t

All cases together

1693

1752

3445

419

546

965:

2474

31*16

2801

I now come to a question of a very important character.
Can any modification of the structure of the body, or any
constitutional condition acquired by an individual in the course
of his or her life, be handed on to the offspring of such
individual, and appear in them in a similar or allied form ?
Here we are face to face with one of the great biological
problems of the day, viz., the possibility or otherwise of the
transmission of acquired characters. A question of such vast
magnitude can, of course, only briefly be touched upon here,
but it is one of a fundamental character, upon the answer to

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626 PRESIDENTIAL ADDRESS, [Oct.,

which depends the correct interpretation of a whole host of
hereditary phenomena.

Nearly two decades have now elapsed since Weismann’s
views were first placed prominently before the world, and yet
the fierce controversies which have thickened round the subject
during that period have failed to prove that author to be wrong
in his main contention. As to the non-transmission of mutila¬
tions, we are probably nearly all agreed, for no properly
authenticated cases of this nature appear to exist. And as
regards the transmission of acquired characters themselves,
many facts which were formerly relied on as evidence of this
have been shown to be capable of explanation upon different
principles.

Here 1 shall merely refer to one or two acquired consti¬
tutional states which have special reference to mental disorders.
I think that those of us who have much to do with the insane
look upon alcoholism in the progenitors as a fruitful cause of
the manifold mental disorders from which our patients suffer.
Alcoholism is, of course, frequently associated with mental
disease in the family histories of our patients, but for the pur¬
pose of this inquiry it is necessary to take only those cases in
which alcoholic excess stands by itself, uncomplicated with
recognised mental disease. It is not possible, within the limits
at my disposal, to do more than give the results of my own
statistics. Out of the 3445 cases which form the basis of the
foregoing analysis, a definite history of alcoholic excess un¬
associated with insanity, in one or both parents (I have excluded
more remote relatives) was found in 578 instances, a percentage
on the whole number of 1677. Separating the sexes, we find
that the male patients show the higher figures, these amounting
to 327, giving a percentage on the total number of males of
19*31, whilst the females (251 cases) give a percentage of
14*32. Doubtless some few of these cases of alcoholic excess
may have been veritable examples of dipsomania, which may
be regarded as itself constituting a neurosis allied to insanity;
but as most of such cases usually show definite mental dis¬
orders at some period or other of their course, the majority of
them will have been included in the foregoing tables of
hereditary insanity. These figures do not give so high a per¬
centage of alcoholic excess in parents as has been published by
some observers, and, in my opinion, they undoubtedly under-

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1902.]

BY J. WIGLESWORTH, M.D.

627

state the case as regards alcohol, for excessive indulgence in
this way by the parents of patients is frequently denied when
collateral evidence has proved it incontestably. Moreover,
opinions differ so much as to what constitutes “ excess,” that
only gross and palpable instances of it are here included. I
think, however, that, excluding insane heredity, it would be
difficult to find any single antecedent in the parents of our
patients which would in frequency reach the figures here set
forth, which are certainly such as to strongly suggest some
causative relation between the two. Whilst on the one hand,
therefore, our experience leads us to believe that there is a
causal relation between alcoholism in the parents and insanity
in the children, we have been told in the controversy that has
arisen on the subject that it is impossible that this should be
so, since acquired characters are not inherited. If this were in¬
deed the right way of presenting the facts, those of us who
adopt the Weismannian position might find it a difficult matter
to reconcile theory and practice. But in truth, in my opinion,
the particular case we are now considering has nothing what¬
ever to do with the inheritance or otherwise of acquired
characters. What we are here concerned with is a direct
poisoning of the germ plasm itself by means of the alcohol
circulating in the blood, and consequent direct injury to the
delicate cells of which this structure is composed, which by
virtue of this injury are thereby prevented from developing
into a stable organism. I think that perhaps we do not
sufficiently realise the extraordinary active growth displayed by
the germ plasm during the whole sexual life of the individual.
Continually being shed and again formed anew, the delicate
cells of the germ plasm are in process of perpetual growth and
development, and are consequently exposed when in a very
susceptible condition to all nutritional influences which affect
the soma generally. But what are the conditions prevailing in
the system of the person who indulges in alcohol to excess ?
The blood and lymph become more or less charged with this
agent, which is thus conveyed into every tissue and organ of
the body. The germ plasm offers no exception. The nutrient
fluid which bathes the cells of this tissue, and conveys to them
the nourishment by which alone their active growth and
development becomes possible, carries also with it the alcohol
which is circulating in the blood. It may be said, indeed, that
XLVIII. 44

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628

PRESIDENTIAL ADDRESS,

[Oct.,

the development of these cells takes place in a weak solution of
alcohol. It might, indeed, be argued that the alcohol is too
much diluted to be capable of doing much harm ; but I do not
take that view. Very dilute solutions of this agent have been
shown by Ridge (®) and others to be inimical to protoplasmic
growth, whether vegetable or animal, and when cells are in
process of development they are, of course, more susceptible to
morbific agents than when fully formed. A general agent of
this kind, acting indiscriminately, might be expected to affect
most the molecules of the cells which control the development
of the nervous system, and more particularly those latest formed
portions of it which, being the last to be developed in the
course of evolution, are on this account the most unstable and
the most liable to give way or to exhibit defects and abnor¬
malities when the nutritional environment is adverse. A morbid
character may thus become stamped on the germ- or sperm-cell
before the union of these two elements, which, if not counter¬
acted by a healthy condition of the other of these two, will
cause the organism to develop on certain lines from which there
is no escape. If the alcoholic poisoning has reached a certain
degree of intensity, idiocy or imbecility may be expected to
result; whilst if of less degree, the injury may manifest itself in
the various forms of adolescent or other insanity when adult
life is developing or has been attained to. Of course, if the
mother be alcoholic, whatever injury may have been done to
the germ will be added to and reinforced by chronic alcoholic
poisoning of the nervous centres of the embryo during the
whole period of intra-uterine life. I think, therefore, that to
this toxic agent acting on the idioplasm of the sperm- or germ-
cells, especially during the susceptible period of development,
can be traced in not a few instances the mental disorders from
which our patients suffer.

Somewhat similar considerations will help us with regard to
a clear understanding of the part played by so-called “ in¬
herited syphilis ” in producing mental disorders. Here, again,
we have an acquired constitutional condition, the effects of
which are handed on to the offspring, but in which the
variations which result are in all probability largely due to the
direct action of a poison upon the molecules of the germ
plasm itself. We have doubtless here to do in many cases
with a specific infection of the germ or of the developing

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1902.] BY J. WIGLESWORTH, M.D. 629

embryo with the syphilitic virus, though in the majority of
these cases the embryo is probably thereby rendered incapable
of full development, and perishes prematurely. But I do not
think that the doctrine of a specific infection will explain all
the cases which occur. Speaking of the nervous system, I
would rather say that a morbid influence of a non-specific
character, albeit dependent upon antecedent syphilis, has been
exerted on the germ- or sperm-cdl, which has so modified the
nutrition of the groups of molecules or biophors contained
therein which preside over the development of those centres
which subserve the function of mind, that these either have
their development arrested, in which case idiocy results, or else
have their resistive capacity greatly weakened, and break down
prematurely in consequence. We have, indeed, to deal with
the effects of a direct injury sustained by the germ plasm.
The process is probably similar to that which underlies the
development of general paralysis in adult life. We recognise
more and more the important rdle played by acquired syphilis
in the causation of this disease, and yet we know that
the lesions of general paralysis are not those of syphilis,
and that in these cases true syphilitic lesions of the brain are
virtually non-existent. We incline therefore to the view
which has been so ably advocated in this country by Mott,
that in this disease the toxines produced by the syphilitic
virus circulating in the blood have so modified the mole¬
cular constitution of the cerebral neurons, that the re¬
sistive capacity of these to stress of all kinds has become
greatly lowered, and a premature decay has set in. We
therefore, following Fournier, style the lesion a “ para-
syphilitic ” one, although we do not fully understand how the
change in question has been brought about. Now if, as out¬
lined above, we transfer our conceptions as to the modus
operandi of the syphilitic virus in the formation of adult
general paralysis to the germ- or sperm-cell, we can form an
idea as to how the poison acts in the development of juvenile
general paralysis, which we have good reason to suppose is
determined, at any rate in most cases, by the existence of
syphilis in the parent.

In a considerable proportion of the recorded cases of
juvenile general paralysis, though by no means in all, definite
stigmata of congenital syphilis have been present on the person

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[Oct,

of the patient, and where these have been absent the history
has often strongly suggested parental syphilis.

I agree, therefore, with the conclusions of the majority of
observers, that, in most cases at any rate (it has not yet been
proved that the connection holds good universally), juvenile
general paralysis owes its origin to antecedent parental
syphilis; but I consider that the relationship between the two
is not one of direct infection, but that a nutritional change of
a parasyphilitic nature has been exerted upon the groups of
molecules of the germ-cells which preside over the evolution of
the cerebral neurons, the result being that these neurons have
their store of vital energy greatly weakened; and hence,
though they may develop normally for a time, they break
down prematurely under the influence of the first physiological
crisis to which they are subjected. And it seems to me not
altogether improbable, as has, indeed, already been suggested
by Mott ( 10 ) and Percy Smith, ( n ) that certain cases of adult
general paralysis may have a similar origin. For the nutri¬
tional vice which causes some individuals to break down at
puberty might, if exerted in a milder form, permit of adult
development, and yet leave its possessor unfit for the ordinary
stresses and physiological crises of life. In this connection I
may refer to the case of a young married woman, aet. 24,.
who was under my care some years ago. When admitted to
the asylum she was suffering from general paralysis in the
first stage, and was at the time pregnant with her first child,,
of which she was confined nearly four months after admission.
The case ran a perfectly typical but unusually prolonged
course—eight years,—and after death the usual cerebral lesions
were found well marked. There is, of course, the possibility
that this woman might have been infected with syphilis prior
to her marriage, which took place about a year previous to her
admission ; but against this view may be set the facts that her
husband had known her for about four years previous ta
marriage, and testified that she had always been a very steady
girl; also that her child, which was bom at full term, was a
healthy one, and showed no signs of constitutional syphilis ;
whilst, in addition, the woman herself, though she was under
observation for the long period of eight years, never at any
time showed any signs of that disease. The family history
obtained was too meagre to be of much value, the only point

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BY J. WIGLESWORTH, M.D.

S3*

of importance being the fact that the patient’s father had
drunk heavily all his life. Whilst, therefore, this case is far
from furnishing proof of a direct causal relation between the
patient’s general paralysis and parental syphilis, it is, I think,
very suggestive of the possibility of such a connection, the
patient having escaped the dangers of puberty only to break
down at the next physiological crisis of pregnancy.

If the view outlined above with respect to the relation
between parental syphilis and juvenile general paralysis be a
correct way of presenting the facts, it is clear that these cases
cannot be regarded as examples of the transmission of acquired
characters in the sense in which Weismann defines that phrase,
since they are instances not of inheritance of modifications of
the soma, but of a vice of nutrition exerted directly on the
germ plasm itself. The direct action upon the germ-cells of
the parent of poisons circulating in the blood or of faulty con¬
ditions of nutrition, however produced, is indeed doubtless a
potent cause of unfavourable variations in the germ plasm, or,
in other words, of degeneration in the offspring. I conclude,
then, that the condition of the soma, regarded from the point
of view of nutritive host to the germ plasm, has a definite in¬
fluence upon germinal variation, which will by degrees become
more precisely recognised, although there is no evidence to
prove that specialised modifications of that soma have any
influence in this direction.

Hitherto we have regarded the question from the point of
view of the inheritance, either direct or collateral, of insanity
and allied conditions. The fact that like engenders like is a
well-known law or principle of heredity, and surprise may be
felt, not that we find this law in continual operation, but that
its effects are so often traversed and concealed by the operation
of other laws which are less fully understood. The familiar
phenomena of atavism merely place the inheritance a little
further back, and do not affect the principle of direct descent.
But however we may define the taint, which may be briefly
styled the insane diathesis, and whatever conditions we may
include under that term (and different observers, as before
remarked, interpret the term with different degrees of elasticity),
and even in cases where the completeness of the family histories
give an assurance of accuracy to our statistics which less com¬
plete records fail to do, there always remains, at any rate, a

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PRESIDENTIAL ADDRESS,

[Oct.,

considerable minority of our patients in which an antecedent
family taint of this sort cannot be recognised. Furthermore,
cases are continually presented to us where a strong direct
taint of insanity exists in a family, and yet some at least of the
offspring entirely escape. We have on the one hand, then, to
deal with numerous cases of insanity which apparently arise
de novo where, the family records being good, we should not
expect to meet with cases of this affection, and, on the other
hand, we frequently fail to find the disease when the family
antecedents of the individuals concerned might lead us strongly
to anticipate its presence. We can perhaps more readily frame
to ourselves a conception as to how the latter cases come
about than as to how the former are developed.

When both parents are affected with insanity, it might be
supposed that few or none of the children of such parents would
escape the disease. This, however, as above indicated, is not
the case, for though statistics show that when both parents
are affected a higher proportion of children are attacked
than when only one parent is so, still a considerable proportion
escape altogether. Doubtless in many of these cases the varia¬
tions in the germ plasm which have culminated in the insanity
of the parents have been of recent development, and hence,
being, as it were, variations of an individual character, would be
less likely to be handed down in all their fulness than if they
had gathered strength by transmission through a long line of
ancestors. We have an illustration in such cases of that
regression towards the mean standard of the race which
Gal ton ( ls ) has called our attention to, and which he has worked
out with such conspicuous ability and clearness with respect to
the stature of the population. As Galton says, “ the law of
regression tells heavily against the full hereditary transmission
of any gift.” And this law, of course, applies equally to the
handing on of bad qualities as well as good ones, and by virtue
of it—that is, in consequence of the fact that racial characters
are more persistent than individual ones—many a child escapes
the insanity of its parents who would otherwise inevitably
succumb to it. Certain it is that the children of the same
parents do differ much among themselves, and this dissimilarity
is explained by Weismann (*) as the result of the halving of
the germ plasm in the process of the “ reducing divisions,”
which, taking place in a different manner each time, gives rise

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1902.]

BY J. WIGLESWORTH, M.D.

633

to numerous different combinations of the primary constituents
of the germ plasm. A recent variation, whether in a good or
a bad direction, would be represented in the germ plasm by
a smaller number of modified elements (“ ids,” as Weismann
terms them) than if the variation dated back for several
generations. And therefore, even though the modified elements
may exist in the germ plasm of both parents, they may still be
in insufficient numbers to preponderate absolutely over those
elements of the ancestral germ plasm which make for a stable
condition of the nervous system, which are implicitly, if not
explicitly, present in both parental idioplasms. Hence, in some
of the “ reducing divisions ” that take place, these unstable
elements will either be eliminated altogether, or be controlled
by stronger or more numerous elements of a stable character,
derived from more remote ancestors, and the offspring thus
conditioned will escape the insanity of their parents. If, how¬
ever, the variations in the germ plasm which produce that
unstable condition of the nervous system which eventuates in
insanity be present not merely in the individual parents but
also in several members of their ancestors, the number of
elements of the idioplasms which will be modified in the direc¬
tion of instability will be considerably greater, and there will
therefore be less likelihood of these being eliminated in any of the
u reducing divisions ” that take place when fresh organisms are
being formed ; in which case few if any of the children would
escape. Although Weismann’s views as to the importance of
the “ reducing divisions ” in producing dissimilarity of offspring
are worthy of all consideration, it cannot be doubted that, even
if they be correct, other factors are at work which operate in
this direction.

But though, as already indicated, direct inheritance and
reversion to earlier types are factors of paramount importance
in the consideration of the phenomena of heredity, they do not
cover the very important groups of cases in which new cha¬
racters appear in the offspring, which are present neither in the
parents nor in the more remote ancestors. New combinations
of the elements of the germ plasm, or variations in these
elements, have arisen, which result in the development of an
organism differing from any which have preceded it. Such
variations are of course of the highest importance in phyletic
development, as furnishing the material which is seized upon

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PRESIDENTIAL ADDRESS,

[Oct.,

by natural selection for the production of new and favourable
varieties; they are therefore at the root of all progress. But
we are here concerned only with unfavourable variations, which
eventuate in some manifestation of the insane diathesis. It is
a fact that we not infrequently meet with cases of insanity
arising in families which, so far as can be judged, are free
from neurotic taint, and in whom the deleterious effects of
such toxic agents as alcohol acting directly upon the germ
plasm of the parents can likewise be, to all appearance, ex¬
cluded. Some such cases are without doubt examples of
insanity which has, in the strictest sense, been acquired in the
course of the individual life, with which cases we are not here
concerned. But there are others where the occurrence of
insanity in several children of the same family points in all
probability to the fact that the affection has had its origin in a
faulty condition of the germ plasm established at the period of
fertilisation. Some interesting cases of this kind have been
under my care, of which I will give one or two examples.

I. K. Family .— Three Cases of Adolescent Mania in the
Children of One Family , without Evidence of Neurotic
Taint .

Paternal grandfather died of phthisis, aged 36 ; paternal
grandmother of old age, aged 77. Maternal grandfather died
of bronchitis, aged 58 ; maternal grandmother of old age,
aged 75. One paternal uncle and two paternal aunts living
and healthy ; one paternal aunt died rather suddenly, aged 50,
probably from an apoplectic attack. One maternal uncle
living and healthy; one died, aged 48, of cancer of stomach.
One maternal aunt living and healthy; one died, aged 25,
of phthisis. No history of epilepsy, alcoholism, or any nervous
disease in any member. Father, a labourer, was a native of
the Isle of Man ; mother a native of Liverpool and born of
Lancashire parents; aged respectively at marriage 28 and 24
years. Both hard-working, steady, and sober people in com¬
fortable circumstances, and both quite strong and healthy.

There were seven children in the family:

1. F., aged 22, healthy.

2. M., aged 21, was an inmate of Rainhill Asylum from
August 24th to December 18th, 1897 ; was 18 years of age

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1902.]

BV J. WIGLESWORTH, M.t).

635

at time of admission. Suffered from simple adolescent mania,
from which he made a good recovery, and has remained well
since (January, 1902).

3 and 4. Two males (twins), died, aged years, of
scarlatina.

5. F., aged 17 (16 when admitted). Was a patient in
Rainhill Asylum from June 26th, 1900, to July 26th, 1901,
suffering from simple adolescent mania. Made a good recovery,
and remained well at the end of 1901.

6. M., aged 15. An inmate of Rainhill Asylum from
August 10th, 1901, to January 25th, 1902, suffering from
simple mania. Made a good recovery.

7. F., aged 9.

Thus out of the four children who attained to or passed the
period of puberty (the fifth is still below puberty), no less than
three developed insanity about the period of puberty and
adolescence. The mental symptoms in each case were very
similar, and all three children presented considerable physical
and facial resemblance to one another ; they were all healthy
and robust. The family history, which was unusually complete,
disclosed no evidence of any mental or nervous disease in any
member of it

II. W. Family,—Four Cases of Delusional Insanity in the
Children of One Family. No History of Insanity in
Family , but a Remote History of Alcoholism.

Paternal grandparents both healthy, and lived to a good
age. Maternal grandfather died, aged 65, of erysipelas; he
drank a good deal. Maternal grandmother died, aged 45, of
“ a decline.” There were four paternal uncles, all of whom
are dead; one of them was a solicitor, and died of a “ stroke,”
aged about 5 5 ; the other three all drank, and appear to have
led fast lives. There were two paternal aunts, both dead ;
one was 88 years of age at death. Four maternal uncles, all
dead ; one died aged 84 ; one died, aged 30, of “ consump¬
tion the two others were lost at sea. Five maternal aunts, two
of whom are living ; one died, aged 25, of consumption ; one,
aged 30, from the effects of parturition ; and one, aged 60,
was found dead in her room one morning—was supposed to
have had an apoplectic fit. Father, a native of Yorkshire, was

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[Oct,

a master mariner and part owner of his ship ; was drowned at
sea, his ship having been lost with all hands. Mother a
native of the Isle of Wight. No relationship before marriage.
Aged respectively at marriage 24 and 23. Both steady and
temperate. Mother living; has stood well the anxiety and worry
connected with the insanity of her children. There were six
children in the family:

1. M., lost at sea, aged about 23.

2. M., now aged 47 ; married, two children. Was in a
business firm in China up till about the middle of 1901, when,
in consequence of the development of symptoms of insanity,
he was sent home to England. Had been out in China
nineteen years. His present symptoms dated from the latter
part of 1900. He developed grandiose ideas as to a great
position he was going to have in some new business firm, with
a very large salary, for which there was not the slightest
ground. He is now in England, and appears to be a case of
chronic delusional insanity, but he has not yet come under my
personal observation.* His wife informed me by letter that
he had always been an abstemious man, and very strong
physically.

3. F., aged 35 on admission. Has been an inmate of

Rainhill Asylum since November, 1897. A chronic delusional
case with ideas of wealth and personal importance, together
with some persecutory delusions.

4. F., died, aged 23, of some intestinal trouble (? tuber¬
culosis).

5. M., aged 32 on admission. Has been an inmate of

Rainhill Asylum since March, 1897. A very typical case of

chronic paranoia ; has very vivid hallucinations of hearing,
and delusions of persecution and grandeur. Is said to have
taken a little drink, but not to excess.

6. F., aged 25 on admission. Has been an inmate of

Rainhill Asylum since May, 1893. At the time of admission
she was decidedly delusional, with grandiose ideas, but has
now become considerably demented.

It is interesting to observe that these four persons became
insane in the inverted order of their ages, from the youngest
upwards, and their mental symptoms showed a good deal of
general similarity.

* I have since seen this man. He is a typical example of paranoia*

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1902.]

BY J. WIGLESWORTH, M.D.

637

It will be noted that there was, as far as could be ascer¬
tained, an entire absence of insanity, epilepsy, or any form of
nervous disease in any of the known ancestry of the patients.
The alcoholic history in some members of the family must not,
however, be overlooked, as it may have been a factor in the
causation of the insanity, in spite of the fact that the parents
were temperate. This factor, however, seems to me inadequate
to account for the extraordinarily strong tendency to insanity
displayed in the fact of four out of six children in one family
(in fact, all the members of it who attained to fully adult life—
twenty-five years) becoming permanently insane, one after the
other.

It is of course possible that if we could trace the history of
such cases far enough back, we might find evidence of insanity
in some forgotten ancestor, which might admit of an explana¬
tion being supplied on atavistic principles. But we are scarcely
entitled to assume without definite proof that such must
necessarily be the case. Such examples seem rather to point
to the fact that there are cases in which the germ plasm of
either parent may itself be healthy and stable, but the com¬
bination of the two produces unstable offspring. It is im¬
possible, in the present state of our knowledge, to give a
satisfactory explanation of such cases. We may, indeed, say
that the male and female elements exhibit a physiological in¬
compatibility for each other, but that is little more than a
statement of the results, and helps us nothing towards a solu¬
tion. We know, indeed, that if the male and female elements
exhibit too great a uniformity, such as arises from close inter¬
breeding, the results are apt to be disastrous as regards the
mental well-being of the offspring. We know, also, that if
these elements show too great dissimilarity in composition,
disaster is similarly apt to ensue. But we know little else.
And as to the causes of variation in general, we are still very
ignorant, although observation and experiment are slowly
bringing new facts to light. Professor Cossar Ewart,( 13 ) in his
interesting and important address before the Zoological Section
of the British Association, has brought forward valuable
evidence in support of his contention that not only is age a
cause of variation, but that the ripeness or otherwise of the
germ-cells at the time of conjugation is also an important

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63 ^ PRESIDENTIAL ADDRESS, [Oct.

factor in this connection. Professor Ewart, in the course of
this address, also refers to the influence which the condition of
the soma has in this direction, a factor which I myself regard
as of great importance, and which I have previously alluded to.
It is clearly, however, a matter of the highest importance that
we should attain to more precise knowledge of these matters.
There may be diatheses represented in the germ plasm, good
in themselves, but which in combination tend to produce an
unstable condition of the nervous system, whilst others may
tend to oppose the insane diathesis and lead to its extinction.
Some years ago, when drawing up a scheme for recording the
family histories of patients, I left a column for noting down the
family diseases ; but the amount of information collected under
this head has, I regret to say, been too meagre to be of value.
The subject is one much in need of investigation. We are
sometimes consulted as to the prudence or otherwise of
marriage in cases where insanity has occurred in a family, and
a knowledge of what sort of diathesis to oppose thereto would
assist us materially in the advice we should give. Or, to take
the cases already indicated, where both sides appear to be free
from nervous taint, with greater knowledge we might be able
to detect physiological incompatibility where such exists, and
thus give a warning all the more needed, as the danger is more
insidious. To be enabled, indeed, whether in health or disease,
to predict the results obtainable from the union of two indi¬
viduals, would indeed be to be possessed of knowledge which
would prove of the highest advantage to the human race. We
are, indeed, insensibly led from the consideration of how to
combat a family tendency to insanity (or, indeed, to any
disease), or to prevent the development of such tendency, to a
consideration of the wider question of the general improvement
of the race by the union of specially selected individuals. Such
a question can, of course, only be touched upon here ; but the
subject is one of too great importance to be passed over in
complete silence. There can be no kind of doubt that an
enormous improvement in the human race could be effected by
selective breeding, did we but possess the requisite knowledge
for that purpose, and did an adequate conception of the import¬
ance of the attainable results render possible the application of
means for securing that end. It is a question whether, under
the haphazard system prevailing, the race is improving to any-

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BY J. WIGLESWORTH, M.D.

639

thing like the extent which most people seem to imagine. To
take the question of mental endowments only, the commonly
accepted view seems to be that the constant use of the brain
entailed by modem conditions of life results not merely in an
increase in the mental capacity of the individual (of which, in¬
deed, there can be no doubt), but that these constant increments
being handed on from generation to generation, a type of
brain is being gradually evolved immensely superior to that of
the ancient civilised races of which we have any record. All
this is open to serious question. If there be no such thing as
“ use-inheritance ”—and I have already stated my belief that
in this respect the Weismannian position at present holds the
field,—then no such improvement in the intellectual faculties
can now be going on in the way above indicated, and the only
known way in which the human brain can be undergoing
further development is by the constant selection of favourable
varieties, a method undoubtedly in operation, but one which the
conditions of modem social life tend to obscure, and in some
respects to traverse. Is it a fact, moreover, that the intellectual
development of the present day is on a higher plane than that
attained to by some of the ancient civilised races ? I am not
at all sure that this question can be answered in the affirma¬
tive. Enshrined in literature and embodied in stone, the
workings of that intellect are displayed to us, and may well
give us pause when we attempt to measure our intellectual
strength therewith. We must carefully distinguish between
intellectual power and mere increase in knowledge. The latter,
of course, multiplies abundantly day by day, and each genera¬
tion, being able to reap the labours of preceding ones, starts its
own career upon a somewhat higher platform. But this is not
the same thing as the development of increased intellectual
power, and the marvellous industrial triumphs of our own time
must not shut our eyes to the fact that in the remote past the
star of human intellect shone at least as brightly as it does at
the present day. But if a period of time, which must be
reckoned by thousands of years, has had no sensible effect in
improving the quality of the human brain, it may not be out of
place to inquire whether the process might not be accelerated
by applying to it the biological knowledge which will attend on
the scientific investigator. Whilst the nineteenth century may
be said to have witnessed the placing of the science of biology

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[Oct.,

on a definite scientific basis with the enunciation of the general
laws underlying the development of the organic world, so it
may well be that the present century may witness not merely
an extension of those laws, but the practical application of them
to the furtherance of the development of the human race. The
world has seen enough of the effects of the defiance of those
laws, imperfectly known to us as they are. Times without
number have attempts been made to foster artificially the off¬
spring of unphysiological marriages entered into for social or
pecuniary reasons ; and the legal profession has exhausted its
ingenuity in contriving enactments as to the disposition of
property, and the retention of this in particular families, to en¬
able such families to survive. But of what avail is all this
when the laws of nature are deliberately broken ? The results
of such artificial efforts are writ large on the page of history—
are spread out before us as on a living tableau. Insanity,
alcoholism, tuberculosis—to name but some of the great race
destroyers—are busy in such families, and hurry them on
through the different stages of decay to the final dissolution.
But the results which men vainly strive after by artificial means
can be obtained by natural means, and the judicious admixture
of strains can secure an immortality for a family which the
most cunningly devised systems of the legal mind are utterly
unable to compass. The time may possibly come when
families will be formed and maintained by the natural worth of
their members, and when such families only will be considered
of any account. Granted that our knowledge of the laws of
heredity is not yet sufficiently precise for the purpose, there is
no reason to doubt that the patient questioning of Nature by
observation and experiment will here, as elsewhere, yield in
time abundant fruit. We all of us can do something to further
this result, and the minute investigation of the family ante¬
cedents of insane persons is a field of inquiry which is very far
from being worked out.

But even if an intellectual assent be given as to the im¬
portance of the results that may be capable of achievement by
the application of such means as those above indicated, the
question will very pertinently be asked as to how such means
can be put into operation.

Francis Galton,( 14 ) whose luminous researches into the
intricate phenomena of heredity we all so much appreciate and

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BY J. WIGLESWORTH, M.D.

64I

profit by, has recently approached this subject in his Huxleian
Lecture delivered before the Anthropological Institute, and he
advocates therein, in order to attain the end desired, a system
of granting diplomas to young persons of both sexes who show
exceptional talent, and encouraging early marriages between
them by affording them assistance, pecuniary or otherwise, by
means of agencies established for this purpose. Galton’s
paper, like everything written by him, will repay careful
perusal; but though there is much in the position he takes up
with which I am quite in accord, I cannot but think that some
of the means he advocates have somewhat too artificial a ring
about them to make one sanguine as to the stability of the
stock fostered in this manner. To what, then, are we to look
for the attainment of the results desired? Certainly not to
legislation, which of all agencies is the one most incompetent to
deal with this question. I should, moreover, be very sorry to
advocate anything which would interfere in the least with
the part which natural affection plays in regard to unions
between the two sexes. But “ falling in love,” as Maudsley
long ago remarked, is much a matter of propinquity, and it
might not be difficult for enlightened parents and guardians to
bring young people into juxtaposition who were physiologically
adapted to each other. And this brings one to the root and
kernel of the whole matter. If any advance is to be made in
the improvement of the race by means of deliberate selection,
it can only be by a full recognition of the vast importance of
the subject, not only on the part of parents and guardians, but
on that of the young people themselves who are to be the
parents of the next generation. Such a result can only be
achieved by means of definite education in the direction
indicated. But there is no reason in the nature of things why
the importance of this question should not be instilled into the
minds of young people of both sexes from their youth upwards ;
why, indeed, they should not be grounded in physiological truths
as they are in religious tenets, and taught to regard the one as
only second in importance to the other. The enormous power
which religious and ^w/-religious customs can obtain over a
community is illustrated by every tribe and nation throughout
the four quarters of the globe. And if the vital importance,
not only of preserving but of improving the race in its moral,
mental, and physical condition was instilled into the minds of

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PRESIDENTIAL ADDRESS,

[Oct.,

our youth with all the fervour that springs of religious convic¬
tions, the social sanction is quite powerful enough to do the
rest. But this social sanction has first to be created, and its
creation will be all the more easy when scientific men are able
to furnish more definite data to work upon than they can do at
present, although enough is known even now to enable a vast
improvement to be made, were public opinion alive to the great
importance of the question.

It may indeed appear Utopian to suppose that such a
public opinion can ever be developed, especially in an age
when the prevalent ideals of life are of such a different order,
and when the tendency is in the direction not of increasing
and improving the stock of a community, but in that of having
no stock at all to improve on. The persistent and consider¬
able falling off in the birth-rate in this country, which has been
so prominent a characteristic of the last quarter of a century,
and which is steadily progressing, is silently working a revolu¬
tion in our social system. Disguised at present by a con¬
comitant fall in the death-rate, the results are nevertheless
gradually developing, and cannot but cause grave anxiety as
to the future well-being of our race. The question has hitherto
been looked on almost, if not entirely, from the statistical
standpoint, and the matter considered as if it were an affair of
numbers only. That the number of units in any given nation
is a factor of vital importance to that nation in the inter¬
national struggle for existence is not, indeed, to be denied ;
but there are other factors of a biological character which enter
into this question, which to my mind may claim to be of no
less importance than the first named. A nation with a virtually
stationary population may continue to exist in spite of an
absence of increase in its numbers, provided that its stock be
sound ; but no nation can survive a deterioration in its stock.
Nevertheless, that such deterioration must be a concomitant of
a stationary population is, I submit, a biological truth which
will declare itself in time, however much the conditions of an
advanced civilisation may for a time conceal it. The virtual
absence of competition which a stationary population would
imply would tend to prevent the best work being got out of
the individual units of the community; and there would
besides be a great falling off in the number of varieties
produced in that community, so that natural selection would

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1902 .]

BY J. WIGLESWORTH, M.D.

643

have a greatly reduced amount of material upon which to
work than would obtain in a vigorous and rapidly growing
population. It is a matter of common observation that the
human organism does not, as a rule, put forth the best of its
powers except under the pressure of some outside stimulus,
and in a community where the numbers of a new generation
were merely sufficient to fill the niches left vacant by the
members of the preceding one, such a stimulus to exertion
would be largely removed with the absence of material for
competition. A tendency to the deterioration of the individual
units of the community would therefore set in. A languor
would insensibly steal over the nation, which would make itself
felt alike in the routine of individual life as in the control of
the affairs of state, which would place that community at an
obvious disadvantage in the international struggle for existence
everywhere in progress. But the defective amount of material
which natural selection would have to work upon would strike
at the very root of racial vigour. Everywhere and always
throughout the whole length and breadth of the organic world,
natural selection acts by seizing upon and fixing favourable
varieties, and the members of a human community are not
exempt from this universal law. All progress is dependent
thereon. The members of any human family differ consider¬
ably amongst themselves as regards their capacities and
powers ; which is only another way of saying that different
combinations of the elements of the germ plasm of the two
parents have produced variable results. And it is vital to the
welfare of the race that these different combinations of the
germ elements should be presented to natural selection, in
order that those varieties which are most suited to their en¬
vironment should be given a preferential claim in the struggle
for existence, and thus have a better chance of handing down
to descendants the inborn germinal variations to which they
owed their own success. In this connection it is interesting to
note the fact established by Havelock Ellis,( 16 ) that men of
genius tend to belong to unusually large families, and that
they are frequently found amongst the youngest children of a
family. But this subject is somewhat of a digression, and
time will not permit of my elaborating it further. Let me,
then, in conclusion, urge a plea for the more vigorous and
minute prosecution of the study of heredity. The subject
XLVIII. 45

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644

PRESIDENTIAL ADDRESS,

[Oct,

requires approaching from all points of view—by the minute
and exhaustive study of human family histories in health and
in disease ; by experiments in selective and cross-breeding,
both amongst animals and plants ; by research in the
biological laboratory. The advances in our knowledge which
have been made on these lines, more particularly during the
last quarter of a century, are very encouraging, and an
abundant harvest may, it is to be anticipated, in time crown
our efforts. Highly complicated and intricate as the phe¬
nomena of heredity are, they are as much governed by laws
as the falling of a stone to the earth is regulated by the great
principle of gravitation. It is our business to attempt to un¬
ravel those laws, however tangled and intricate the skein may
be. The ultimate result—the improvement of the human
race—is surely an object worthy of the highest and noblest of
human efforts.

Dr. CLOUSTON. —I am assured that I speak amid universal
approval when I say we return our most cordial thanks to the
President for his interesting and most scientific address. There
is not one of us who will not be the better for having heard it,
who will not be induced by it to think about problems, we
have before us in our daily professional work, with higher in¬
terest and fuller knowledge. Heredity is one of the problems
in the air at present; and we are indebted to Dr. Wiglesworth
for having seized updn it, for having used the facts at his dis¬
posal, and at the disposal of each of us, in order to elucidate
and to give greater interest to our daily practical duties, and
to stimulate us to further investigation. We are not here to
criticise the views put forward. In very much that he has
said I personally agree with our President, particularly with
regard to the function of the germ plasm, and to the effect of
alcoholic and syphilitic virus. In regard to the transmission
of hereditary and acquired characters I do not agree with him.
It would be a poor world were the transmission of character to
be so limited.

Dr. M‘Dowall. —I second the proposal with great pleasure.
I have listened with the deepest interest. The address brought
to my mind questions which have troubled me for many years.
As intelligent men, we owe our thanks to the President for
having brought this subject to our notice, so that in our daily

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THE PATHOLOGY OF INSANITY.

1902.]

645

work we may search further into this great secret of nature
which occupies the attention of every man in this room.

The motion was received and passed with applause.

The President. —Dr. Clouston and gentlemen, I thank
you sincerely for the kind way in which you have received my
address, and for the attention with which you have listened to
me. It was difficult to concentrate so wide a field of inquiry
into the limited time necessarily allowed.

( x ) Weismann, A., " Essays upon Heredity and Kindred Biological Problems/’
edited by Poulton, Schonland, and Shipley, 2nd edit., 1891-2. “ The Germ Plasm :
a Theory of Heredity,” * The Contemporary Science Series/ 1893.—(*) Farquhar-
son, W. F., 44 Heredity in relation to Mental Disease,” Journ. Ment. Set., July, 1898.
—( s ) Stewart, H. G., 44 On Hereditary Insanity,” journ. Ment. Sci., April, 1864.
—( 4 ) Thurnam, 4 Statistics of the Retreat ’ (quoted by Stewart).—( 5 ) Baillarger,
44 Recherch. statis. sur I’H^reditd de la Folie,” Annal. Mtd. Psych., 1844.—(•)
Turner, J., “Statistics dealing with Hereditary Insanity, based on upwards of a
Thousand Cases occurring in the Essex County Asylum,” Journ. Ment. Set., July,
1896.—( 7 ) Brigham, quoted by Bucknill and Tuke in ‘ Manual of Psychological
Medicine/—( 8 ) Revington, G. T., 44 The Neuropathic Diathesis, or the Diathesis
of the Degenerate,” Journ. Ment. Sci., Jan. to July, 1888.—( 9 ) Ridge, 4 Alcohol
and Public Health.’—( 10 ) Mott, 44 Notes of Twenty-two Cases of Juvenile General
Paralysis,” ‘Archives of Neurology from the Pathological Laboratory of the
London County Asylum at Claybury.’—( ll ; Smith, Percy, “ Cases of Adult
General Paralysis with Congenital Syphilis,” British Medical Journal, Feb. 16th,
1901.—( 14 ) Gafton, Francis, 4 Natural Inheritance.’—( 13 ) Ewart, Cossar, Presidential
Address before the Zoological Section of the British Association, 1901.—( 14 )
Galton, Francis, “The Possible Improvement of the Human Breed under the
Existing Conditions of Law and Sentiment,” Nature, October 31st, 1901.—( 14 )
Ellis, Havelock, 44 A Study of British Men of Genius,” The Popular Science
Monthly , Feb. to Sept., 1901.

A Statistical Contribution to the Pathology of Insanity .
By T. Duncan Greenlees, M.D.Edin., F.R.S.E., Medical
Superintendent, Grahamstown Asylum, South Africa.

An inquiry into the condition of the various organs of those
dying insane cannot fail to be of interest to those who believe
that mental disease and physical disorders are, in the majority
of cases, closely associated.

Every organ of the body, if its functions are perverted, in¬
fluences the mind to a greater or lesser degree ; in some cases
the mental affection is only temporary and slight, while in other
cases the mind becomes permanently affected, at least so long
as the physical condition giving rise to the mental morbid state
exists.

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646

THE PATHOLOGY OF INSANITY,

[Oct.,

The following observations are an attempt, on a small scale,
to sift the information obtained from 232 post-mortem examina¬
tions held in Grahamstown Asylum during the past eleven and a
half years. A comparison between the organs of the insane
and those of the sane should throw some light on the pathology
of insanity. Whether we are going to arrive at the ultimate
cause of mental disease by this method may be open to doubt,
for latterly scientists have been studying the chemistry
rather than the pathology of the tissues in insanity, and their
results, more suggestive than conclusive so far, are such as to
awaken the keenest interest of all scientific alienists.

As this is purely a pathological contribution, however, I purpose
confining my remarks to the naked-eye appearances of the
various organs of those dying insane, a considerable propor¬
tion of whom were coloured patients, viz., Kaffirs, Hottentots, etc.

TABLE I. —Showing the Causes of Death in 232 Persons

dying Insane .

Males: E., 78 ; C., 96. Females: E., 20; C., 38.

•

Males.

Females.

Total.

Percent¬
age of
total.

Diseases of nervous system

37-8

Exhaustion from mental disease

IO6

Diseases of respirator)' system

15-6

„ circulatory „

8-2

„ digestive „

IV?

„ genito-urinary „

—

Constitutional diseases

l 9

9*8

Senile decay.

5 *i

Totals

8 S

104

I0 9

148

1000

The causes of death in those dying insane .—In Table I the
causes of death are shown in 232 cases, and it is interesting to
note that diseases of the nervous system account for a large
proportion of the deaths. In slightly over 8 per cent, of the
total, diseases of the circulatory system—chiefly organic heart
disease—were the cause of death. The respiratory system
accounted for 154 per cent, of the total, and this after excluding

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN. 647

certain cases of general tuberculosis where the lungs were
secondarily affected. Diseases of the digestive system caused
death in thirty cases—chiefly among natives,—being at the rate
of 117 per cent.; death was due in the majority of these cases
to affections of the intestinal tract, such as dysentery, etc. As
regards the genito-urinary system, it is interesting to note that
in no case was death due to lesions, although uterine and
ovarian disease existed in a number of cases.

Table II. — Showing the Weights, in ounces , of the various
Organs of those dying Insane.

The organs.

Europeans.

Coloured races.

Average
weights in
the sane.

Males.

Females.

Males.

Females.

Males.

Females.

Brain ....

4863

43-58

3953

Right hemisphere

2 i '59

1883

21 02

1884

Left

21 '55

1845

21 03

1871

Cerebellum, pons, etc.

4-18

477

603

5 7 1

Heart

i ri2

809

IO67

722

Right lung .

2260

1364

2244

2233

Left „ . . .

23-81

12-78

20-16

1098

Liver ....

4970

34 7 1

47 ' 18

40*22

Spleen ....

524

306

404

2-87

I Right Jddney

5 ’ 2 i

372

494

379

5 *

4 *

j Left „

546

383

499

383

5 *

■

The various organs will now be considered in their proper
order, beginning with—

The Brain. —As is usual in persons dying insane, we both look
for, and usually find, gross lesions affecting the brain or its
membranes (vide Table III).

Table III. — Showing the Situation of the Lesions affecting
the Brain in those dying Insane.

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648

THE PATHOLOGY OF INSANITY,

[Oct.,

The dura mater was thicker than normal, or adherent to the
skull or meninges of the brain, or inflamed on its visceral surface,
in 122 cases, being 62 5 per cent of the total number examined.
One or other of these conditions occurs very frequently among
the insane, irrespective of other pathological conditions of the
brain and mental state. It is generally supposed, however, that
thickening of the dura is most frequently found in long-standing
cases of insanity, but I have found an abnormally thickened
dura in children, as well as in persons in whom the mental dis¬
order had only existed for a few days before death.

The pia mater ,—Pathological changes in the pia arachnoid
are by no means rare in the insane. In 132 cases I found
thickening, or opacity, or adhesions, more or less extensive, to
the subjacent cortex. In general paralysis, as well as in alco¬
holic insanity, if chronic, and also in cases of secondary dementia,
adhesion of the pia mater to the brain substance was common.
A thickening of the membrane and a milky, cloudy opacity is
frequently found in long-standing cases of chronic mental
disease, as well as in cases of senile decay. According to the
extent of this thickening there is consequent atrophy of the
brain.

Pachymeningitis hceinorrhagica was found in thirteen cases,
in one case traumatic in origin. In the majority of my cases
it presented the appearance of an organised clot. As regards
its frequency in the insane, Wiglesworth found it in 8*47 per
cent., Crichton-Browne in 5 per cent., Bevan Lewis in 5*2 per
cent., and I found it in 5*6 per cent, of all my cases.

The cerebral cortex, —Cortical softening was found in eighty-
three cases, being 47*6 per cent of the total. The frontal lobes
were affected in twelve cases,—in three the right, and four the left,
and in five both lobes were affected. The parietal lobes alone
were softened in twelve cases,—five on the right side and five on
the left, and in two cases the cortex of both parietal lobes was
affected. Six cases showed softening of the occipital lobes,—
one occurring in an epileptic ; in seven cases the temporal lobes
were affected,—in one the right side alone, and in six the left
side. Cortical softening was general, or not specifically defined
as to area affected, in forty-six of my cases. It might be sur¬
mised that, as the frontal lobes are considered the seat of the
mental and intellectual faculties, in the insane lesions of these
regions should be found with greater frequency than in other

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN.

649

portions of the cerebral cortex. My statistics do not bear out
this idea, and cortical softening does not occur more frequently
in the “ intellectual areas ” than in those areas more concerned
in motor and organic functions.

Abnormal hardening of the cortical tissue, amounting almost
to a sclerosis, and occurring in local patches, is a rare condition
as found in the insane; it has been noted in cases of epilepsy
as affecting the occipital lobes, but in the majority of cases it is
evidently the result of old haemorrhage. Among the rarer
forms of brain disease I have noted were the following:—cysts
in five cases, one being an example of hydatid cyst; extensive
haemorrhage, old or recent, was found in four cases ; one case
each of cerebral abscess, atrophy of the olfactory bulb and left
optic nerve; and four cases of cerebral tumour.

Cerebral tumours .—These four cases are of such interest that
a few extracts from the post-mortem register may not be out of
place here.

Case i. —M—, aet. 77, reg. No. 965, an old male
native, suffering from senile dementia, died June 25th, 1893.
Examination of the meninges revealed an extensive “ false
membrane ” (pachymeningitis haemorrhagica). Occupying the
supra-orbital fossa on the left side and growing from the left
frontal lobe was found a tumour about the size of a walnut.
It appeared to grow from the white cerebral matrix, and was
encapsuled so that it could be easily removed, leaving behind
a cavity the walls of which were in part formed by the thinned
cortex. In structure the neoplasm was soft and pulpy, appa¬
rently breaking down, and stained with effused blood. Micro¬
scopically its structure was that of a round-celled sarcoma.

Case 2.—C. R—, aet. 35, a male European, suffering from
epileptic dementia, died on September 10th, 1893. At the
autopsy, on exposing the brain, a tumour the size of a small
orange was found occupying the mesial line, with its greater
bulk, however, more to the left than to the right side, and
connected with the inferior surface of the frontal lobe, the
brain in this situation being firmly adherent to the skull. On
separating the hemispheres two thirds of the tumour were found
to occupy the position of the left inferior frontal convolution,
while the remainder of the neoplasm implicated the corre-

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65 O THE PATHOLOGY OF INSANITY, [Oct.,

sponding gyrus on the right side. Immediately behind and
above the new growth the left frontal lobe was excavated by a
large abscess-like cavity, containing gelatinous material. In
structure the tumour was hard and almost cartilaginous on
section, and it presented no definite limiting membrane.

Case 3.—B. F—, aet. 73, reg. No. 1271, a male
European, suffering from senile dementia, died on July 3rd,
1895. No tumour was noticeable until the brain was
removed, but on cutting through the crura a tumour about
the size of a Kei-apple (/. e. y a little larger than a cherry) was
discovered, occupying a position posterior to the crura and
implicating both hemispheres. On separating the hemispheres
the tumour, which was rounded posteriorly, was found to pass
forwards, in the middle line, to a point implicating the inferior
and posterior portions of the corpus callosum and the posterior
two thirds of the septum lucidum. Anteriorly the tumour was
pyriform in shape, extending one inch into the white matter,
and posteriorly it embraced both occipital lobes. To the
naked eye its structure appeared to be angiogliomatous, and
microscopically numerous large multinucleated cells, as well
as blood-corpuscles and cholesterin crystals, were found.

Case 4.—F. I. M—, aet. 47, reg. No. 1848, a male
European, suffering from mania merging into dementia, died
on September 5 th, 1900. When the cerebral hemispheres
were separated a small tumour, about the size of a split pea,
was observed in the middle of the optic thalamus. A closer
inspection disclosed the fact that it was pyriform in shape, on
section dark in colour, and penetrated about two lines into the
cerebral tissue. The optic nerves on both sides were softened
and in a shrivelled condition. This man had been blind for
years, and it is possible the blindness was originally due to the
new growth, the softening of the optic tract being secondary
in point of time.

The weight of the brain (Tables II and IV).—A study of
the condition of the brain as found in the insane would not be
complete without some reference to its weight, as observed in
different races, different sexes, and different forms of mental
disease.

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN.

651

TABLE IV.— Showing the Average Weight , in ounces , of the
Brain in the various forms of Insanity .

Form of insanity.

Total
No. exa¬
mined.

Males.

Females.

Average

totals.

Mania

50*30

46-52

44-62

39*95

45*35

Melancholia

52*50

5175

44*00

4200

4756

Epileptic insanity . !

50*50

48*60

4573

30*62

4603

General paralysis

48-20

4420

4 i *33

37*oo

42-68

Dementia . . . ;

46-95

45-58

4262

39-50

43-66

Imbecility and idiocy .

4333

4500

—

3812

42-15

Totals and averages .

204

48-63

4695

. 43-58

39*53

44-67

A reference to Table II will show that the brain, taken as a
whole, is heavier among European insane than among native
insane by an average of about 2 oz. Further, the brain of the
European female exceeds that of the native female by over
4 oz. These facts are of interest, although increase in mere
weight of an organ does not necessarily imply increased
functional activity ; or, to put it conversely, elaboration of the
cerebral organisation apparently does not influence the gross
weight to any appreciable extent. While we can show
philosophers with brains of enormous weight, on the other
hand cases are not infrequently found in idiot institutions of
brains just as heavy.

Again, it is interesting to note the influence, if any, race has
on the weight of the brain among white patients, and to ascer¬
tain this the weights of the brains of fourteen British subjects,
born in England, were taken, and also the weights of the
brains of a similar number of Dutch patients. These cases
were taken in sequence, and without any picking or choosing,
and I found the average weight of the “ British ” brain to be
42*32 oz., while that of the “ Dutch” brain was 43*21 oz.! I
would again emphasise the fact that it is not quantity but
quality of brain tissue that influences the intellectual capacity
of any individual person or race. I further noted, in ten
consecutive cases of each, that the brain of the British-born
subject exceeded that of the colonial-born by no less than
4 oz. on an average.

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THE PATHOLOGY OF INSANITY,

[Oct.,

652

The left hemisphere is generally considered to be the most
active half of the brain, at all events in right-handed persons,
and it might be reasonable to assume that this half exceeded
the right in weight; but I found in a large series of observa¬
tions that the hemispheres were almost exactly equal in weight,
the right, as a matter of fact, exceeding by a trifle the left
hemisphere. These observations confirm those of Dr. Clapham,
who examined the brains of 449 persons dying insane.

The heaviest brain in my series weighed 58 oz., and the
lightest, occurring in an adult male native, only weighed 36 oz.
Among the male natives the weights ranged from 36 oz. to
56 oz., the average being 46*96 oz.; and among the female
natives the weights varied from 36 oz. to 4 y\ oz., the average
being 39*53 oz.

Generally speaking, my observations agree with those of
Dr. Thurnam, who showed that the average weight of the
“ insane ” brain was less than that of the “ sane ” brain ; and
yet it is important to note that in my series I have three
brains whose average weight was 58 oz., an average higher
than that of the brains of ten distinguished men, among whom
were Abercrombie (63 oz.), Cuvier (64£ oz.), and Spurzheim
(55-06 oz.).

As regards the weight of the brain in the various forms of
insanity, attention is directed to Table IV, where several inter¬
esting facts are disclosed. We note that the brain is very
light in general paralysis, a disease which generally attacks
men in the prime of life, at a time when the intellectual
faculties might be supposed to be keenest. Further, the brain
is heaviest in cases of melancholia, and here again an interest¬
ing explanation may be offered. While mania is considered a
disease of undeveloped brain, melancholia may be regarded as
one of developed brain ; the intellectual strata that are highest
are the latest developed, and are therefore most ready to break
down, as occurs in cases of melancholia ; whereas in cases of
mania the higher mental layers are not yet formed, and here
the mental break-down takes place in, intellectually speaking,
an undeveloped mental organisation.

These theories help to explain why mania should be so much
more common among savage tribes than melancholia. In South
Africa, while simple mania is extremely common, melancholia is
very rare, and is usually found only in “ educated ” natives.

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN.

653

In the epileptic insanities the mean weight of the brain is
high. The presence of epilepsy, when acquired, very fre¬
quently indicates high mental powers. We have but to refer
to the many distinguished men in history who were epileptics
to prove this point ; and it would seem that while epilepsy, if
long continued, materially damages the minute structure of the
brain, it does not appreciably affect its gross weight.

The Circulatory System .—In a previous number of this
JOURNAL and in an unpublished thesis I have treated fully of
diseases of the heart and blood-vessels in insanity, and it will
suffice if a brief rtsumt of my work is given here.

As a cause of death among the insane, heart disease occupies
a most important position, being third in point of frequency,
cerebral and pulmonary diseases being first and second
respectively. In English asylums, out of 101,296 deaths, ex¬
tending over a period of five years, diseases of the circulatory
system accounted for 12*41 per cent, of the total, while in
Grahamstown Asylum, during the past ten years, heart disease
was the cause of death in 10 per cent.

Forms of heart disease .—1. Hypertrophy , most frequently of
the left ventricle, was found oftener among Europeans than
natives ; it was common in cases of mania, rare in melan¬
cholia ; common in general paralysis, seldom noted in
epileptic insanity; frequently found in dementia, but rare in
cases of congenital mental defect.

2. Atrophy of the heart is a rare condition among the in¬
sane, being found in only 5*3 per cent, of the total autopsies.
It was most frequently found associated with fatty degenera¬
tion, and in cases of wasting disease, such as phthisis pul-
monalis. The smallest heart in my series belonged to a
Hottentot woman, suffering from secondary dementia, and
weighed only 4 oz., but this was undoubtedly a congenitally
small heart, and can hardly be considered as a true example of
atrophy of the heart. Further, Hottentots are a small race,
and all their organs are smaller than exist among Europeans
or Kaffirs.

3. Fatty degeneration of the heart .—The myocardium is
here pale or flabby, or even greasy to the touch ; this con¬
dition was found in 26 per cent, of my cases, and was likewise
found most frequently associated with exhausting diseases.

4. Pericarditis was found in 13*7 per cent., and was

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6 54 the pathology of insanity, [Oct,

generally found co-existing with considerable hypertrophy of
the heart itself.

5. Valvular disease was found in 25 per cent, of my cases ;
the aortic valve is the most frequently affected, and when the
mitral valve is diseased, as a rule the aortic cusps are likewise
affected, and consequently left-sided hypertrophy was common
in these conditions.

6. Arterial disease .—Thickening of the walls or calcareous
deposits, as found ( a ) in the main arteries of the body, and
(< b ) in the cerebral arteries, were conditions frequently noted.
Hypertrophy of the arterial muscular coat, and atheromatous
deposit in the vessel, are conditions common to old age, even
in the sane ; but it is interesting to note that in general para¬
lysis, and this in cases dying at a comparatively early age, one
or other of these conditions was commonly found affecting not
only the general arterial system, but also the cerebral arteries.
This condition of the arteries in general paralysis no doubt led
the older authorities to the belief that this disease was essen¬
tially in its nature a premature old age, and it has an im¬
portant bearing on the sequelae of the disease.

While arterial disease was found in 20 per cent, of cases of
mania, it occurred in 60 per cent, of my cases of general
paralysis ; in the former disease it was only found in cases of
long-standing disease, whereas the average duration of the
latter disease is only about three years.

7. The weight of the heart. —The average weight of the
heart of those dying insane exceeds slightly that of those
dying sane. The average weight of the native insane is less
than that of the European sane, although the heaviest hearts
in my series were found in two natives, viz., 38 oz. and
18 oz. Hearts weighing 26 oz. and 22^- oz. were noted in
two male Europeans.

The Respiratory System. —Diseases of the respiratory system,
as might be expected, are very common among the insane. A
general lowering of the vital processes, from inhibited nerve
function, especially in cases of dementia, tends to induce acute
pulmonary complaints, and the same condition reduces the
power of resistance to disease, so that death results in the
insane more readily than it does in the sane, suffering from
apparently the same condition.

In addition to this factor in the causation of pulmonary

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN. 655

disease, over-crowding and defective ventilation, such as are
found too frequently in our asylums, explain the frequency of
phthisis pulmonalis in the insane, a fact which Dr. Clouston
pointed out many years ago. In point of frequency phthisis
pulmonalis alone accounts for more deaths in our asylums
than any other one disease, except those of the nervous
system ; and in England, of 8133 deaths in asylums, 1169, or
14*4 per cent., were due to this disease.

We will here briefly refer to the three chief diseases affect¬
ing the respiratory system, viz., phthisis pulmonalis, pneumonia,
and pleurisy.

1. Phthisis pulmonalis .—The lungs presented tubercular
deposits apart from the condition named “ pneumonic
phthisis,” which will be referred to later, in fifty cases of my
series. The right lung alone was affected in nine cases, the
left in six, and both organs in thirty-five cases. Thirty-nine
were natives, and only eleven were Europeans. Of the
natives, twenty-four were men and fifteen women ; of the
Europeans, nine were men and two females. The percentage
of cases of male Europeans with tubercular deposits in their
lungs was 18, and among male natives it was 36 per cent.

That phthisis pulmonalis should be a frequent and fatal
disease among the native insane of this country is not to be
wondered at; coming, as these patients generally do, from
districts up country, where they have been accustomed to
an open-air existence and the simplest of diets, to an institu¬
tion where they are called upon to wear clothes like any
European, where they have to live and sleep in over-crowded
day-rooms and dormitories, and where they have to partake of
food more suited for highly organised beings, is it surprising that
their vital powers become depressed, and that they are unable
to offer any resistance to the tubercle bacillus ? On the other
hand, it is interesting to note the rarity of tubercular disease
among the European inmates of our local asylum, where it is
only 11 *2 per cent., as against 14*4 per cent, in English
asylums.

2. Pneumonia was found in thirty-seven cases ; the right
lung was affected in twelve, the left lung in nine, and both
lungs were diseased in fifteen cases. Pneumonia existed in 27
per cent, of the cases examined, and in English asylums it was
the cause of death in 7*1 per cent. In Grahamstown Asylum

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THE PATHOLOGY OF INSANITY,

[Oct.,

pneumonia occurs most frequently among the natives, and is
more common among men than among women. The tendency
of pneumonia, as it occurs among the natives, is to break down
into vomicae, and in the majority of the cases examined the
lungs presented all the stages through which pneumonia is
known to pass ; thus congestion, red hepatisation, grey hepati-
sation, and broken-down lung tissue were all frequently found
in the one organ, the condition being in the majority of cases
most advanced at the bases.

3. Pleurisy. — {a) Adhesions of the lungs to the chest walls
occurred in eighty-eight cases—64*2 per cent, of the cases
examined. Adhesions were found on the right side in thirty-
four cases, on the left side in twenty-two, and on both sides in
thirty-two cases. These adhesions in sixty-four of the cases
examined were apparently of old date, consisting of tough fibrous
bands ; and in twenty-four cases were evidently of recent for¬
mation, consisting of lymph deposit gluing the visceral and
parietal layers of the pleura together. Pleuritic adhesions were
found in twenty-eight Europeans and sixty natives, and old
adhesions were relatively more frequent among the latter than
among the former.

{b) Pleurisy with effusion , either purulent or serous, was
present in only sixteen cases ; in four the right side was
affected ; in one the left; and in eleven fluid was found in
both pleural cavities. Here, again, the condition would appear
to be more frequent among the natives than among the
Europeans, being present in twelve of the former and only
four of the latter.

While as a cause of death pleurisy may be comparatively
rare, it is important to note the frequency with which it is
found in the deadhouse, and this points to the fact that very
few insane die without having had at one time or other of their
lives suffered from this disease. Combined with pneumonia, it
is relatively frequent as a pathological condition ; but alone, with
the lungs in a healthy state, it is decidedly rare. Pleurisy
caused death in thirty-five cases out of 8133 in English
asylums—o\43 per cent.

In only one case—a female European—were the lungs
found infiltrated with cancerous deposit, and this was secondary
to scirrhus of the mammae.

With the exception of pulmonary phthisis as found in the

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN. 657

insane, I am unable to trace any statistical information relative
to the frequency with which other lung diseases—either
pleurisy or pneumonia—exist among the insane.

According to the Reports of the English Commissioners in
Lunacy it would appear that, as a cause of death , pneumonia
accounts for one out of every fourteen cases, pleurisy one out
of every 233, and phthisis one of every seven deaths. In
Grahamstown Asylum I found pneumonia to exist in one out
of every six autopsies, pleurisy in one of every three, pleuritic
effusion in one of every thirteen, and pulmonary phthisis in
one of every four cases.

Weight of the lungs in the insane .— (a) Right lung .—Among
male Europeans I found the average weight of the right lung
to be 2 2*60 oz., which is lighter than the same organ in the
sane. In ten cases this lung weighed 30 oz. and upwards, in
three it exceeded 40 oz., and in one case it weighed 56 oz.
Among female Europeans the right lung averaged 13*64 oz.,
being less likewise than the “ female sane right lung.”

Of sixty-five male natives the average weight was 22*44 oz *»
in seventeen it exceeded 30 oz., in five it exceeded 40 oz., and in
one case this lung weighed 5 1 $ oz. The average weight of
the right lung among female natives was 22*33 oz.; the
heaviest of this series weighed 53 oz., while ten exceeded
20 oz. in weight.

( b ) Left lung .—The average weight of the left lung among
male Europeans was 23*81 oz.; the heaviest in the series
weighed 72 oz., thirty weighed 20 oz. or upwards, twelve
exceeded 30 oz., and three exceeded 40 oz. The lightest male
European left lung weighed only 8$ oz. Among female
Europeans this lung averaged 1278 oz., or, excluding the case
of a girl whose lung only weighed 3 oz., then the average of
the remainder would be 14*41 oz. The heaviest lung in this
series was 26 oz. The average weight of the left lung among
male natives was 20*16 oz., and the heaviest weighed 46 oz.;
three exceeded 40 oz., eleven exceeded 30 oz., and the lightest
of the series was only 6 oz. in weight. Among female natives
this lung weighed, on an average, 10*98 oz. ; only one exceeded
30 oz.; and the lightest, occurring in an adult female,
weighed 5 oz.

Comparing these figures with the average weight of the lungs
of persons dying sane in England, it is noted that the

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6 58

THE PATHOLOGY OF INSANITY,

[Oct,

“ colonial ” lungs weigh less. If pulmonary disease, with its-
consequent consolidation, tends to increase the weight of the
lungs, then we may boast of a comparative immunity from lung
disease in this country.

Diseases of the liver in the insane .—From time immemorial
functional derangements of the liver have been considered as
closely associated with mental disorders,—the circulation of
“ black bile ” in the blood being, among the ancients, the sup¬
posed cause of melancholia. In spite of this apparently most
ancient theory as to the cause of insanity, it would seem as if
little real scientific attention has hitherto been paid to the con¬
dition of the liver in the insane.

It is curious to note the difference of opinion expressed by"
various authors regarding the relationship that is supposed to
exist between somatic disease and insanity. On the one hand,,
some take the extreme view that observation has failed in
eliciting any connection between the two, or that the former
can, ipso facto , produce the latter ; while others maintain that so
intimate is the relationship that exists between the body and
the mind that all and every disease of the body may cause
insanity, and that, as a matter of fact, many of them do.

Given a rfcurotic diathesis, I affirm that disease of any organ
of the body may induce mental disease that may be of so marked
a type as to constitute “ certifiable ” insanity. Who, for
example, is going to draw the line of distinction between
the depression associated with biliousness and the melancholia
which is certifiable ? The conditions are identical, and differ
only in degree. In both the origin is the same, and the
results depend very much on whether the patient is one of
a neurotic tendency or not; for in all these cases, before we
can have psychic manifestations, there must be some pre¬
disposing tendency pre-existing,—in this case an unstable
nervous or mental system.

While vague statements have been published from time to-
time referring to the influence of liver disease in inducing"
insanity, I have been unable to discover any published record
bearing upon the actual condition of this organ in mental
disease. This is strange, for one would naturally expect that
some attention should have been given to an organ upon whose
healthy functions so much of our happiness and peace of mind
depends.

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN. 659

Regis casually refers to the relationship existing between
liver disease and insanity, but declines to be as emphatic as
Hammond, who maintained that all cases of melancholia were
due to hepatic disease !

During the past eleven years the livers of 199 cases dying
in Grahamstown Asylum were examined, and in only 35 cases
was this organ noted as “healthy” (vide Table V).

TABLE V .—Showing the Diseases of the Liver found in those

dying Insane .

Disease.

Males.

Females.

Total.

Percentage of
cases

examined.

Simple congestion of liver

.13

3838

3170

Cirrhosis—general or local, fine or

697

I *62

coarse

Fatty degeneration of liver

1046

406

Perihepatitis.

Il6

650

Among the morbid conditions more frequently observed
were the following :

1. Congestion or engorgement of the liver was noted in 72
cases, being 36*2 per cent, of the total.

2. Cirrhosis , fine or coarse, was present in only 8 cases,
4 per cent. In only one—a male European—did I find
“ hobnail ” liver.

3. Fatty degeneration existed in 24 cases, 12 per cent., and
the liver was described as “ large, yellow, and fatty ” in three
natives.

4. Perihepatitis was found in 9 cases, 8 of whom were
natives, and the—

5. Gall-bladder was full or distended in 46 cases ; males,
E. 16, N. 17 ; females, E. 6, N. 7.

Among the rarer pathological conditions found were 4 cases
of biliary calculi; 11 cases with caseous or tubercular deposits ;
a calcareous nodule in the substance of the liver in a male
native; a total absence of lobulation in another. A large
abscess was found in a male, and hydatid cysts existed in the
liver of a female, in both cases natives.

xlviii. 46

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66 o

THE PATHOLOGY OF INSANITY,

[Oct.,

The weight of the liver (Table II) in health is said to be
about 48 oz. (for men 53 oz., and for women 44 oz.). These
averages are considerably above those I show in my
series, and may indicate that the “ sane ” liver is a heavier
organ than the “ insane, 1 ” in spite of the theory that the latter
may probably have been the most active functionally so as to
produce the mental disease. One would certainly have
expected higher average weights than are here shown, espe¬
cially among male Europeans, in a hot country where social
habits tend to throw extra labour on this organ. The heaviest
liver in my series weighed 69 oz., and belonged to a male
European ; in 9 cases it exceeded 60 oz.; in 17 it ranged
from 50 oz. to 60 oz., and the smallest liver weighed only
2 2 oz.

A liver which weighed 73 oz. was found in a male native,
and one weighing 5 8 oz. in a female native. The lightest liver
found among natives weighed only 1 5 oz., and this occurred
in an adult female.

Table VI.— Showing the Diseases of the Spleen found in those

dying Insane .

Disease.

Males.

Females.

Total.

Percentage on
cases
examined.

E j C.

F..

Capsule diseased—thickened, etc. .
Simple congestion of spleen .
Spleen markedly friable .

Spleen abnormally pale in colour .
Tubercular disease of spleen .
Supernumerary organ

5‘12

12*83

20*51

11*53

2*56

2*67

>7-85

>875

9*82

7*84

3*57

Diseases of the Spleen in the Insane (Table VI).—The spleen
is an organ one would naturally expect to see diseased in
patients dying in an asylum in this country, especially among
Europeans. My records, however, show that the spleen is
rarely affected in the insane; and, for the most part, the
morbid conditions noted were of a trivial and unimportant
character. In 61 per cent, of all the cases examined the
spleen was described as perfectly healthy ; in six cases of

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN. 661

these, however, a supernumerary spleen existed. Of the
“ diseased ” cases, thirty were noted as being simply congested,
twenty were pale and anaemic-looking; in seventy-one the
organ is noted as being very friable, and in seventeen cases the
capsule was thickened or even cartilaginous in consistence.
Tubercular disease existed in eight cases—all natives,—and
was found only where tubercle existed in other organs as well.

As regards the weight of the spleen (Table II), text-books
inform us a broad margin is allowed within the limits of
health,—that, in fact, anything between 3 oz. and 10 oz. need
not be considered as abnormal, while 6 oz. for men and 5£ oz.
for women may be regarded as representing the average
weights of this organ in health.

If this statement can be taken as correct, then, according to
my observations, the spleen of the insane weighs less than it
does in the sane.

The largest spleen in my series occurred in a male Euro¬
pean, and it weighed 11 oz.; and the smallest was found in a
male native, weighing only i oz., being just the size of a florin.

TABLE VII.— Showing the Diseases of the Kidneys found in
those dying Insane.

Disease.

Males.

Females.

Total.

Percentage on
No. of cases
examined.

Capsules adherent to renal cortex .

2436

2i'S7

Congestion of kidneys .

2692

2058

Cirrhosis of kidneys—fine or coarse

1282

784

Fatty degeneration—large, pale or

, 7‘97

I960

yellow

Tubercular disease of kidneys

S '13

3'92

Cystic degeneration—chiefly cortical

—

769

2’92

Lobulation of kidneys .

3' 8 4

O98

Diseases of the Kidneys in the Insane (Table VII).—Disease
of the kidneys is very frequently accompanied by psychic
phenomena, so that the insanity of Bright’s disease forms one
of the subdivisions in all classifications of mental disease.
The circulation of effete products normally excreted by the
kidneys acts as a direct poison on the protoplasm of the

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662

THE PATHOLOGY OF INSANITY,

[Oct.,

cerebral cells, perverting their functions, and producing the
delirium of renal disease. Further, if we recognise Bright’s
disease as of the nature of a general arterio-sclerosis, then
such an affection, occurring within the cerebral arteries, must
necessarily interfere with the supply of blood to the tissues,
and produce actual starvation of the cerebral cells, perverting
their functions to a marked extent.

Any slight disease of the kidneys, such as is frequently
found in the insane, must, to a greater or lesser extent, impede
the excretory powers of the kidneys, so that the cerebral
functions are consequently affected by retained excretions
To what extent interference with the function of any excretory
organ acts as a direct contributory cause to the mental disease
we cannot yet say. The arrest of the cutaneous secretions in
many cases of melancholia, and the marked concentration of the
urine in cases of mania, clearly point to the powerful influence
non-elimination has on the mental functions, and the perfect
performance of their functions by the kidneys is as essential to
mental as it is to physical health.

In my observations I note that the kidneys were found
diseased in 59*3 per cent, of all the cases examined. They
were most frequently affected among male Europeans, and
least so among female natives. Thus—

Male Europeans, kidneys diseased 42 of 64 cases * 65 62 per cent.

Male natives, ,, 52 of 81 ,, = 6419 ,,

Female Europeans, „ 5 of 13 ,, — 38 46 „

Female natives, „ 9 of 24 „ = 37*50 „

As a rule, when disease attacks the kidneys, both organs
become affected, although generally one organ is in a more
advanced condition than the other. In only one case did I
find one kidney healthy while the other was diseased.

In a female native the supra-renal capsule was noted as
abnormally large, but no constitutional disturbance existed in
the case.

Kidney disease is more common among men than among
women in the insane, and I have no reason to doubt, were
statistics available, that the same rule would hold good among
the sane.

The capsule was found adherent to the renal cortex in
twenty-one cases; congestion was noted in forty-two cases.
The organs were described as large , pale y yellow , or fatty in

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN.

663

seven male Europeans, sixteen male natives, one female Euro¬
pean, and four female natives. Cirrhosis, fine or coarse, existed
in both organs of eight male Europeans, six male natives,
two female Europeans, and two female natives. Cysts, usually
cortical in situation, were found in the kidneys of five male
Europeans, one male native, and one female European. Tuber-
cular disease occurred in four male Europeans and four male
natives, but was absent from the kidneys of the females.
Lobulation of one or both organs was found in three male
Europeans, one of whom was an idiot, one female European,
one male native, and two coloured females.

In only one case, that of a male European, a solitary organ
—the right kidney—existed, and a floating kidney—the right
also—was found in a female native.

As regards the weight (Table II) of the kidneys in the
insane, it is noted that the weight of the “ insane ” male
kidney closely approximates that of the male “ sane ” organ,
while the average weight of the female “ insane ” kidney is
exactly 1 oz. less than that of her sane sister.

Further, my observations bear out those of previous writers
that the left kidney is heavier than the right, and this holds
good in both sexes, and among natives as well as among
Europeans.

Right kidney .—Among male Europeans the heaviest organ
weighed 8 oz., while the smallest only weighed 3 oz.

Left kidney .—The largest weighed 9$ oz. and the smallest
only li oz., these representing the two extremes in my series.

Natives are not distinguished for large kidneys ; in none
did the weight exceed 8 oz., and among women, both native
and European, the average weight was approximately the
same.

Diseases of the Gastro-intestinal Tract in Insanity .—Diseases
affecting the digestive tract exercise a marked influence upon
the mental system, many delusions being referable to
diseased or disordered conditions of these organs. For
example, the gnawing caused by a gastric cancer is often
referred to by the patient as rats eating away the stomach,—
an example of a delusion having a direct material origin.

In Grahamstown Asylum lesions of the stomach and
intestines were of frequent occurrence, and were in many cases
the cause of death.

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664

THE PATHOLOGY OF INSANITY,

[Oct.,

Among the male Europeans we note that in nine cases the
intestinal tract was affected ; of these in five the large bowel
was inflamed, and in two it was ulcerated as well. In one of
these cases this inflammation was due to the presence of tape¬
worm. The pylorus was thickened and its lumen diminished
in one, while pyloric cancer was found in another case.

Of the female Europeans only two presented inflammation
of the mucous membrane of the bowel. In one of these
cancerous nodules also existed, and in the other evidences of
old peritonitis were found.

Among male natives nineteen cases presented lesions of the
stomach or intestines; of these thirteen had inflammation or
ulceration of the bowel ; seven were cases of peritonitis—
mostly tubercular in character,—and one was a case of secondary
peritonitis and dropsy in a cardiac case.

Nine female natives had colitis or enteritis,—in one due to
the presence of Ascaris lumbricoides , with which the entire bowel
was packed. In one case cicatrices of old rectal ulcers were
found, and in five peritonitis existed, being tubercular in origin
in three.

The prevalence of dysentery and tuberculosis in the natives
of this country is well known, and fully borne out by the
statistics of Grahamstown Asylum.

Diseases of the Genito-urinary System in the Insane. —In
only three females—all natives—were lesions of the internal
genital organs discovered. Congestion of the left ovary, cystic
degeneration of both ovaries, and atrophy were the conditions
noted.

In this connection it may be of interest to refer to the
case of hermaphroditism occurring in a native, admitted under
my care as a male, and who was exhibited to the Medical
Congress several years ago. Death took place from tuber¬
culosis, and a careful examination of the genital organs was
made.

She was admitted as a male, and insisted on being treated
as such, but there was little doubt as to the prominence of
female organs of generation over those of the male sex. She
was married to a woman, who, however, refused to live with
her for obvious reasons, and while in the asylum she refused
to live in the female wards. She menstruated regularly, and on
these occasions it was considered advisable to keep her in a

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1902.] BY T. DUNCAN GREENLEES, M.D.EDIN.

665

room by herself. She knew there was something the matter
with her genital organs, and exposed herself readily enough for
examination,—not from immodesty so much as from a real
desire that operative interference might be attempted to “ make
her a better man.”

The following is a description of the post-mortem appearances :

“ Body of an adult native ; no hair on face ; the configura¬
tion of body that of a female, the mammae being large and
glandular structure evident; nipples large and prominent.
Pelvis capacious and female in character ; external dimensions :

“Diameter between external spines . 8J inches.

„ „ iliac crests . . io£ „

„ „ great trochanters . 12^ „

“ External genitals .—The penis was rudimentary, about two
inches long, and was bound down inferiorly to the body of the
vulva by a fraenum. It was not perforated by a urethra ; the
glans and prepuce were normal, although very small in size.
The urethral orifice occupied the usual female position. No
external orifice corresponding to the vagina existed, but there
was some sanious fluid coming from the urethral orifice.

“ Internal genitals .—In the right pelvis there was an organ of
ovarian structure, with the usual appendages and Wolffian
remains. On dissection it was noted that the channel which
communicated with the uterus and bladder was single for about
half an inch from the urethral orifice, then it divided into two
passages communicating respectively with the uterus and
bladder. The uterine opening to the Fallopian tube existed on
the right, but no corresponding opening was discovered on the
left side. The uterus was of fair size and virgin-like; the cervix
was soft and pulpy to the sense of touch, and contained
grumous fluid ; and the uterine mucous membrane was slightly
inflamed, presenting indications that the menstrual function was
active at the time of death.”

I am informed that hermaphroditism is by no means un¬
known among the natives of this country, but this is the first
case that has come under my notice.

In no case did I find lesions affecting the male genital
organs.

Lesions of the Bladder in the Insane .— Diseases of the bladder
or the presence of calculi are so rare among the insane as only
to require a passing reference. In some cases of general

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666

THE PATHOLOGY OF INSANITY.

[Oct.,

paralysis paresis of even non-striated muscular fibre takes
place, so that the bladder fails to act and catheterisation is
required ; after death the bladder is often found in these cases
distended, its walls having apparently lost their contractile
powers.

Cystitis occurred in a few females, and the walls of the
bladder were found much thickened in several cases, but in
none were the conditions such as to be the direct cause of
death, and in no case were other lesions or diseases noted.

Remarks .—The figures upon which these observations are
based are hardly such as to justify dogmatic statements as to
the prevalence of physical diseases in insanity ; they do, how¬
ever, indicate, even in a small way, the direction in which such
investigations should be carried out, and the character of the
results were similar inquiries made, but on a larger scale.

With the figures at the disposal of the Collective Investiga¬
tions Committee of the Association, referring to all the asylums
with which they will have to deal, some definite statements
should accumulate to throw more light on this, as yet, the
most obscure of all diseases.

Whether the insanities are the outcome of altered meta¬
bolism in one or other of the organs of the body, or whether
they originate in delicate changes in the constitution of the
protoplasm of the cerebral cells, due perhaps to toxic in¬
fluences, science has not yet enlightened us. The tendency of
modern thought is that there is a physical basis to all types of
mental alienation.

It may be taken as an axiom that although an insane mind
may exist in a sound body, much more frequently do we find
the unsound mind in the unsound body, and, recognising this
fact, we are guided in our treatment of our insane patients,
searching for, in every case, a physical cause for the mental
symptoms, and devoting our knowledge towards the alleviation
of the bodily ailment in the reasonable expectation of con¬
sequent improvement in the mental symptoms.

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1902.] REPAIR AND DECAY OF THE NERVOUS SYSTEM. 667

Importance of Stimulus in Repair and Decay of the
Nervous System . By F. W. Mott, F.R.S., M.D.

The title of my paper is almost a platitude, for we all know
from experience that stimulus is essential for the generation
and regeneration of nerve structures and function ; and that
the importance of stress (excess of stimulus) incidental to
modem civilisation and town life in the production of nervous
diseases and insanity is beyond dispute ; yet when we are
asked to give precise data to prove these premises, the matter
is not so easy.

The nature of stimulus .—Nerve stimulus is a molecular
vibration travelling at a definite rate (30—33 metres a second)
along a nerve ; the amount of energy liberated by the stimulus
is not necessarily proportional to the exciting stimulus ; in
fact, it is usually disproportional. The passage of a stimulus
along a nerve does not cause fatigue ; if a neuron ceases to
function from excessive stimulation, it is due to the effects of
fatigue products upon its terminal arborisations at the peri¬
phery or in the central grey matter. The whole nervous
system may be considered to be composed of physiologically
correlated nervous units, each of which has a nutritional in¬
dependence, a vita propria. The vulnerable parts of the
neuron are the terminal expansions of the essential fibrillary
conductile substance which is continuous through the body of
the cell on the one side with the axon and its terminal arbori¬
sation or end organ ; on the other with the branching pro¬
cesses of the dendrons in the central grey matter. Delay to
the passage of stimulus takes place at the neuronic threshold,
that is at the point of junction of the terminal arborisation of
the fibrils of one neuron with the next in the series ; it is here
in the delicate gossamer of the grey matter that ingoing
stimulus is reflected to outgoing channels ; it is here that it
may spread and cause the liberation of stored energy, or redis¬
tribution of active energy ; it is here that the blood-supply is
most abundant and oxygen is continually used up, and carbon
dioxide and heat produced.

Currents which represent nervous energy are continually
flowing in all directions in the central nervous system. They

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668 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

flow with the greatest readiness along systems of neurons
which have by habit and use been most functionally corre¬
lated ; and then less potential is used and less fatigue ex¬
perienced than when new paths have to be opened up by
attention.

A stimulus has been defined by Sir William Gowers (“ Dy¬
namics of Life”) as a process which causes another process
greater in degree, e. g. tickling the sole of the foot with a
feather ; but, as he points out, unless there is conscious atten¬
tion you do not get the successive series of violent muscular
discharges. But what is this attention ? a concentration of
consciousness upon the stimulus from without ; the seat of
consciousness is in the cerebral cortex, the arrival and de¬
parture platforms of all afferent and efferent stimuli. The
muscular discharge is partly spinal reflex, but also cortical
reflex. Bubnoff and Heidenhain showed experimentally that
stimulation of the skin by stroking increased the excitability of
the cortex to faradic excitation, and probably each successive
excitation of the skin, in addition to the stimulus provided by
excitation of the peripheral afferent nerve-endings, increases
the excitability and diminishes the resistance to the passage of
stimulus in the spinal and cortical circles of neurons (vide
figure, p. 671). But we believe that inhibitory impulses are
continually flowing from the cerebral cortex to the spinal centres,
which inhibitory impulses antagonise both cortical and spinal
reflex discharges. Experiments of Sherrington and Hering
support the view that these impulses are conducted by the
pyramidal systems. We could then explain the successive
series of violent muscular discharges in tickling by arrest of
this inhibitory controlling function of the cortex. Now, if we
suppose that there is normally a correlative localised and
specialised antagonism between augmentor and inhibitory
impulses flowing from the cerebral cortex, when once the
balance between the two is turned and effectual control lost,
the outgoing flow of nervous energy is along the lines of least
resistance, and becomes semi-automatic, and incapable of
control by attention, although consciousness obtains. Does
attention, then, mean concentration of potential and liberation
of nervous energy ? If so, in this case the distribution would
be along particular efferent systems of neurons ; and can we
thus explain the phenomenon of conscious attention being

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1902.]

BY F. W. MOTT, M.D.

669

necessary in order that tickling may produce the successive
series of violent muscular discharges, and thus support Sir
William Gowers' proposition that the stimulus in this case
causes another process enormously greater in degree? Or
should we adopt the view that stimulus in semi-automatic and
subconscious movements may flow in and flow out without
using up comparatively any potential ? In fact, there may be
even a storage of energy by a bio-chemical transforming pro¬
cess, especially in those structures which have been latest
developed, and which form the great bulk of the central
nervous system, viz. the association neurons. Resistance to
the passage of impulses occurs where delay is greatest, viz. at
the junctions of the dendrons of one neuron with the terminal
arborisations of the axon of another ; but, as Von Monakow
points out, no sensory neurons are in direct relation with motor
neurons, and the delay therefore occurs especially where inter¬
calary association neurons (which even in the grey matter of the
spinal cord are much more numerous than the motor neurons)
intervene. The great bulk of the brain is made up of associa¬
tion neurons, and their numbers in the cerebral cortex are
infinite. Yet we must suppose that every conscious sensation,
however simple, affects the whole cerebral cortex, leaving
traces of its passage in the form of molecular changes, which
facilitate more and more up to a certain point the passage of
the same excitation the oftener it is repeated. These mole¬
cular changes may be bio-chemical or bio-physical in the sub¬
stance of the neurons or their synapses. I should incline to
the opinion of Sir William Gowers that the changes occur at
the synapses, which are the innumerable anatomical or physio¬
logical junctions of the neurons. It is even possible to con¬
ceive a hypothetical substance representing latent nervous
energy in these synapses.

Is nervous energy derived directly from the transformation
of chemical energy incidental to the life of the neurons ? or are
we to accept the entirely opposite view of Professor Gotch,
who maintained in a recent paper read before the Psychological
Society at Oxford that all nervous energy comes from without,
there is no storage or accumulation of energy, only redistribu¬
tion ; there is a greater amount of ingoing than outgoing
stimulus, the balance being converted into chemical and
thermal equivalents? This hypothesis was mainly supported

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670 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

by various experimental observations by him on the lower
animals.

I would agree with Gotch that there is no spontaneous
discharge from the spinal motor neurons, directly or indirectly ;
a present stimulus is necessary. Again, I would agree with him
that there is possibly a greater total amount of ingoing than
outgoing energy, but I disagree with him entirely in not
allowing the possibility of storage or accumulation of energy
by a process of transformation of bio-physical into bio-chemical
energy.

Every thought, feeling, and emotion has its particular
muscular concomitant; it may not be sufficiently intense to
rise into consciousness—indeed, we can only be made aware of
its existence by the concentration of consciousness upon ingoing
impressions from the muscles, especially those depending upon
the minute alterations in the tensions of the eye muscles and
the muscles of expression. Darwin showed the intimate rela¬
tion of the emotions to their muscular concomitants. Even
the patient suffering with auditory hallucinations probably is
affected simultaneously with a particular motor attitude of
attention with its corresponding ingoing stimuli, both kinaes-
thetic and auditory sensations being fused in consciousness.
There is, however, no proportional relationship between the
mental effort involved in attention and the muscular mass
moved—and therefore the consequent incoming kinaesthetic
impressions ; just as there is no proportional relationship
between the area of cortex representing specific movements
and the mass of muscles moved. Eye, face, and hand move¬
ments represent the great bulk of the excitable area of the
cortex.

Attention, we may suppose, represents a liberation of
nervous energy in the cortex cerebri, either due to a direct
bio-chemical generation in the neurons, or to accumulated
energy transformed. The sense of nervous fatigue is distinct
from muscular fatigue ; it is the result of the lowering of
nervous potential which especially is used up in processes
involving attention of a constantly varied nature ; for continu¬
ous attention to one thing, no matter how complex, leads to
the nervous process becoming more or less subconscious and
semi-automatic ; the discharge of nervous energy becomes
diminished, and less fatigue is experienced in connection there-

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1902.]

BY F. W. MOTT, M.D.

071

with. Professor James remarks that in action grown habitual,
what instigates each new muscular contraction to take place is
not a thought or a perception, but the sensation occasioned by
the muscular contraction just finished. A glance at the
diagram representing the three nervous circles which are in

continuous molecular vibration will indicate how, when once
habitual movement has been started by a signal from the
brain, stimulus will flow in and flow out. The volitional signal
as a result of experience and associative memory has arranged
a correlation of subcortical afferent, efferent, and association
neurons in such a way that stimuli flow in from sentient
structures, and flow out to synergic groups of agonist and
antagonist muscles in co-ordinate and orderly sequence, so that
the most perfect precision of movement is accomplished with
the least expenditure of nervous and muscular energy. In
locomotor ataxy the ingoing sensory channels are abolished,
and co-ordination has to be effected by new paths (visual and
vestibular) involving attention. Practice makes perfect, and
habit diminishes the constant attention with which our daily

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672 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

acts of life are performed ; but habit, or this tendency of
stimulus to flow along lines of established least resistance
(Bahnung), not only allows us to do the right thing at the right
time, but often compels us to do the wrong thing at the wrong
time. The oftener a wrong thing is done, just as a right thing,
the more likely is the establishment of loss of control and
establishment of lessened resistance along the wrong neurons
to become permanently installed ; and it seems probable that
many neuroses and psychoses keep themselves going simply
because they happen once to have begun, e.g. epilepsy,
hysterical contracture, catalepsy. Again, the commonest
subjective symptoms of insanity, delusions, illusions, and
hallucinations may be explained thus. Auditory hallucina¬
tions, so frequent a symptom in the insane, often commence as
simple noises; these are followed by “ voices,” which even¬
tually become so distinct and real that the greater part of the
patient's psychical existence is determined by and concentrated
upon this abnormal stimulus from within, indicating progres¬
sive strengthening and fixation of the perverted functions of
the mind, and progressive weakening and dissolution of the
normal functions. If we suppose that the total nervous
potential (stored nervous energy) is at the disposal of the
whole nervous system, then in the insane we must suppose
that it is constantly* being used up in a wrong way. Although
there is undoubtedly a trophic independence of the neurons it
is doubtful whether there is an anatomical, and there is certainly
not a physiological independence. Seeing that the sign of life
and the fundamental property of living matter is the capability
of transforming energy, it is conceivable not only that
incoming energy may be stored, but redistributed.

The effect of stimulus depends not only upon the intensity
of the excitation, but also upon the excitability of the neurons
stimulated. Thus stimuli which are insufficient to rise into
consciousness may do so by attention, and this constitutes
what might be termed the subjective attitude of the individual,
and is therefore a personal equation. But the personal factor
itself may vary according to the health of the individual and
the quality and quantity of the blood supplied to the nervous
system, especially to the cerebral cortex.

Every day experience shows that alterations in the blood,
whether caused by subminimal defects, by poisons engendered

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1902.]

BY F. W. MOTT, M.D.

673

within the body, or poisons derived from without, will change
the subjective attitude of the individual to the stimuli which are
continually flowing into the central nervous system by all the
external and internal sensory channels maintaining the normal
reflex muscular tonus upon which, in great measure, the sense
of well-being depends. The sensations coming from internal
structures which we cannot explore by sight or touch are
normally of such low intensity as not to rise into consciousness,
although with phasic or periodic regularity stimuli continually
flow from the viscera into the central nervous system. If they
exceed a certain intensity they give rise to ill-defined uneasy
sensations, and when intense they may assume the forms of
pain which may be referred in consciousness (that is by the
cortex cerebri) to morphologically correlated skin areas. But
by morbid introspective concentration of consciousness (associ¬
ated often by the knowledge of the possession of an organ
which they believe with reason or not to be delicate or diseased)
these normally absent or ill-defined visceral sensations may be
intensified into severe pains. The psychopath and neurasthenic
hypochondriac may be thus liable to suffer; when his nervous
potential is beginning to run down, his higher controlling
centres of the cortex are the first affected, and no longer exercise
a restraining influence upon incoming stimuli; consequently
every peripheral excitation, even those of low intensity, may
produce a maximum effect upon consciousness. Many poisons
produce similar effects. The question arises, how do the higher
centres control consciousness in attention ? For attention
is both a positive and negative process as regards stimulus.
We cannot concentrate consciousness upon stimulus from some
external object without shutting out of consciousness all other
stimuli. Is this a process of switching off as well as switching on of
active potential, or is the negative effect the result of opposition
of nervous currents (as in the correlative antagonism of muscles)
resulting in the production of thermal and chemical equivalents
(heat and CO s ) removed by the blood ? The latter hypothesis
would explain the fatigue occasioned by concentrated attention,
especially upon continuously varied objects. Every stimulus
revives the past, and behind the association wave which rises
into immediate consciousness is an unseen ocean, which under
normal circumstances is kept out of consciousness. In insomnia
and delirium of fever, and certain poisons, such as haschisch,

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674 REPAIR and decay of the nervous system, [Oct.,

where the higher controlling centres are fatigued or paralysed,
the negative process no longer takes place,but mainly the positive
in the perceptive and ideation centres. Often because these
lower centres are also partially affected, the ideation is
grotesque, confused, and abnormal. These mental states are
mainly related to visual stimuli, because vision and its associa¬
tions play by far the most important part in our psychical
existence.

But I will now pass from these speculations to the more
solid ground of physiological and anatomical facts.

Experiments have shown that nerves are incapable of fatigue,
or at least that they continue to conduct impulses without any
apparent loss of excitability to electrical stimulation for a
long time.

The experiments of Halliburton and Brodie upon the nerves
of the spleen show that a non-medullated nerve is just as
difficult to fatigue as medullated nerve; and these observers
conclude that while fatigue is demonstrable in nerve-cells, it
has never yet been shown to occur in nerve-fibres of either the
medullated or non-medullated variety. This does not, however,
imply that nerve-fibres undergo no metabolic changes during
the transmission of a nerve impulse. It probably means that the
change is slight, and the possibility of repair in the healthy
nerve great ; and that fatigue in the usual acceptation of the
term cannot be demonstrated.

Certainly Dr. Waller’s experiments tend to show that during
the passage of a current along a nerve some transformation of
energy occurs, as evidenced by the electrical variation and the
formation of carbon dioxide ; (*) and Waller puts forward an
ingenious explanation when he says, “ I wonder does this
carbon dioxide become altogether dissipated ? may it not per¬
haps be re-involved in some storage combination, as the nerve-
fat, perhaps, that is so prominent a constituent of fully evolved
nerve ? Such nerve consists of proteid axis and fatty sheath ;
the axis, which is the offshoot of a nerve-cell, is the specially
conductile part; the sheath is a developmental appendix, not
directly connected with any nerve-cell; yet cut nerve and
sheath as well as axis undergo Wallerian degeneration, which
is evident proof of a functional commerce between sheath and
axis. You have seen, further, that such nerve is inexhaustible ;
yet that it exhibits very clear symptoms of chemical change

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1902.]

BY F. W. MOTT, M.D.

675

after action. All these things, to my mind, reconcile them¬
selves with the notion that the active grey axis both lays down
and uses up its own fatty sheath, and that it is inexhaustible,
not because there is little or no expenditure, but because there
is an ample re-supply.”

Although Waller’s explanation is not supported by the
experiments of Eve, Brodie, and Halliburton on non-medullated
nerves, yet to my mind there is much to be said in its favour,
which I will show by certain observations.

If we can look upon a nerve impulse as a molecular wave of
increasing irritability propagated along its fibres, the electrical
variation and the production of carbon dioxide marking its
passage are evidences of a discharge of energy in another
form, both the added energy of the impulse and the electrical
energy must be transformed latent chemical energy of the fibre.
The added energy may come from chemical changes in the
myelin. If this is inconsiderable in the fibre with its neuri-
lemmal sheath, it may be considerable in the delicate myelin
sheath covering the terminal brushwork of fibrils which enter
the grey matter, for it is here that the oxygen supply is most
abundant; and the relation of the oxygen to the molecular
vibration along the fibril is most intimate, for they are only
separated by the extremely delicate sheath of myelin, whereas
in the peripheral nerve-fibre thes£ intimate relations between
the nerve current and the oxygen of the blood do not exist.

That the myelin serves another purpose than an insulator is
highly probable for the following reasons :

(1) Impulses transmitted by the non-medullated fibres of
visceral and vascular structures are of low intensity as compared
with the medullated fibres of somatic structures. It would
serve no useful purpose for these impulses to be of high
intensity and to rise into consciousness. They only do so
when the nerves are in an abnormally irritable state from
inflammation or disease ; on the other hand, it is essential that
we should be aware of the slightest touch of the skin, and it is
conceivable that we are aware of these very slight impressions
by added energy , derived from metabolic changes in the myelin,
as the stimulus traverses the neuron. Each intemodal segment
may act, as Sherrington suggested a little while ago, as an
electrolyte.

(2) The metabolic activity of the nervous tissues may be

xlviii. 47

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6y6 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

shown by the examination of the cerebro-spinal fluid and of
saline extracts of nervous tissue. The observations of
Gumprecht and Gulewitz show that minute traces of choline
can be detected in normal cerebro-spinal fluid ; likewise traces
can be proved to exist in the saline extract of perfectly fresh
nervous tissue, especially in the grey matter, sufficient, indeed,
to yield both chemical and physiological tests indicating its
presence. Halliburton and I have shown that choline is a
product of degeneration of the complex phosphoretted fat of
myelin called protagon. It may be supposed that anabolic
and katabolic processes continually lead to the recomposition
and decomposition of this chemical basis of myelin. Whatever
view may be taken as to myelin being a source of nerve energy,
there can be no doubt that—

(3) The development of the myelin sheath is related to the
passage of stimulus along the axial fibre, for we find the
ingoing tracts of the central nervous system are myelinated
before the outgoing, and in the cortex cerebri of the new-born
child we have each myelinated sensory sphere representing a
centre of elemental consciousness unconnected by any mye¬
linated efferent projection or association systems, except some
fibres of the corpus callosum which unite the two halves of the
brain, and unify these elemental spheres of tactile consciousness
of the two halves of the body. As a result of ingoing impres¬
sions reflected down the cortical efferent tract to the cord,
myelination of this projection system occurs, and with it the
development of conscious response to stimulus (or elemental
volition); later the dawn of intelligence is coincident with the
development of function of the association systems as shown
by the myelination of the fibres of other parts of the brain,
and then a simple sensation limited to a sphere of elemental
consciousness is presumably impossible ; for even the simplest
sensory stimulus perceived must be accompanied by a spread
to association systems, resulting in associative memory.

(4) Again, it is known that the myelin sheath of the optic
nerves of an infant born at full term is not so well developed
as the myelin sheath of an infant born at eight months, and
who has lived a month with its eyes exposed to the light.
The experiments of Ambron and Held and Berger upon
animals bom blind have shown that if the eyelid on one side
be stitched up, so that the stimulus of light does not act upon

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1902.]

BY F. W. MOTT, M.D.

677

the retina to the same degree as on the other side, the
myelination is more advanced in the optic nerve of the eye
exposed to light. We have in this experiment a direct proof
of the influence of stimulus in the production of myelin.

(5) The converse is also true; the absence of the inflow of
stimulus leads to slow regressive atrophy—first of the protagon
in the myelin sheath, next of the axis-cylinder process. This
is strikingly shown in the nerves, posterior roots, and their
projections in the spinal cord, following the amputation of a
limb. In the case of the sensory neurons the posterior spinal
ganglion cells are the last to show changes. There is, in fact,
an atrophy in inverse order of structural development. The
last to come, the first to go. The efferent fibres which supplied
the muscles that were removed in the amputated limb also
undergo atrophy from lack of stimulus. In intra-uterine
amputations, and those in early infancy, atrophy arrests
development not, only of the spinal afferent and efferent
neurons, but of the cortical centre of the limb, as was first
shown by Edinger and our president, Dr. Wiglesworth.
Again, the atrophy of correlated groups, systems, and com¬
munities of neurons which are in physiological, but not neces¬
sarily in direct anatomical association, is due to failure of
stimulus and disuse. Thus a lesion destroying the thalamus in
one half of the brain produces atrophy of the whole cerebral
cortex of the same side, of the opposite half of the cerebellum,
and of associated structures in the spinal cord. This was shown
in a striking manner in a paper published in Brain by Dr.
Tredgold and myself.

(6) The failure of the formation of myelin, or, at any rate, the
normal formation in regenerating nerves when stimulus is dimin¬
ished or absent. Lately I have been engaged with Professor
Halliburton in endeavouring to ascertain if, in the absence of
stimulus, nerves regenerate as readily as when stimulus exists.
It has long been known that sensation returns before movement,
and in some experiments which we made concerning the
chemistry of regeneration we were of opinion that the sensory
nerves regenerated before the motor, at least small cutaneous
branches had a better developed myelinated sheath than the
motor nerves obtained from the same limb. Of course this is
not a strictly conclusive experiment, for other conditions may
have favoured the earlier myelination of the one than the other.

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678 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

The observations we have lately been engaged in were made
with a view of ascertaining the part stimulus plays in regenera¬
tion ; it is well known that electricity, massage, and passive
movements facilitate the return of function. And while not
denying that this may be due in great measure to improved
lymph and blood supply, it may also be due to stimulus of the
nerve structures undergoing regeneration. One would expect
that if the limb of an animal were rendered motionless,
stimulus produced by every change in position would be
wanting; but such a condition must be brought about without
interfering with the nutrition of the limb or the connection of
the nerves with their trophogenetic centres. Professor
Sherrington and I showed that the fore-limb of a monkey can
be deprived of voluntary movement by section of the posterior
roots of the sensory neurons of the limb. We showed that
this loss of movement was not due in any way to affection of
the efferent path, for stimulation of the cortex cerebri produced
movements equally well on both sides. The immediate effect
of the operation, if a sufficient number of roots had been cut,
was a very great loss of reflex tonus, and the animal in the
majority of cases was unable to perform any voluntary move¬
ments. Dr. Warrington has shown that chromolytic changes
occur in the posterior and lateral groups of the anterior horn
cells as a result of this section of posterior roots ; it may be
presumed that the withdrawal of the normal stimulus incidental
to reflex muscular tonus may be associated with this change.
The observations which Halliburton and I have been making
are as follows :—A sensory paralysis of the fore-limb of
monkeys was produced by section of the posterior roots, then
both ulnar nerves were cut at the elbow and sutured; the
nerves were examined after different periods of time had elapsed,
first by stimulation of the nerves under an anaesthetic ;
second, by histological investigations. Various difficulties have
arisen owing to anastomosis of the ulnar and median nerves, so
that our results are as yet inconclusive, although they strongly
support the view that stimulus does play an important part in
regeneration and myelination of the motor fibres ; for in a few
successful observations we found that stimulation with the
strongest faradic current of the ulnar nerve below the suture on
the side in which the posterior roots had been cut was attended

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679

1902.] BY F. W. MOTT, M.D.

by movement, whereas on the other side a moderate current
gave a contraction.

Likewise histological observations, as far as they go, show
that the nerves are in a more advanced state of regeneration on
the side in which the roots have not been divided than the other.
I may say that section of the roots has no effect upon the nerve
above the lesion. It therefore looks as if the passage of
stimulus incidental to muscular movements plays an important
part in the generation of ingoing currents and myelin formation.

The effects of excessive stimulus .—The passage of currents
through neurons is attended by katabolic changes, and if the
neurons are in a low state of nutritional equilibrium the processes
of disintegration are in excess of those of integration. The nutri¬
tional state of the neurons depends upon several circumstances :
first, the inherent durability or vis propria ; and secondly, the
supply of nutrition, both as regards quantity and quality of the
blood and lymph.

The vulnerable part of the neuron is that most remote from
the cell body and its nucleus—the terminal arborisations, where
the discharge of energy, and presumably the katabolic processes
reach their maximum. Thus it is in the primary degenerations
we find a number of factors conspiring together to produce
degenerative changes, which commence in the fine collaterals
and terminals and proceed back towards the cell of origin.

The reason why stress or excessive stimulus can be an im¬
portant factor in the production of degeneration when the
neurons are subjected to the influence of poisons is probably
that the nutritional equilibrium cannot be maintained, disintegra¬
tion processes attended by the discharge of energy being in
excess of integration.

The action of poisons in the blood may be selective,
affecting certain systems, groups, or communities of neurons ; or
taken as stimulants to excite to further action the neurons in
a low state of nutrition, they blunt the natural safeguards of
pain and weariness, which serve as signals for repose and re¬
cuperation ; for pain, as Sherrington defines it, is a psychical
adjunct of a protective reflex. It is the neuropath, psychopath,
and neurasthenic who take to alcohol in order to give them fresh
nerve energy, who are liable especially to suffer from the effects
of the poison.

In my practice at the hospital and in the asylums I have been

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680 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

struck with the importance of excessive stimulation in determin¬
ing degenerative lesions in those parts of the nervous system most
subject to the stress. This view of the importance of stress in
the production of degeneration was emphasised by Edinger and
supported by experiments ; he found that poisons such as
pyridin injected into animals produced a severe anaemia, but
degeneration does not result therefrom. If, however, these
animals (rats) are put into a wheel cage and made to do
excessive work, degeneration of the posterior columns in some
respects resembling tabes occurs ; also chromolytic changes in
the anterior horn cells were found.

These facts, moreover, show that degeneration occurs in the
terminals of the posterior spinal neurons, presumably from the
fact that the degeneration is shown by the Marchi reaction in
the fine myelinated collaterals and the myelinated fibres of the
posterior columns, which are without a neurilemmal sheath.

Under the influence of the poison there is a nutritional
deficiency of the whole of the nervous system, but the rats
placed in a wheeled cage, and made to go on working con¬
tinuously although fatigued, are unable to get rid of the fatigue
products, and the sensory fibres of the reflex arc are con¬
tinually stimulated and discharging energy under unfavourable
nutritional conditions, the result being that the disintegration
processes are in excess of integration, and progressive degenera¬
tion ensues.

Edinger claims that this experimentally produced degenera¬
tion stands in close relationship both as to cause and localisation
to the tabetic degeneration of the posterior columns in man.

Observations which I have made on a very large number of
tabes cases support Edinger’s statement ; the syphilitic poison
produces a loss of durability, or, as Sir William Gowers terms
it, an “ abiotrophy,” and therefore a nutritional deficiency which
interferes with the balance of repair to waste. The great
majority of my patients suffering from tabes had led an active
life, or followed an occupation involving stress of the legs. In
some the disease commenced in the arms; and this is of
interest, because one was a mounted policeman, and the pains
were first felt in the arm with which he held the reins ; two
were packing-case makers, and one was a parcels post sorter.
As a rule, Charcot’s knee-joints are, according to my experience,
much commoner in women, and I attribute this in a great

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1902 .]

BY F. W. MOTT, M.D.

68 I

measure to the kneeling which they do; whereas the most
marked case of tabo-arthropathy of both knees in a man which
I have seen was in a carpet planner. A great many other
instances of tabes I could bring forward did time permit, but I
will content myself with enumerating some other nervous diseases
illustrating the effect of stress in determining the seat of
degeneration. A man who suffered with alcoholic dementia,
paralysis, and wasting of the muscles of the upper extremities—
the lower being unaffected, which is unusual—was shown to me
as a case of progressive muscular atrophy, and I found that he
was a Covent Garden porter, employed in carrying heavy
boxes on his shoulders all day. Two cases of amyotrophic
lateral sclerosis have come under my notice, in one of which
the disease began in the right hand and arm ; the man was a
cooper, and wielded all day long a 4-lb. hammer; the other
was a waiter who carried his tray on his left hand, and the
disease correspondingly began in the left hand and arm.
Experience, therefore, shows that in nervous diseases stress
plays an important part in determining the seat of degeneration
in a system which is subject to poison or inherited or acquired
loss of durability.

In seven cases of conjugal tabo-paralysis which have of late
come under my observation the history was usually this,—that
the wife developed the disease after the husband, probably
because she was infected by him with the syphilitic poison, the
mental disease arising as a result of this, and of the worry
occasioned by her husband’s illness. However, it would be
absurd for me to point out to an audience of alienists the fact
so self-evident that mental stress is an exciting factor in the
production of insanity. But I have often thought how little is
done in our asylums in the way of applying stimulus or
diminishing it by hydrotherapy, massage, and electricity in
carefully selected cases.

( l ) There is no direct chemical proof that C 0 2 is evolved. Waller infers that
it takes place because the effect of long-continued activity or the galvanometric
response of nerve is the same as that produced by exposing a nerve to a small dose
of that gas.

Discussion

At the Annual Meeting of the Medico-Psychological Association,
Liverpool, 1902.

The President.— We owe Dr. Mott a very special debt of gratitude for coming
among us to-day and giving us an account of these exceedingly interesting

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682 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

researches, which it is impossible to value too highly. Our asylums we know
are full of patients who have come there as the result of over-stimulation of the
nervous system. Anything which will put this inquiry on a scientific basis, and
show us the physical causes underlying these conditions, is of the utmost value.
The other point which Dr. Mott touched upon rather briefly—the repair of the
nervous system—is of almost equal importance. We have many cases which we
find lapse into stupor. In those stimulus is very important from the point of
view of cure. Many are purely cases of over-stimulation and require rest. We
have to be careful not to begin our stimulating process too soon. The whole
subject is one of extreme interest and value. I will ask Professor Sherrington to
address us.

Professor Sherrington. —I must thank you, sir, for the privilege, being a
visitor here, of being allowed to listen to the admirable and valuable address by
Dr. Mott. I have often heard him before with great advantage to myself, but I
doubt if on any occasion I have listened to him with greater profit. Dr. Mott has
touched on so many points, and so many are of practical value, that I am in¬
capable of dealing with any beyond some aspects of the questions which appeal to
the laboratory man. As physiologists we are particularly grateful for such work
on account of the help it gives in a problem which physiologists consider most
urgent—the answer, namely, to the question Dr. Mott so frequently referred to,
and which he insisted was proved—the intercommunication which must and does
occur between the independent units constituting the vast network of the nervous
system. To what he has to say on that subject the physiologist listens with con¬
fident and attentive expectation of help. The nature of this intercommunication
—the view that whatever the functional mode of conjunction, the nervous system is
and must be one—is the answer to the question which Dr. Mott told us. I wish Pro¬
fessor Gotch were here. One would like to hear him defend his view, which Dr.
Mott mentioned with great reserve, that the nervous system only liberates the same
amount of energy as a stimulus communicates to it. I would like to have it examined,
and if found unsound rejected as early as possible, because one of the most
helpful of the assumptions we can use in dealing with the problems of the nervous
system and of diseases of the nervous system is that which regards the nervous
system as more or less a reservoir of energy to be discharged, the discharge
depending very much on the condition of the reservoir itself; but it is very far
from being a rigid system, which simply conveys in various directions within
itself the amount of energy conveyed to it by some peripheral stimulation. What
Dr. Mott has told us with regard to the nutritional character of the disturbance
which use or stress causes seems to me largely bound up with the periodicity, the
proportion between exercise and rest. That results very distinctly from what he
said, that a certain amount of exercise is extremely favourable. The beautiful
and ingeniously devised experiment which he brought before us shows in a con¬
clusive manner the influence which a certain amount, not an abnormal amount,
of functional exercise has on the repair of these units of the system. There is
evidence of a similar kind which can be ranged alongside of his, that the closure
of one eye for some weeks in a newly born animal, complete closure, retards the
development of the myelin sheath of the fibres of the optic nerve on that side.
Well, this instance shows in the most striking and undeniable way the influence
of nerve stimulus upon nutrition. At the same time we have well-known examples
of the harmful effect of too great excitation. If, therefore, there are these
two results at the extremes of the range, then there must be between them a
position, a zero position, of normal nutrition, a position in which nutrition is
most beneficial. I presume that the same question underlies the arrangement of
hours of work and rest in the schoolroom, which is at present largely occupying
the attention of many experimental observers; in other words, there must be a
particular apportionment between length of lesson and playground interval which
will secure the largest amount of general nutritional welfare to the nervous
system of the child. To return to the view which Dr. Mott commented upon in
Professor Gotch’s argument, there are very strong points to urge against it. I
would like to mention one or two of them. That a nerve cell, or still more a
chain of nerve cells, gives out the same amount of energy, or rather less energy,
than is conveyed to it in the stimulus of the system is hardly borne out by the
somewhat analogous case of the nerve cells of the muscles. Regarding the whole

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683

1902.]

of the organism as made up of units which have the same fundamental qualities,
we have the fact that a nerve cell of the muscles multiplies the energy conveyed
to it perhaps half a million times. Let us take a laboratory instance which
occurred to me while listening to Dr. Mott We have a number of dogs in which
the spinal cord has been completely transected. After a certain time the spinal
reflexes beyond the point of transection have been very brisk. We have one of
those aesthesiometers, Frey pattern, which can be pressed on the section and used
as a stimulator. Adjusting this so that it just suffices to excite sensation when
applied to the tip of the forefinger, the amount of mechanical energy used in the
application of the bristle at the end of a penholder is not more than enough when
measured on a delicate chemical balance to shift the scale; it represents the
tenth of a milligramme or less. In these dogs by that means we have elicited
reflex action shaking the whole posterior half of the animal, and conveying
movement to the anterior half as well. There we have a case in which the
multiplication of energy must be many millionfold. I saw in the laboratory of
Professor Gould many years ago a dog which by large lesions in the cerebral
hemispheres had been reduced practically to the condition of a reflex animal. It
was simple enough as the animal walked along to flash a bright light in one
eye. That caused it to swerve to the opposite side. The amount of energy
conveyed to the nerve in the vibrations of ether as compared with the amount
necessary to deflect the course of a heavy animal is an instance of multiplication
manifold.

Although the result is more or less an intricate one, controlled and regulated
by the condition of the reservoir in which the explosions of energy occur, it is
useful to have before us the relation of stimulus to the exertion of nerve force,
and it is more and more useful in view of such doctrines as Dr. Mott has
exemplified and illustrated. In the light of these doctrines the whole series of
phenomena—the processes of disease and of what is akin to disease, exaggerated
fatigue—become much more easily explicable. It has been a privilege as well as
a pleasure to listen to what Dr. Mott has had to say.

Dr. Warrington. —I should like to associate myself with the concluding
remarks of Professor Sherrington. The paper we have heard this morning is
extremely suggestive and at the same time very practical, because observations
like these we have just heard tend to prevent the routine observation and routine
reflection which is so harmful. It is a gratifying feature of research in neurology
that it is assuming a practical aspect. I have no new facts to bring forward, but
I may say a few words on what the study of the histology of the nerve cell shows.
One goes back to the original observation of Mann and Hodge on fatigue, where
they have shown that actual morphological alteration takes place. The proto¬
plasm of the nerve cell has been aptly described as consisting of a working
material and of a fundamental basis. We know that, for instance, in the
salivary glands marked changes of structure occur during hours of fatigue.
One thing which strikes me in studying the histology of the nervous system is
that there must be an extremely rapid restoration of equilibrium in all kinds
of animals. As far as histology goes I do not think we find evidence of chro¬
matolysis in the normal condition. Whatever changes take place in life must
be very rapidly repaired. I regard the appearance of cells showing chro-
matolytic change as distinctly unusual unless there is some morbid process
attached to it. The effect of excess of stimulation has been alluded to by Dr.
Mott. To his remarks I have little to add. As lie has pointed out, the
vulnerability of the nervous system in those diseases in which excess of stimulus
plays an important part must depend on inherent or acquired want of stability.
That, I think, is important, and it appears obvious in many cases. Dr. Mott has
brought forward a number of actual clinical examples where excess of stimulus
has been connected with degenerative changes in the neuron. I mention the case
of a young man of twenty, an expert pianist, who developed what I took to be the
symptoms of chronic anterior horn disease. It was limited to the right hand, the
hand which he used a good deal in playing. It struck me as a good example. I
advised him to drop excessive pianoforte playing. I have watched him now for
three years and he has got no worse.

We have Edinger’s well-known experiment in which fatigue plus a poison pro¬
duced degeneration of the posterior columns. Similar changes occur where the

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684 REPAIR AND DECAY OF THE NERVOUS SYSTEM, [Oct.,

stimulus is deficient. Dr. Mott has mentioned the changes which take place
when the afferent impulses are cut off. These and like observations, when the
axon is divided and chromatolysis results in the cells of the region, show how
excess or deficiency of stimulation is connected with nutritional change. Lugaro
maintained that after section of the peripheral axon of the posterior spinal
ganglion cell that cell did not as a general rule recover. There the resulting
alteration of the stimulus must have been, and is, very much larger than
occurs when the axon on the cord side of the root-cell is severed. The anterior
horn cell may be regarded as part of the arc receiving impulses in a down¬
ward direction and in an upward direction, and again as giving them off; and
it will be seen that interference with this periodical stimulus is very readily
attended by changes in the nerve cell. As a rule, if the efferent axon is cut,
the cell after a time repairs and equilibrium is restored; nutrition also becomes
normal. But it is an interesting fact that sometimes nutrition is not restored; the
cell dies. For some reason, I do not know why, but we do know, that after
section of the efferent axon the disturbance may be so great that the nucleus
becomes extruded and the cell perishes. I was much struck by the remark Dr.
Mott made in emphasising the vis propria of individual cells. That is always to
be borne in mind in working at these histological changes, and I think it accounts
for some of the difference of observations made in regarding the localisation of
nuclei of origin.

Dr. Clouston.—As practical men we are much indebted to Dr. Mott for
enabling us to breathe the air of science in so pure a form. The first part of the
paper we shall probably not feel ourseives qualified to discuss. One point men¬
tioned by Dr. Warrington is the curious independence of neurons in close
proximity to each other. Ford Robertson mentioned to me the other day a
curious case of general paralysis which had certain mental and motor features,
but the lesions were extremely circumscribed. You had certain small groups of
neurons completely destroyed, and immediately, in the same field of the micro¬
scope, neurons in the most extraordinary state of perfection ; it was the most
marked localisation I have ever seen. These are things we do not explain, what¬
ever theory of general paralysis we adopt. A burning question with us is whether
we should treat some of our patients by bed or by exercise. Dr. Mott’s remarks
bear on that subject. “ If we could devise a drug by which the patients could be
put to sleep, if we could suspend the higher neurons for, say, a week, suspend
consciousness, and at the same time allow nutrition to go on,” one has always
been saying. The absurdity of the position is shown at once by Dr. Mott’s obser¬
vations. You suspend the oncoming stimulus, and the patient, instead of getting
up better, might get up very much worse. Then as to the use of massage, many
people went massage mad. It was used for every kind of disease, and especially
in incipient cases of melancholia. A great many of these incipient melancholiacs
were greatly aggravated by the course of massage to which they were subjected.
Taking the ordinary case of melancholia, you have to establish a nutritional
equilibrium. But when you get a case of excited variability have you not rather
to establish a kinetic equilibrium? You have to prevent the waste of outgoing
energy both in those cases and in cases of mania, but the kinetic equilibrium may
not be the same as nutritional equilibrium. That they must have a close relation¬
ship to each other I admit, but what we have to prevent is the burning up, the
explosion, the waste of the higher energy of the cortex in a useless way. That
is a question we have to face every day. In regard to the manner in which we
deal with many of the maniacal patients, there is the process of putting the
patient in dark seclusion. You remove many of the stimuli; you employ a degree
of restraint which prevents a great explosion of muscular energy. A great many
cases are much the worse for this treatment. It is one of the most important of
clinical questions how much we should allow muscular energy to be expended.
Now we see how physiologically important it is that the patient should take a
walk in the sunshine. You have the stimuli from the brain and the outward
stimulus from the sunlight. Speaking of stimuli, I think Dr. Mott said too much
about stimuli of the mechanical kind and too little about stimuli from proper
nutrition. If you stimulate without the proper supply of blood there must be loss
of energy. It is absurd to say the central nervous system does not bottle up
energy; the fact is unbelievable by any practical man. The central nervous

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1902.]

BY F. W. MOTT, M.D.

685

system does bottle up energy as much as if you put wine into a bottle and drink
it yourself; the experiments show this strongly. As to warm baths, they exercise
a soothing influence. We have not got, however, into the trick of using them
rightly. Some of us have cured patients in twenty-four hours with warm baths,
others have killed them. Then, again, there is a clinical fact of the utmost interest,
that an insane patient is always worse in the morning. By every principle he
ought to be better, but he is not. When he is getting better, and has been
subjected to stimuli in the sunshine, the first thing we notice is that he has an
hour of sanity nearly always in the evening. He has been maniacal in the morn¬
ing, but turn on the electric light in the evening, and he becomes sane and con¬
scious. This saneness later on disappears. That is a clinical fact in our daily
experience, and it is a fact of the greatest importance. I said to the head nurse
in the hospital the other day, referring to a woman who had just begun to have an
hour’s sanity in the evening, “Are you not clever enough to make that two,
three, or four hours instead of one ? ” “ If you and I,” she replied, “ were clever

enough to discover that, we should cure 20 per cent, more.”

Dr. Hyslop. — I would like to ask Dr. Mott whether he considers the work
done by Flechsig regarding the development of the brain in childhood, which has
been described as a development underlying the mental functions of man gene¬
rally, as sufficient proof that you have development of mind coincidently with
these physical developments. I believe Flechsig’s work in this direction has
been in part misleading. He has described the development of sensorial
functions and motor functions, but we want something deeper. In some
idiots and imbeciles we have found that there may be these developments
physically without coincident development mentally. That Flechsig did
not take into account. Dr. Mott showed us a diagram of sensory nerves
appearing to come from the muscular substance. I have not been able to trace
the evidence which proves that these are in reality sensory nerves. I am in¬
clined to think from the experiments of Goldscheider and others that we have no
such thing as pure muscular sensation. We have sensations of pain, but I
believe we get our sensation altogether from the cartilages and the skin. As to
other organic sensation, I do not believe we get any sensation whatever except
from pain. It may be open to argument from a psychological point of view that
we can remember a pleasurable sensation such as the appeasement of hunger, but
then that is merely the removal of a sense of pain. The sensations we derive
from muscles and from viscera are really those sensations of actual pain which
it is assumed have a totally different anatomical basis. The point on which one
can agree with Dr. Mott and appreciate to the full is that relating to the nerve-cell.
We are coming to accept the unit theory of cells in the brain, by which we assume
that each cell is discrete, and that function is by contact and not by structural
continuity. If we can establish that theory we shall have taken a great step
towards the elucidation of various problems of consciousness; many problems of
physiology will become more clear, and we shall have a much more definite basis
to work upon as explanations of mental phenomena. One point we have got to
remember is, that by cutting off sensory stimulation you may cause the death of
the cell. Berkeley of Baltimore, who experimented with alcohol on rabbits and
other animals, has described the process of cellular degeneration—first the decay
of the myelin sheath, and then degeneration of the nucleus constituting the
cytoclasis of the cell. To-day we have to thank Dr. Mott for carrying us still
further, and for enabling us to recognise that, so long as a current can pass, the
nucleus will remain in full life and regeneration is possible.

Dr. Mott in reply said: First I must thank the members of the Association
for kindly giving me their attention, as I fear that I have taken up more time
than was intended, and some parts of my paper which were of a speculative
nature had to be omitted. I also wish to take the opportunity of thanking the
President for his kind allusions to my remarks, and especially I wish to con¬
gratulate the Association on having present one of the most distinguished
physiologists in Europe, one who has added so much to our knowledge of
neurology and experimental psychology, Prof. Sherrington, whom I wish to thank
most warmly for his appreciative remarks upon my paper, also for his suggestive
criticisms upon certain points therein, which I put forward with the express
purpose of raising discussion as to their validity. At this late hour of the

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686 REPAIR AND DECAY OF THE NERVOUS SYSTEM. [Oct.,

morning, when other important papers are awaiting delivery, I will not trespass
long upon your time and patience.

There are a great many points which I should like to touch upon. One in
particular is the very remarkable experiment alluded to by Prof. Sherrington,
and which is distinctly in favour of the storage of energy and even the formation
of nerve energy, which appears to be quite independent of the amount of
incoming stimulus. He wishes that Prof. Gotch were here; at the meeting of the
Psychological Society at Oxford we were all wishing Prof. Sherrington was there.
He seemed in some doubt as to whether I had accepted Gotch’s new views. I
admit the possibility of all stimulus coming from without, but disagree entirely
with the doctrine that there is no storage. It is a remarkable fact that the nervous
system does not undergo wasting, and the metabolism, although extremely
complex, is not massive in healthy conditions. May it not be that the neurons
have the property of converting the molecular vibrations of incoming stimuli
into stored nervous energy, which we regard as “ potential,” and which can be
redistributed as from a reservoir ? At some future period I hope to bring forward
some facts in support of this. Of course this is a mere theory, and I have only
advanced it with a view of promoting discussion and, as Dr. Warrington suggests,
of avoiding the routine reflections. I was much interested in what he said with
regard to the independent vis propria of individual nerve-cells, and particularly
struck with this in the observations I made on the effects of poisons and experi¬
mental anaemia, which are fully related and illustrated in my Croonian
Lectures, 1901. I think this will explain the observations of Ford Robertson
referred to by Dr. Clouston.

We are all very glad to hear the practical remarks of Dr. Clouston; there is
one point, however, to which I should like to call attention. He relates what is
well known, that an insane patient is always worse in the morning. We
cannot wonder at this, for besides the fact that a patient who is the subject of
hallucinations is more troubled in the evening and at night, his whole attention,
which I maintain to be a loss of energy, is concentrated upon these abnormal
stimuli. It is well known that one form of hallucination will call up another;
thus visual hallucinations will occasion auditory hallucinations, and vice versd;
and if thus the natural periodic recuperation—and by this I mean physiological
and not artificially produced sleep—is interfered with, there is necessarily a lowering
of nervous potential. Again, in the early morning, when the temperature is lowest,
the nutritional exchange and the vitality of the organism is at its lowest ebb. At
such a time death frequently takes place.

Dr. Clouston also alluded to the influence of light. I had a striking example
the other day of the effect of shutting out the light in the production of symptoms
of insanity. When testing an insane tabetic I covered up his eyes in order to
test the skin sensibility of the chest; he immediately began to hear voices, and he
told me that he invariably heard the voices at night. An interesting fact which
is very difficult to explain is the abeyance in the symptoms of ataxy and
progress of the disease in patients who are afflicted with optic atrophy. Is it
because the stimuli which enter the nervous system by the visual sense are cut
off, and with them a great part of the excitation which leads to the using up of
nerve potential, thereby conserving tissues which have a lowered durability, but
are able under these conditions to maintain nutritional equilibrium ?

Dr. Hyslop’s remarks touch upon many points in anatomy, physiology, and
psychology; it is always well to have criticism, for that purpose my paper was
written, and I am much obliged to him for taking an opposite view, but I am
sorry that time does not permit me to enter the arena with Dr. Hyslop, except to
touch upon the following. He denies the existence of the muscular sense, and
considers that I have no right to make the diagram which shows fibres proceeding
from muscle to the central nervous system. 1 always thought Prof. Sherrington
had, by the most conclusive and beautiful experiments, shown that from one third
to half of the fibres entering muscle came from the posterior spinal ganglia and
were sensory in function. The kinaesthetic sense is in my opinion a fundamental
principle in psychology, and depends upon a complex of sensations in which the
alteration in the tension of the muscles is the principal factor by virtue of
stimulus of the sensory fibres proceeding from muscle and tendon. I would
request Dr. Hyslop to argue this point with Prof. Sherrington.

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1902.] THE SURGICAL TREATMENT OF INSANITY. 687

(Prof. Sherrington. — I think I can do that better at luncheon.)

Dr. Hyslop has taken exception to Flechsig’s work. I admit that much of it
has been disputed and some of it refuted, but on the main points I touched upon
he has undoubtedly shown the correlation between the development of the
elemental functions of mind and the formation of the myelin. With regard to
the myelinatlon of imbeciles and idiots I cannot see any reason to throw doubt
there on Flechsig’s work, for in proportion to the grade of amentia there is a
failure of development of the later developed and more superficial myelinated
fibres of the cortex. With regard to Berkeley’s work, I believe it mainly rested
upon observations made by the Golgi method; I do not like to dispute the
labours of such an eminent man, but I am convinced from experience that this
method is not reliable for pathological changes, especially if they be acute.

This reply was curtailed owing to pressure of time, but has by the courtesy of
the Editors now been slightly extended.

Some Remarks on the Surgical Treatment of Insanity .
By Damer Harrison, F.R.C.S.Edin.( 1 )

Mr. President and Gentlemen,— While recognising the
undoubted fact that what may be called ordinary insanity has no
demonstrable lesion, the disorder being in the “subtle chemistry
of the nerve-cells, and that no surgical procedure can correct
aberration in tissue chemistry, 1 ' I still think there are a small
number of cases, not only of traumatic but also of non-traumatic
origin, in which surgical treatment may have beneficial results.

There is reason for believing that mental impairment much
more frequently follows head injuries than is generally admitted.
Within a comparatively recent experience I have met with
four such cases following fractures of the base, one following
bullet wound of the brain, and four cases of decided insanity
following fracture or blows upon the vault. The number of
cases of insanity due to head injury appears to be about 2 per
cent, of all cases, and it is only a limited proportion of these
which are open to relief by operation ; for it is essential that
some localising indication of a lesion should exist which can
readily be reached, to justify surgical interference.

The actual lesions found at operations are very variable :
Depressed bone, with or without osteophytes or splinters
from the inner table ; thickened bone arising from a circum¬
scribed inflammation of the vault; cysts of haemorrhagic origin,
either upon or beneath the dura or cortex; diseased bone ;
foreign body within the cranium (bullet) ; adhesions of the cortex

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688

THE SURGICAL TREATMENT OF INSANITY, [Oct.,

to the dura from circumscribed meningitis of chronic character ;
adhesion of dura or pericranium to the bone ; tumours. The
locality of the lesion has sometimes been in the frontal,
occipital, temporal, and fronto-parietal regions. In three cases
of my own, the lesion was in the frontal, fronto-parietal, and
occipital regions.

CASE i. —F. W—, aet. 50, received a severe blow from
the revolving handle of a windlass upon the right frontal region,
causing a wound down to the bone, and fissure of the skull.
There was weakness in the grasp of the hand. The wound
suppurated, and there was a small exfoliation of bone from the
outer table. From the time of injury in 1886 to October,
1888, the history was as follows:—First, giddiness upon lying
down or standing up, or any sudden movement of his head.
These symptoms became worse, and on three or four occasions
he lost consciousness for a moment. During these attacks he
would frequently fall to the ground. During the second year
after the injury he became very restless, had fits of great
depression, and noticed that after the attacks of giddiness he
was very irritable and bad-tempered. During this time he
became troubled with strange delusions, thought people were
following him, saw grotesque faces looking at him through the
windows at night, and would go out to drive them away. His
eyesight since the accident was not so good. During Septem¬
ber, 1888, he had two attacks of homicidal impulse, and became
very melancholic, with attacks of increased irritability. On Octo¬
ber 1st, 1888, Dr. Craigmile sent the case to the Liverpool Northern
Hospital. Upon examination I found a slightly depressed
cicatrix, one inch in length, in the right frontal area, antero¬
posterior in direction, and two and a half inches perpendicularly
above the external angular process, corresponding to second
frontal convolution. I determined upon an exploratory opera¬
tion over the site of the frontal cicatrix, and proceeded to do
this on October 2nd, 1888. A semicircular flap was reflected
downwards, and an opening in the skull was made with an inch
trephine at both ends of the depression in the bone, cutting
away the intervening bridge of bone with a chisel. The bone
was found to be nearly an inch in thickness. The dura mater
bulged into the opening, but there was no brain pulsation
to be observed. Upon opening the dura mater a subdural cyst

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1902 .]

BY DAMER HARRISON, F.R.C.S.EDIN.

689

was opened, from which escaped about three teaspoonfuls of
serum. The brain bulged into the opening, arid still showed no
pulsation. A fine trocar and cannula was then pushed into
the brain, in a direction vertical to the cortex, and about three
quarters of an inch deep a cavity was opened, from which about
half an ounce of serum was removed. The pulsation of the
brain having become normal, the dura mater was closed with a
continuous catgut suture. The inner table of the bone removed
was chiselled from the outer table and replaced. The bone
removed being so enormously thick, I thought it advisable not
to replace the whole of the fragments. The wound healed by
first intention, without any rise of temperature, except on the
night of the operation, when it only reached 99*4°. The
patient left the hospital on the sixteenth day after the opera¬
tion, with eyesight much improved, power restored to the left
hand, and entire freedom from all mental symptoms. I have
been able to keep this case under observation from year to
year since October, 1888, and have seen him quite recently
and am glad to say that he remains perfectly well.

Case 2.—The second case I have to report is that of a
young man aet. 26, whom I first saw in November, 1896, in
consultation with Dr. Blair, of Wigan, and Dr. Street, of
Haydock Lodge Asylum. I was then told the history of a
severe blow which he had received on the left frontal region
four years previously, which had rendered him unconscious for
several days, and kept him in bed for several weeks. From
the time of this accident until the beginning of 1897 he
had been subject to occasional attacks of severe headache,
which became increasingly frequent. These attacks would
last for a day, and were accompanied by delirium and talking
nonsense, and followed by complete loss of memory for all the
events of the days when these attacks occurred. In the spring
of this year, 1897, he gradually became insane. Among other
symptoms, he became suspicious of all his friends; would
occasionally run out into the street, and create a considerable
disturbance. On one occasion ran several miles, arriving home
in a very exhausted condition, thinking he was being pursued
by imaginary enemies. Sometimes he would keep his wife up
all night and into the next day, making her sing, while he
lay in bed, etc., etc. He at last became so troublesome at home

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690 THE SURGICAL TREATMENT OF INSANITY, [Oct.,

that the question of removing him to an asylum had to be
considered, and Dr. Street was asked to see the case in
consultation with Dr. Blair. I saw the case a few days
aftenvards.

Upon examination the only objective symptoms I could
observe were as follows :—There was distinct weakness in the
grasp of the right hand. A small scar upon the left frontal
region, well in front of the motor area. Slight percussion with
one finger upon the scar, but particularly a little to the median
line adjoining the scar, gave rise to pain, and evidently a
startling sensation in the brain. This appeared to indicate
some lesion involving the dura mater, and therefore a cortical
lesion, and this was further suggested by the weakness in the
grasp of the right hand. The patient had become steadily
worse for some time, both mentally and physically, and, when I
first saw him, looked very emaciated and ill. I advised an
exploratory operation in the left frontal region, which should
take the area of tenderness for its centre.

The case was admitted into the Northern Hospital on
September 17th, and I operated upon him the next day. A
piece of bone was removed in one piece with the chisel, two
inches in its antero-posterior, and one and three-quarter inches
in its vertical diameter. The posterior margin of the opening
was three-quarters of an inch in front of the fissure of Rolando,
the upper margin two inches from the median line, the lower
margin of the opening two and a quarter inches perpendicularly
above the external angular process. The pulsation of the brain
could hardly be seen through the dura mater. Upon opening
the dura the pulsation was still hardly to be seen. There were
no adhesions to be found until the dural elevator was passed
backwards beneath the margin of the bony opening, and also
below. Adhesions, which were extensive in character, were
then separated over the base of the second frontal convolution,
and over the base and anterior to the base of the third frontal
convolution, the dura sutured, and the flap of scalp replaced ;
but it was considered wiser not to put back the bone, consider¬
ing the nature of the lesion. The wound healed by first inten¬
tion. On the day after the operation he was found to be
suffering from slight motor aphasia and paralysis of the right
side of his face. All signs of his previous insanity had, how¬
ever, quite disappeared. On the fourth day he had a slight fit,

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1902.] BY DAMER HARRISON, F.R.C.S.EDIN. 69 1

without loss of consciousness, limited to the lower jaw. For
the next thirteen days he had a large number of Jacksonian
attacks, once or twice losing consciousness. During this time
there was considerable bulging from a collection of serum
beneath the dura, which I made no effort to drain, as I con¬
sidered this might be left to be reabsorbed, and in the mean¬
time might prevent further adhesions forming between the
brain and the dura mater. As this collection of serum became
less, the paralysis of the right side of the face and right hand
became less, together with a rapid improvement in the aphasia.

For a considerable time after being convalescent, he had
complete hemianaesthesia of the right side of the body, with a
loss of the muscular sense in the right arm. For instance,
with his eyes closed, when 5 lbs. were placed in one hand and
one penny in the left, he thought the weights were equal. The
anaesthesia first disappeared from the foot, and in the course of
two or three hours disappeared from the rest of the right side
excepting the arm. This remained anaesthetic when he left
the hospital on October 24th. He forgets where he puts
his hand last, and has to look for it. There was also some
improvement in the muscular sense. The mental condition
since the operation has been perfectly normal. The patient is
quite above the average intellectually, and it is interesting to
talk to him about his previous mental condition. He remembers
nothing of his life for the four months preceding the day after
the operation, with the exception of one event—the breaking
of a bicycle.

The question arises as to the way in which the adhesions
gave rise to the mental symptoms. Was it from the dragging
action exerted upon the cortex only, or was the action also
causing a disturbance of the circulation to certain centres ?

An interesting point in this case is the fact that the point of
extreme tenderness on the scalp was at some distance from the
lesion, and shows the importance of making a large opening in
the bone. If this practice had not been followed in this case, the
lesion would not have been discovered. This patient remains
perfectly well five years and eight months after the operation.
He still has loss of the muscular sense, and some anaesthesia in
the right arm and hand, but can do good work as a cabinet
maker.

My third and last case of, operation for traumatic insanity

XLVIII. 48

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692 THE SURGICAL TREATMENT OF INSANITY, [Oct.,

was one that I saw in consultation with Dr. Wiglesworth, of
the Rainhill County Asylum, in November, 1897.

The patient was a male attendant in the Asylum, who, four
and a half months previously, while in special attendance upon
a dangerously suicidal case, was struck by the patient a very
heavy blow on the back of the head, a little to the left of the
centre, and at a point corresponding to the second occipital
convolution. The resulting scalp wound extended to the bone,
but there was no fracture of the skull observable.

The man was kept in bed for from ten days to a fortnight,
and, when sufficiently recovered, was sent home for a months
holiday. During the month at home the patient’s relations
noticed a change of manner, the man becoming strangely quiet,
and hardly speaking to any one. He eventually returned to
his duties at Rainhill Asylum, where the change in manner was
noticed by his fellow-attendants. About two months later he
began to suffer from hallucinations with regard to the man who
had struck him ; he frequently thought that he saw him in the
room, and threw things at the apparition. The site of the
cicatrix corresponding with the second occipital convolution is
interesting in relation to the hallucinations as to vision. Two
or three days later, and nearly four months after the injury
was inflicted, an acute attack of suicidal mania suddenly came
on, and for a week to ten days it required the combined efforts
of several attendants to restrain him. I saw the case with
Dr. Wiglesworth about the eighteenth day from the beginning
of this outbreak. The patient was then quite quiet and
rational, and explained to me that, although at that moment
he was only suffering from a feeling of depression, he had
during the previous night been seized by an almost irresistible
impulse to commit suicide by smashing his head against the
wall. Dr. Wiglesworth at this time considered it necessary to
have the patient watched night and day. It was decided that
an exploratory operation should be performed, the scar in the
occipital region being taken as the guide. This was done two
days later. A semicircular flap was made to reflect down¬
wards in the usual manner, and a piece of bone was removed,
one and a half inches by two inches in diameter. The only
abnormal condition found was adhesion between the cicatrix and
the bone i it being questionable as to whether the bone removed
was thickened to some slight extent or not. The bone was

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1902 .]

BY DA^ER HARRISON, F.R.C.S.EDIN.

693

not replaced. The wound healed up by first intention, with a
normal temperature throughout; the patient recovered mentally
from the date of the operation. As Dr. Wiglesworth con¬
sidered that this man was not fitted to continue his occupation
as an asylum attendant, the governing committee granted him
some compensation, and he returned to his home. He
remained quite well until last heard of, and there is good reason
to believe that no relapse has taken place since, from the fact
that no relapse has been reported to Rainhill Asylum.

My next case is also of traumatic origin, and one which I
have now under observation in the Northern Hospital, and is
here to-day for this meeting to see.

The case is that of a boy set. 13 years, with the following
history :—He is the only child of six births born alive. At
eighteen months old a squint was observed which was some¬
times absent and sometimes present. Nystagmus has always
been present. At three years looked at things with his head
on one side. At about five years went to school, and learnt to
read and write, and reached the third standard, and was con¬
sidered of fair average intelligence. Between eight and nine
years had a bad fall upon his forehead down some steps, due
to defective eyesight. Had two bad falls last year, due to
the same cause—one in September, the other in November,—
and in each case cutting his forehead at the site of the original
cicatrix. Up to this time he was quite normal in speech, gait,
etc., and his eyesight was still good enough (although defective)
to allow of him being educated at an ordinary board school.

You will observe now that he has a peculiar gait in walking,
and is quite abnormal in the movements and power of his hands ;
he speaks with a staccato delivery, suffers from frontal head¬
ache, is very sensitive over the site of the frontal cicatrix ; his
eyesight has become much more defective, with optic atrophy,
and his mental condition has markedly changed during the last
two or three months. He will continually talk to himself, and
when at the school for the blind, to which he was sent by the
Liverpool School Board, could be taught nothing; sometimes
will sit for considerable periods laughing and clapping his
hands; he will, however, answer questions with apparent
intelligence. It appears to me that an exploratory operation
at the site of the frontal cicatrix is advisable, and I should like
to have the opinion of gentlemen present upon the case.

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694 THE SURGICAL TREATMENT OF INSANITY, [Oct.,

The next case is one which, I hope, will be of special
interest to this meeting, as it is a case of non-traumatic origin.

It is that of a gentleman aet. 46, who held an important
Government appointment, who was admitted into the Hay-
dock Lodge Asylum under the care of Dr. Street on June 4th,
1896. His sufferings were then of a year’s standing, and the
special point about the case was that he never himself believed
in his delusions, and was always perfectly clear as to their
fictitious character. The delusions consisted in the constant
hearing of voices, night and day. They were, however, always
voices which he recognised as those of people he had known,
chiefly near relations and friends. The voices were generally
disparaging and threatening.

He became deeply depressed, agitated, and emotional, and
would frequently burst into tears.

He did not believe in these hallucinations, except when
worn out from want of sleep ; he would give way so far as to
say that “ he was afraid there must be something in them.”

Under these depressing influences, he inflicted a severe
wound upon his throat with a razor, and was afterwards
taken to Haydock Lodge Asylum. The only points in his
physical history requiring notice are that there was a scar on
the penis, dating from 1883, which was followed by constitu¬
tional symptoms, and that he had also acquired the alcoholic
habit. Dr. Street and Dr. Davidson, after close observation,
considered this case of such an unusual character that it was
considered advisable to ask me to see the patient.

From all the subjective symptoms, the view arrived at was
that there might be an irritative lesion influencing the auditory
centre for speech. The fact that the patient was a right-
handed man, and that I detected two tender spots in the region
of the auditory centre on the left side, determined the side
upon which to operate. A large opening in the bone was made
almost semicircular in shape, being three inches in the antero¬
posterior diameter and two and a half inches in the vertical.

The bone appeared to be unusually brittle, and the dura
mater, on exposure over the central portion of the opening,
had a slightly abnormal yellowish appearance.

The brain, covered by dura mater, bulged into the opening
of the bone, the pulsation being so slight as to hardly be per¬
ceptible. The dura was then opened.

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1902.]

BY DAMER HARRISON, F.R.C.S.EDIN.

695

The brain surface in the centre of the opening presented a
somewhat cloudy appearance, and at a point corresponding to
a point on the lower aspect of the superior temporo-sphenoidal
convolution there was a small elevation in the cortex, some¬
what transparent in appearance, as if due to a thinning of
the cortex from deep pressure. This gave way upon pal¬
pation, and a small current of serum escaped, which at first
spurted vertically into the air. This flow of serum continued
for several minutes, the cortex gradually assuming a concave,
instead of a convex, bulging surface. At the same time, the
pulsations of the brain became quite normal. A few strands
of, horsehair were used as an intra-dural drain, the dura being
closed by a continuous catgut suture. The wound healed by
first intention.

For the further notes of this case I am indebted to the late
Dr. Cheetham.

The day after operation. —The patient said that unless he
pays especial attention, what were voices of yesterday are now
simply a jumble of noises, and far more distant than formerly.

Four days after operation .—His opinion about the voices is
very vague ; he thinks he hears them at times, but says that he
has not been so peaceful and comfortable for eighteen months.
His general mental aspect has undergone a marked change ;
instead of being entirely wrapped up in his own misery, silent,
and often in tears, he watches what is going on in the room,
is inclined to talk, his manner is bright, and he frequently
expresses his thanks for all that has been done for him. He
chats with his nurses, and is anxious as to their comforts,
walks, hours of sleep, etc.

All this shows a complete change in the man as we have
known him during the past seven months.

Five days after operation. —Sounds very indistinct and un¬
certain, and cannot identify them as voices.

Seven days after operation. —Hears no abnormal sounds.

Ten days after operation. —All traces of depression have left
him.

Twelve days after operation. —No voices or abnormal sounds;
sleeping well without sedatives.

Twenty four days after the operation. —Discharged from the
asylum in quite a normal condition. I saw the case three
months later, and there had been no relapse.

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696 THE SURGICAL TREATMENT OF INSANITY. [Oct.,

This case is of such a unique character that one cannot
base any generalisation upon it, but it appears to me that it
does establish the fact that here and there a case may be met
with of a non-traumatic character which may be treated
surgically with success, if the mental specialist is prepared to
consider such a possibility.

Was the cause of the symptoms in this case due to a cir¬
cumscribed molecular disturbance or altered circulation arising
from the presence and pressure of the cyst ?

I understand that some physicians (such as Sir Wm.
Broadbent) are of opinion that epilepsy and some other excit¬
able conditions of the nerve-centres is largely caused by an
anaemic condition, and it has occurred to me that such might
be the cause in this case.

Two recent cases that I have met with I think may be con¬
sidered examples of this.

In one case the patient suffered from symmetrical fracture of
both femurs high in the upper third, which necessitated the
suspension of both lower extremities above his head for several
weeks. When they were brought to the general level of his
body, he became, for a time, mentally deranged, but soon re¬
covered, and I attributed this disturbance of function to lowered
blood-pressure.

A second case was that of a woman who, after severe injury
to the skull, acquired a cerebral hernia, and during this time
suffered from delusional insanity, but promptly recovered when
the hernia was reduced by elastic pressure.

All the cases in which the dura is principally involved would
appear to be caused by reflex irritation.

In conclusion, I hope this meeting will forgive me for the
very fragmentary way I have dealt with this subject, but I
thought it better to keep this paper within the small limits
of my own practical experience.

Appendix .

Since the foregoing paper was written the boy who was
shown to the meeting has been operated upon.

An opening in the skull was made over the site of the frontal
cicatrix, and was eventually extended until it was three inches
in diameter. Little or no pulsation could be observed. The

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1902.] INCIPIENT AND TRANSIENT MENTAL DISEASES. 697

dura, which was dark in colour, was opened, and the cortex
was found to be covered by what appeared to be a very thick
membrane of a plum-juice colour. This was followed back¬
wards until it apparently became continuous with a thickened
yellow membrane. At this point a large cavity was opened,
which had for its boundaries the dura and the thickened yellow
membrane already described. This was filled with a yellow
gelatinous material, the remains of an old blood-clot. The
brain had evidently been subjected to long-continued pressure,
and the whole of the parieto-occipital region presented a con¬
cave surface. The cavity was cleaned out with a spoon and
irrigation ; egg-shell membrane was placed over the frontal
cortex, and the dura was then closed by continuous suture.
The wound healed up by first intention and without tempera¬
ture, and during the next few weeks the boy showed great
mental improvement. He became “ clean in his habits ” for
the first time, and his general intellectual condition became that
of a normal child of about half his age. He remembered more
or less all that he had learnt at school, and what was left of
his eyesight had sufficiently improved to enable him to pick
out from a number of photographs of distinguished people the
one you might ask for. This remarkable improvement has,
however, only lasted for a short time, and during the last fort¬
night he appears to be losing ground and lapsing into the con¬
dition which obtained before operation.

( 1 ) Read at the Annual Meeting of the Medico-Psychological Association at
Liverpool, July, 1902.

The Possibility of providing Suitable Means of Treatment
for Incipient and Transient Mental Diseases in our
Great General Hospitals . A Discussion opened by

T. S. CLOUSTON, M.D., at the Annual Meeting of the
Medico-Psychological Association, Liverpool, July 25th,
1902.

Dr. CLOUSTON said : I shall endeavour to keep in mind that
my duty is to initiate discussion, and not to attempt to read
anything like an exhaustive paper. Since my friend Sir John
Sibbald has treated this subject in a full and careful manner

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698 INCIPIENT AND TRANSIENT MENTAL DISEASES, [Oct.,

from the historical and other points of view, I shall put it in
the form of a series of questions and short answers.

The discussion on this subject should at least cover the
following points :

1. Does any adequate provision exist at present for the
right treatment of the early stages of such diseases as have
mental disorders for their chief symptoms, or for the slighter
and more transient insanities, among the class who come to
our general hospitals for advice and treatment ?

The answer must be “ no.” Our hospitals for the insane
treat the developed cases in the best way known to modern
science, but such cases as I have indicated cannot be sent to
them in the present state of the law, and should not be sent.
Most cases, as we know, require some treatment. Many cases
require at least removal from home or change of environment
in addition.

2. Is it desirable to supply this want ?

The whole history of modern hospitals and the whole trend
of philanthropic efforts to cure disease have of late years been
in the direction of providing for the poor every means of treat¬
ment for diseases of every class. In regard to mental disease, it is
in the early and incipient stage that it is most curable. Every
case of mental disease has an early and incipient stage.
During that stage it is not a case of technical legal insanity.
It is a condition where you require to make the patients
realise that there is something wrong with them. Dr. Mott has
told us to-day the extreme importance from the purely scien¬
tific point of view of any form of bad brain habit. It will be
admitted that men on the point of insanity add daily to the
risk of what I may call the organisation of the morbid process,
and every day adds to the difficulty of getting the case off the
morbid and on to the normal mode of working. That, as
neurologists and physiologists, none of us will deny. The rich
can and do have such means of treatment; the poor at
present cannot. This does not apply to any other class of
disease. Mental disease is the most pitiable of all. To allow
such mental symptoms to run to such a degree of disturbance
that they can be officially certified as technical insanity seems
a cruel neglect, as well as an expensive dereliction of duty
on the part of society. For the man so afflicted ceases to be
a producer, and becomes incurable.

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1902.]

BY T. S. CLOUSTON, M.D.

699

At present insanity costs the British public about
.£5,000,000 a year, and increases—largely by accumulation—
to the extent of thousands of patients annually, so that now
there are 145,000 registered insane persons in the United
Kingdom, of whom 133,000 are paid for out of the rates by
the industrious portion of the community ; and this class of
insane persons is increasing at a far greater ratio than the
private and richer class.

3. Why should not an extension of the present asylum
accommodation fulfil this purpose ?

The answer is that it cannot fully do so just because it is
asylum accommodation, and therefore has attached to it the
unfortunate and cruel prejudices and repulsions which would
prevent patients from voluntarily taking advantage of it when
they need it most, and when it would do them most good*
Many mental cases, too, are certifiable which should not be
certified, and still more are not certifiable and yet need definite
treatment.

4. What advantages would the present general hospitals
have over asylums or any other mode of treatment ?

Firstly, any one may go to seek advice at a hospital, or to be
treated in one, without losing any of his self-respect, injuring his
prospects in life, or going counter to any special prejudice in his
mind. Secondly, the treatment of this class of disease—I
attach enormous importance to this argument—would educate
our poorer population, and, indeed, the whole population into
entertaining the belief that mental disease is on all-fours with
other classes of disease, and that it in no way implies shame or
repulsion. If this education could take place to any degree it
would sweeten life to every family in which mental disease has
occurred, and that would probably comprise every fourth or fifth
family connection in the land. Besides, it would diminish one of
the most poignant terrors in the lives of those who have suffered
from the disease or fear its occurrence. The absence of this
prejudice and fear would of itself greatly aid recovery.

In the Copenhagen General Hospital,where,since 1863,mental
patients have been treated, the following result has occurred.
Professor Pontoppidon, the Professor of Psychiatry there, says,
“ The adding of the pavilion as an integral part of a hospital for
general somatic diseases has influenced public opinion in modem
and scientific directions, and has done away with much of the

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700 INCIPIENT AND TRANSIENT MENTAL DISEASES, [Oct.,

mysticism which, in public opinion, too often clings to mental
disorder. Patients and relations as well as doctors seldom
hesitate to make use of the insane ward of the Commune
Hospital in the hope that the patient will soon recover, knowing
that he will here be at once placed under rational treatment,
which so often greatly improves the prognosis.” We cannot
set aside these weighty words of a man who has already tried
this particular mode of making provision for insanity. A great
advance would be made towards removing the reproach of
insanity by educating the public as to its true nature.

5. Would not this provision simply be an extension of the
recent specialisations in medicine and in surgery which have
been provided for in the modern hospital with such admirable
results in the past fifty years ? It would also prove of great
benefit to other branches of medicine and surgery.

6. Would not the cost of such provision be too great ?

At present each occupied bed in the general hospitals of the
United Kingdom costs from £50 to £100 a year. I have no
hesitation in saying—and in this I am fully confirmed by com¬
petent alienists, one of whose chief functions is to know and
count the cost of such things—that the cost of a psychiatric bed
would not exceed by any considerable sum that of a medical
bed, and would scarcely come up to the average of a
surgical bed.

7. Would it imply extensive structural alterations in the
present style of hospital ward ?

Our modem experience in the treatment of insanity enables
us confidently to answer this question in the negative. A few
simple alterations, and the addition of one or two single bed¬
rooms to each ward, with special baths, and a small amount of
day-room space, would suffice. A very large number of such
hospital-treated cases would be kept in bed most of the time
they were in hospital. Dr. Macpherson, Sir John Sibbald, and
I went carefully into this question with regard to one of the
ordinary medical wards of the Royal Infirmary, Edinburgh,
and we satisfied ourselves that few structural alterations in that
ward would be needed to make it an efficient mental ward.

8. Would the treatment of such cases not be attended by
risk of disturbing other patients in the hospital ?

This, if the patients suitable for this mode of treatment were
carefully selected, could be avoided. The success of the

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1902.]

BY T. S. CLOUSTON, M.D.

701

scheme would depend on the careful examination of such
cases before admission by a physician acquainted with mental
diseases, their diagnosis, and their ordinary course, and it would
have to be the duty of such physician to exclude all unsuitable
cases. Probably, to begin with, and while the ward was some¬
what of an experiment, this exclusion would have to be rather
on the rigid side.

9. Would the general administration of such ward be so
different from the administration of ordinary hospitals that it
would complicate and upset the whole internal working of the
institution ?

To this I think we can answer “ no ” with some confidence.
Modern experience on this point is most valuable. It is well
known that some asylums in the north have such public
annexes, and call them hospitals. These are run by ordinary
nurses. The male patients at some places—Larbert, for instance
—are nursed entirely by a female staff. This gives us an
experience which becomes very valuable in the discussion of
this question. In the light of that experience there would
be no such risk of disturbing the general administration. At
Morningside we started two such hospitals, with female nurses
in each, and these, with open doors, have been run for twenty
years. We have never had a serious accident in them, and the
Scottish Commissioners in Lunacy have been almost urgent in
their recommendations that such hospitals should be attached
to every asylum.

10. Would not such wards need special staffs?

Certainly, and they will have no chance of a full success

unless staffed by physicians of special training and experience,
who will bring to the treatment of the patients all that
modem psychiatry can teach them, just as general hospitals
need trained and experienced ophthalmologists and gynaecolo¬
gists. Who would propose that gynaecology should be taken
charge of by general surgeons ? All we ask is that the same
principle should be applied to mental disease. The nurses,
too, would require special experience and training; but the
system of examination and training put into force by this
Association of late years provides us with a ready-made staff
for that purpose.

11. Assuming that there would need to be a time limit, say
six weeks or two months, to the stay of those patients in such

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702 INCIPIENT AND TRANSIENT MENTAL DISEASES, [Oct.,

wards, just as there is in the case of most ordinary medical
and surgical patients, would such comparatively short period
be sufficient for effective treatment? In a large number of
cases this period would be sufficient. In the cases of those
who got worse, or in whom the symptoms were prolonged, we
have the asylum to fall back *pon. We have the means,
therefore, of continuous special treatment where needed. I
have found that out of the ordinary certified patients io per
cent, recover, and are discharged within six weeks ; 20 per
cent, within two months. A much larger number treated in
the earlier stage for the milder form of disease would re¬
cover ; and many could safely leave the hospital to complete
their recovery at home. If you have broken the bad brain
habit, if you have successfully contended by proper treatment
with the worst symptoms, the patients would with safety go
home to complete their convalesence.

12. Are there actually in existence so many patients in any
community whose mental condition makes this treatment, apart
from asylum treatment, urgently needed, and would such
patients come to hospitals to be so treated ?

Those who have had much experience in mental consulta¬
tion practice will say “ yes ” to these two questions, with, no
doubt, some reservations, but “ yes ” in the main. The poor
cannot be so different from the better off that they will not
take advantage as a free gift of what others are willing to pay
for. I have no doubt there will be in many cases some degree
of moral pressure on the part of the relations. I know, for
instance, that only about 20 per cent, of the patients about
whom I have been consulted in private practice were in such
a condition that they needed to go to an asylum for treat¬
ment ; but, of course, such people can afford skilled nursing,
and special private accommodation in villas—equivalent, in
fact, to what the poor would get in hospitals if such provision
as I am advocating was made. The education of the public,
to which I have referred, would have the effect of making the
patients know the value of taking things in time; for most
cases have a preliminary stage in which the patient realises
that he is ill.

13. How would such provision affect the knowledge and
experience of treating mental diseases possessed by the medical
profession ? It would be an enormous gain to our profession

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1902.]

BY T. S. CLOUSTON, M.D.

703

and therefore an equal gain to the public. It would supplement
and complete the clinical instruction now given to all students
in asylums, by enabling them to see, to diagnose, and to treat
rightly the early symptoms of the disease—those symptoms
which they do not sufficiently see in asylums, which the
general practitioner has to treat, and which for the patients
good should be recognised and treated at once. It is pro¬
bably of more importance to the patient to have early sym¬
ptoms in mental disease properly treated than is the case in
almost any other disease.

14. It is possible to take too sanguine a view of the effect
of this provision, but I believe it would sensibly diminish the
amount of mental disease in the country ; but even if there
were an element of doubt on that point, are not the advantages
I have endeavoured to point out in themselves so great that
it would be worth while to make the experiment in the public
interest ?

15. Why did the mental wards in the old hospitals fail?

We know that a great many hospitals in the old days pro¬
vided for the treatment of mental cases. They failed because
the worst cases were sent to them, and they had to treat un¬
suitable cases with the exceedingly limited means at their
command, and with unscientific nursing.

16. What would be an ideal provision for treating mental
diseases among the poor ?

In my judgment we should require four provisions. First,
a mental ward in the hospital for incipient, transient, and suit¬
able cases. Second, a reception hospital for certifiable cases
of an acute character situated near a large town, with plenty
of nurses and plenty of medical attention. Third, an ordinary
asylum for cases which run on month after month. Fourth,
a boarding-out system for the really quiet and manageable
cases, who could be restored in a modified degree to family life.

Sir John Sibbald. —I shall detain you with very few words, because in the first
place I have said already in print, perhaps to tediousness, what I have to state on
this subject; and secondly, because I shall speak on the question at Manchester
next week to some of the gentlemen I see present. Dr. Clouston has stated
exceedingly well many points which are not in my paper. With his views I very
cordially agree. There is one point I would like to refer to, however,—Dr.
Clouston perhaps put the absence of provision for the treatment of cases with
mental symptoms a little more strongly than the facts quite warrant. It is true
that such patients are as a rule excluded from general hospitals, but it is also true
that in some hospitals they are admitted pretty freely. It is necessary to refer to
this because I have heard that put forward as a reason why such wards as Dr.

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704 INCIPIENT AND TRANSIENT MENTAL DISEASES, [Oct,

Clouston recommends should not be established. That is a point which ought to
be clearly understood. We say that where a general hospital excludes mental
patients these wards are obviously and urgently required; but we contend that
they are required even where there is no rule against receiving such patients, be¬
cause ordinary medical wards are not equipped tor the treatment of every kind of
mental case, and therefore they cannot receive many of the patients who ought to
be provided for. We have also to keep in view that although the physicians to
ordinary medical wards are sometimes admirably qualified to undertake the treat¬
ment of mental disorder, this is not always the case, while in the wards we propose
the physician would necessarily have devoted special attention to psychiatry. The
same would be true of the nursing staff. I think it rather too much to expect
of the ordinary nursing staff of a general hospital to deal with patients suffering
from mental disease. I feel that, treating of this subject myself, I was rather
in the position of a suspected person,—that is to say, that I could not perhaps
be recognised, as I should like to be, as a representative of asylum doctors,
having, as has sometimes been suggested to me, deserted the asylum doctors
some years ago. I did not desert them; I certainly did not desert them in
spirit; but the fact that Dr. Clouston, an acknowledged representative of asylum
physicians, should come forward and advocate the treatment of mental disease in
general hospitals should carry weight, because he is able to do it from a position •
absolutely free from any kind of disqualification. I am grateful to him for the
support he has given to a view which both he and I hold strongly.

Dr. Rayner. —This is a subject in which I have for many years taken interest.
So long ago as 1884-5 I had a correspondence in the Times in connection with the
establishment of such wards in the London hospitals, and the duty of hospitals to
treat the sick insane. Some seven or eight years ago I was able to get an out¬
patients’ department for mental diseases started at St. Thomas’s Hospital. It was
in the hope and expectation that sooner or later this department would lead to
the establishment of wards for such patients as might require treatment in the
hospital. I am not Without hope that this will even yet be done. The out-patients’
department has very strongly confirmed me in the conviction that such an arrange¬
ment would be of the greatest advantage to the community. I could quote a
number of conditions which I am certain would be cured and saved from going to
an asylum by a very short period of such treatment under the conditions so admir¬
ably sketched out by Dr. Clouston. There are many whom we now treat as out¬
patients in absolute need of hospital treatment as in-patients. Seeing patients
in this way was to me quite a revelation in regard to insanity, as I had previously
seen only fully developed insanity in asylums. My experience of seeing patients
under out-patient conditions has convinced me that there are a large number
of cases in which, in the earlier stages, the removal of the physical cause, or
other alleviation, at once arrests the progress of the mental aberration; but if the
case has gone on to a certain point, when the brain has come to react on the
body and to affect the bodily health, a much longer time is needed for recovery.
The patient is then a case for the asylum. You may at this latter stage take
away the physical cause which induced the disorder without at once bringing about
any marked improvement in the mental condition, and that is why I, as an asylum
superintendent, regarded the removal or alleviation of bodily causes of disease as
having profoundly less effect on the mental condition than is in accord with my
subsequent experience. There is a great cause of mental disorder which we
never see tabled in our statistics. A large number of cases in the incipient stages
are associated with indigestion troubles. Again and again have I simply attended
to that one cause, and saved the patient from, or got patients better of, marked
melancholia and delusions. A considerable amount of observation and experience
leads to the conviction that general hospital treatment for the incipient insane
is most desirable, and that indeed the provision of it is a pressing public duty.

Dr. Newington. —Every one of us is ready to support Dr. Clouston in the main
principle of his contention. Undoubtedly there are a great number of asylum manu¬
factured cases, but whether we can get this mode of hospital treatment universally
established or not is another question. In country districts it would be almost im¬
possible, because in some counties, particularly agricultural ones, there is no town
with a hospital big enough to allow the experiment to be tried. That, however,
does not apply to London or to large urban areas generally. In large places like

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1902.]

Liverpool we might establish a receiving asylum and get the right cases in, but in
counties, where the question of a person having to go to some sort of asylum
has to be settled by a medical man without much experience of mental disease it
would obviously be difficult to pick out the cases which it would pay best to treat
in hospital wards. Dr. Clouston, I think, has taken rather too short a time in fixing
six weeks as a limit. For the purpose of settling the size of the acute hospital at
Hellingly, we went carefully into the figures of the Haywards Heath Asylum, an
institution serving the same population as our own. I found that those who got
well did so on an average in about five months or thereabouts. There would be a
great risk in fixing too short a limit. What would be the moral effect of taking a
patient away from the reception hospital and putting him among the incurable ?

I should think that three months at least would be a fair time to give a doubtful
case before one could say that removal is justified.

Dr. Brush (who was invited to speak by the President, and was received with
applause) gave an interesting account of his visit to the German clinics, and
of the efforts that are being made in the United States to deal with incipient and
transient mental disorders.

Dr. Savage. —This is, after all, a reversion. Guy’s Hospital had after my time
two wards for the reception of lunatics. The late Sir William Gull was super¬
intendent. Sir William himself thought it was a mistake that thev had been done
away with. The wards at Guy’s are still open from time to time tor the reception
of patients of this class, but the patients we see at Guy’s had better not be
there. Patients suffering from alcoholic or nervous troubles when sent to the
strong ward are not being treated in the proper way. I would rather see them in
the asylum. This question ought to be considered calmly and coolly. Admittedly
there are a number of patients who, in the earlier stages of mental disorder, may be
treated in the general hospital or at home. If their homes are not good enough,
let them be treated in some hospital attached to the general hospital rather than in
the general hospital itself. The advantage to students and to medical science
would be very great, but much has to be sacrificed for the good of patients. For
many of these patients rest in bed would be very useful, but it should not be rest
in the city. I do not think that rest in Smithfield or in the Borough is the best
treatment for patients who are emphatically run down and in want of hygienic
surroundings. How is the hospital treatment of mental disorders to be carried
out ? There are three courses: special wards in a general hospital, special hos¬
pitals attached to a general hospital, reception hospitals for acute cases. The
latter course appeals to me more strongly than wards in a general hospital. One
feels that in the reception hospital for acute cases at Morningside these patients are
treated in the best possible way. I do not stand in the way of experiment, but in
general hospitals such cases would have to be treated with all caution. For instance,
if patients break into mania, you must restrain their liberty. Then at once you are
beginning to interfere with a very grave principle. If, on the other hand, patients
are suicidal, you must take precautions; and precautions turn the hospital ward
into an asylum under rather inconvenient conditions. I would therefore watch
the experiment with great pleasure; but if asked if I advised it, uncompromisingly 1
would say no.

Dr. Davidson. —I fully agree with Dr. Clouston that it would be a great advan¬
tage to impress upon the public that asylums for the treatment of mental cases are
not gaols, but hospitals. I am in favour of the suggestion of a special ward in a
general hospital. I do not think that this necessity is limited to the poor. It
applies to the middle class who cannot afford a separate house and separate nurses
and attendants. Dr. Savage speaks of the proposal as a reversion. I thought the
old arrangement in the Royal Infirmary, Liverpool, a very good one. There was
a small ward called the “ D. T.” ward, No. 10. Acute cases were put in there—
many of them alcoholic, but others not so. The difficulty at the present day is
that the committees of hospitals have no enterprise. They do not want to be
bothered with troublesome cases. Personally I would limit the treatment of mental
cases in a general hospital to two or three weeks. If they are not going to get
well at once, put them into the charge of proper specialists.

Dr. McDowall. —We all seem agreed as to the desirability of having these
special wards, but it is evident from the discussion that there is much variety of
opinion as to the details. Many years must elapse before what Dr. Clouston has

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yo 6 INCIPIENT AND TRANSIENT MENTAL DISEASES, [Oct.,

suggested can be carried out. Meanwhile we ought to do our best to educate the
profession and the general public regarding what we consider best both for our
patients and for students and medical schools. I have attempted at Newcastle, in
connection with the medical school there, what Dr. Rayner has accomplished at
St. Thomas’s. The managers have opened an out-patients’ psychological
department. I go every week to Newcastle and see a limited number of people.
I have had one or two gratifying cases of melancholia. If we can get men in
charge of county asylums to establish psychological departments in adjacent towns
and t?ke the trouble to deal with patients in an out-door department, although only
a small beginning, it would bring us back to the hospital treatment of disease, and
by associating us with the ordinary hospital staff would gradually instil into the
professional and public mind the great benefit of having specialists in mental
diseases permanently attached to hospitals with special wards for the treatment of
these cases.

Dr. Mould. —For a number of years I have been in the habit of seeing cases
among poor people, and of advising them. There is not the slightest doubt that if
this could be done in association with the out-patients’ department of large
hospitals, and suitable cases sent not into hospital, but to places where they could
be treated outside asylum life, much good would result. Most of the cases which
have come under my notice in this way have been simple melancholia, as a rule
suicidal or on the borders of suicidal melancholia. We have a difficulty in recom¬
mending a patient who is in that condition to be treated outside an asylum. But
we might do it by adopting the German system described by Dr. Brush. Among
the richer class we have many cases which place themselves voluntarily under care.
One eighth of the patients in our asylum are not certificated at all. You could
have little colonies associated with asylums. In an out-patients' department the
advice of an able and experienced man at once relieves the pressure of anxiety on
patients and their friends. It would be of immense benefit to poor people if they
could be sent from an out-patients’ department to little colonies in the country. I
am convinced you cannot successfully treat these patients in a large general
hospital. Anything more dreadful than lying in bed near a high window which
you cannot see out of I do not know. Fifty years ago they had these wards in the
Manchester Infirmary, but since then the cases were transferred into the country;
and the colony has been a flourishing institution ever since. There are between
thirty and forty houses. Many of the patients are not certified.

Dr. Urquhart. —It is not easy for us, having not only a professional bias but a
specialist bias as well, to detach ourselves from our ordinary asylum functions and
ideals. Let us, however, in discussing this question, depart from asylum methods
altogether. The proposal is that if a person is in slight degree out of health
mentally and physically, he should be immediately skilfully treated and restored
without the apparatus of asylums if possible. We had from Dr. Mott to-day a
most instructive paper which offers us a scientific basis for our opinions. If
you look back over the asylum reports of the last century, you will find their
authors continually appealing for early treatment of insanity. They formed their
eclectic opinions, which are now reinforced by the acknowledged and recorded
effects of fatigue, the effects of toxins, etc. Let us face the fact that people do not
want to go to asylums—nobody wants to be certified, nobody wants to be a
voluntary patient in an asylum. The proposal is not one to interfere with the
appropriate uses of asylums, but to deal with patients whom, granted adequate
medical treatment, we never wish to see in asylums. If one cannot make up his
mind after six weeks’ observation of a patient whether he ought to go into an
asylum or not, the specialty has sunk to a low ebb of usefulness. A few days
should generally determine the question. The physician who cannot predict with
some degree of certainty is of little avail in practice. If these wards are provided
in immediate connection with general hospitals, the specialist physician in charge
should have every help from the dentist, the ophthalmic surgeon—from everybody
working for the amelioration of disease. We want the best that the hospitals can
give us, and we want it promptly.

Dr. Hyslop. —In recent times this subject has been approached in a very different
manner. A special committee was some years ago, as the Association may
remember, appointed by the London County Council to consider the treatment of
acute cases. Of the members of that committee not more than one or two knew

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BY T. S. CLOUSTON, M.D.

1902.]

707

anything about mental diseases, and of those who gave evidence some knew some¬
thing about mental disease and had visited asylums, others knew little or nothing.
As the result of that inquiry a report was printed which, as an example of fatuity,
was perfect. On the strength of that report I believe .£100,000 was voted by the
County Council to build a hospital for the treatment of insanity. Soon afterwards,
however, people began to dissect the matter, and they soon recognised that the
report was worthless. In f ,the report the argumentum ad hominem was resorted
to—they attacked the asylum physicians. They first assumed that mental disease
was based on physical conditions simply and solely, and that every case had some
physical disorder requiring hospital treatment. Of course the venture proved a
fiasco. It is to be hoped, however, that, approached as the subject has been to-day,
we shall arrive at some definite conclusion backed up by soundness of opinion. When
I saw that this subject was to be dealt with I took the liberty of issuing a circular
to the hospitals in London and the larger hospitals in the provinces. The circular
was as follows:—**A discussion is to be opened by Dr. Clouston on July 25th
at the Annual Meeting in Liverpool of the Medico-Psychological Association upon
the treatment of transient and incipient insanity in the wards of general hospitals.
The question is a burning one in Scotland, and many of our leading authorities
are taking part in the discussion. May I venture to ask you to answer the follow¬
ing questions ?—(1) Have you an out-patient department for mental diseases at
your hospital ? (2) Would your hospital authorities be disposed to equip a

department for the clinical investigation, care, and treatment of cases of insanity
in their early stages and not certifiable as insane ? (3) How are your cases of
mental disease disposed of at present ? (4) Have you on your staff an expert in

lunacy to refer to in cases of insanity P” All who have answered appear to me to
solicit further information. In two places they say they have the subject under
consideration, and if I can furnish them with data, more especially in regard to
the discussion, they will consider it at their autumn meetings. If any good is to be
done in this matter, it will not be done by condemning the knowledge of general
physicians—we seek their help as they ought to seek ours. I think each general
hospital in connection with a medical school ought to have an efficient alienist
attached to the staff, and each school ought to afford sufficient opportunities for
instruction in mental diseases. At Bethlem, which is a hospital for acute cases,
we have nearly the ideal condition which Dr. Clouston has indicated. We have
not only our own staff, but also the advantages of being able to consult outside
physicians. We also have our own dentists, and so on. As to the patients who
come to Bethlem, our experience is not quite the same as in the north. Patients are
often anxious to go there as voluntary boarders, and we find the only patients we
require to send away to general hospitals are those who fear the stigma of a
hospital for the insane. These usually turn out to be cases of simple hypochon¬
driasis or simple insomnia. I believe that 80 to 90 per cent, of our cases are cases
which have become insane from want of proper treatment in the earlier stages of
insomnia. To some of these cases I think general hospitals might be more lenient
and open their doors. As a rule they are loth to devote a bed to a patient who
simply fails to sleep at nights. They feel that in doing so they would be misapply¬
ing their funds, and, as you know, the struggle to get funds is very keen. I believe,
however, that if we join hands with the physicians and surgeons in an honest and
friendly way, we can conduct the campaign—for it is going to be a campaign—
with'more success than hitherto; and even though we do not obtain hospitals on
the lines laid down by Dr. Clouston, we shall nevertheless have done good and
have made an attempt to benefit humanity.

Dr. Bruce. —The treatment of mental diseases in general hospitals is advisable
for three reasons. Firstly , the present asylum system is not preventive. The
insanity in the country is not decreasing. The system is good as far as it goes,
but we want something better. Secondly , we want opportunity to observe our
patients. Thirdly , and probably most important, we must educate the medical pro¬
fession as to what insanity is before we can educate the public. The more you
come into contact with the general physician the more you are convinced that his
knowledge of insanity is absolutely nil. The teaching of insanity is bad. The
men are good enough, the lectures are good enough, the system is altogether
wrong. A student listens to most excellent lectures, he is taken to see clinical
cases. That is not enough. He ought to see the case from day to day whenever
XLVIII. 49

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708 incipient and transient mental diseases. [Oct.,

he likes, just as you see your cases at a general hospital. Until that is done I do
not believe you will get the ordinary general practitioner to know what insanity
really is. To Dr. Clouston’s ideal hospital I would add an out-patients’ department,
and urge that it is the most important of all, because if we get out-patients’ depart¬
ments, it will not be long before we get wards ; but do not lay down any limit of
time, leave it altogether to the discretion of the physician. If you wish to make
observations, let the patient remain on for two years if necessary.

Dr. George Robertson. —In this Association there are differences of opinion
as to how practical difficulties may best be overcome. Very likely one method
will not be found to suit all cases. Dr. Savage has suggested the possibility of a
separate receiving hospital, but I think he is slightly mistaken as to the class of
cases to which Dr. Clouston desires to apply this special form of treatment. I do
not gather that Dr. Clouston wishes to prevent cases goingto asylums which would
be better for asylum treatment. What he urges is that for cases which can be
cured without being sent to asylums there should be a means of treatment outside
asylums—that is treatment in the wards of general hospitals. The cases described
by Dr. Savage are not cases which ought to be treated in general hospitals. If
you had a special hospital for asylum cases, the mental wards in the general
hospital would not be likely to be regarded as part of an asylum, and patients would
not have the same hesitation in going into them. The treatment of mental cases
in general hospitals is, in the first place, very different from the plan followed in
asylums. The patients are much more commonly treated in bed, and, in my
opinion, rightly so. The next point of difference is that in asylums it has been
the custom to have numerous single rooms for special cases. I would say the
reason is defective supervision at night. If the night staff was increased to one
third the number of the day staff, there would be no necessity for single-room
accommodation, so that the treatment in asylums might approximate more closely
to the treatment in general hospitals. Only the other day I received a visit from
a Commissioner in Lunacy for Scotland who wished to know whether the asylum
was free from noise through having all the acute cases in dormitories instead of in
single rooms, and he reports that only one patient was talking, and that no patient
was making a noise. Thirdly, in general hospitals patients, male and female, are
managed by female nurses. That plan is being adopted in certain asylums. There
is really no difficulty in managing the vast majority of cases by that means. More
than six years ago I appointed a resident matron in the receiving ward of the
asylum, and put it entirely in charge of women. All cases passed through that
ward, and only a very small percentage were unmanageable. Now, if developed
cases can be managed by female nurses, incipient cases can be managed still more
easily.

Dr. Yellowlees.— I do not believe that a hospital ward is the best place for
cases of incipient insanity, or that these are proper cases for a hospital ward.
Such cases had far better be sent into the country. When consulted as to private
patients we advise that course frequently, and with success. A large number of
persons enter asylums as voluntary patients; but this scheme almost seems to
suggest that an asylum is a place by all means to be avoided. Have we not
been spending our lives in showing that asylums are merely hospitals for the
insane ? The proper place for truly incipient cases is a hospital for nervous
diseases where people could go of their own accord. There would be about such
hospitals none of the obloquy which attaches to a “ madhousewe should have the
help of their physicians, and opportunities of study for ourselves and our students.
In Glasgow we have that very thing in operation for pauper patients. The parish
of Glasgow has a population of 540,000. They have two asylums in the country,
and in the city a Reception hospital, which is an ideal arrangement. There the
new and incipient cases, unless they are obviously severe, are received and treated
for a short period, and the expense of transferring them to an asylum is often
saved, for many cases recover in two or three weeks. I am earnestly in favour of
that part of Dr. Clouston’s proposal, and if county councils knew what was good
for their patients and for their rates they would establish such places. I believe
that we as an association could do much to promote their establishment.

Dr. Urquhart.— May I ask Dr. Yellowlees one question? Has he not always
done his best to keep patients out of asylums ?

Dr. Yellowlees. —Most certainly, if it was good for them to be kept out.

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1902.] MEDICO-PSYCHOLOGICAL STATISTICS.

709

Dr. Nathan Raw said that he entirely agreed with what Dr. Yellowlees had
said. Referring to this question as it affected Liverpool, he said that he would like
to see established a reception house for mental diseases of all forms where patients
might be treated and kept under observation for a limited period. He considered
that the necessity for such an institution was abundantly proved by the fact that
during the last five years in the Mill Road Infirmary in the cases of no less than
1006 patients who had been certified as insane the mental symptoms had quite
disappeared in periods under seventeen days.

The President. —I am not in favour of treating cases of insanity in a general
hospital, except those acute cases which would get well in four weeks. I would
shorten Dr. Clouston’s period of six weeks rather than extend it. If the case is
not to recover rapidly, it ought to be taken out of town. In that I agree with Dr.
Yellowlees. You get far more curative value in the country than in town hospitals.
My own idea is the establishment of clinics like those in Germany, only I
would have them outside the town not only for mental cases, but for all forms of
nervous disease. I would make them places which it would be no stigma to enter,
and the superintendent a professor in the university, who should have sufficient
assistants to deal with the cases which came in. I think we could do much more
good on those lines than by establishing mental departments in our general hos¬
pitals. Such clinical hospitals ought not to be far out of town, a few miles at
most.

Dr. Clouston. —I desire, sir, merely to add that my object in bringing this
question forward has been amply fulfilled by the thorough, kindly, and most
vigorous discussion that has taken place. Whatever the issue, I am certain this
discussion will do good. I hope that when we meet next year the experiment will
be actually at work in the wards of the Royal Infirmary at Edinburgh.

Medico-Psychological Statistics : the Desirability of
Definition and Correlation with a View to Collective
Study . By C. Hubert Bond, D.Sc., M.D., Senior

Assistant Medical Officer, London County Asylum,
Bexley.

Introductory.

In many, the very word “ statistics ” rouses a feeling of dis¬
tinct repugnance or distrust. Repugnance, because not a few
people dislike this method of expressing information, which
indeed is not to be wondered at, bearing in mind that the study
of statistics is now a science in itself, and requires considerable
training to appreciate. Distrust, because it must be confessed
that deplorably misleading statistics have been frequently and
unblushingly set forth; this being either the result of ignorance
of certain statistical laws and fallacies, or owing to a proneness
possessed by some to be carried away by an apparently
happy “ working hypothesis,” and to then endeavour to make
statistics support their theory.

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710 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

The familiar sentence that “ statistics can be made to prove
anything ” is no doubt an expression of this unfortunate dis¬
trust ; but no greater libel could be uttered against any science.
As a matter of fact, the exact converse is the case. Statistics,
framed to give complete and not partial information, whose
every head-line is adequately defined, and in whose arrangement
the possibility of fallacy has been constantly borne in mind,
can only yield one thing, and that is Truth.

Preliminary Considerations.

A feelingthat more might be attempted .—Leaving generalisations,
and turning at once to the subject-matter of this paper, it would
appear desirable to say a few words with regard to a growing
feeling of dissatisfaction as to the present form of the tables of
our Association ; a dissatisfaction which is probably shared by
most here present to-day, which is surely a healthy one, and
one that reflects no discredit on the tables themselves or bn
their original framers. Opportunity, too, is here taken to
earnestly disclaim, in the following suggestions and remarks,
any intended destructive criticism of the previous efforts of
others. Were it necessary to say anything in defence of the
twelve tables now in use, a remembrance of the fact that they
have not only held their own for well-nigh forty years, but
have also received practically universal adoption in every
British asylum, would be a weighty enough testimonial on
behalf of them and the efforts of those who originated them.
Indeed, were the latter here to-day, it is certain that they
would be the first to welcome and support any changes or
extensions which had progress and the furtherance of truth as
their goal. Moreover a reference to vols. xi and xiii of the
Journal of Mental Science will demonstrate that the system of
tables now in use was never intended to be final; indeed,
the five tables which follow No. VI were framed at a later
date than the first six, at subsequent meetings of the same
committee, and were launched largely owing to the favour
which their predecessors had found.

The very circumstance that the tables have existed undis¬
turbed for over thirty years—during which time progress in
many directions has been made, certain facts have come to be

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BY C. HUBERT BOND, D.SC., M.D.

7II

1902.]

looked at in new lights, and fresh questions have been constantly
demanding elucidation—is almost of itself a mandate that we
should at least meet and discuss whether our present means of
tabulation are capable of bearing their increased burden. If
further plea for the pertinence of this paper be needed, the
Editorial in the January number of the current volume of the
Journal of Mental Science may be cited.

The information at present supplied by the Association Tables .—No
doubt we all possess a fairly clear mental picture of the tables
as at present annually compiled, but as the points of informa¬
tion they supply number over fifty, a tabulated statement of
them will probably facilitate reference.

Points of Information from Tables in their Present

Form.

The Movement of the Institution’s Population,
a. During the current year.

Table I.—

1. Differentiating between “first admissions” and “not first admis¬

sions.”

2. Total cases under care during the year.

3. Cases discharged— (a) recovered; (b) relieved; (c) not im

proved.

4. Deaths.

5. In asylum on January 1st and remaining in on December

31st, current year.

6. Average number resident during the year.

b. From opening of asylum to end of current year.

Table II.—

7. Total admissions since the opening—differentiating between

“ persons ” admitted and “ readmissions.”

8. Total cases discharged since the opening— (a) recovered; (b) re¬

lieved ; (c) not improved.

9. Total deaths since opening.

10. Remaining in on December 31st, current year.

Table III.—

11. Admissions (not differentiated) for each year since the opening,

with total.

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712 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

12. Discharges for each year since the opening, with totals, differen¬

tiating between recovered, relieved, and not improved.

13. Deaths for each year since the opening, with totals.

14. Remaining in on December 31st each year since opening.

15. Average number resident during each year, and for whole period

since opening.

16. Percentage of recoveries on the admissions for each year for the

whole period since opening.

17. Percentage of deaths on the average number resident each year,

and for whole period resident since opening.

c. The current year's history of each year's admissions since the opening

of the asylum .

Table IV.—

18. The admissions during each year, differentiating between “new

admissions ” and “ readmissions.”

19. Of each year’s admissions the number discharged recovered

during current year.

20. Of each year’s admissions the number discharged relieved during

current year.

21. Of each year’s admissions the number discharged not improved

during current year.

22. Of each year’s admissions the number died during current year.

23. Total discharged recovered, of each year’s admissions, on Decem¬

ber 31st, current year.

24. Total discharged relieved, of each year’s admissions, on Decem¬

ber 31st, current year.

25. Total discharged not improved, of each year’s admissions, on

December 31st, current year.

26. Total died, of each year’s admissions, on December 31st, current

year.

27. Total remaining of each year’s admissions on December 31st,

current year.

The Character of the Admissions, Discharges, and Deaths
during Current Year, and of Patients remaining in on
December 31ST.

Table V.— The causes of death for the current year.

28. Causes of death—one cause only ascribed to each case.

29. Ages at death in quinquennial periods.

30. Total number of cases, males and females, in which P.M. exami¬

nations were held.

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-M.

1902 .] BY C. HUBERT BOND, D.SC., M.D. 7 1 3

Table VI.—

31. The length of residence of those discharged recovered, and

of those dying during the current year. Arranged in
periods increasing from “ under one month ” to quinquennial
ones.

Table VII. —The duration of the mental disorder on admission, first
attack cases or otherwise being differentiated.

32. Within three months on ad-'

mission, and a first attack.

33. Above three, and within

twelve months, and a first
attack.

34. Less than twelve months,

and not a first attack.

35. Over twelve months, and

attack not differentiated.

36. Congenital.

Table VIII. —The ages in quinquennial periods of those during
current year.

37. Admitted.

38. Discharged recovered.

39. Discharged relieved or otherwise.

40. Died.

41. Remaining in on December 31st.

42. Mean age of;— (a) admissions; ( b) recoveries; ( c ) other dis¬

charges ; (d) deaths; (e) those remaining in on December
31st.

Table IX. —The civil state of the—

43. Admissions during current year.

44. Discharges recovered during current year.

45. Discharges relieved or otherwise during current year.

46. Deaths during current year.

47. Of those remaining in on December 31st.

Table X. —

48. The probable causes of insanity in the admissions during the

current year.

Table XI. —The form of mental disorder—

49. On admission in the admissions.

50. On admission in the recoveries.

51. On admission in the deaths.

1. Admissions.

Each 2. Discharged recovered,
"in the"

3. Discharged relieved or

otherwise.

4. Deaths.

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714 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

52. On December 31st, current year, of those remaining in on that

date.

Table XII.—

53. The occupations of those admitted during the current year.

The advantage of deleting repetitions .—An examination of the
above summary will readily show that several of the fifty odd
items occur in more than one table. 0)

It will probably be a profitable subject for consideration, in
any contemplated revision of our tables, if some of these
repetitions of figures could not with advantage be eliminated.
Space might be found for the inclusion of others which
experience has shown are of value.

The necessity for adequate definition .—It would be necessary
also to carefully consider whether the headings of the above
items as they appear in the tables are at all ambiguous;
whether more than one interpretation can be placed upon the
information expressed by each; in other words, is each pro.
perly defined ? Failing which, any attempt at collective study
of tables from several or every asylum is obviously rendered
absolutely futile. That dual interpretation is in several
instances unfortunately possible must, it is feared, be con¬
fessed. This is clearly demonstrated by consulting the various
asylum Annual Reports. From some two dozen of these
that happen to be at hand the following table has been
compiled. In it are set forth several additional points of
statistical information given at certain asylums, together with
some important variations in the form of some of the tables.

Additional Points of Information given in the Annual
Reports of certain Asylums.

1. Patients admitted in the current year who had previously been

in any asylum.

2. Number of admissions excluding double entries (*•£., criminal to

pauper list, lapsed orders, etc.).

3. Number of informal admissions, expiration of order, etc.

4. Admissions differentiated in Table I. into Private, County, and

Out-county.

5. Persons, distinct from cases, admitted during the year.

6. Persons, distinct from cases, recovered during the year.

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1902.]

BY C. HUBERT BOND, D.SC., M.D.

715

7. Persons, distinct from cases, under care during the year.

8. Transfers from this asylum during the year.

9. Transfers to this asylum during the year.

10. Percentage deaths on total number under treatment during the

year.

11. Percentage recoveries on total number under treatment during

the year.

12. Percentage recoveries on average number resident during the

year.

13. Percentage recoveries on admissions, deducting transfers during

the year.

14. History of recovered persons —

a . Admitted since opening of asylum.

b. Percentage of whom discharged recovered.

c. Percentage of latter readmitted relapsed.

d . Leaving recovered not relapsed.

e. Relapses discharged recovered.

/Net recovered persons .

g. Latter expressed as percentage on total admissions since
opening.

15. The same as “ 14,” excluding transfers from other asylums.

16. Percentage of persons relapsing during twelve months from

recovery to total recoveries since opening or for a period of
years.

17. Table of previous attacks :

a. The number of admissions who have had one, two, three,

four, or more attacks.

b. Number of times these cases had recovered—(1) in this

asylum; (2) in any asylum.

18. Length of time after discharge at time of readmission.

19. Age on “first attack” of the admissions, in decennial periods,

commencing with congenital.

20. Age on “ first attack ” of the admissions—“ new cases ” and “ re-

admissions ” differentiated.

21. Ratio of the admissions per 1000 of the general population,

according to parishes.

22. Education of the admissions—good; fair; can read and write;

can read only, etc.

23. Religious persuasion.

24. Prognosis on admission.

25. Curable cases on the books on December 31st.

26. Causes of death partially correlated, e. g., “ Epilepsy and

Phthisis,” etc.

27. Length of residence of those remaining in on December 31st.

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716 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

28. Periods of length of residence diverse from those in Table VI.

29. State of bodily health of the admissions—these sometimes pri¬

marily divided into epileptics, general paralytics, and other
cases.

30. State of bodily health of the admissions—dividing them primarily

into those “in indifferent health” and “in bad health and
exhausted,” and detailing a list of bodily abnormalities
found.

31. Causes of insanity in the recoveries and deaths, as well as

admissions.

32. Causes of insanity in the admissions more or less correlated in

certain groups.

33. Causes of insanity in the admissions, correlated with “here¬

dity ” and “ prior attacks.”

34. Heredity table—differentiating degree of relationship in detail.

35. Form of mental disorder:

a. All setiological varieties omitted.

b. The word “recent” substituted for “acute,” and defined as

being within twelve months.

c. The word “subacute” introduced.

d. A certain degree of correlation between epilepsy and the

symptomatological varieties.

e . General paralysis and epilepsy omitted from the list of

symptomatological terms and correlated in side columns.

36. Table of suicidal propensity :

a. Attempted.

b . Meditated.

c. Forms of insanity in both “a ” and “ b”

d . Means adopted in both “ a " and “ A”

37. Record of epileptic fits:

a . Number of fits each month—males, females, total.

b. Number of epileptic patients under observation each month.

c . Proportion of fits to each patient.

d. Daily mean number of fits.

e. Greatest number on any day.

/. Least number on any day.

38. Monthly incidence of admissions, discharges, and deaths.

To cite one or two examples from this list, the first item,
“ patients admitted who had previously been in any asylum,”
shows that, as regards Table I, there has been a doubt in the
minds of some whether “not first admissions” refers to the
particular asylum or to any asylum. And in like manner

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BY C. HUBERT BOND, D.SC., M.D.

717

1902.]

item 9, “ patients transferred from other asylums/* is evidently
an addition found necessary because the figures representing
the year’s admissions are not defined as including transfers or
not. It would be tedious, and it is needless at the moment, to
multiply these examples further. It will suffice to say here
that even if no other reforms were agreed upon, it would
materially enhance the value of our tables if the scope of the
word “admissions,” occurring as it does in ten out of twelve,
were clearly defined, particularly as to whether or not transfers
are included. The number of cases transferred from asylum
to asylum at the time the tables were framed was probably not
nearly so great as is now the case. From the last annual
return of the Lunacy Commission it will be seen that, of the
total admissions—using the word in its widest sense—into
county and borough asylums of England and Wales, no less
than 11 per cent, were transfers. The inclusion of these into
the tables dealing with the age on admission, civil state, cause
of mental disorder, etc., practically nullifies these for scientific
purposes. For instance, their inclusion into the cause table
falsely raises the percentage of those causes that are least often
followed by recovery, and lowers the percentage of those which
are most favourable as regards recovery. It is here suggested
that the word “admissions,” unqualified by any limitation, be
taken as including every case, transferred or otherwise,
regularly or irregularly, admitted, and that the admissions be
subdivided according to the subjoined table.

Admissions.

I.—a. Recent cases— that is, have not been admitted into any other
institution or to single care, on present reception order.

i. First admissions —that is, have not been previously cer¬

tified as insane.

ii. Not first admissions —that is, have been previously cer¬

tified as insane, and have been discharged, recovered,
to care of friends or otherwise relieved.

a. Previously in this asylum.

b. Previously in this or any asylum.

b. Transferred from other asylums, registered hospitals, licensed
houses, or single care.

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718

MEDICO-PSYCHOLOGICAL STATISTICS,

[Oct.,

c. Due to expiration of Order , 53 V., c. 5, s. 38.

d. Informal admissions . — Transfers from criminal and private

class to pauper register, second reception orders necessary
through irregularity in first one, etc.

II.— a. Private eases.

b. County eases.

c. Out-county cases.

It would be a point for deliberation as to how many and
which of these sub-classes of admissions should be included in
any particular table. Some suggestions as to this will be
thrown out later. It cannot, however, be too strongly urged*
in order to avoid fatal confusion, that, whether or not the
recent cases are subdivided into “ first ” and “ not first ”
admissions, they at least be clearly separated from transfers.

The desirability of correlation .—Before passing to a considera¬
tion in detail of each of the twelve tables, there is one other
general matter that should be touched upon—one which, if
approached on broad lines and with uniformity, may probably
yield results of the utmost value. It is the desirability of
endeavouring to correlate our channels of information. An
example will more quickly render apparent what is meant by
this than any extended exposition. Thus to see from Table X
that of the female cases, an insane heredity was present in
27 per cent., childbirth was the factor in 6 # 6 per cent., and
13 per cent, occurred during adolescence, is no doubt a state¬
ment of three very important facts in the aetiology of the
admissions; but to be able to correlate these three factors,
and to further state that there was an insane heredity in
50 per cent, of the childbirth cases, and 34 per cent, in the
adolescent cases, and that 38 per cent, of the childbirth cases
occurred during the period of adolescence, and so on, is to
make a statement that is tenfold more valuable. It is also a
mode of dealing with aetiological factors, going far to rob them
of a fallacious standard of value, which, from figures one often
sees quoted in lay reports and newspapers, is only too often
apparently ascribed to them. To give one more example of
this aim at correlation, Table XI, setting forth the form of
mental disorder (on admission) in the admissions, discharges,
and deaths, is no doubt very valuable, as is also the age in
quinquennial periods (from Table VIII) of the admissions.

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1902.] BY C. HUBERT BOND, D.SC., M.D. 719

discharges, and deaths; but again their value would be in¬
creased tenfold if these two channels could be combined,
enabling us, for instance, to make such a statement as that, of
the cases of acute mania which ultimately died, so many were
aged, say, forty and under forty-five. And if in addition to
this we could further indicate in the table that of these cases
in this quinquennial period so many were aged twenty and
twenty-five on first attack, etc., the value of our statement
would surely go up a hundredfold.

The Tables considered seriatim.

The ground has now to be cleared sufficiently to permit
of each table being taken up in turn, and a few observations
made as to the utility of each, with some suggestions whereby
perhaps that may be increased.

Tables I, //, and III .—It will be convenient to refer to these
together. They deal chiefly with the annual movement of the
institution’s population. That for the current year is dealt
with in Table I; Table II gives a summary of the annual dis¬
charges and deaths since the opening of the asylum. In both
the admissions are subdivided, but although corresponding
figures are implied, different subdividing words are used, which
is unfortunate. Also the terms used—“ first admissions,” “ not
first admissions,” and “ readmissions ”—are not defined as to
whether they refer to that particular asylum or not. Table III
gives much the same points of information, but for each year
since the asylum’s opening. Each column in it is totalised, so
that the totals appearing in Table II are repeated in Table III,
with the exception that in the latter the admissions are not
subdivided. In neither table is any account taken of transfers;
their number cannot be found, nor is it stated whether the
figures expressing the admissions include them or not (as a
matter of fact they always are included). Table III also gives
the percentage for each year of the recoveries on the admissions
and of the deaths on the average number resident. With
regard to the former percentage, again it is not stated whether
transfers are included—obviously a most important fact to define,
and one which nearly every asylum does define, or else gives the
percentage with and without their inclusion. It is difficult to
see the possible value of such a percentage if transfers are

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720 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

included, therefore it would be well to always exclude them and
to say so.

Methods of calculating the recovery rate .—Here is probably the
proper place in this paper to say something further upon this
method of expressing the recovery rate. The question is a
most important one, for what more common question do we
have addressed to us by lay persons than “ how many of your
cases recover ? ” Many hard things have from time to time
been said about this mode of calculating recoveries. Some of
them are probably justified, but the Commissioners in Lunacy
and most superintendents appear to retain their faith in it, and
there does appear to be little doubt but that, given a fairly
stable rate of admissions (recent cases), the proportion of
recoveries calculated in the above way often remains very con¬
stant. There are several circumstances, however, which, if
they occur, can easily falsify the resulting percentage. As
stated in the above paragraph, transfers are almost invariably
excluded from the admissions, but it appears to be usually the
practice to include in the total recoveries any which take place
among transfers ; so that obviously, if the transfers happen to
be comparatively recent cases, the recovery rate for purposes of
comparison with other institutions will be fictitiously high. The
exclusion of transferred cases from both the admissions and
recoveries would be the remedy for this source of fallacy. The
recovery rate for asylums for districts which happen to have a
great centripetal tendency—for instance, London—is apt to be
lower than it otherwise would be, owing to the number of cases
which are adjudicated and removed before they have time to
recover. The difficulty would be met by excluding from the
admissions all recent cases adjudicated and removed to their
proper parishes within, say, nine months of their certification,
and adding to the admissions (recent cases) all transfers whose
reception order was less than nine months old at the time of
their transfer. Some asylums also give a recovery rate based
on the total number of cases under treatment or on the average
number resident, sometimes on both of these bases. To clearly
grasp the precise value and scientific accuracy of either of these
three modes of stating the recovery rate is by no means easy.
The whole root of the matter, however, appears to lie in an
ability to gauge the character of the population of any indi¬
vidual asylum from a recoverability point of view; the popu-

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1902.]

BY C. HUBERT BOND, D.SC., M.D.

721

lation for present purposes being those remaining in on
December 31st of last year, and those admitted during the
current year, in other words, the total number under care during
the year. If the length of residence of those discharged
recovered, as given in Table VI, be examined for a large number
of asylums (county, borough, and private), and averages of the
results be taken, it will be found that roughly, but to a fairly
accurate degree, of every 100 recoveries, 5 take place under one
month’s residence, 20 after one month and under three months,
30 after three and under six months, another 20 after six and
under nine months, 10 after nine and within twelve months, and
another 10 after one year and under two years ; the remaining
5 per cent, are scattered irregularly over longer periods. With
these data, if the length of residence or still better the duration
of the reception order of those remaining in on December 31st,
and the monthly incidence of admissions during the current
year be known, a mathematical recoverability of the total cases
under treatment during the year can be calculated. And it is
here suggested that this would be a safe and scientifically
sound basis upon which to state a percentage of recovery.

Tables /, 17, and III continued .—To revert again to the
contents of these three cables, it is manifest that one, arranged
on the lines of Table III, could without difficulty be framed to
express every point at present dealt with by the three. The
additional points, which so many asylums give as foot-notes or
otherwise, and which are of decided value, could easily be
included, and the opportunity would doubtless be taken to
secure complete definition of the points of information desired.
Considerable clerical labour and paper space would also be
saved. A suggested table drawn up with the above object is
here annexed.

Tables IV and VI .—These will also be conveniently con¬
sidered together. Table IV is elaborate, and involves no little
clerical labour. As expressive of the history of the annual
admissions of any individual asylum it is admirable; and when
that asylum happens to be free from old cases transferred into
it from other institutions it is also of real scientific value.
The same remarks apply to Table VI, except that it is a simple
one; practically the whole of its information is contained in
Table IV (but in a more accessible form), except that the current
year’s length of residence is in Table VI subdivided into five

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72 2 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

periods. But how rarely is it the case for an asylum to be free
from transfers! Their effect is that these two tables become
of only local interest, and it is impossible to try to draw any
deductions from a summary of the figures of all the asylums
grouped together. The remedy is patent: the year in Table IV
should not refer to the year of admission, but to the date of
the reception order, and in Table VI “ length of residence ”
should read " duration of mental disorder as judged by the
date of the reception order.” This, of course, would nullify
them from a local point of view. It is urged, however, that
wider interests should prevail, and that collective study should
be our goal. A compromise might perhaps be made—Table
VI remaining in its present form, while Table IV might be
amended as above suggested. To make it complete the
current year would have to be subdivided into the five periods,
“ under one month,” “ one month and under three,” etc. The
other alternative would be to state them in their present form,
and to repeat them according to the date of the reception
orders.

If Table VI were amended on these lines, a most valuable
addition to it would be a third column expressing the duration
of the reception order for those remaining in on December 31st.
Indeed, this would become a necessity if the recovery rate
were calculated as above suggested.

In passing it may be noted that, as regards Table VI, some
asylums still further subdivide the periods of length of resi¬
dence. This is well meant, but if care is not taken it may
prevent their table being compared and summarised with those
of others; for example, if six and under eight, eight and under
ten, ten and under twelve months are periods chosen, it
becomes impossible to refer to the period of nine and under
twelve months.

Table V relates the causes of death, and of necessity is a
very important one. In it the causes are now given in the
same order and terminology as set forth in the table of deaths
annually furnished by every asylum to the Commissioners in
Lunacy; but the age for each cause is given in quinquennial
periods instead of as a mean. No death table would of course
be complete without expressing the age at death, and both
these methods are useful; the two might with advantage
appear in the same table. In the Commissioners’ table the

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1902.]

BY C. HUBERT BOND, D.SC., M.D.

723

number of post-mortem examinations is asked for, for each
cause of death; this is a more complete correctory than
merely stating a total as is done in our Association table,
particularly for those asylums which have not been able to
secure a high proportion of these examinations. (As the
majority of asylums are able to secure at any rate much over
50 per cent., it would save figures if the column referring to
post-mortem examinations asked for the number of instances
opposite each cause of death in which one had not been held.)

It is not proposed to say anything about the classification of
diseases which has been adopted; it appears now to be very
satisfactory. But it is suggested that there are certain other
points in addition to the above that could, without difficulty
and with great value, be combined with the causes of death—
such, for instance, as the duration of the mental disorder
(judged, for the sake of definition, by the date of the reception
order). The duration of the causes of death themselves is
now demanded on the notice of death sent to the coroner, etc.,
and this information could also easily be incorporated in the
death table. Further, the monthly incidence of deaths is infor¬
mation well worth having, especially if this is particularised
for certain causes, e. g., colitis, other diarrhceal diseases,
phthisis and other respiratory diseases.

The value of these additions is probably, however, quite
subsidiary to that of an important proposed reform now to be
brought to your notice. When it has fallen to the lot of any of
us to prepare Table V, we no doubt have each been then puzzled,
in cases where more than one cause of death has definitely been
in operation, as to which cause should be returned; for, as you
are aware, the tabulation of only one cause is permissible.
Most of us will probably be willing to agree that the cases
where one cause alone brings about death are in the minority.
In the majority of instances there is at least a primary and
secondary (using these terms in a chronological sense) cause—
sometimes more than one of each. The Registrar-General
provides for these in the form of death certificate used by
every general practitioner. It must be admitted, however,
that there are times when it is by no means easy, indeed it
may be said to be a matter of great difficulty, to decide which
is primary and which is secondary. But such cases occur far
too seldom to seriously impair the value of an honest attempt
xlviii. SO

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724 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct,

to state the primary as well as the secondary cause of death.
For instance, a child with measles, dying of bronchitis as a
sequela, a case of diabetes succumbing to phthisis, a pro¬
tracted case of phthisis ultimately contracting and dying from
ulcerative colitis (asylum dysentery), are examples where there
is no room for doubt as to which was the primary and which
was the secondary cause of death. A more complicated
example would be the case of a patient in whom was a
syphilitic general arterio-sclerosis, who had symptoms of
Bright’s disease due to contracted granular kidneys (very
probably the result of arterial degeneration), who also had an
hypertrophied and fatty heart (explicable as secondary to the
kidney condition and the general vascular degeneration), whose
brain was in a state of marked general atrophy with many
small areas of softening (again easily explained by the state of
the vessels), and who ultimately died of oedema of the lungs
due to the failing fatty heart.( 2 ) Obviously the initial primary
cause of death was syphilis, and the final secondary one was
oedema of the lungs. Opinions may differ whether the arterio¬
sclerosis, the chronic renal cirrhosis, the cardiac hypertrophy
with fatty degeneration, and the cerebral atrophy with multiple
softenings should be returned as primary or secondary. In all
these examples no one will surely gainsay the fact that much
greater accuracy and figures of infinitely more value would
be obtained by some form of death table which would permit
of combinations of two or more causes of death being tabulated.
Failing that, some rules for our guidance as to which cause to
return are urgently needed. A table such as is indicated
above, and the value of which is confidently urged, has been
annually compiled at Bexley Asylum. A photograph of that
for the year 1901 is here produced, and from it Dr. Stansfield
in his Annual Report was readily able to give, among others,
such details as—

“General paralysis is responsible for 89, or 31 per cent, of the total
number of deaths, and of these 77 were males, representing 49 per
cent, of the total number of male deaths. The physical wrecks which
these people were on admission is strongly indicated when one examines
the table as to the duration of the disease as judged by the date
of the reception order. These figures are so remarkable that I here
give them in ecctenso:

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1902.]

BY C. HUBERT BOND, D.SC., M.D.

725

Males.

Females.

—

Under 1 month.

Over 1 and under 3 months.

>1 3 11 6 11

3 •••

11 6 „ 9 „

,1 9 »» 12

„ 1 year and under 2 years,

„ 2 years „ 3 »»

11 3 11 11 5 11

“ •••

11 5 11 11 7 11

It (general paralysis) was in combination with phthisis in 10 cases,
colitis in 5, and pneumonia in 4.”

Except the bare number of general paralytics, none of these
facts could have been obtained from the ordinary table.
Moreover on the right of this photograph of the table you will
see three columns of figures (male, female, and total); these
contain the actual figures which will be found opposite the
causes of death in the annual report to be published this year.
A glance at them will show that the more important all fall
short of the actual truth, with the exception of general paralysis
(because wherever it was in combination with other causes the
latter were neglected). Phthisis you can see, for instance, will
appear as a cause of death in twenty-five instances, while in
reality it was so in forty; and colitis will be recorded in fifteen
cases, while its true number should be twenty-four, etc. It is
here strenuously pleaded that every institution publishing a
table of causes of death could without difficulty adopt this
principle, and that the extra time and trouble involved would
be amply repaid by the knowledge that our labours expressed
to the best of our ability the whole truth, and not merely
fragments, the quotation of which might easily lead to most
fallacious deductions. ( 8 ) The fact that the total of the figures
opposite the various death causes would not agree with the
total number of deaths should not weigh against the adoption
of such a form of table, any more than does the same fact in
the case of Table X dealing with the causes of insanity.

Tables VII , VIII , IX, and XII refer respectively to the
duration of the mental disorder on admission; the ages of the
admissions, discharges, deaths, and those remaining in at the
end of the year; the civil state of the same; and the occupation
of the admissions. They are grouped thus together because it
is not proposed to say anything lengthy as to any of them, and
because as regards the admissions one radical flaw is common

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726 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

to each of them. This flaw has already been emphasised on
page 717 and has reference to the confusion of recent cases with
transfers. That the two classes should be sharply distinguished
is practically non-controversial, and it would materially increase
the scientific value of the tables if asylums saw their way to sub¬
divide the recent cases as suggested on pages 717 and 718. The
transfers, indeed, might be altogether omitted from the admis¬
sions in these four tables. But if they are included, it should
be defined in Table VII whether the duration of the insanity
prior to admission does or does not in their case embrace the
period of residence in the asylum whence they have been
transferred. And in this table there should be some marginal
guide as to what is implied by the word “ congenital;”
presumably the figures here should tally with the congenital
cases in Table XI, whereas it is seldom they do so. Table VIII,
dealing with the ages, if amended to exclude or at least separate
the transfers, would be a most valuable one as it otherwise
stands. But we shall all agree that it could be made in
finitely more so if the age at commencement of present attack
and the age on first attack were also indicated; this could
easily be arranged by giving three lines, instead of one,
to each quinquennial period. As regards the admissions
(transfers excluded), these two new rows of figures would of
course usually be practically identical with those in the present
single row. Table IX expresses the civil state; whether it has
been or can ever be productive of value commensurate with
the labour of its production is doubtful. Its chief value would
be probably retained if it were allowed to refer only to the
admissions; and there again its utility could be much enlarged
if certain other facts were correlated—such as the age in three
or four broad epochs, and, in the case of the widowed, the
duration of the widowhood. If the table remains in its present
form, the words “ on admission ” should be added in reference
to the discharges, deaths, and those remaining in on December
31st. There is little to suggest with regard to the table (XII)
of occupations of the admissions. It would be worth while as
regards “ housewives ” to endeavour to subdivide these accord¬
ing to the occupation of the husband ; a line would have to be
retained for “housewife, undifferentiated,” where this infor¬
mation was lacking. Then a large proportion of asylums now
supply an education table; and it is possible for its contents to

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1902.] BY C. HUBERT BOND, D.SC., M.D. 727

be easily and with advantage correlated with the occupations,
by introducing such columns as “ University,” “ College,”
“Private,” “Board,” “Can write only,” “Can read only,”
“ Can do both,” “ Can do neither.”

Table X . The causes of the insanity among the admissions .—
In all diseases, if we wish to do something more than treat
symptoms, if, in other words, it is desired to really cure the
disease , it is of paramount importance to have the fullest
possible knowledge of its aetiology. Viewed from this stand¬
point, this table must take precedence of all others, and it is
certainly one upon whose preparation no pains should be
spared and no labour grudged. Of all others, it is the one
whose figures are most likely to be, indeed are most frequently,
quoted by lay writers in newspapers and elsewhere; and there¬
fore they should not only be reliable, but admit of no misinter¬
pretation, particularly of no exaggeration. Does the table,
valuable as it is, meet these requirements in the present form ?
Probably few would say that it does. Take, for instance, the
figures purporting to state the cases due to alcoholic excess
(these are probably the ones we see most frequently quoted);
and to reduce these to a concrete example, it may be seen that
of last year’s admissions to Bexley Asylum (transfers excluded)
there were 181 cases, or 24 per cent., associated with alcoholic
excess. Now we all know that it is seldom only one cause is
found, but in its present form there is no means of ascertaining
from the table in how many instances any individual cause
acted alone, or, when not alone, with what other causes it was
combined. As a matter of fact, of the 181 instances stated to
be due to alcohol, there were only three in which no other
cause was associated. Thus, should this percentage of twenty-
four happen to be publicly quoted as expressing the true role of
alcohol as an aetiological factor, the uncomfortable feeling
arises that one is responsible for the dissemination of state¬
ments which cannot bear strict investigation. No endeavour
is here being made to champion the cause of alcohol—in truth,
its far-reaching effects are very difficult to state in figures;
merely is an endeavour being made to earnestly press a plea
that we should refuse to lend ourselves to a statement of
figures whose truth-bearing character could be successfully
challenged. All that was said above on page 718, and again
with regard to the death table, concerning correlated points of

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728 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct.,

information, fully applies here. Our table of causes should
clearly indicate in how many instances each cause acted alone ;
and when in combination, the extent to which other causes
were associated. Such a table is quite easily arranged, and a
photograph of last year’s one for Bexley Asylum is now shown
you.

The field of usefulness of this table has probably been much
reduced by its name. Had it been designated a table of
“ Possible Causal Factors and other Associated Conditions,”
had common usage placed no limit by the appearance of the
line entitled “other causes” on the number of associated
conditions to be recorded, and had these various conditions,
cause or not, been correlated with each other on some such
plan as here suggested, it is confidently asserted that our
knowledge as to the aetiology of insanity might be much more
precise and complete.

It should be clearly laid down that the existence of any of the
factors should always be recorded, whether or not it appears
to act as an actual cause, and marginal notes might profitably
be used to explain any possible ambiguities or incompleteness
of definition.

A powerful light, too, might be thrown upon the relative
importance of any given factor or group of factors by repeating
this table for both the recoveries and deaths. This is done by
a few—but very few—asylums. No hesitation is felt in saying
that the extra labour involved in a general adoption of the
custom would be amply repaid.

Two Tables supplementary to Table X .—This is probably the
place to introduce to your notice two tables which have been
drawn up with a view to elaborating the information given
with regard to the two most important predisposing causes of
insanity, namely, heredity (including not only insane, but
neurotic, phthisical, and alcoholic) and previous attacks. As
a matter of fact several asylums already make a practice of
specially correlating in Table X these two with other factors.

(a) Table of previous attacks .—Most asylums issue a special
table of previous attacks (usually designated II a). It is
suggested, however, that the present form of this extra table
is not a very happy one ; and that although it is interesting to
know the number of cases that have had one, two, three, or
more attacks, yet there are some other points the absence of

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1902.]

BY C. HUBERT BOND, D.SC., M.D.

729

which really makes the table of comparatively small value.
For instance, one would be glad to know the ages of the
patients at commencement of present attack, and when first
insane, not necessarily in quinquennial periods, but according
to certain broad and important periods. The part which
insane heredity, direct and collateral, played in these cases
could also easily be expressed. And, finally, if with these
facts was combined the interval that had elapsed between the
present attack and recovery from the last one, the information
with regard to previous attacks would be very complete, and
might suggest some prophylactic measures. The interval
since last recovery might be expressed, say, in periods corre¬
sponding to those of duration of residence in Table VI;
or, if simplicity be desired, merely the number of cases which
relapse within twelve months of their discharge might be
indicated. This is a very useful period, and offers too some
comparison of the degree of stability required by various
asylums.

(b) Heredity table .—The question of heredity is admittedly
one of such immense importance in any aetiological statement
regarding insanity, that it is surprising how few asylums do
more than content themselves with simply recording the
number of admissions in which it is found; seldom even is
any division into direct and collateral made. A few do, it is
true, specially correlate it with other causal factors, and a few
issue a special table giving in detail the members of the
patient’s family so affected. But having regard to the position
in which most of us believe heredity stands to our specialty,
and holding that the education of the public in the matter is a
sounder prophylactic path than mere legislation, our tabular
statement of it should surely be the most thorough that we can
devise. In estimating the rdle of heredity in any given case not
only is it necessary to know the patient’s age at time of onset
of insanity, but similarly the age at which the patient’s relative
became insane; and also what relatives are still living, because
as long as they are alive they are potential factors. Further¬
more, we believe that an insane heredity is not the only form
of diathesis that acts as a predisposing cause. We believe
that a neurotic, phthisical, or alcoholic family history is
also of importance; it would therefore add to the complete¬
ness of our statement were the existence of one or more of

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730 MEDICO-PSYCHOLOGICAL STATISTICS, [Oct

these correlated with insane heredity. An attempt at such a
table is here shown you.

Table XI expresses the form of mental disorder in the ad¬
missions, recoveries, deaths, and those remaining in the
asylum—in the last class on December 31st, in the first
three classes on admission. Considerable diffidence is felt in
approaching this table owing to the wide differences of opinion
that exist on the subject of classification. No suggestions as
regards nomenclature are going to be offered, but a strong protest
is ventured to be lodged against the usual practice of mixing
symptomatological and aetiological terms. We cannot serve
two masters ; one is inevitably neglected, and probably neither is
served satisfactorily. It is contended that the inclusion of
such terms as “ acute mania ” and “puerperal mania ” in the
same column is a flagrant breach of statistical laws. We all
know that some of the most typical examples of “ acute mania ”
are puerperal cases. Under such circumstances what is our
rule for recording such a case ? Some probably adopt one
custom and some another, with the result that collective sta¬
tistics become impossible. And even were one line of action
agreed upon, it follows that if the figures opposite one of these
varieties are complete those opposite the other are under¬
stated. It would be infinitely less confusing to keep clearly
before us that there are two modes of classifying our cases,
one according to the mental picture, and the other chiefly
according to the aetiology. We can thus tabulate them
strictly according to their mental symptoms, and then, on the
same principle which has been indicated in other tables,
correlate their aetiology with these. We should, for instance,
be able to say that of our puerperal cases so many were
imbeciles, so many simple mania, so many acute mania, so
many stupor, etc.

To render the table more complete, the ages (at commence¬
ment of present attack) in quinquennial periods could with
advantage be incorporated as is done in the death table;
and as regards the recoveries, deaths, and those remaining in,
it would be an additional great advantage to indicate the dura¬
tion of the present attack of insanity (see Plate II).

In conclusion it should be understood that it is not sug¬
gested that all or even many of the above modifications could
receive universal adoption in their entirety. It is a recognised

Digitized by v^,ooQLe

ibles /, //, and III\ and

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total cases recovers -
under bility of

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treatment.

Average Total cases
number under

resident, treatment.

Year.

F. M. F. M.F.T. M. F.

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Names of mental disoi
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mental features from those referring
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Btational]

1902.]

BY C. HUBERT BOND, D.SC., M.D.

731

principle of statistics that to ensure success their form should
be as simple as is consistent with accuracy. It is hoped, how¬
ever, that where special facilities exist some of the above
suggested elaborations may prove of service.

It remains for the writer to thank his colleagues, Drs. Piper,
Lord, and Hughes, for ready assistance in filling in the extra
columns of the Table of Deaths and that of Causes.

( J ) Thus the admissions, differentiated into “ first” or “ new,” and “ not first ”
or ‘‘readmissions” (points 1 and 18), appear in Tables I and IV, whilst their
total appears again in Table III, point 11. The current year’s discharges
(differentiated into recovered, relieved, and not improved) may be found in
Tables I, point 3; III, point 12; and IV, the totals of points 19, 20, and 21. In
the same three tables the deaths are numbered in points 4, 13, and the total of
22. Those remaining in on the 31st December can be found in Tables I, II, III,
and IV, points 5, 10, 14, and the total of 27. The average number resident during
the year may be found in Tables I and III, points 6 and 15. The total admissions
since the opening of the asylum are given in Tables II, III, and IV, points 7, 11,
and 18; in the first and last points they are differentiated into “persons,” “new
admissions,” and “ readmissions.” The total cases discharged (differentiated into
recovered, relieved, and not improved) and the total deaths, since the asylum’s
opening, may be found in Tables II and IV, points 8 and 9, and the totals of 23
and 26 inclusive. The age at death in quinquennial periods is set out in Tables
V and VIII. The length of residence of those discharged and died during the
current year for periods over one year can be worked out from Table IV as well
as seen in Table VI. The figures opposite “ congenital,” expressing the duration
of mental disorder prior to admission, in Table VII for the admissions, recoveries,
and deaths, should presumably agree with those in Table XI, expressing the total
of congenital cases admitted, recovered, and died.—(*) Such was the clinical and
post-mortem record of a woman, Reg. No. 1702, who died at Bexley Asylum,
June 23rd, 1902.—( 3 ) Dr. Tatham, Superintendent of Statistics, General Register
Office, kindly writing his opinion on this table, says, “Although in our national
system of death registration it has hitherto been found impracticable to follow
out the plan you advocate, still there is no doubt that, wherever any such system
can be carried out—as, for instance, in a large public institution—the additional
information would be exceedingly valuable.”

Discussion

At the Annual Meeting of the Medico-Psychological Association,
Liverpool, 1902.

The President. —We are indebted to Dr. Bond because the subject is both
important and one which we are shy of handling. He is right in many of his
criticisms. The mass of material obtained in asylums every year might be
utilised to much greater advantage if our tables were brought down to modern
requirements.

Dr. Newington. —The Association is to be congratulated on having these
figures taken up and reviewed in excellent style. The Committee which drew up
these tables was bound to remember that they were throwing a large amount of
labour on people who had already a great deal to do. It was felt that very
recondite questions could not be asked. But it is now recognised in most asylums
that it is proper to send in the information required by the Association, and in
the form suggested by the Association. We can almost hope the time will come
when still more voluntary effort will be undertaken. Dr. Bond has pointed out
in a proper way the shortcomings of these tables. I beg to move—“That
XLVIII. SI

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732

THE NEUROGLIA CELL AND ITS PROCESSES, [Oct.,

Dr. Bond be thanked for his paper; and that it be remitted for consideration to a
committee. That the said committee be requested to report to the next Annual
Meeting upon the present statistical tables of the Association as to whether, and
if so in what direction, their alteration or amplification would be of advantage;
that individual members of the Association be hereby invited to communicate to
the committee any views they may have on the subject; and that such committee
consist of Drs. Rayner, Hyslop, Whitwell, Stewart (Glamorgan), Bond, Yellow-
lees, Easterbrook, Nolan, Dawson, and Bedford Pierce; that Dr. Yellowlees be
appointed Chairman, and Dr. Bond Secretary; that the quorum be three, and
that the committee have power to fill any casual vacancy.” These names have
been very carefully chosen as those of gentlemen in every way competent to deal
with the subject.

Dr. Rayner. — I have great pleasure in seconding the resolution. We are
indebted to Dr. Bond for having taken up this subject, and bestowed upon it so
much time and attention. I shall be happy to be associated in carrying out the
object he has in view. I suggest that the Treasurer’s name be added to the
others.

The resolution, as amended on Dr. Rayner’s suggestion, was passed unani¬
mously.

Observations on the Neuroglia Cell and its Processes.^)
By R. R. Leeper, F.R.C.S.I.

I wish to-day to direct the members' attention to the
neuroglia cell and its processes, although time does not permit
me to do more than refer in the briefest manner to the present
state of knowledge respecting the subtle relationship of the
changes of these glia cells to insanity.

Neuroglia-cell change is as constantly found in the brains of
the insane as are the other cellular chromatolytic and vascular
pathological appearances with which we are familiar. The glia
changes are, however, less readily seen, and require a some¬
what more careful and painstaking study to demonstrate their
diseased appearances than one is accustomed to give to the
examination of the other cortical and medullary structures.
Great, however, is the* importance of the study of these changes
and appearances, both in the normal and pathological brain.
The normal function of these neuroglia cells is not clearly, if
at all, understood, and I, for one, whilst admitting that much
of what has been written may be correct, believe that the
vibration of each ventricular systole finds one of its most
distant and delicate expressions in the fibrillary network of
the neuroglia, and these cells by their inherent elasticity serve

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BY R. R. LEEPER, F.R.C.S.I.

7 33

1902.]

not alone as a mere mechanical support, but as the vaso-motor
mechanism of the higher centres of the brain, protecting them
from sudden toxic action, isolating and cherishing them by
physiological forces of which we may but dimly discern the
purpose, and can but conjecture as to the means of their
morbid or beneficent action. It may yet be possible to accord
to the glia cells and their processes all the power and com¬
plexity of function which Cajal has claimed for them. One
wonders at the frequent presence of pigment granules in all
large nerve-cells of men and animals, and it seems to me a
matter beyond conjecture that this pigmentary substance is
essential to normal nervous function.

What, then, is the interpretation of the presence of these
pigment granules in and around the neuroglia cells ? Is it the
crude substance we see around the neuroglia, and is the filtrate
seen deposited in the neuron itself, or is this circular pigmen¬
tary precipitate in the neuron to be excreted vid the vascular
and intercellular processes of the glia cells ? or, again, is this
yellow granular pigment a kind of intercellular storage battery
to be used alike by neuron and glia in the development of
nervous force? The pigment grows more noticeable as the
cellular structures grow older and require a stronger stimulus
to excite them to a functional activity. Is this pigmentary
substance, in short, an accessory to normal nervous cerebral
function, or are we to regard it as a sort of intra-cranial stigma
of degeneration, only appearing in cells whose functions are no
longer capable of the highest activity, but still in some way
necessary to their declining lives ? The processes of the neuro¬
glia cells closely resemble the fiagella of certain motile bacteria,
and are stainable by the same histological methods; and in
connection with this fact it is well to remember that Spina
and Vejnar have observed glia cells in movement, also a cilia¬
like motion of their reticular network in the living frog.

The sclerosis of the brain differs from that of all other tissues
in that there is little contraction of the affected area, a fact
which must be due to the elasticity and adaptability of the re¬
placement tissue, which we know to be largely made \ip of
proliferated and hyperplastic neuroglia cells; this shows that the
neuroglia cell must possess a higher organisation than that of
its ordinary fellow-worker in the connective tissue of other parts
of the body, and I feel sure that its motorial and contractile

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734 THE neuroglia cell and its processes. [Oct.,

powers will be fully verified as we gain more knowledge of its
function.

No part of the neuroglia cell is more constantly looked for or
better worthy of our attention than the so-called vascular pro¬
cess of Bevan Lewis. One frequently sees this process ap¬
parently in contact with an endothelial cell in a capillary wall,
or attached to the vascular canal between the endothelial cells.

If a fine fibrillary network is always interposed between the
termination of this process and the capillary wall, it is easy to
understand the powerful effect which contractility of this
process must have upon the cerebral circulation, and the hyper¬
trophy of this process in morbid brains must have some direct
pathological significance.

Again, this process may be the excretory channel for the
products of cellular decomposition, the particles of chroma-
tolysed nerve-cells finding their exit from the cortex by means
of these octopus-like tentacular processes of the glia cells; or
the converse may be the case, and we may find that the lymph
is absorbed from the pericellular and perivascular spaces by
these cell-endings and conveyed centripetally by these means
for the nourishment of the glia and its dependants, to be subse¬
quently passed into the neuron itself if the neuroglia exercises
a trophic influence upon the nerve-cell.

In conclusion I wish to remark upon the importance of
examining these cells as soon as possible after death, as they, in
common with the other cellular structures in the cortex, rapidly
manifest cadaveric change, and then examination is liable to
give results of little value if not quickly fixed in a suitable fluid.
My object in bringing these facts before you to-day is to
endeavour to emphasise the importance of the study of these
cells and their processes, and to notice the r 6 le which they play
in cerebral function, morbid and normal; and I feel sure that
increased knowledge of their structure and physiological
function must mean a great gain to neurological science.

( J ) Read at a meeting of the Irish Division of the Medico-Psychological Associa¬
tion in Dublin, May 23rd, 1902.

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1902.] PATHOGENESIS OF DIABETIC INSANITY.

735

Note on the Pathogenesis of Diabetic Insanity . By
W. R. Dawson, M.D.(Dublin), F.R.C.P.I. ; Medical
Superintendent, Farnham House, Finglas ; Examiner in
Mental Disease, University of Dublin^ 1 )

True diabetic insanity is a rarity, and when it occurs does
not always take the same form. But it is by no means
uncommon to meet with certain lesser mental abnormalities in
diabetes which are very constant in character; and what is
usually regarded as the typical variety of diabetic insanity is
simply an intensification of these abnormalities probably due
to inherited or acquired cortical instability.^) Hence this
psychosis derives its interest from the definiteness of its
aetiology and the constancy of its symptoms.

Many diabetic patients develop by degrees a morbid
“ listlessness and depression of spirits, weakness of mind,
and peevishness of temper ” (Saundby), and in some few
instances this becomes accentuated into a form of insanity
which, in the words of Maudsley, “ is inclined to be of a
whining and wailing character, tedious and chronic, largely
hypochondriacal in its complexion, 1 ”—a description which
1 can corroborate in the main from observation of a case
recently under my care.( 8 ) This peculiar form of weak,
lethargic melancholia, with impaired intelligence and peevish
irritability, may therefore be accepted as the characteristic
psychosis of diabetes ; but it is not peculiar to that disease,
being met with also in anaemias and states of general
cachexy, and where, as in phthisis, emphysema, and some forms
of heart disease, there is imperfect aeration of the blood. It
may therefore be taken as the special psychosis of defective
supply of nutriment, but particularly of oxygen, to the brain,
this deficiency of oxygen being one to which the cortical nerve-
cells have been shown, by experiments with carbon monoxide,
to be peculiarly sensitive.( 4 )

The anatomical changes in diabetic brains support the con¬
clusion, derived from the symptoms, as to the atrophic origin
of the psychosis. Not only has chromatolysis been found in
such brains by Marinesco and others, but still more numerous
naked-eye observations show that wasting of the convolutions,
with consequent widening of the sulci, enlargement of peri-

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736 PATHOGENESIS OF DIABETIC INSANITY, [Oct.,

vascular spaces, and other changes, are common occurrences ;
and these changes were found to a very marked degree in the
brain of one of Clouston’s two cases of diabetic melancholia
which was examined, and which, though that of an adult
woman, weighed only 38 oz.( 6 ) Clearly, therefore, the
mental symptoms are due to a gradual failure in function,
ultimately leading to atrophy, of the brain ; and as it is
acknowledged that the changes in the central nervous system
in diabetes are, with the exception of some rare focal lesions,
of secondary origin, it may be instructive to inquire how they
are produced.

Stress was laid above on the importance of a proper supply
of oxygen to the brain, because it seems to me that it is the
failure of such a supply to which the cerebral lesions and the
symptoms may mainly be ascribed—a failure which I believe
to be due, principally at least, to the appropriation of much of
the oxygen by the glucose circulating in the blood. It is true
that in some cases a marked reduction in the number of red
cells has been found, but it is doubtful if this would, of itself,
be sufficient to account for the symptoms, at all events in the
majority of cases.

There is not wanting evidence in support of this hypo¬
thesis. In the first place, the presence in diabetic blood of
a substance with marked reducing powers has been shown
sufficiently by the fact, discovered by Williamson and con¬
firmed by numerous others, that such blood is capable of
decolourising methylene blue—a reaction attributed by nearly
all observers to the glucose, which is the most powerful reducer
of all the substances known to exist in such blood. Weak
solutions of glucose, moreover, produce the same result, which
I have obtained in a few minutes with a 0*4 per cent, solution
rendered feebly alkaline with sodium bicarbonate. The
reducing substance, therefore, is probably glucose. Supposing
now, as seems almost certain, that glucose acts in the same
way upon the haemic oxygen, its effect might conceivably be
to reduce some of the haemoglobin. I have found that a
solution of glucose as weak as 2 per cent., rendered slightly
alkaline with sodium bicarbonate, and kept at about body tem¬
perature, will reduce the haemoglobin in time, though not for
many hours. As this solution contains much more glucose
than has ever been found in the blood (the highest percentage

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1902.]

BY W. R. DAWSON, M.D.(DUBLIN).

737

detected by Naunyn being 07),( 6 ) the result of these experi¬
ments does not at first sight seem to lend much colour to the
hypothesis. But beyond the fact that a weak solution of
glucose will reduce haemoglobin, no conclusion can fairly be
drawn from these results. The presence of numerous other
bodies in the blood and its rapid motion render it incomparable
with simple solutions in vitro (solutions, moreover, which were
not in the first instance effectively deoxygenated, and which, in
most cases, were exposed to the atmospheric oxygen) ; but in
addition there is another consideration which must be taken to
account. Every student of chemistry knows that in working
with very dilute solutions a reaction is greatly delayed in its
inception, but once started will progress rapidly. In the blood,
the supposed reduction of haemoglobin would be continuous. For
these reasons the time and strength of solution required in
vitro are not valid arguments against the occurrence of reduction
under the ordinary conditions in the diabetic body, apart from the
fact that the blood from the right side of the heart must con¬
tain an enormously larger amount of sugar than that of the
general circulation. Lastly, it may be mentioned that some
observers have found the red cells to stain badly with methy¬
lene blue, which may conceivably be due to the sugar which
they contain,( 7 ) though, on the other hand, the corpuscles, when
separated from the plasma, are stated to have little or no effect
upon methylene blue in solution.

There is therefore every probability that some reduction of
the haemoglobin does take place ; but, in addition to this, it
must be borne in mind that the glucose comes into intimate
contact with the haemic oxygen under two other conditions,—
first, when the oxygen is free in the plasma of the pulmonary
capillaries on its way to the corpuscles, and secondly, when it
is redissolved after being liberated from the haemoglobin, to
be conveyed to the tissues ; and there can be little doubt that
a good deal of this free oxygen is absorbed by the sugar, more
especially as, on leaving the haemoglobin, the gas is in the
energetic nascent state. The following would therefore be the
order of events :—The blood from the right side of the heart,
loaded with sugar from the hepatic and portal circulation, and
i° or 2° higher in temperature than that in the left side,
encounters free oxygen in the pulmonary capillaries as it seeks
to reach the corpuscles, and levies toll of it first. During the

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738

CARE OF IDIOTS AND IMBECILES,

[Oct.,

course of the blood through the brain and circulation generally,
the haemoglobin is being robbed of a certain amount' when
the energetic nascent oxygen is set free in the systemic capil¬
laries for the use of the tissues, a further portion is absorbed,
and possibly combination may take place even in the tissues.
There can therefore be little doubt that a sensible diminution
takes place in the amount of oxygen available for use by the
tissue cells, the vital activity of which is lowered in conse¬
quence; and, as the metabolism of the cortical cells is already
very low,( 8 ) they feel this deprivation more than those of
• other organs.

From all these considerations, then, clinical, pathological,
and chemical, we are, I think, entitled to conclude that chronic
reduction of the oxygen supply to the cortical cells is in all
probability the principal cause of the characteristic insanity of
diabetes, aided though it no doubt is by general malnutrition,
due to the operation of the same cause on the other tissues (as
shown by the numerous atrophies which are so marked a feature
of the disease), and also by other influences.( 9 ) One is
tempted to assume that the resulting degeneration and ultimate
atrophy of the nervous structures is simply due to disuse,
or rather diminished use; but the process is probably more
complex.

i 1 ) Read at the General Meeting, July 24th, 1902. — ( a ) Under the latter
head may be included exhaustion by mental work and worry.—( 8 ) “ Glycosuria
and Insanity,” Case I. Med. Press and Circular , Jan. 1st, 1902.—( 4 ) L. Borri,
Rivista di Medicina legale , ecc., Oct. 15th, 1897. (Recension by Chiozzi in Riv. di
Patolog. nerv. e ment., Dec., 1897, p. 552).—( 4 ) Lectures on Mental Diseases, p.
657, 5th ed.—( 6 ) “ Der Diabetes mellitus,” Nothnagel’s Spec. Pathol, u. Therap.,
Bd. vii, Th. vi, p. 150.—( 7 ) Naunyn, op. cit., p. 243.—( 8 ) L. Hill and D. N.
Nabarro, Joum. of Physiol., vol. xviii, p. 220.—(*) Raimann {Wiener klin. Woch.,
1901, p. 513) has found that the power of assimilating sugar is reduced in melan¬
cholia, so that alimentary glycosuria is more readily produced. It is thus possible
that a sort of vicious circle may be established in diabetic insanity.

The Care of Idiots and Imbeciles . By J. H. SPROAT, M.B.
(Lond.), Senior Assistant Medical Officer, Somerset and
Bath Asylum.

The question of better provision for the care of idiots and
imbeciles has of late been one of some prominence in the more

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1902.]

BY J. II. SPROAT, M.B.(LOND.).

739

thinly populated counties, and in several of these the county
authorities are being urged to act in the matter. In large
centres of population, where the number of the congenitally
deficient is sufficiently great, and is under a single authority
responsible for their care, it is more economical to provide for
this class in separate institutions; but where you have, say in a
county, a number of authorities, each responsible for the main¬
tenance of only a few cases, it is on the face of it an expensive
business for each of them to provide special and separate
accommodation ; still, it is highly desirable that some steps
should be taken to put this class of case under more favourable
conditions than at present.

I will first of all consider the different classes of cases to be
cared for. They may be grouped as follows :

1. The feeble-minded (mainly children of backward or slow
mental development).

2. The imbecile.

3. The idiot.

The difference between these three classes is simply one of
degree; for practical purposes each group must be divided into
children and adults, as the accommodation to be provided
depends so much on whether a juvenile or grown-up individual
has to be considered. I might here point out the loose way in
which the word “ imbecile ” is used by the laity, including, as
they do, the secondary dements and senile cases, as well as
those mentally deficient from birth, in the same category.
As secondary dements and senile cases may be amply provided
for in other ways, their inclusion amongst the congenital
deficients complicates matters, and accounts for much of the
confusion which exists amongst lay committees who are
appointed to consider the subject.

The first class of cases, namely, the feeble-minded, is an
extremely difficult class to deal with. The children of this
class would undoubtedly derive an enormous benefit from special
teaching and training, and many of them might be brought to
an almost normal degree of intelligence. Detention of these in
any special institution, as the law stands at present, is not
possible, but under the Elementary Education (Defective and
Epileptic Children) Act of 1899, school authorities have the
power to arrange schools or classes for such children in their
district who, not being imbeciles, are incapable of receiving

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740

CARE OF IDIOTS AND IMBECILES,

[Oct,

benefit from instruction in ordinary elementary schools. As
school authorities are not compelled to make provision for such
cases, this Act is in a great measure neglected, and the feeble¬
minded children are allowed to grow into feeble-minded and
more harmful adults. The adults of this class are not to be
reached unless they come within the scope of the lunacy or
criminal law. They oscillate between the asylum and the
prison, with an occasional sojourn in the workhouse; and a
number of them, having sufficient instinct to appreciate the
extra comforts of asylum life to those of prison life, make no
effort to oppose their classification as chronic lunatics.

The remaining two classes, namely, idiots and imbeciles,
according to their age and mental capacity, may be divided as
follows :

1. Juveniles capable of some educational or industrial
training.

2. Juveniles requiring merely custodial care.

3. Adults capable of useful employment.

4. Adults requiring merely permanent custodial care.

The first class, that of juveniles capable of some educational
and industrial training, form the section of imbeciles proper.
These are of different grades of intelligence, and it is this class,
if any, which will repay the authorities for any trouble or
expense they care to lavish upon them.

The Idiots Act of 1886 is designed to provide for this class
of case. The name Idiots Act is a misleading one, for the Act
only deals with those cases of congenital mental deficiency
which can be certified as being capable of receiving benefit
from care, education, or training ; therefore cases suitable to be
dealt with under this Act must be capable, to a certain degree,
of mental development,—that is, they must be imbeciles (of a
higher or lower grade) rather than idiots.

To the class of those merely requiring custodial care belong
the true idiots, or those whose capacity for mental development
is so slight that they cannot be educated or improved to any
appreciable extent. If this class cannot be cared for, there is
at present only the workhouse or the asylum provided for them.
The presence of idiot children with grown-up lunatics or paupers
is highly objectionable from many points of view ; they learn
habits of indecency, bad language, and generally become more
degraded. Also there is, where they are warded with adult

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74i

1902.] BY J. H. SPROAT, M.B.(LOND.).

lunatics, the danger of their being injured physically. This is
a class specially to be considered in any scheme for the
improvement in the care of the congenital deficients.

The third class, namely, adults capable of useful employ¬
ment, is a much less difficult class to deal with. The quiet
and harmless of them are welcomed in workhouses, where they
make useful permanent drudges; they give no trouble, and
probably show, in actual value of work done, to as much advan¬
tage as if they had been half taught a trade, and could point to
so many shillings and pence of earned money. Those who are
capable of some useful work, but are nevertheless the subjects
of excitement or violence, as many of them are, can easily
be certified, if necessary, under the Lunacy Act, and be detained
in pauper lunatic asylums, which is the safest and most suitable
method of dealing with them.

Those adults who merely require custodial care, and who are
incapable of any useful employment, can be cared for in work-
houses or lunatic asylums,—in which depends upon the nature
of each individual case. Country workhouses are, for the most
part, much understaffed as regards attendants, and the conse¬
quence is that any inmate of this class who gives trouble—and
most of them do at some time or other in some way—is
promptly sent to the asylum without, in many cases, a due con¬
sideration of the fact as to whether the case is a fit one for
permanent detention in such an institution or not.

Let us now consider the provisions at present existing for
the care of the classes of the mentally deficient which have
been mentioned. They are as follows:

1. At home under no special educational treatment.

2. At home, but attending special classes or schools under the
Elementary Education (Defective and Epileptic Children) Act.

3. In workhouses.

4. In idiot asylums, under the 1886 Act.

5. In lunatic asylums.

Home care and the Defective and Epileptic Act should go
together, and, if advantage is taken of the provisions of this Act,
it might be sufficient as far as the feeble-minded are concerned.
For members of this class detention in special institutions
would be a difficult matter, as they would not readily be sent
to such institutions by their parents, for the feeble-minded
child is often the pet of the family. An objection to such

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742

CARE OF IDIOTS AND IMBECILES,

[Oct.,

cases being treated at home as opposed to compulsory deten¬
tion and education in an institution is the fact that the organic
appetites, notably the sexual proclivities, are more often than
not developed to a greater extent than the higher intellectual
and inhibitory faculties. This, as is well known, constitutes a
grave social danger, leading, as it frequently does, to inadvis¬
able marriages, which too often result in offspring even more
undesirable to the community than the parents from whom
they sprang. If these unions were impossible without legal
sanction this evil would be to some extent mitigated. This
unfortunately is not the case, and the illegitimate offspring of
the imbecile mother is only too frequently in evidence.

The accommodation at present provided in workhouses is
not suitable for the care and treatment of all classes of idiots
and imbeciles. It is certainly not adapted for the education
and training of patients capable of such, and the ordinary
workhouse, without some modification of the arrangements
which at present exist, leaves much to be desired, even in the
matter of those requiring merely custodial care. For adults
who are capable of useful employment, whatever its nature,
who are not dangerous to themselves or others, the workhouse
is eminently suitable. This statement also holds good as
regards the fourth class, that of adults requiring merely
custodial care. This latter class of case too often finds its
way to the asylum, as under the present conditions the work-
houses turn asylums into dumping-grounds for any case which
gives more than a minimum of trouble, whether they are
harmless idiots, imbeciles, secondary dements, or purely senile
cases. This is, of course, putting the asylum to a use for which
it was never intended. There are two chief causes which
produce this state of affairs, viz., ( a ) the four-shilling grant;
(b) the inadequate staff of attendants in workhouses and the
deficient supervision of them. The four-shilling grant must
rank as a prime factor in the production of this class of asylum
inmate, and as Poor Law guardians have been considered to be
in the first place guardians of the ratepayers’ pockets, and only
secondarily guardians of the poor, they allow with complacency
those who should be taken care of by them in the workhouse
to be labelled insane and sent to the asylum. The frequency
with which patients are admitted to the asylums who are
proper cases for workhouse care is well known to all asylum

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743

1902.] BY J. H. SPROAT, M.B.(LOND.).

authorities. The majority are reported to be either actively
suicidal, extremely violent, or troublesome. As an example,
two patients were admitted to Wells Asylum within a short
time of each other, one an idiot four years old, said to be
actively suicidal, and one an old woman of eighty-four, who
was said to be extremely dangerous; after admission the child,
as might have been expected, showed no suicidal tendencies,
and the old woman was in too feeble a state of bodily health
to be anything approaching dangerous. Both cases were
certainly dirty in their habits and required frequent attention,
this fact undoubtedly furnishing the clue to their removal from
the workhouse. It is well known that in workhouses where
the attendants are frequently overworked and underpaid, a
patient who gives any trouble can, by a report to the visiting
medical officer that such patient is extremely dangerous, or
has shown suicidal tendencies, be readily certified and removed
to a lunatic asylum.

The idiot asylums established under the 1886 Act provide for
a large number of the cases under consideration. As one of
the conditions, as already mentioned, is that the case must be
capable of improvement, it will naturally follow that they can
only provide for those falling into the first class, that is
patients capable of some educational or industrial training.
I have no doubt if this condition were rigidly adhered to, the
accommodation at present provided by the existing institutions
of the kind would be quite sufficient for the needs of the
community ; but on looking over the statistics of a few of these
institutions one is forced to the conclusion that too sanguine a
view must have been taken before the patients’ admission of
their capacity for improvement. The statistics of one of these
institutions show that in thirty years 2019 patients were
admitted and went through their seven years’ training with the
following results. Seven are said to have recovered—a state¬
ment which requires no comment; 1047, that is more than a
half, were not improved at all; and out of the total number
only 254 were classified as much improved; and it must be
borne in mind that all these were under the Idiots Act, and
were certified on admission as being capable of some improve¬
ment. It would appear that a much more careful selection of
the cases to be dealt with under this Act might be made, so
that the expensive and special arrangements for treatment,

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744

CARE OF IDIOTS AND IMBECILES.

[Oct,

teaching, and training should not be wasted on those w’hich
eventually would be as well off in a more inexpensive place.
In this connection I should like to quote the words of the
Commissioners in Lunacy on the matter. In their forty-fifth
Annual Report, on page 48, they say, “ We think that the larger
counties, or two or more of the smaller in union, might well
consider the advisability of exercising another power given by
the section quoted (241 of the Lunacy Act, 1890), namely,
building asylums for idiots. Such asylums, in our view, should
be of an inexpensive character, and should not aim at too much
in the way of attempts at education or development, but should
mainly be receptacles for unimprovable idiots, in which they
would be fed, clothed, kept clean, and treated with kindness,
leaving to other and specially equipped institutions the training
and development of imbeciles of a higher degree of intelligence.

The last form of accommodation to be considered is that
provided by existing asylums. As at present constituted,
asylums are intended primarily for the cure of insanity, and in
a secondary degree for the care and custody of those in¬
curable and unimprovable cases who, from their habits and
propensities, cannot at present be suitably cared for in any
other way.

In asylums we always find a certain number of juveniles for
whom there is at present, unfortunately, no more suitable
accommodation to be found. This class is, luckily, not a large
one, and is mainly composed of congenital epileptics and the
bad bargains of idiot asylums. Few asylums at present are
provided with any facilities for the separate treatment of these
cases, and they are, as a rule, scattered throughout the asylums
under conditions which are quite inadequate for their needs, as
I have already pointed out.

I have briefly attempted to show the class of idiot and
imbecile for whom provision is required, and what attempt
is at present made to meet their requirements, incidentally
pointing out how far these provisions fall short of the ideal.
I do not feel justified in a short paper of this nature in
suggesting a new and complete scheme for dealing thoroughly
with the whole of these unfortunates, but will content myself
with indicating a few of the more glaring defects, and the
lines on which they may be modified.

The Elementary Education (Defective and Epileptic

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BY J. H. SPROAT, M.B.(LOND.).

745

1902.]

Children) Act is being taken advantage of in 107 instances;
of these fifty-nine are in London and forty-eight in the provinces.
Those in the provinces are confined to twelve counties which
contain large centres of population; the average number of
pupils in each school is, roughly speaking, about 40. Twenty-
four authorities have adopted the Act, but have taken no steps
to carry out its provisions, inasmuch as they have no certified
schools or classes of their own. The only instances in the
West where the Act is taken advantage of are at Bristol and
Plymouth. These figures speak for themselves, in showing
what scope there is for a little more enterprise and energy in
taking advantage of such a beneficial Act.

The extension of the four-shilling grant to lunatics in work-
houses, while it might conduce to the detention there of suitable
cases, might,on the other hand, tend to defeat the object forwhich
it was originally given, namely, as an inducement to guardians to
send to the asylum early, recent and curable cases of insanity.
Also, although in the long run it would materially improve the
conditions under which at present those of unsound mind exist
in workhouses, there would be a great temptation, even more
than at present, to classify (or brand, some might call it) every
possible case as insane. There is, however, a way, although
a somewhat circuitous one, of keeping idiots and imbeciles
in workhouses, and also retaining the advantage of the four-
shilling grant, namely, under Section 26 of the Lunacy Act.
Under this section the asylum authorities can board out suit¬
able cases in workhouses, if the accommodation be sufficient, and
such cases being retained on the books of the asylum, the four-
shilling grant is payable: this section is at present taken advan¬
tage of in only two or three instances. Guardians, to exercise
their proper functions as such, must be somewhat more liberal-
minded in their provision for the care of idiots and imbeciles,
and not only make more suitable accommodation for such cases,
but also see that the administration and staff is such as to make
the detention of these cases possible without so frequently resort¬
ing to the help of lunatic asylums to take slightly trouble¬
some cases off their hands. There are numbers of imbecile
and idiotic children at present kept in their homes who would
be much better off, mentally and bodily, for being subjected to
the regime of a well-ordered institution ; but as things are,
no institution of the kind exists except lunatic asylums.

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746 CARE OF IDIOTS AND IMBECILES, [Oct.,

As regards idiot asylums, matters should be so altered as to
give greater facilities for the admission of suitable cases. At
present parents with an imbecile child have three methods of
gaining admission for it into an idiot asylum : first of all, they
may send it to the workhouse in the hope that the guardians
will obtain admission for it; they may endeavour to obtain
admission for it themselves—this is a matter of pure chance, as
if they cannot get the support of subscribers to such institutions
the case is hopeless, even if the child is an eminently suitable
case; or they may gain admission by paying for the child
themselves, which latter method is an almost impossible one
for parents of the class under consideration. There is no doubt
that there are no more suitable or better equipped institutions
for dealing with improvable cases, and it is a pity that their
record should be spoilt in so many instances by having foisted
upon them idiots for improvement who are not in the slightest
degree susceptible of any. Conditions should be so altered that
no child who is undoubtedly a suitable case should have any
difficulty about admission into an idiot asylum ; whilst influence
with subscribers should not facilitate the admission of more
than doubtful or definitely unsuitable cases into such institu¬
tions, to the exclusion of other and more appropriate inmates.
Alteration in this direction, combined with a more careful
selection of patients, would much enhance the usefulness of
idiot asylums, and the records of their treatment would make
more pleasant reading than they do at present.

Lastly, failing any steps being taken to improve the ac¬
commodation in, and to facilitate the admission to, the institu¬
tions mentioned, we have to fall back on lunatic asylums.
There is much to be said in favour of placing idiots and im¬
beciles under the care of asylum authorities. Looked at
broadly, the minds of the low-grade imbecile and the secondary
dement are much in the same condition, so much so that it is
frequently impossible to tell the difference between the two
when the imbecile has reached adult life. As asylum
authorities are experienced in the care of one class, they would
naturally be well suited to look after the other; but, at the same
time, for reasons of economy the hopeless idiot or imbecile
should not be treated on the same liberal scale as the curable
lunatic, who may be restored to health and usefulness. It
would therefore seem advisable—if the asylum must be utilised

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1902.]

BY J. H. SPROAT, M.B.(LOND.).

747

for this class of case—to provide separate accommodation, to
whatever extent required, for at least the juveniles of this class,
it not being very apparent what harm the adults would take
from being warded with the ordinary chronic insane. The
accommodation for the children might take the form of a small
annexe; or if the accommodation in the asylum is sufficient
they might be given a ward to themselves, as far removed from
the influence of the adult population as possible. This last
suggestion appears to me to be the only feasible and practi¬
cable method at present available for the amelioration of the lot
of these unfortunates, and nothing can be hoped for in other
ways until Boards of Guardians wake up to a sense of
responsibility in the matter, and do not allow false economy to
stand in the way of efficiency in this direction.

Discussion

At the South-Western Divisional Meeting, April 22nd, 1902.

The Chairman said that they would all agree that Dr. Sproat’s subject was a
very important one, and one which had reached a very acute stage, in that county
(Somerset) at least. The difficulty seemed to be to know who should deal
with it. They were all agreed that there should be some educational process
for imbeciles. At present the matter lay between the county councils and the
boards of guardians, neither of which would undertake the responsibility. It
seemed that there was not sufficient power without alteration of the standing laws
to deal with the matter, and another difficulty was that of finance. It was im¬
possible for them to expect guardians to provide instruction and training for
imbeciles as Dr. Sproat had said, as they had such a small number. The experiment
would be too expensive, but it seemed to him that if the guardians in several
counties were to amalgamate and provide a large idiot asylum such as they had in
the North, such as the Royal Albert Asylum (which, however, was charitable), that
would meet the difficulty. He thought that they should confine themselves to
children to start with, as he did not think much could be done with adults. As
regards the financial question, the staff would have to be numerically as strong as
in an asylum; and on account of the more individual care required, the pay would
be higher, so that the experiment would be a costly one. They hoped, however,
that careful training would produce sufficient ability on the part of the inmates to at
least partly repay by their labour some of the costs of the institution. Then there
was custodial care, which was important for many reasons. After training there
should be great care with the cases on leaving the institution; and secondly, cases
that could work together could be kept together, and were much more likely to be
profitably undertaken.

Dr. Davis said that the matter had come up in Devonshire, and they had been
informed that the Act prevented the county council building for idiots and imbeciles.
The idea had been that Devon should co-operate with, say, Somerset and Cornwall,
and build an institution which would be suitable, but the Act of Parliament pre¬
vented them, and the matter remained in statu quo. In asylums the majority of
cases were capable of very little training.

Dr. MacBryan said that with regard to what Dr. Davis had said about the
inability of the county councils to act, he was under the impression that Middlesex
County Asylum had built a place in its own grounds.

Dr. Braine Hartnell said that at Worcester they had several instances, chiefly
in the case of girls, of what they might call moral insanity—they had no idea of
decency. Directly they went out in the world the strain was too much for them,

XLVIII. 52

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748

MENTAL SYMPTOMS AND BODILY DISEASE, [Oct.,

and they broke down again. Could not some place be got as a sort of after-care,
where these people could go and live and work to earn money to pay for their
keep ? They were absolutely unfit to go out in the world, yet it was the greatest
difficulty to certify them.

Dr. Laing questioned whether any school authority had any power to build a
school or institution for idiots. He believed that a school authority had power to
maintain a school for imbeciles.

Dr. Macdonald said that the real difficulty raised by Dr. Sproat, and referred
to by the majority of speakers, was the question as to what power any county
council had to provide a home for those cases not certified. Personally he did not
think they would get two or three counties to combine for purposes of this kind.
They might get them to do it if the places were maintained by voluntary subscrip¬
tion, but not from the rates. He had been for years, and was still of the same
opinion, that each county should do as Middlesex and Hampshire had done, and
that was to provide a special block for the treatment of idiots and any other cases
which it might be thought fit to send there. He was quite sure that the Legisla¬
ture never contemplated that there should be more than one lunacy authority, and
that one was the county council. He did not wonder at the boards of guardians
refusing to do this, because if they did so it would be converting every workhouse
in the country into a miniature asylum. Workhouses were not meant for that class
of people, and they would find that the Legislature would force the hands of the
councils until they had made provision for every one of these cases. He believed
the blocks at Fareham and Wandsworth answered admirably ; he had tried to get
a case admitted, but he was told that all they could do was to provide for their own.

Dr. Sproat, in replying, said that he thought it was fairly settled that the county
councils could not provide for idiots and imbeciles other than as lunatics, and as
the law stood at present there was no place except lunatic asylums for them.

The Relation of Mental Symptoms to Bodily Disease,
and their Treatment . By Nathan Raw, M.D.,

M.R.C.P.(Lond.), F.R.S.(Edin.), Physician, Mill Road
Infirmary, Liverpool.

During the last few years great importance has been
attached to the consideration of the treatment of those patients
who, though not permanently insane, presented mental sym¬
ptoms requiring immediate and active treatment. Physicians
who are brought into contact with large numbers of cases of
bodily disease are generally agreed that many of them exhibit
mental symptoms concurrently with their bodily illness which
are entirely due to the disease itself, such as the initial delirium
of pneumonia or the profound depression of influenza.

The nervous system may be attacked in precisely the same
way as any other system by toxic poisoning, such as alcohol or
arsenic, or by the toxines produced in the course of any of the
specific infective fevers. Having made a diagnosis of such a
case, the question of prime importance arises, How are we
going to treat the case ? Many patients exhibit such

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1902 .]

BY NATHAN RAW, M.D.

749

dangerous homicidal and suicidal tendencies that it would be
highly injudicious to attempt their treatment at home or even
in the wards of a general hospital.

' If a patient with raving delirium of pneumonia jumps out of
a hospital window, a coroner’s jury will probably attach some
blame to the hospital authorities, whilst if a patient committed
suicide at home the medical attendant would no doubt come in
for some censure from the relatives. To the medical man
there is no question which causes him such anxiety. There is
no time for delay, the onset of the symptoms is rapid and un¬
certain, and it is necessary for the protection of the patient
himself and his neighbours that he should be placed under
proper restraint and control at once.

Where is he to go ? It is a fact that in a large city like
Liverpool there is actually no facility for treating a case of
delirium tremens excepting the workhouse, and perhaps one or
two nursing homes who do not encourage their reception. In
the present state of the Lunacy Law all such patients requiring
treatment in an institution must be certified as lunatics, either
pauper or private.

My earnest contention is that there ought to be some pro¬
vision made by law for the treatment of temporary or incipient
mental cases outside a lunatic asylum, either in wards attached
to a general hospital or in a reception house or mental hospital.
The period of stay in this mental hospital should be strictly
limited to time—to, say, six weeks,—and on the expiration of
that period, if no improvement showed itself, the patient
should be legally certified to an asylum.

My opinions are based on experience, as during the last five
years, whilst in charge of this large Poor Law infirmary, I
have had under my care 3129 lunatics, made up as follows :

Admissions from July, 1897, to July, 1902: males, 1671;
females, 1458; total, 3129. Nearly all these patients were
admitted under Section 20 of the Lunacy Act, 1890, on a three
days’ order. Under the powers of this Act I have authority to
further detain the patient for a period of fourteen days, and
even a further three days, making in all a total legal detention
of twenty days .

Taking advantage of this authority, I have been able to dis¬
charge recovered no less than 1006 patients out of a total
admission of 3129, or 32 per cent. It is only fair to say that a

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750 MENTAL SYMPTOMS AND BODILY DISEASE. [Oct.,

large number of these cases were due to excess in alcohol,
the effects of which generally pass off in four or five days, but
often extend to weeks.

The point I wish to emphasise in this paper is this—A great
number of people are sent to lunatic asylums every year
unnecessarily, necessitating the provision by the asylum
authorities of a great number of beds for acute cases. What
is the result ? The asylums are overcrowded with the
accumulation of chronic cases, with no room, as at present,
for the reception of acute cases. At least, this has been the
position in Lancashire for some years.

The remedy for this chaotic and unsatisfactory condition
in dealing with the insane which I suggest is as follows:—
In each city or town a reception hospital for mental cases
should be established, either attached to the general hospital or
provided by the municipality at the expense of the rates, for the
reception of all acute cases, or those people found wandering at
large by the police. These patients to be placed under the
best possible conditions, and treated by expert physicians. In
a great number of instances the patient would completely re¬
cover, and be discharged to his friends; those who did not re¬
cover in six weeks would be certified to a private or pauper
asylum. In addition to this, the workhouse authorities might
arrange to detain every lunatic for the full period of twenty
days in the wards of the infirmary before removing him to the
asylum,—that is in those cases which required this detention.

The advantages of such a system of treating such cases are
obvious ; in the first place a large percentage of lunatics would
never require to be legally certified, and would thus be spared
the stigma of having been associated in a public asylum with
hopeless dements and imbeciles, resulting in loss of employment
and distrust for the rest of their lives. I have known a respect¬
able man who was certified to a lunatic asylum suffering from
the initial delirium of typhoid fever. On his discharge he was
dismissed from his post as he was not considered safe. Then,
again, there would be a great opportunity of teaching students
and demonstrating to them cases of acute mental disturbance,
which they have little or no opportunity of studying at
present.

The objection (if such it can be considered) would be that
the lunatic asylums at present would be deprived of the most

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CLINICAL NOTES AND CASES.

7Si

1902.]

interesting and curable cases of insanity, and their statistics
would suffer accordingly; but I cannot think that any asylum
medical officer would seriously raise such an objection if
the principle was for the public good. There will always
continue to be numbers of acute cases requiring active asylum
treatment, but my plea is for those who are not really lunatics
in the true sense of the word, but rather temporary lunatics
for the most part suffering from toxic poisoning of their nervous
centres. In spite of what may be said to the contrary, there is
a real stigma attached to a person and his friends who has been
legally certified as insane; and I only contend for those who
ought not to be certified,—for those who are really insane the
disabilities must follow.

With regard to whether fresh legislation is necessary to
establish such mental hospitals, and the details of supervision
and management, I am not at present in a position to discuss
them; but I earnestly hope to see some such effort made to
remedy the present unsatisfactory manner of dealing with the
insane.

In my opinion the time will come when the whole responsi¬
bility of dealing with the care and treatment of the insane will
devolve upon the county councils and city and borough
councils, and be entirely removed from the Poor Law
authorities.

Clinical Notes and Cases.

A Case of Epilepsy with Glioma following on Traumatic
Injury of the Brain, By A. R. Urquhart, M.D., and
W. Ford Robertson, M.D.

V.P. 73, set. 34, admitted into Murray’s Asylum, Perth, on October
12 th, 1897. A married male.

Family history ,—Vigorous and healthy, the various members of the
family having occupied positions of responsibility with great credit.

Personal history ,—Generally healthy. As a young man he was of
exceptional ability, especially clever as a linguist; and at the age of
twenty-one entered the Indian Civil Service, in which he was duly
promoted. He was notably kindly and obliging in disposition, and very
popular with all classes. To the end he maintained this reputation.

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In 1887, at the age of twenty-four, he fell from his horse, and was so
severely injured that he remained unconscious for ten hours. In the
beginning of 1896 a remarkable change occurred ,* he then became
apathetic, sedentary, and disinclined for his usual sports and pastimes.
This was noticeable in his dress and in his relations with his wife and
child. He lost interest in everything, and could not fix his attention on
his work. These symptoms did not seem to be appreciated by himself,
and his affairs were allowed to drift. In August of that year attacks of
petit mal were noticed, and in February, 1897, the first major attack was
recorded while he was presiding in Court. Between the following May
and July, while living in the Nilgiri Hills, he had two seizures, and petit
mal was of frequent occurrence. He then left for England, and severe
epilepsy occurred at uncertain intervals, so that prior to his admission
the nature of his malady was undoubted. There was nothing whatever
in the life history of the patient or his parents to account for the
development of epilepsy except the traumatic injury received nine years
before the symptoms became apparent.

On admission the patient was to all appearances in good physical
health, except that he exhibited marked local tremors. Albuminuria had
been reported, but was never evident during his stay in Perth. The
tremors were at first limited to the right forearm in the attitude of pro¬
nation. Supination at once inhibited the motion, and it could be con¬
trolled at will. When attention was called to the tremors, they ceased
until his mind was otherwise engaged. Appetite hearty, and bodily
functions well performed. Mentally he was slightly demented, his
manner childish, and his finer characteristics blunted.

During residence in the asylum petit mal was of almost daily
occurrence, and major attacks were frequent. Medicinal treatment was
absolutely ineffectual. In December, 1897, the right foot dragged in walk¬
ing, and at that time the first observed fit was recorded :—Head turned to
the right shoulder ; conjugate deviation of eyes to the right; pupils
widely dilated ; slight opisthotonos; limbs extended. The tonic stage
lasted fully two minutes. The convulsions then became general,
markedly affecting the right side—the right arm more than the right
leg. Eyes rolling, with occasional internal strabismus. In the post¬
epileptic stage the tremors of the arm and the dragging of the leg were
more apparent. In the course of the same month trophic symptoms
occurred—an oedema of the left eyelid, eyebrow, and cheek, as if these
had been scalded.

This was immediately followed by a herpetic eruption over the area
of the first division of the fifth nerve, with great pain in the left eye and
ear. This became neuralgic in character. In February, 1898, during
a major attack the left arm and leg were violently convulsed, while the
limbs of the right side remained still. This phenomenon had been
previously observed by his attendant, and on the second occasion it
was possible to confirm the observation by medical evidence.

In March, 1898, Dr. Byrom Bramwell concurring, Mr. Cotterill
exposed the motor area on the left side. A spicule of bone was
observed projecting towards the brain, but it may have been detached
by the operation. Along the side of the arm-centre a patch of opales¬
cent membrane was noted, and a piece of it was submitted to Dr. Ford

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Robertson for report. There was undoubted evidence of high tension,
but no tumour could be defined. Dr. Ford Robertson reported that
the piece of pia arachnoid was affected by a long-standing inflammatory
process.

The immediate result of the operation was to stop the local tremors.
The major epilepsy ceased, but the petit mat continued unabated. On
April 26th a major fit occurred, and the subsequent history of the case
was characterised by gradual physical and mental deterioration.
Towards the end of 1899 he became markedly amnesic. In Novem¬
ber, 1901, the following facts were noted:—Smell normal; taste de¬
praved—salt could not be discriminated from sugar, but quinine was
slowly recognised by the bitterness; eyes myopic; fundi normal; inter¬
mittent diplopia; colour-vision normal. Common sensibility and locali¬
sation of sensation were dulled on the right arm, otherwise normal;
perception of heat and cold normal; no anaesthesia of face; reflexes
normal; knee-jerks exaggerated; left pupil dilated and reacting
sluggishly to light and accommodation. Slight drooping of the right
side of the face allowed saliva to trickle from that angle of the mouth.
Movements of facial muscles apparently equal on both sides. Faint
tremors of tongue and jerking movements of right arm and leg, specially
involving the flexors and rotators of forearm and wrist and the ex¬
tensors of the ankle. These were no longer controlled by attention
and position did not affect them. Dynamometer grip, R. 45, L. 35. No
evidence of electrical phenomena of degeneration. Memory very
defective ; aphasia marked. The aura at first was a “ rush of blood to
the head,” latterly “people shouting” and a feeling of globus hystericus,
preceded by a very bitter taste. At first the patient had time to lie
down before the fit occurred, but in the end he had no interval of
voluntary movement.

The aphasic symptoms were principally connected with the names of
objects, and were apparent in speech and writing. Writing was always
shaky and illegible. The names of objects entirely disappeared from
memory, but some could be recalled by trying various nouns—wrong
many times, but right at last. On pantomimic representation of the use
of things, the names of which were forgotten, he could often recall the
word. Latterly the patient wrote fairly well to dictation, and copied
fairly ; but he had great difficulty in expressing his thoughts in writing.
This was intensified in the post-epileptic condition.

He died on February 19th, 1902, during a major attack. Death was
due to failure of respiration, the respiratory act having been arrested in
extreme inspiration.

Abridged Pathological Report by Dr . W. Ford Robertson .—
Examination of the brain has shown that this case was one of
infiltrating glioma of the left cerebral hemisphere. The new
growth (after hardening of the tissues in formalin) is, for the
most part, of a grey colour, intermediate between that of
normal cortical substance and of white matter, and has a soft
and elastic consistence and gelatinous aspect. It passes almost

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[Oct,

insensibly into the normal tissues, and therefore its limits can¬
not be defined accurately. The following portions of the left
hemisphere are, however, distinctly involved:—The whole of
the island of Reil (which was probably the seat of origin of
the morbid growth), the greater part of the white matter
(adjacent) of the frontal and temporo-sphenoidal lobes, the
basal ganglia, the whole of the cornu Ammonis, the white
matter of the centre of the parietal lobe as high as the level of
the upper surface of the corpus callosum, the cortical substance
of the anterior third of the temporo-sphenoidal lobe and of the
posterior two-thirds of the inferior aspect of the frontal lobe,
and the tissues in the interpeduncular space. In the last-
named situation the right side was involved to some extent
as well as the left. Portions of the tumour taken from
various parts present under the microscope the typical struc¬
ture of a glioma. In the centre of the left parietal bone, the
flap raised at the operation is still distinctly defined, having
only in part undergone osseous union. It measured three
inches by two and a half. Subjacent to this flap the dura
mater and pia arachnoid had become adherent to each other
(report of post-mortem examination), and the latter had also
evidently become attached with abnormal firmness to the
cerebral tissues. The brain presents in this position an exten¬
sive area devoid of pia arachnoid, and having a slightly eroded
appearance. This area measures two and a quarter inches
antero-posteriorly, and three inches from above downwards.
Its anterior margin just touches the fissure of Rolando ; the
upper margin is one inch from the great longitudinal fissure.
Microscopic examination of this area reveals a slight degree of
sclerosis in the outermost layer of the cortex and a well-marked
sclerosis of the white matter. The nerve-cells show advanced
pigmentary changes and central chromatolysis. In the corre¬
sponding portion of the right hemisphere there are similar but
less marked nerve-cell changes, whilst the sclerotic changes are
practically absent. There is a small area of necrosis in the
bony flap, but this does not appear to have been associated
with any accumulation of pus between the bone and the dura.
The piece of small intestine submitted for examination shows
a very severe condition of long-standing atrophic catarrh. It
is very probable that the process of gliomatous infiltration was
set up by the traumatism recorded in the history. Numerous

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755

cases of both spinal and cerebral glioma have been recorded,
in which a severe traumatism seemed to have initiated the
disease.

Remarks .—The interest of the case lies in the localising
lesions and the apparent degeneration of the brain tissue at the
time of operation. It was evident that it was of such a wide¬
spread nature that nothing could be done to avert the fatal
issue. Yet, as might be expected, the relief of the internal
pressure for a time resulted in amelioration of the grosser
symptoms. In a case which we reported in the January number
of the Journal of Mental Science , epilepsy followed on traumatic
lesion of the frontal lobe, and in the present instance a similar
result has been noted. It is common knowledge that cerebral
injury may remain, as it were, latent for many years, and while
we would narrowly scan the evidence on which such cases are
generally accepted, there is now accumulated certain evidence
in favour of this belief. At least, in these cases we have a
certain history of trauma and consequent degenerative lesions,
as ascertained by post-mortem examination.

A Case of Sulphonal Poisoning . By H. de M. Alex¬

ander, M.D.(Edin.), Senior Assistant Physician, Royal
Asylum, Aberdeen.

A YOUNG woman of fair physique and 32 years of age,
who looked anaemic but did not suffer from constipation, had
been labouring under chronic mania of over two years* duration.

After a comparatively quiet interval of six weeks she
became acutely maniacal, destructive, and impulsive. As on
former occasions when an acute exacerbation of her mental
affection had occurred, sulphonal was again administered to her
in 30-gr. doses daily for one week, producing as much sedative
effect as was desired without any untoward symptoms ensuing.

About twenty-eight hours after the last dose she refused her
breakfast, and vomited shortly afterwards. Her skin was
observed to be cold and clammy; pupils normal; pulse 86
per minute, of low tension, and somewhat irregular ; respirations
normal; temperature subnormal. Her gait was “ groggy/* but
not to any marked extent; articulation was rather slow, but
otherwise perfect, and her mental condition, though apathetic,

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was clearer than it had been for many months. The patient
complained chiefly of feeling “ very cold,” and she was placed
in bed and treated as a case of sulphonal poisoning.

The leucocytes numbered 5642 per c.mm., and remained
under 6000 per c.mm. till the^nd. The urine, which was of a
deep port-wine colour, contained a trace of albumen, and on
being examined at the laboratory of Professor Hamilton was
reported to contain haematoporphyrin.

In spite of treatment her condition became rapidly worse.
Flaccid paralysis appeared first in the legs, and spread rapidly
upwards until the patient was barely able to turn her head.
A varying amount of anaesthesia to touch, heat, and cold was
present, and was most marked in the lower extremities. The
muscles were very tender to deep pressure, and shooting pains
were complained of, chiefly in the lower limbs.

Bullae appeared on the heels, calves, elbows, and the radial
side of the left forearm. The superficial and deep reflexes
were lost, and the contents of the bladder and rectum were
passed involuntarily. The act of swallowing became gradually
more and more impaired, the respirations hardly perceptible,
and speech a mere lisp. Though naturally a certain amount
of mental lethargy was present, the patient was cognizant of
everything that went on around her, and her intellectual
faculties remained remarkably clear until her death, which
occurred on the fifth day after the toxic symptoms were first
observed. A post-mortem examination was not obtained.

Though the above case may be regarded as an example of
chronic sulphonal poisoning, certain “by-effects,” as is well
known, may ensue shortly after an initial dose of sulphonal or
trional ; the usual symptoms being vomiting, muscular inco¬
ordination, and mental torpor, with, in the more severe cases,
a considerable amount of prostration associated with a rather
rapid low-tension pulse.

Of ten cases in which we have observed these symptoms,
sulphonal (30 grs.) was the drug administered in eight of them,
and trional (20 grs.) accounted for the other two. All of these
patients were women, and under treatment they recovered
more or less rapidly.

In nine of these cases the menstrual epoch was imminent
or already present ; hence it would appear that sulphonal and
trional should be used with caution in women at this period.

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Occasional Notes.

The Annual Meeting of the Medico-Psychological Association.

The Sixty-first Annual Meeting of the Association was held
at Liverpool on the 24th and 25th of July under favourable
auspices. By the courtesy of the Medical Institution, their
spacious rooms were set apart for the scientific and business
engagements usual on these occasions, and in no small degree
contributed to the success of the meeting.

It may be confidently stated that the Association has never
shown greater activity in dealing with the questions of the
day, that it has never been more intensely vital in discussing
subjects of real importance.

The work of the various committees already existent has
proved insufficient for the energies of the Association, and we
rejoice to note that the statistical tables of the Association have
been referred for consideration and report next year. In view
of recent advances in our specialty, the time is ripe for some
improvements in our statistical methods and some enlargement
of the scope of our observations. While that is so, we would
plead for a retention of so much as is of value, especially for
purposes of comparison. We cannot forget how Dr. Hack
Tuke laboured to perfect the tables that are at present in use,
how he sought for expert advice, and what importance he
attached to Table I la as a record of results as accurate as can
be obtained. We think that the time has come when our
newly appointed librarian should collect and arrange all asylum
reports for reference. Untold labour has been expended
upon the production of these statistics, and they are in danger
of being lost to investigators. If our medical officers are to be
encouraged to continue their annual work in this direction, they
should enjoy the hope that it will not be fruitless. We feel
assured that sets of these reports might be obtained without
great expense or difficulty, and that at least the statistical
tables of such as are out of print would be sent to the library
in manuscript. If the Association does not set a mark of
appreciation on these annual reports by collecting and con¬
serving them now that it is in possession of means so to do,

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it is of comparatively little use to urge its members to more
labours. Again, the latest investigations into the causation of
mental disorders reveal the importance of early symptoms.
We desire to know the prodromes, the events of the onset—we
should ascertain and record all the facts of physical and mental
deterioration in the precise order of occurrence. It will be for
the committee to consider such questions as these, and so to
thoroughly revise and modernise the statistics of insanity.

Dr. Wiglesworth, in his most interesting and practical
presidential address on some of the problems of heredity,
showed how important to the welfare of humanity such studies
are; and it would be well if that address made a deep impres¬
sion on the minds of the Statistical Committee and issued in
some more precise and useful methods of recording observa¬
tions than those we at present employ. We attended the
meeting in full confidence that our President would set before
us facts and conclusions garnered by his wide experience and
illumined by his great ability. Whatever may be said in
adverse criticism of overgrown asylums, it is evident that they
impose no disability on high thinking and scholarly attain¬
ments. We congratulate the Association on having elected a
President who has done so much to render our last annual
meeting entirely worthy of the high aims of our Association.

We have no doubt that this number of the Journal will be
perused with great interest, as we have been able to present to
our readers much of the transactions of the Liverpool meeting.
We need not refer in detail to the various items of interest, but
would remark on the high standard of the work done. While
the Association can attract men of science and men of affairs
its progress cannot be other than triumphal.

The Prevention of Syphilitic Insanity.

The prevention of disease, apart from the so-called prevent¬
able diseases, has at last attracted the attention of the public,
as evidenced by the movements now in progress in regard to
tuberculosis and cancer.

Syphilis, the most preventable of all diseases, is also now
beginning to be brought into notice by the medical profession,

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759

and we trust that the same success may attend efforts in this
direction as in the two above-named diseases.

The dissemination of syphilis of late years has been per¬
mitted to be carried out to an unlimited extent, especially under
the aegis of the religious (?) feeling of the country, and the
plea of the liberty of the subject. The liberty of the subject
to spread scarlatina and even smallpox has been greatly inter¬
fered with, but this more dangerous disease is allowed to be
disseminated under the most favourable conditions, until at
last it is becoming a national evil.

Insanity resulting from syphilis is probably the most obvious
of all the innumerable evils resulting from it, although in every
medical text-book on every disease the part that syphilis plays
is luridly painted.

Statistical evidence of syphilitic insanity is, however, very
defective, and bears witness to something wanting in our
methods of arriving at the actual rather than the apparent
causes of disease. In the Report of the Commissioners in
Lunacy for the year 1901, seven deaths only are ascribed to
syphilis, whilst in the quinquennial average of the assigned
causes (either sole or combined) on admission the number is 341.
Upwards of 1200 patients suffering from general paralysis are
admitted in each year, whilst no less than 1500 died of it in
1901. Yet this disease is said by some observers never to
occur without syphilis. This is, however, by no means the
only form of insanity which can be traced to syphilis, so that
the want of record of this element of causation is indeed
striking, and definitely points to a conspiracy of silence. How
this difficulty is to be overcome is indeed a serious question ;
physicians have naturally an objection to hurting the feelings of
patients’ friends by stating syphilis as a cause on the death
certificate, and this objection cannot readily be removed.
Statistical evidence of any value could probably only be
obtained by a voluntary census of the existing cases in indi¬
vidual asylums and if possible of all asylums. Even this would
probably fall far short of the truth.

Heredity of syphilis is probably an important factor in the
predisposition to insanity, being ascribed in 2 to 5 per cent, of
idiots, and detectable in many persons of unsound mind.

The question we have to ask is, If syphilis were abolished,
what would be the reduction in the number of cases of insanity ?

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Observers would give very different answers to this question,
and the estimates would probably range from 5 to 15 per cent.
However valuable such an estimate might be, it would not be
sufficiently reliable to form a foundation for an application to
Parliament for legislation to prevent the present untrammelled
propagation of the disease. The Statistical Committee
appointed by the Medico-Psychological Association will do
good work if it can devise a method by which, without offend¬
ing the susceptibilities of patients, some definite record of in¬
herited and acquired syphilis in the insane, and of its share
in the production of insanity, could be obtained, with a view
to aiding in future legislation for the prevention of this disease.

Drug Therapeutics .

The investigation of the therapeutic action of drugs from the
darkest ages has ever been of the most unsystematic kind, nor can
the present methods of arriving at their actual value be con¬
sidered as satisfactorily scientific, many new drugs being
introduced into professional medical use in a manner that
is open to very grave objection.

The common method is for a firm of druggists to get hold
of a new chemical compound whose immediate physiological
effect has been tested by laboratory experiments, to persuade
a number of physicians to try it, and to select for advertise¬
ment the reports that are favourable, ignoring all others.
The actual advertisement is then made in what is really a
monthly drug list, garnished with a little scientific quotation
and a few medical platitudes, to give it the semblance of a
therapeutic journal of a professional character.

The drug is then still further distributed to medical men and
druggists, and some few sanguine members of the former class
venture on trying it, or the public, reading the advertisements
or hearing of the marvels from the chemist, press their doctors
to prescribe it.

If a physician of repute takes it up, it becomes the vogue
until some other novelty arises, so that at seaside resorts the
chemists complain that they are heavy losers by their stocks of
drugs, which in one season are contained in every prescription,
and in the next are absolutely disused.

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1902.]

The remote effects of these drugs are not at once ascertained,
and it is only after a time that their defects or uselessness or
real use are demonstrated by a very desultory experience.

Scientific therapeutical investigation indeed can scarcely be
said to exist. The organised bodies of the medical profession,
whose duty it should be to issue authoritative information and
to protect the public, are absolutely apathetic. The College of
Physicians is assuredly the one body whose clear duty it is to
undertake such investigations, and it should be aided by the
Society of Apothecaries. The College, instead of leading,
guiding, and instructing in all matters relating to social medi¬
cine, appears to be content if its opinion is asked on any of
these matters in regard to which action is being taken by
public initiative. It appears to have lost all sense of its high
duties and opportunities.

The Medico-Psychological Association, although burthened
by no duty in this respect, might well set a good example of
initiative by collecting and recording the vast amount of
therapeutic experience that is available in asylums for the insane,
and of which an infinitesimal portion is available for scientific
purposes. New remedies are tried in every institution, and if the
experience thus obtained could be to some extent combined,
valuable information might be put on record, which now is
almost utterly lost.

The health of the country suffers so much from quack treat¬
ment, proprietary medicines, and the attractive preparations of
the advertising chemist that it has become the most prominent
duty of the medical profession to combat the rapidly increasing
evil. The recognition of this obligation by one association
would soon be imitated by others, and might lead ultimately to
a re-awakening of our somnolent medical corporations.

Notes of a Visit to Continental and British Asylums . (*)

Mr. Clifford Smith’s remarks on the various asylums he
visited are of so much value that the report should be read by
every one interested in asylum structure and management.

The report deals, as would be expected, mainly with struc¬
tural and engineering points. The asylum administrator will
find in it instructive and valuable information, which is set

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forth clearly, tersely, and in business-like language, conveying
the impression that great care has been exercised to state facts
accurately and honestly without waste of words. It forms a
very clear exposition of the present state of affairs as regards
asylum construction, and at the same time it is interesting
reading for any one attached to the staff of an asylum.

The author visited twenty-eight institutions in all, situated
in France, Germany, Holland, Scotland, and one in England.
He apparently left very little unseen worth seeing. The report
is illustrated by close upon ninety woodcuts of various kinds,
reproducing indoor and outdoor photographs and plans. Their
origin is, wherever possible, suitably acknowledged, as are the
sources of information generally, and also the attention bestowed
him on his tour.

The first part consists of descriptions of various institutions.
This is followed by a summary dealing with each country
visited; and finally various conclusions are set forth, and
recommendations made. We can only deal with the latter
here.

After careful comparison of the various systems of asylums
which Mr. Clifford Smith saw on his tour, and comparing these
with the London asylums, he suggests that the coming asylum
should be in three sections. The first should be for recent and
acute cases, comprising admission pavilions, acute and infirmary
pavilions, and pavilions o; villas for convalescent patients; all
being detached buildings with ample space about them. This
section, which he calls the hospital, should be designed upon
hospital lines, and should be distinct and well removed from
the other sections of the asylum. It should be adjacent to the
administrative centre, and the type of building should be a
combination of pavilion and villa, except for the convalescent
cases, for which the house-villa type alone would suffice.

The second section should be for refractory and infirm
chronics. Its buildings would be similar to those for the acute
cases, but of a humbler type, all being detached, and all within
a reasonable distance of the administrative department.

The other section, for quiet and harmless patients, would
consist wholly of detached houses and villas arranged in suit¬
able positions about the estate.

He recommends the two-storey type of building for the first
two sections.

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The author goes into details, discusses the problem, and
gives reasons for his recommendations; and concludes with a
table showing the comparative cost of buildings and the main¬
tenance rates of some of the main asylums.

Mr. Clifford Smith and the Council are jointly to be con¬
gratulated on the report, which testifies to the further awaken¬
ing of the public interest in the mentally afflicted.

( J ) Clifford Smith, C. W.: Report to Asylums Committee, London County
Council, 1901.

Increase of Certified Lunacy.

The steady increase in the number of the certificated insane
is evidenced by the rise in the number of first admissions to
asylums, single care, etc. The report of the Commissioners in
Lunacy just issued shows that the ratio of first admissions per
10,000 of the population has increased from 4’94 in 1898 to
5*31 in 1901. This, if not due to exceptional or temporary
causes, is so serious that it would seem to demand attentive
consideration.

The importance of the increase may not, of course, be so
great as it at first appears; the greater part of the advance
(from 5*05 to 5*31) having taken place in the last year (1901),
and cannot therefore be regarded as a fixed increase until the
statistics of the present year are available to confirm or nega¬
tive it to some extent.

The increase in these years may be due in a considerable
degree to the vigorous campaign of prosecutions for illegal
treatment carried on during the last few years, which has had
the result of making medical men and others taking charge of
borderland cases much more careful to obtain certificates in
any cases of doubt. Another possible element of increase is
the cessation of the war, the excitement and interest which
sustained many during its continuance leading to a breakdown
when the stimuli ceased to act. Such an increase of insanity
following on the cessation of war has been noted on more than
one occasion.

The increase, if not attributable to some such temporary condi¬
tions, would lead to the conclusion that mental disease was
really increasing rapidly, and would be an additional reason

XLViii. 5 3

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[Oct.,

for the more speedy and extended adoption of the means for
the special treatment of incipient disorder by hospitals and
reception houses, which afford the best hope of making any
marked progress in the prevention of insanity.

New (Ninth) Asylum for London .

“ The cry is still they come/’ and speculation tries in vain to
foresee the end of the procession.

In the new annual report of the London Asylums Committee
just published it is stated that “ as a result of the report ( l ) of
the asylums’ engineer (Mr. Clifford Smith) we shall in due
course recommend that the ninth asylum be a modified form of
the villa type. The preliminary plans, etc., in connection there¬
with will be prepared by the asylums’ engineer, the Council
having voted a sum of £1000 for this purpose, but until they
are completed we are unable to give particulars as to accommo¬
dation or an estimate of the cost.”

The issue of the plans will be awaited by the specialty with
considerable interest, although the general arrangement of the
new asylum may be imagined from the description of its being
of the modified villa type, in the light of the engineer’s very
lucid report.

The estimate of cost will also be awaited with interest; it
will be disappointing if an institution on such lines cannot be
provided at a cost very greatly below that which has been
attained in previous asylums.

( ! ) Elsewhere alluded to in this issue of the Journal.

Insanity in Jerusalem.

The letter published in “ Notes and News,” from the Super¬
intendent of the English Hospital in Jerusalem, draws attention
to the want of provision for the enlightened treatment of the
insane, as well as to an interesting instance of maltreatment.

The Christian (?) belief that insanity is due to possession by
evil spirits, etc., led to much if not all of the barbarous mal¬
treatment of the mentally afflicted throughout Christendom

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OCCASIONAL NOTES.

1902.]

765

during the middle ages, and even into the beginning of the
nineteenth century.

That this horrible idea should still flourish in the scene of
Christ’s teachings twenty centuries later is one of the most
grotesquely ironical facts that can be conceived.

The picture of an almost nude lunatic chained for forty days
and nights (the period of Christ’s temptation ?) to the altar of
an “ orthodox ” Christian church is one that should bring a
blush of shame to every believer in Christianity, and should
stir up an indignant desire to overcome such an anachronistic
and antichristian anomaly.

Mahommedans treated insanity, as mentioned in our last
issue, in connection with their hospitals, recognising it as
disease, and the first hospitals for the insane in Europe were
those established in Spain,—due, no doubt, to the influence of
Moorish ideas and examples. If the above-mentioned fact were
sufficiently widely known, there is little doubt that an effort
would be made to remove this reproach from the Christian
-Mecca.

Another Messiah .

The latest claimant to Messianic dignity is Mr. Piggott, of
Clapton, who has been associated with a body known as the
Agapemonites, and some members of that body have accepted
him in this aspect.

The Clapton public, however, appears to have taken the
matter very seriously and excitably, with the result that the new
Messiah has received very extensive advertisement in the daily
papers. This is to be regretted, since it is exactly what would
best further the aims of designing imposition, and would be
unkind if it were mere lunacy.

That the press and the public are not better informed of the
frequency of the Messianic'delusion is also a matter for regret.
If the statistics of the number of persons now in our asylums
who labour under this special delusion could be publicly
announced, it is possible that the appearance of one more
claimant would be received with greater equanimity, and lead
neither to local commotions nor sensational paragraphs.

The treatment of these unfortunates prior to their qualifying

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REVIEWS.

[Oct.,

for admission to asylums should consist in avoidance of any¬
thing that could be construed into persecution, whilst their
weak-minded dupes should be exposed to nothing more serious
than kindly ridicule. This attitude would probably be more
easily adopted if #the commonness of the delusion in this and
all Christian countries was more widely known. It would be
therefore of real utility if some amicus curia would collect and
publish the necessary statistics.

Part II— Reviews.

Lehrbuch der Nervenkrankheiten fur Aerzte und Studirende [Text-book
of Nervous Diseases for Practitioners and Students]. By Prof.
Dr. H. Oppenheim. 3rd edition, improved and enlarged. Berlin,
1902, S. Karger. Pp. xii, 1220.

The third edition of Prof. Oppenheim’s well-known and excellent
text-book of nervous diseases requires no lengthy notice. It is con¬
siderably enlarged, and the number of the illustrations has been
increased from 287 to 369, but the arrangement and general principle
of the work remain the same as in former editions, the author rightly
considering that the favourable reception accorded to these indicates
that in essentials his plan and methods are correct. His efforts,
therefore, are still directed to rendering the work practically useful,
and for this reason most attention is given to symptomatology, dia¬
gnosis, prognosis, and treatment; pathological anatomy being only
described so far as it throws light on one or other of these subjects.
Many will regret, however, that in order to economise space, he still
refrains from giving any bibliography.

The book opens with a short introductory part on methods of
examination and general symptomatology. In speaking of vaso-motor
disturbances the author maintains the existence of a cortical vaso-motor
centre in the motor region, both on experimental and clinical grounds;
and to account for trophic disorders he advances the theory that
diseases of the spinal cord which interrupt the passage of stimuli from
the spinal ganglia lead to an accumulation of stimuli in the cells of
these ganglia, and so to a pathological increase in peripheral nutritive
processes; while affections of the peripheral nerves which impair but do
not altogether interrupt their continuity set up conditions of irritation
which, extending to the trophic centre, alter its function so as to cause
nutritional disorders in the corresponding peripheral area.

The special part, forming the bulk of the book, deals in order with
diseases of the spinal cord, peripheral nerves, brain, the neuroses,

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767

diseases of the sympathetic, and conditions of intoxication in which
the nervous system is especially involved. The descriptions of the
symptoms are characterised by an admirable lucidity and conciseness,
while at the same time nothing of importance is omitted. The sections
on the diagnosis of the various diseases show a grasp and judgment
which might be expected from the author's reputation; while those on
treatment are, one might almost say, models of what such sections
ought to be, omitting nothing of importance, while not overburdening
the reader with .valueless remedies and methods. In this department
the author's object was, as he says, to avoid excessive scepticism as
well as “the far more dangerous fault" of uncritical acceptance of
statements, and in this we think he has upon the whole succeeded.
Among the countless points that might be noted, it may be mentioned
that the author, while giving a number of theories as to the first point
of incidence of tabes, declines to commit himself to any of them, and
also that he does not hold either this disease or general paralysis (of
which an excellent account is given) to be essentially syphilitic, while
not denying the immense importance of syphilis as a factor in their
causation. He speaks well of Frenkel’s “ Uebungstherapie " in the
former. There is an interesting account of the symptoms arising from
disturbances of the cerebral circulation. In the section on the
neuroses, without wishing to institute comparisons, we may mention
that the article on migraine is good, and the same may be said for that
on morphinism amongst the intoxications, though in the latter the
account of the treatment leaves something to be desired, as there is no
indication given to enable the reader to decide as to the best mode of
withdrawing the drug. The work as a whole may be unreservedly
recommended to all who require an accurate, concise, and fairly full
treatise on the subject from the clinical standpoint; and last, but not
least, it is written in a very readable style. VV. R. Dawson.

Clinique des Maladies du Systeme nerveux (Hospice de la Salpetriere),
ann^e 1898-9, Quatrieme et Cinquieme S^rie. Paris : Octave
Doin. 8vo, 579 and 648 pp. respectively, with figures and

plates.

These volumes, which succeed three others of similar size issued
in previous years, consist of lectures delivered by Prof. Raymond at
the Salpetriere. The subjects dealt with are of the most diverse kind.
A few may be enumerated:—Two cases of Tumour of the Rolandic
Zone; The Diverse Forms of Progressive Muscular Atrophy; Affec¬
tions of the Terminal Cone; Juvenile General Paralysis; Partial
Epilepsy; Topography of the Cortical Centres of General Sensibility;
Three cases of Scleroderma; Infantile and other Forms of Myx-
oedema.

These works are of interest more particularly to the neurologist
The subjects dealt with are, with one or two exceptions, outside the
domain of mental disorders. There is a chapter on the Psychical

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768

REVIEWS.

[Oct.,

Equivalents of Epilepsy, but the conditions described in this, as in the
chapter on Juvenile General Paralysis, are well known to the student
of mental disease. At the beginning of each lecture is a summary of
the subject-matter, and the same appears in the table of contents at
the end of each volume.

It would serve no useful purpose to select one or two chapters—and
space would allow no more—of these tomes for review. Although it
must always be highly instructive to peruse the work of one holding
such a distinguished position in neurology as Prof. Raymond, and of
such great experience, yet but few, we conceive, will have the leisure to
peruse unsystematic works of so voluminous a nature. By students of
neurology they will doubtless be highly appreciated. The lectures are
marked by all that aptitude for lucid exposition which we associate
with the great French teachers of medicine. E. G.

The Elements of Mind: being an Examination into the Nature of the
First Division of the Elementary Substances of Life . By H.
Jamyn Brooks. London: Longmans, Green, & Co., 1902.
Pp. 312, 8 vo. Price ioj. 6 d. net.

The title of this book might suggest that it comes within the region
of psychology; the phrase “substance of life” in the sub-title indi¬
cates, however—what is in fact the case,—that the scope of the work
is entirely metaphysical. Like many other people with a passion
for thinking, Mr. Brooks has worked out for himself a theory of the
universe. “ By a fortuitous train of thought I believe I have dis¬
covered the elements of Mind, which, when compounded with those of
Force and Matter, constitute the mysterious substance we call Life.
In this I claim to have found the solution of a great and world-old
problem.” Thousands before Mr. Brooks have thought the same.
Every metaphysician thinks his own philosophy the one philosophy in
the world, just as every youth thinks his own sweetheart the one girl
in the world. Youth is required for this faith. Mr. Brooks began
early. He tells us how, though orthodoxly brought up to believe in a
personal devil, he thought out for himself the nature of virtues and
vices, and found out that, however mischievous human vices may be,
the majority are but virtues carried to extremes, while virtues are
generally vicious impulses under the restraint of moderation; so that
up to a certain point all nature is good, and beyond that point all evil.
These youthful conclusions—which contain a real and subtle element
of truth—constituted the germ of Mr. Brooks's philosophy, which may
fairly be described as monistic and pantheistic, though the author
would not admit that these designations are strictly correct

Mr. Brooks writes with much appearance of lucidity and clearness,
but it cannot be said that his arguments are always easy to grasp, this
being due to the fact that his definitions are by no means sufficiently
precise. The author writes to attract the scientific reader, and appeals
for support to various scientific writers (including “ Weissmann ”), and

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769

1902.]

the refreshing eagerness with which he puts forward his views may
be found stimulating by those who like the construction of meta¬
physical edifices on a more or less scientific basis. Mr. Brooks must
scarcely expect, however, to attract either devoted disciples or active
opponents outside his own circle. To influence the world a meta¬
physical system must either be the elaborated outcome of a lifetime of
work and thought, as in the case of Hegel or Spencer, or else it must
be interesting because, as in the case of Ostwald or Verwom, it
represents the ideas of a man who has already attained eminence in a
special field of science. Mr. Brooks may console himself with the
thought that a like fate has befallen many works of greater intellectual
distinction. Havelock Ellis.

Ueber die sogenannte “ Moral Insanity ” [Concerning So-called “ Moral

Insanity”]. By P. Nacke. Wiesbaden: Bergmann, 1902. Pp.

65, 8vo.

This pamphlet belongs to the excellent little series of Grenzfragen
des Nerven-und Seelenlebens, devoted to the exposition of various
current problems in psychology and psychiatry. Dr. Nacke has often
discussed the subject of moral insanity before, and here presents his
latest views. He doubts if any cases of moral insanity, in the strictest
sense, occur at all, with the possible exception of that recorded by
Bleuler, and is not in favour of retaining the name. It is very doubt¬
ful, he argues, whether, in such cases as have been recorded, the
intellect is ever quite intact. Considering only the broad lines in
their clinical aspects, there are two types of these cases—an active and
more dangerous type, a passive and more harmless type. In the first
there may be slight nervous disturbances from an early age, but the
child is chiefly notable for its domineering, cruel, and unaffectionate
disposition, and is always a liar and a hypocrite. He becomes the
black sheep of the family, and is perhaps sent abroad, or passes from
prison to prison, from asylum to asylum. The girls show inaptitude
for any honest occupation, and tend to become prostitutes, even if of
good family. Sometimes, however, the individuals of this type are
placed under circumstances which enable them to achieve success, even
fame the aureole of the hero. Such were some of the conquistadores,
like Pizarro, and Nacke is inclined to place in the same group certain
Englishmen of recent times, especially Cecil Rhodes and a well-known
living politician. Even, however, when we admit abnormality, these
suppositions seem a little hazardous. Nacke’s second type is marked
by indolence, indifference, egoism; but, in consequence of less
active energy for evil, it is more capable of adaptation to social ends.
All the cases of either type may be classed pathologically, Nacke
believes, under one of three heads: (1) imbecility; (2) periodic or
cyclic anomalies ; (3) psychic degeneration in Magnan’s sense. The
use of the term “moral insanity ” is thus regarded as unnecessary.

Concerning the forensic aspect of such cases, the author has little

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77 o

REVIEWS.

[Oct.,

that is novel to bring forward. He demurs to the statement of the
present reviewer that the “ moral imbecile ” is properly regarded as a
criminal. But at the same time he insists that the prison should be
made “ a kind of hospital and educational institution,” and advocates
the indeterminate sentence. “ Moral insanity ” is admittedly a some¬
what peculiar form of insanity. Since, therefore, it is possible to treat
it in a prison it is surely reasonable to do so, and, in so doing, to avoid
unedifying and usually fruitless wrangles between the representatives
of medicine and of law. Havelock Ellis.

Psychologic du Delire dans les Troubles psychopathiques. Par N.

Vaschide et Cl. Vurpas (Encyclopddie des Aide-Memoire).

Paris : Masson & Gauthier-Villars, 1902. Pp. 190, 8vo. Price

2 f. 50.

This little volume—written by a psychologist, who has previously
done good work, in conjunction with an alienist—is somewhat dis¬
appointing. The aim of the book is excellent. It is proposed to deal
with “ the psychological mechanism of delirium,” and to reach a clear
critical conception of this highly important element in mental disturb¬
ance. The authors decided, however, to discard the experimental and
strictly scientific methods with which they are most familiar, and to
make a study of “ the complete bibliography of the question, guided by
the simple desire to know where the question stands, what methods
have been employed to investigate delirium, and what the worth is of
the psychological analyses that have been reached.” This is a legiti¬
mate method of approaching the question, but it obviously involves
some scholarship, and in this respect, it is too clear, neither author is
well equipped. For ancient writers they constantly quote from Treat's
historical work on insanity ; their knowledge of German authors, when
not translated into French, seems to be confined to summaries in
journals; English authors are mostly ignored. So easily accessible an
ancient classic as Aretseus is only known to them at second hand ; and,
still stranger, so is a French classic, Pinel. This lack of direct grip on
the writers they are investigating renders much of the book bald and
uninforming, although the opinions of a great many authors are here
brought forward.

In their first chapter, and again in the concluding chapter, the
authors attempt to limit and to define the term “ delirium,” which has a
more precise and explicit sense than “insanity,” having reference to
“what passes in consciousness independently of the motor reactions
by which it is manifested.” It is suggested that the key to the genesis
and mechanism of the various states included under delirium may be
found in the association of ideas. The authors regard delirium not as
a special “ syndrome,” but as “ the efflorescence of a subconscious
psychological activity which, in its fundamental elements, exists not
only in morbid but in normal states,”—not merely in dreams, but in
“ the intimate essence of human activity, that human loquacity which
so feverishly intoxicates the intelligence.” Havelock Ellis.

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1902.]

REVIEWS.

771

Gli Arii in Europa ed in Asia [The Aryans in Europe and Asia].

By G. Sergi. Bocca, Florence, 1902. Pp. 372, 8vo. Price

5.50 lire.

In this volume Prof. Sergi has presented us with a supplement to his
Mediterranean Race , and has further discussed the great problem of the
peopling of Europe and the origin of European civilisation. In the
earlier volume he marshalled before us all the evidence which is gradu¬
ally tending to show that the greater part of the population of Europe
and the best part of its culture may be traced back to the dolicho¬
cephalic people—by him termed Eurafrican race—inhabiting both
shores of the Mediterranean. In the present volume he discusses the
origin of the Asiatic brachycephalic element in European popula¬
tions, and its relationship to the Aryan family of languages. It is
admitted that Asiatic migrations into Europe occurred at the end of
the Neolithic period, and that at the same period metals appeared in
Europe, as well as the practice of cremation. Sergi has come to the
conclusion that the Asiatic invaders brought with them the primitive
Aryan languages, but that they were savages, and that the appearance
of metals at about the same period was a fortuitous coincidence.
These invaders were of the same race as the Tajiks and Usbeks who
to-day inhabit the regions to the north of India, and may be regarded
as Mongoloid peoples, representing a cross between Eurafrican dolicho-
cephals and Asiatic brachycephals. He does not, however, consider
that these Mongoloid tribes originated the Aryan speech, but that they
learnt it in the course of mingling with the dolichocephalic people of
India, by whom they may be said to have been Aryanised. Sergi rightly
regards the term “ Aryan ” as having a merely linguistic sense, and not
as the name of a human variety. It is curious, however, to observe
that, by a complete but silently made change, he now uses the term in
an entirely different way from that in which he formerly used it.
Before he called the brachycephalic invaders of Europe Aryans, now he
regards them merely as “ Aryanised,” the “legitimate Aryans” being
the dolichocephals belonging to the extreme eastern branch in India. It
is evident that the less we use this elusive term “Aryan” the better.

The book remains, however, an interesting contribution to a problem
which will doubtless long continue to prove fascinating. The author
has sought to avoid all unnecessary technicalities, so that the volume
is easy reading. It is illustrated with maps and many excellent facial
types. Havelock Ellis.

Merck's Annual Report , 1902.

This valuable r&sume of the recent advances made in pharmacology
and therapeutics is each year becoming more widely known and appre¬
ciated : the present number maintains the excellence of preceding
years.

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REVIEWS.

[Oct.

Of special interest to the alienist will be found the references to the
cacodylates, in which the arsenic present is regarded as to some extent
latent. The administration is chiefly by hypodermic injection, accord¬
ing to rules which are strictly laid down in this number and in Merck's
report, 1900, but the administration per os or per rectum is also
employed. The cacodylates are prescribed as metabolic stimulants
in states of malnutrition, also in neurasthenic states and in conditions
of mental depression associated with defective nutrition (Paulet and
Gautier).

In connection with this the glycero-arseniates may be referred to.
The lime salt is employed in conditions in which its counterpart,
calcium glycero-phosphate, has been employed, viz., in states of mal¬
nutrition. The administration by mouth promises most, as the hypo¬
dermic method involves the use of citric acid as a solvent, and this
causes pain.

Lecithin claims attention for similar reasons, viz., as promoting a
healthy tissue activity. Administered either by mouth or hypo¬
dermically, it has been used in neurasthenia and various nervous
affections (Gilbert, Fournier), in tabes, general paralysis, certain
psychological conditions, and in hysteria (Hartenberg). In addition it
is used in various states of impaired nutrition. Lecithin is easily
assimilable, and is a vehicle of phosphorus, to which element much is
attributed.

The list of nutrients is swelled by such preparations as alboferine,
iron-tropon, mutase, piantose, roborin (obtained from the blood, and
consisting mainly of calcium albuminates), sicco (a dried form of
haematogen). We stand in great need of a reliable valuation of the
many nutrients now on the market.

Among drugs of much interest may be enumerated bromipin and
iodipin, which, as vehicles of bromine and iodine action, appear to
convey their influence with less risk of intoxication. Recent investiga¬
tions confirm the value of these drugs, and the former has now been
extensively and successfully used in epilepsy.

Dionine continues to gain ground as a morphia substitute, and it has
been recently prescribed by Maewski in states of mental excitement,
also in cases of increased sexual impulse, and in paroxysmal masturba¬
tion. In these cases dionine is injected hypodermically in the dose of
gr. |—In the treatment of morphinomania it may be administered
per os in doses of grs. four times daily, whilst at the same time
pure water is injected subcutaneously as a placebo.

Further use of dormiol (amylene chloral) confirms its usefulness.
It is stated on the authority of a fresh list of observers to be without
the depressant effects of chloral hydrate, and the unpleasant taste of
paraldehyde and amylene hydrate. It acts more promptly than sul-
phonal, and gives a refreshing sleep of five to eight hours. It is best
administered in capsules containing 7—8 grains; the dose is one, two,
or three capsules.

Hedonal (methyl-propyl-carbinol-urethane) cannot be said to make
headway; its taste is unpleasant, its action uncertain, and its price
high. E. 'Muller, who reports more recently upon it, finds it a harmless
hypnotic in doses of 30—45 grains, and suited to mild forms of

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ANTHROPOLOGY.

773

1902.]

insomnia, but even in these cases its effect is found to diminish, and
the dose has often to be very considerably raised, viz., to grs. 80 and
over.

There are many other drugs to which we might refer, but we can do
no more now than commend this valuable report for careful study.

Harrington Sainsbury.

Part III—Epitome of Current Literature.

1. Anthropology.

The Sexual Impulse in Women. (Amer. Journ. of Dermatology, March,
1902.) Havelock Ellis.

This paper is an abstract of a study which is to be embodied in the
author’s Psychology of Sex.

Ellis points out that there is considerable divergence of opinion as to
the frequency and strength of sexual impulse in women. His own
direct observations on educated Englishwomen of the middle class
dispose him to think that genuine cases of absence of sexual feeling are
extremely rare. Notably he found that amongst the more highly
intelligent energetic women, the sexual emotion was strong.

The impulse in women, however, differs from that in men in at least
five well-marked characteristics : (1) it shows greater apparent passivity;
(2) it is less apt to appear spontaneously, more often needing to be
aroused ; (3) it tends to become stronger after sexual relationships are
established, and the threshold of excess is less easily reached than in
men ; (4) the sexual sphere is larger and more diffused; (5) there is a
more marked tendency to periodicity in the spontaneous manifestations
of desire. Largely as a result of these characteristics, the sexual
impulse shows a greater range of variation in women than in men, both
as between woman and woman, and in the same woman at different
periods. W. C. Sullivan.

Brain of a Criminal\Das Gehirn des Morders. Bobbe\ ( Corresp.-Blatt d.

Deutsch. Gesell. f. A nth., Nov. and Dec., 1901). Waldeyer.

The eminent Berlin anatomist here gives a summary of his examina
tion of a German criminal, who after murdering a number of persons,
apparently with much deliberation, finally shot himself. His crimes
extended over some years.

The skull offered no special peculiarities, except that it was relatively
large and thin. It was mesocephalic. The brain, when removed from

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77 4

EPITOME.

[Oct.,

the skull, weighed 1510 gr.—a very respectable weight for a small man
weighing little more than 100 lbs. ; with all corrections made Waldeyer
estimates the brain weight as 1400 gr., still over the average. The
convolutions were well developed; at the occiput the longitudinal
fissures were better marked than usual. On the whole, it might be
regarded as “ the type of a normal human brain.”

In the body generally there were various anomalies. The subject
was a small man, with delicately made extremities, but well-developed
muscles. He was slightly hump-backed, and the ribs were not sym¬
metrically disposed at the sternum. Moreover, the tibialis posterior
at its insertion in the foot, showed on both sides a peculiarity of atavistic
character common in some of the lowest human races.

It is scarcely necessary to observe that in the hands of a highly
competent investigator observations are equally valuable whether the
results are negative or positive. This case, so far as it goes, supports
the contention of those who believe that anomalies of the body
generally are more significant than gross anomalies of the brain.

Havelock Ellis.

a. Physiological Psychology.

On the Perception of Tactile Impressions \Sopra la Percezione delle

Impressioni Tati Hi]. (Arch, di Psichiatr ., vol. xxiii, fuse. //, Hi.)

Grandis.

When a sensitive area of skin or mucous membrane is stimulated by
weak induced currents from a Du Bois-Reymond’s coil, the subject
experiences at first a vibrating, creeping sensation, w'hich, if the electrodes
are not moved, quickly changes to a simple sensation of contact.
Grandis has studied this phenomenon in a series of twelve individuals,
operating on the tip of the tongue with currents just above the
Reizschwelle . He finds that the period during which the sensation has
a vibrating character corresponding to the nature of the stimulus varies
in different individuals, and in the same individual at different times.
As far as could be inferred from a very limited number of experiments
touching the point, the duration of this period increases with the strength
of the stimulus. It did not appear to vary with alterations in the
frequency of the shocks. In a series of observations with short intervals
of rest, the period of correct perception was found to decrease rapidly
to a couple of seconds. A shifting of the electrodes increased the
length of the period, thus suggesting a peripheral exhaustion as the
cause of the paraesthesia. The author, however, without absolutely
rejecting a peripheral element, is inclined to attribute the phenomenon
more to a central exhaustion; he points out that the increase on moving
the electrodes is never up to the initial period; and further, that even
when the experiments are renewed after some hours of rest, and the
electrodes are not placed on the same spot, the period of correct sensa¬
tion is always a good deal shorter than at the start. The interval
between the successive shocks is too long to allow the phenomenon to

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/ETIOLOGY OF INSANITY.

775

1902.]

be explained by a blending of impressions. The author maintains,
therefore, that the change in the character of the sensation is due to
fatigue of attention, and he suggests that the duration of the pre-par-
aesthetic period may be a practically useful measure of the individual’s
power of attention. W. C. Sullivan.

Voluntary Mydriasis and Epilepsy in a Man of Genius \Midriasi
Volontaria ed Epilessia in Uomo Geniale\. {Arch, di Psickiatr. f
vol. xxiii, fasc. /V, Hi.) Lombroso and Audenino .

The case, exhaustively reported in this paper, is chiefly interesting as
an example of the uncommon condition of voluntary control of the
pupillary movements. The subject, an hereditary degenerate with
epilepsy, was able in a dim light to dilate his pupil from a diameter of
3 mm. to 6 mm. or more. The effort of will required was considerable,
as was evident in the increase of vascular pressure and the acceleration
of the pulse and respiration which accompanied the dilatation (illus¬
trated by cardio-pneumographic tracings).

The authors consider that this mydriasis depends on a contraction of
the vessels of the iris; the pallor and rise of blood-pressure would
support this view. Lombroso, of course, advances as an alternative the
inevitable explanation by atavism : why should not an epileptic of genius
with innate criminal dispositions have a striated dilator muscle in his
iris as have many birds of prey ? W. C. Sullivan.

3. Etiology of Insanity.

The Genesis and Nosographic Position of Progressive Paralysis \Genesi
e Nosographia della Paralisi Progressive^. {.Riv. Sper. di Frenia-
tria, vol. xxviii, fasc. /, 1902.) Bianchi.

This paper is chiefly concerned with the aetiology of general paralysis.
Bianchi reaffirms his well-known views that syphilis is not the only, or
even the most important factor in the genesis of the disease. It is a
dystrophic malady of the nervous system, due to the accumulation in
the nerve-cell of the waste products of its own activity. The syphilitic
poison is one of many causes which can produce this bio-chemical
change in the cell; alcoholism, arthritism, neuropathic heredity, sexual
excess, are other and not less important agents. As a rule, in any given
case several of these causes co-operate. They create the predisposition ;
any over-strain of the nerve-cell—mental work, worry, excess—develops
the disease.

Statistics are not competent to decide a question of aetiology. In
this matter, moreover, they are discordant, and at the best they do not
support the exclusively syphilitic origin of the disease. Bianchi, as aq
instance, gives statistics of eighty-seven personal observations : syphilis
was only found in forty-seven cases, and in all but twelve cases other
causes were also noted. Psychopathic heredity, on the other hand, was
found in forty-eight cases, and figured as the sole cause in seventeen.

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EPITOME.

776

[Oct,

The greater frequency of the disease in educated women than in
prostitutes, and its rarity in syphilitic but mentally inactive communities
such as the Arabs and the Abyssinians are facts which tell against the
luetic theory.

Bianchi attaches particular importance to arthritism as a cause of the
disease, especially in the upper classes; and he admits a special renal
form of the affection with initial epileptiform and apoplectiform attacks
of uraemic nature. The source of the disease is never manifest in
peculiarities in its anatomical lesions or in its clinical symptoms.
Clinically it is proteiform.

Bianchi emphasises the grave import of loss of the knee-jerk and im¬
potence as precursory signs of the disease. During remissions there
may be an almost entire re-establishment of the normal personality ;
under such conditions the testamentary capacity of the patient ought to
be admitted. W. C. Sullivan.

4. Clinical Neurology and Psychiatry.

The Unilateral Occurrence of Kemig's Sign as a Symptom of Focal Brain
Disease. (Amer. foum. Med. Sci., May, 1902.) Sailer,/.

Two cases in which Kernig’s sign was present only on one side, and
appeared to bear some reference to a cerebral lesion on the other side
of the brain, are here reported.

The author states that this sign was described by Kemig in 1883
before the Medical Society of St. Petersburg, and the next year
published in German. His attention was first directed to the pheno¬
menon in a patient recovering from epidemic cerebro-spinal meningitis.
This patient could walk perfectly well, could lie in bed with legs
extended, but whenever she sat in a chair she found it impossible to
extend the legs on the thigh beyond a right angle.

Subsequently, he studied fifteen cases of meningitis, nine of which
were confirmed by autopsy, with reference to this sign, and found it
present in all. It could be elicited whether the patient sat up, lay on
the back, or on the side. He describes it as a flexion contracture in
the legs (and occasionally in the arms) when the thigh is flexed to a
right angle upon the trunk. Under these circumstances, any attempt to
extend the leg on the thigh meets with severe resistance as a result of
contraction of the hamstring muscles, and it is impossible to extend the
leg beyond an angle of 135 0 , or even, in extreme cases, beyond a right
angle. When the thigh is extended the hamstring tendons are relaxed
and soft; when, however, the thigh is at a right angle to the trunk, and
an attempt is made to extend the leg, they become tense and prominent.
The contraction is not ordinarily associated with pain, nor with any
increased rigidity in any other part of the body, and Kemig particularly
noted that the retraction of the head did not become greater when the
patient sat up. He states that the sign usually persists long into
convalescence; it may vary from time to time in the course of the
disease; it is not produced by mechanical irritation of the sciatic

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

777

nerves, and may, as he noted in his original communication, occur in
certain other conditions, although in all of those that he observed there
was reason to believe that irritation of the membranes existed.

Sailer then proceeds to deal with the literature on the subject, which
he describes as inconsiderable, although the presence or absence of
this sign is now usually mentioned in connection with a suspected case
of meningitis. The first important article on the subject was that of
Friis, who found it present in seventy-four of eighty-six cases, and
Henoch also obtained it frequently in children suffering from meningitis;
but Netter’s extensive series of investigations, in which he found it
present in nearly all cases of meningitis, practically called general
attention to the existence of this sign. Henoch was the first to
mention the fact that it is more often absent in tuberculous than in any
other form of meningitis, >vhich observation has been confirmed by
Netter, Herrick, Dieulafoy, and others. With the exception of one of
Herrick's cases, in which the sign was elicited in the unaffected leg of a
woman suffering from gonorrhoeal gonitis, mention has not been made
of its unilateral appearance. The author then proceeds to describe at
length two clinical cases which have been under his care in the
Philadelphia Hospital during the last year in which the sign was
unilateral, and appeared to be a symptom of focal encephalitis. He
afterwards criticises the theories of Friis, Henoch, and other authors as
to the nature of the mechanism by which Kernig’s sign is produced.
He points out that Kernig himself is the only writer who states that the
arms may be affected in a similar manner to the legs. He thinks that
it is obvious that it is not a lesion of the meninges, but of the subjacent
nervous substance that causes this sign.

Finally, he believes that the following conclusions are justified :—
First, Kernig’s sign may occur as a symptom of focal encephalitis, and
in this condition may be present upon only the opposite side of the
body. Sometimes it is associated with spastic paresis of the leg upon
that side. Second, in these cases there may be a persistent tonic spasm
of the flexor muscles of the arm, which, however, does not resemble
Kemig’s sign in its mechanism. Third, the most reasonable explana¬
tion of Kemig's sign that we have at present is to ascribe it to an
irritative lesion of the pyramidal tract that diminishes, but does not
destroy its functional activity.

At the request of the author, his resident physician, Dr. Shields,
appends to this article a “ Report of One Hundred Cases, all Non-
meningitic, examined for Kernig’s Sign.”

He found this sign to be present in five cases; three showed the sign
unilaterally and two bilaterally, one case of uraemia and one case of
typhoid fever, and it is interesting to note that in both of these cases
the sign could not be obtained after recovery. Kernig’s sign persisted
in the three remaining cases—two cases of right-sided hemiplegia, and
one of typhoid fever,—and in all it was obtained on only one side. The
case of typhoid fever, he states, is still quite ill, and it is possible that
the sign will have disappeared by the time the patient has regained her
normal condition. In both cases of typhoid fever which showed the
sign delirium was marked and persistent. This predominance of
mental symptoms may have been an indication of febrile or toxic

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EPITOME.

77 8

[Oct.,

cerebral irritability, which might have in some manner been accountable
for the presence of the sign.

In addition, also at the author’s request, Dr. Clark reports “Three
Cases of Meningitis in which Kemig’s Sign was persistently Absent,”
the diagnosis in all three cases having been confirmed by autopsy. One
was a case of acute cerebro-spinal leptomeningitis, whose bacterial
nature was not determined; and two were cases of tuberculous menin¬
gitis, this fact confirming the opinion that Kernig’s sign is especially
unreliable in the latter disease. A. W. Wilcox.

On the Classification of the Psychopathies [Sulla classificazione delle
psichopatie]. (Piv. Sper . di Freniatria , voL xxviii, fasc. /, 1902.)
De Sanctis .

In this report, presented to the eleventh congress of the Society
Freniatrica Italiana, De Sanctis gives a succinct critical and historical
account of the various attempts at classification of mental diseases, and
discusses the principles on which a modem scheme of classification
should proceed. It appears to have been generally felt in Italy that the
classification introduced by Verga in 1874, which is still in use for
official returns, has become hopelessly out of date, and it was especially
with a view to devising an improved system for statistical purposes that
the congress took up the matter. De Sanctis, however, has not confined
himself to this strictly practical point of view, but has dealt with the
whole problem of classification, and has gone into several thorny
questions of nomenclature and of psychiatric doctrine related to it.
His extremely able essay does not lend itself to condensation, and it
is accordingly only possible to indicate a few of its salient points.

What is the trend of current thought in Italian psychiatry ? On this
point the replies to a questionnaire addressed by the author to a number
of leading alienists are very instructive. They show that Italy is in¬
fluenced to a very remarkable extent by German ideas. The majority
of the classifications in use—and classifications are, perhaps, the clearest
expressions of doctrine—are taken more or less directly from the
Germans,—from Krafft-Ebing and Schiile among the older authorities,
from Kraepelin more lately. Kraepelin’s views, in particular, seem to
have met with a rapid and striking success in Italy. On the other hand,
very little direct French influence is acknowledged. In general the
Italians, with the exception of the Neapolitan school, seem to share in
the intellectualist bias which has always been stronger in German than
in French or British psychiatry.

Coming to the constructive part of his paper, the author discusses
the criteria of classification. In the present state of science the clinical
criterion is the safest. The effort must be made to arrange systemati¬
cally as many clinical entities as can be distinctly established, grouping
the remaining syndromes of uncertain position in a provisional fashion
as morbid states,—accepting, that is to say, the distinction between
Geistesstoningen and Geisteskrankheiten . This opens the vexed ques¬
tions of the position of mania, and the soundness of Kraepelin’s con¬
ception of maniaco-melancholic insanity and dementia prsecox. On
all these problems the author leans to Kraepelin’s views, though, in

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1902.] CLINICAL NEUROLOGY AND PSYCHIATRY.

779

order to secure general agreement, he does not give them explicit en¬
dorsement in the classification which he suggests. This classification,
in the form in which the congress finally accepted it, is as follows :

1. Congenital psychoses :—Arrests and deviations of psychic develop¬
ment, phrenastenias, moral insanity, sexual psychopathies.

2. Simple acute psychoses :—Maniacal states, melancholic states,
amentia, sensory frenzy (hallucinatory psychosis).

3. Primary and secondary chronic psychoses:—Paranoia, periodic
psychoses, senile psychoses, states of dementia, (i) primary juvenile ;
(ii) secondary.

4. Paralytic psychoses :—Classic general paralysis, paralytic dementias
from syphilis, alcohol, cerebral softening, etc.

5. Neurotic psychoses:—Epileptic, hysterical, neurasthenic, choreic,
etc.

6. Toxic psychoses:—Alcoholic insanity, morphinic, cocainic, etc.;
pellagrous insanity.

7. Infective psychoses :—Post-influenzal, typhoid, syphilitic, etc.;
acute delirious mania.

It is explained that in this list “ amentia ” is given as a comprehensive
term for the confusional psychoses ; a separate entity is, however,
allowed to those forms where the psycho-sensorial disturbance is recog¬
nised as antecedent to the delirium or confusion ; they rank under the
rubric of “ Frenosi sensoria.” The term paranoia is retained for chronic
cases only, including Magnan’s dtlire chronique. The scheme does
not appear to have excited much enthusiasm in the congress.

W. C. Sullivan.

Report of a Case of Dementia Prcecox . (Amer. Joum. Med. Sri., Jan.,
1902.) Dunton, W. R.

As dementia praecox is not well known in America the following
history seemed to the writer to have sufficient points of interest to
warrant publication.

The case is that of a married woman, aet. 31 years on admission,
the mother of three children, the youngest being eighteen months old at
that time, who was under the author’s observation for over two years.
The family history was negative. The only history of serious illness was
one of chronic bronchitis after the birth of her last child, from which,
however, she had entirely recovered. The clinical notes are then set
forth at length, the physical characteristics of the disease being more
fully noted than the mental, partly, the author explains, because he was
not sure of certain phases apparently shown by the patient, and partly
to avoid making the report too long.

He then quotes Kraepelin at some length as to the symptoms of
dementia praecox, and mentions the characteristic symptoms given by
Tromner and by Christian.

A summary of the case he here reports shows that the patient was
mentally depressed. There was an exaggeration of the tendon reflexes,
a weakening of the heart’s action, cyanosis, and a decrease of weight
while taking nourishment well. At one time she refused food, and had to
be fed; later she took nourishment well. Simple perception of external

XLVIII. 54

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7 Bo

EPITOME.

[Oct.,

ideas was not interfered with, but there was fallacious sense perception, as
was evidenced by the early complaints of street noises, etc. Negativism,
while present, was not especially marked. (Negativismus, or negativism,
Kraepelin defines as the senseless struggling against every external
influence. It is shown in the mutism or the senseless dumbness, as
well as in the complete inability to influence the patient.)

There was disturbance of her emotional life, as was shown by her
periods of depression and attacks of boisterousness. Stereotypy and
verbigeration were shown on several occasions. Katatonic rigidity was
also present.

The author is of opinion, from the symptoms, that this case is one of
the katatonic form of dementia praecox.

The age, thirty-one years, at which the onset is noted, is somewhat
uncommon, being beyond the period of puberty, which Christian has
placed between the ages of fifteen and twenty-five. Kraepelin found
(and illustrated by a diagram in his Text-book of Psychiatry) that 60 per
cent occur before the twenty-fifth year, but over io per cent, occur
before thirty-five years. Tromner has placed this diagram side by side
with one showing the occurrence of the maniacal-depressive forms of
alienation (mania, melancholia, stupor) in the same periods of life. It
shows very strikingly that dementia praecox is not so essentially a
puberty psychosis as was supposed, and that the maniacal-depressive
forms are more common in early life than was generally thought

The condition of tonic muscular contraction shown by this patient
has not been much studied. It occurs without accompanying mental
symptoms, but the correlation between the two is practically unknown.
The author hopes that physicians may become interested in this condi¬
tion, and by reporting cases, either with or without accompanying
mental symptoms, add to our knowledge of the subject.

A. W. Wilcox.

5. Pathology of Insanity.

Clinical and Anatomo-pathological Studies upon Idiocy [Studii Clinici ed
Anatomo patologici sulP Idiozia\ {Ann. di Freniatr ., voL xt\
fasc. 4). Pellizzi , G. B.

In this number Dr. Pellizzi finishes a series of papers on the
pathology of idiocy, which he has since published in book form. He
devotes most attention to sclerosis of the brain, a rare form of idiocy,
at least in Britain. He reproduces at great length twenty-two observa¬
tions of Boumeville and others, to which he adds three of his own
(filling forty-seven pages). He lays down some interpretations of his
own which are valde probanda .

The rest of Pellizzi’s work comprises a diligent study of divers papers
in various languages upon cases of insanity, idiocy, etc. He deals
mainly with what is seen through the microscope, touching very slightly
on the clinical side. He devotes fifty-two pages to an attack upon the
classifications of idiocy used by some writers, and advances a new one.

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1902.]

PATHOLOGY OF INSANITY.

781

The classifications in vogue are composed mostly of the same forms
arranged in a somewhat different order; and this even holds good of
Dr. Pellizzi’s classification, though to some forms he gives strange
names, and adds numerous subdivisions taken from descriptions of
rare cases. Each writer on the subject uses his own classification,
and peaceably leaves his fellow-worker to do the same. In time we
may arrive at some common agreement upon a sound anatomical and
pathological basis. Pellizzi denies the existence of a form of idiocy
determined by epileptic attacks. He will have it that the primary cause
is a histioatypie, meaning apparently some unusual formation of
the tissues of the brain, which is the cause both of the idiocy
and of the epilepsy. Apparently such may cause the mental
deficiency without epilepsy, or epilepsy without idiocy. The epilepsy is
but a symptom of the arrest of cerebral development, which is partly
atavistic and partly teratological. Neurologists generally admit an
unusual nervous irritability in those liable to epilepsy; but whether this
predisposition be accompanied by any abnormal appearance in the cells
and fibres of the brain is doubtful. The appearances which Pellizzi
loosely indicates by the word atypy seem to be of a varied character.
In the general statement that there is a structural peculiarity in the
nerve-cells of epileptic idiots Pellizzi has been long ago anticipated by
Bevan Lewis, whom he does not mention in his long parade of
authorities. The changes in the nerve-cell declared by this distinguished
English microscopist to be characteristic of epileptic dementia have been
called in question by other observers, and it seems to me doubtful
whether those noted in epileptic idiocy are primary or secondary.
Epilepsy may be called a symptom, but it is a good deal more. The
epileptic attack is a grave event profoundly disturbing the whole
organism, especially the nervous centres. The immediate results are
extreme exhaustion and mental stupor, and, if the attacks are often
repeated, a gradually increasing mental fatuity and sundry perversions
of function. Surely no experienced medical man has failed to observe
this in the adult, and why not in the child ? Or at what age does this
deleterious influence of epilepsy begin? Has the Italian pathologist
kept his eye so closely upon his microscope that he has never observed
cases in which the beginning of the idiocy dates from the first epileptic
attack, is aggravated by recurrence of the seizures, and improves when
they are checked ? Heretofore the aim of those who have to treat such
patients has been to prevent the recurrence of the epileptic attacks. A
new attack is deplored as throwing the patient back : sometimes its
disturbing effects on the mind can be traced for weeks. In studying
diseases we must begin with clinical forms, after which we are pleased
if the histologist can find in the dead tissues a lesion that is characteristic
and constarlt to the disease ; but when he does not succeed we are not
going to credit a dogmatic assertion that the clinical form is untrue. As
physicians, we deal with the functions and harmonies of the whole
organism, not solely with slices cut from the brain. We have often seen
a lesion declared characteristic by one observer, and freely contradicted
by another. William W. Ireland.

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782

EPITOME.

[Oct.,

6. Treatment of Insanity.

New Toxic and Therapeutic Properties of the Blood-serum of Epileptics
and their Practical Employment [Nuove propriety tossiche e terapeu-
tiche del siero del sangue degli epilettici e loro applicazioni pratiche\
(Piv. di Patol. nerv . e ment, y voL vi, Nov, y 1901.) Ceni, C.

Very briefly Dr. Ceni describes certain experiments on epileptics, in
which the serum of the epileptic subject was injected, repeatedly and in
rising doses (i°) into another subject of the disease ; (2 0 ) into the patient
himself (auto-injection). The material consisted of ten cases of the
severer forms of epilepsy, in which, besides the motor manifestations,
there existed more or less grave symptoms, psychic and psycho-sensory.
In eight of the ten cases marked benefit ensued, but in the other two
the effects were toxic and epileptogenic. Of the eight cases of thera¬
peutic success, five received their serum from other cases of the disease,
whilst three were injected with their own serum. Of the two cases of
toxic effect, one derived the serum from another case, the other
supplied his own serum. The beneficial effects noted comprised a very
marked improvement in the general nutrition, in addition to a diminu¬
tion in the morbid symptoms. Increase in weight to the extent of one
to two stone occurred on an average. The two instances of toxic
results were cases of congenital hereditary epilepsy. The observations
covered a period of two years.

Dr. Ceni proceeds very cursorily to discuss the meaning of these
results, after first having excluded the possibility of their being due to
blood-serum in general. (This he did by a series of injections of the
blood-serum of healthy subjects. The effects of these upon the subjects
of epilepsy were entirely negative.) He concludes that the blood-
serum in epilepsy contains a specific stimulating substance, to which
are due the good effects noted, these not' being explicable on the
theory of antitoxins and of immunisation. The explanation of a
specific stimulating substance is not exactly enlightening, whilst the fact
that this positively beneficial substance should in certain cases (two out
of the ten) cause an aggravation of the disease is more than puzzling.
In these latter the tissues are supposed to be incapable of a physio¬
logical reaction, and therefore react pathologically ! Theory is best
left alone if it advances us no more than this.

It is to be regretted that the observations are not more numerous.

Harrington Sainsbury.

Treatment without Isolation Cells by Hydropathic Measures [ Versuche
mit zellenloser Behandlung und hydro-therapeutischen Massnah-
men], (Cbl. f Nervenheilkunde und Psychiatric , March , 1902,
/. 153.) Alter , W.

This very interesting therapeutic contribution describes the remark¬
able success which has attended the treatment of the insane by hydro¬
pathic means—baths and packs. At the time of writing, Dr. Alter
states that not a single patient was isolated, not one confined behind
closed door or closed windows. The reduction in the administration

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TREATMENT OF INSANITY.

783

1902.]

of sedative drugs on this system is very striking; thus, whereas during
ten days of the year preceding the adoption of the treatment, the drug
list for fifty-five patients gave as follows : 14 grms. of trional, 3 grms.
sulphonal, 3 grms. chloral, 12 grms. chloral with morphia, 8 morphia
powders, 4 morphia injections, 4 Dover’s powders, 94 grms. paralde¬
hyde, 160 grms. bromide,—during a period of twenty days (double the
time) of the present year, only 2 scopolamine (hyoscine) injections, and
2 ten-drop doses of scopolamine solution were administered. On the
other hand, during a period of twenty-eight days under the new system
there were given 174 baths of two hours’ duration, 41 baths of four
hours, 14 of six hours, hi day-baths, 18 night-baths, and 531 packings,
—these in addition to the usual cleansing baths. The labour involved
needs no comment, and Dr. Alter shows that his ability to meet these
demands has arisen from the fact that his service has averaged one
attendant to 2*4 patients, as against the 7—9 patients of the average
public asylum. Uninterrupted supervision by trustworthy attendants is
essential, but, in general, one attendant suffices for four patients in
the bath. The baths were given at a temperature of about 93 0 to
95 0 F.; in the case of weakly patients, at about 97 0 . The hands and
feet are well greased before the bath. The baths are covered with
sheeting, and in the case of general paralytics (all cases), and in other
cases when the bath is of more than four hours’ duration, the patients
are supported in the bath on stretched sheeting; in this way any sore
from rubbing against the bath is avoided. Of the packs Dr. Alter
speaks in highest praise as a general sedative, and more especially
in the case of sleeplessness. In the case of the restlessness and
insomnia of general paralytics, the wet pack often works wonders. The
pack is ordered at 90° to 95 0 F. Among other beneficial effects, the
appetite is often strikingly improved. Harrington Sainsbury.

Treatment of Mental Disorders by the Continuous Bath [Le Traitement
de Falienation men tale par le bain continu ]. {Brog. Mid .,
May 3, 1902.)

Dr. P. Keraval reports upon the recent developments of this treat¬
ment in Germany, and more particularly upon the work of Drs. Kraepelin
and Alter, as detailed in the discussions of the Society of Alienists of
South-western Germany, November, 1901.

The details of the baths, which may be maintained day and night for
weeks, and even months, consecutively, the arrangements for sleeping,
eating, reading, or working (crochet), smoking, etc., are given. The
temperature of the water in which this life is lived is 34 0 C. (93° F.).
Occasionally during the treatment a tendency to faintness is observed ;
this is met by an appropriate dose of caffeine, strophanthus, camphor,
or ether.

In nearly every respect the results of Dr. Alter confirm those of
Dr. Kraepelin, and it is therefore unnecessary to repeat them.

Messrs. Fuerstner and Schiile, and also M. Kreuser, raised certain
objections, and were not convinced of the value of the wholesale applica¬
bility of the system ; but, on the other hand, MM. Alzheimer, Bayer,
and Bieberach were strongly in favour of the method.

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784

EPITOME.

[Oct.,

The bath treatment above described is supplemented by Dr. Krae-
pelin by the use of wet packs, these often serving as introductory to the
more radical treatment. Harrington Sainsbury.

Contribution to the Dietetic Treatment of Epilepsy [Zur diatetischen
Behandlung der Epilepsie]. ( Neurol . Cbl., Jan. i, 1902.) Schaefer
( Pankow ).

In a short note, Dr. Schaefer describes the effect of a diet poor in
chlorides upon three severe cases of epilepsy. During a period of
eighteen months the attacks in these cases had averaged twenty to thirty
per month, without counting occasional exacerbations of the disease
when the attacks became so very frequent, and the patients so violent
in the post-epileptic stages, that isolation became necessary. The
reduction in the number of the seizures is most striking according to
the table of results, but we learn, in addition, that the w r hole mental and
physical bearing underwent a marked improvement. A return to the
ordinary diet brought back within a few days a renewed activity of the
disease. No mention is made of the administration of bromides, and
the results are given as instances of the effect of diet alone on epilepsy,
in confirmation of the teachings of Toulouse and Richet, and, after
them, of Bdlint.

Bdlint’s diet consists of ij litres of milk, 40—50 g. of butter, 3 eggs
(without salt), 300—400 g. of bread and fruit; but to this diet he adds
3 g. of a salt of bromine (bromide). Harrington Sainsbury.

Chloral Hydrate Poisoning \Chloralhydratvergiftung\ (Psychiat.

Wochenschr ., Nov. 23, 1901.) Liickerath , M.

Two cases of marked poisoning are recorded, the one after a total
dosage of 13 grms. (200 grains), administered during a period of twelve
days ; the other after two doses of 2 grms. (30 grains). In the former
case, the maximum dose at any one time did not exceed 3 grms. (46*5
grains). In this case, the symptoms consisted of marked congestion of
the face, followed by a scarlatiniform eruption which affected the whole
body, catarrh of the mucous membranes, in particular conjunctivitis and
bronchitis, further swelling of the parotids and moderate fever. A good
recovery ensued after copious desquamation. In parts it was noted at
one time that the eruption was urticarial in type.

In the second case, the patient was admitted with general paralysis of
the insane, and the nutrition was less good than in the first case. The
symptoms here were congestion of the face and then a wide-spread
eruption, purpuric in many parts, mild conjunctivitis, great general
depression of vitality, high fever, catarrhal jaundice, death.

Dr. Liickerath points out that the dosage w'as a very moderate one in
both cases, and that, in view of the enormous doses which have been
tolerated on occasions, these two results must be regarded as instances
of idiosyncrasy. Like effects have, however, been recorded sufficiently
often to make us recognise in chloral hydrate an uncertain and, at times,
dangerous remedy. The cause of death in the second case is not clear
(though the rash, etc., may be attributed certainly to the drug), for the
dementia was in an advanced stage; moreover amyiene hydrate in the

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1902.]

TREATMENT OF INSANITY.

785

dose of 45 grains was administered subsequently to the second dose of
chloral. Harrington Sainsbury.

Onanism, and its Treatment by Hypnotic Suggestion \L'onanisme et son
traitement par la suggestion hypnotique\ (Rev. de Vhyp ., Sept.,
1901.) Berillon.

This contribution is a protest against the attempts to treat onanism
by mechanical restraints—in particular the employment of the ceintures
de chastete and of the tying of the hands is deprecated, and the author
indeed goes so far as to say that when the case proves an obstinate one
we may generally conclude safely that mechanical means of restraint have
been adopted for some long period. Dr. Bdrillon urges the treatment
of such cases by suggestion, so as to awaken or re-educate the will, and
in effect to create new centres of inhibition, perhaps one should say
rather to reinforce old centres. He points out that suggestion gains
enormously in power by the establishment first of the hypnotic state,
and he goes on to describe the procedure he adopts. If the hypnotic
state can be induced cure is the rule. An essential in the procedure
appears to be the impressing upon the child or patient (under hypnotism)
that it is the subject of paralysis (psychic), and that whenever the
impulse arises to give way to the habit this paralysis will reappear and
effectually prevent the act. Harrington Sainsbury.

The Psycho-mechanical Treatment of the Choreas, the Tics, and Habit
Movements Generally [Le Traiteme 7 it psycho-mecanique de la chorte,
des tics, et des habitudes automatiques\ (Rev. de Hyp., Dec. 1901.)
Btrillon.

The essence of this treatment consists in the enforced execution by
the patient of definite gymnastic movements whilst in the hypnotic state.
To this mixed method of hypnotism with the practice of mechanical
movements, active or passive, Dr. Berillon applies the term psycho¬
mechanical. To its successful employment it is necessary that the
hypnotic state should be developed to the fullest extent possible, and to
this end it may be requisite to call in the help of adjuvants, such as
Braid employed, or even the use of hypnotic drugs.

The state established, suggestion is first made of the kind to arouse
the attention and to hold it, and further to stimulate the dormant will
powers, whose failure to act lies at the root of the evil habit. An absence
of will power, a true “ aboulie,” is characteristic of this group of cases.

Finally, the movements are either prevented by holding and fixing the
limb, or they are overcome by passively enforcing antagonistic move¬
ments, or, as a still more potent means, the patient under the hypnotic
influence is bidden to perform, by an effort of will, the very same move¬
ment which, in the waking state, he performs involuntarily and even un¬
consciously, and then this effort is opposed by main force, and the
patient’s attention called to the fact of the arrested movement, and the
sensorium awakened, as it were, to the accompanying sensation of the
arrest. A memory of control is thus revived, and inhibitory centres re¬
called into activity. These exercises, performed at first only in the
hypnotic state, are later on repeated in the waking state, and in this w*ay

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EPITOME.

[Oct.,

the automatic and unconscious act gives place to the voluntary and
conscious performance. Harrington Sainsbury.

7. Sociology.

On Military Crime [Sulla Delinquenza militare]. ( Riv . mens, di

Psychiat. for ., March , April , and May , 1902.) Saporito.

This paper is based on a series of eighty-five observations of insane
military offenders in the criminal lunatic asylum of Aversa. The author
summarises in tabular form the results of his exhaustive examination of
the hereditary and personal antecedents, and the morphological and
functional stigmata of degeneracy in the whole series, and in an appendix
gives full reports of fifteen of the cases.

Hereditary taint to some extent was present in nearly all the
subjects; its most frequent forms were insanity (17*6 per cent.) and
crime (12*6 per cent.).

Insane heredity was present in a notably large proportion of homicidal
cases. The investigation of personal antecedents gave a history of con¬
vulsions in infancy in 23*5 per cent., of nocturnal enuresis in 11*7 per
cent. The majority of the subjects had always shown a very indifferent
moral character, and 16*4 per cent, had been convicted of criminal
offences.

Somatic stigmata of degeneracy were present in all the cases; none
had less than three such stigmata, most had more. One individual had
as many as seventeen.

Functional stigmata were found in all the cases, the number in
individual subjects ranging from one to eight W. C. Sullivan.

The Practical Direction that Psychiatry can give to Education [DIndi-
rizzo pratico che la Psichiatria pub dare alia Pedagogia ]. (Piv.
Sper. di Freniatria, vol. xxviii, fasc. i, 1902.) Agostini.

This is a report presented to the Ancona Congress of the Society
Freniatrica Italiana.

The author indicates the defects of method in the present purely
empirical system of education. He dwells specially on the want of
correspondence between the matter of instruction and the aptitude of the
child at different age-periods, on the excessive duration of the hours of
work with resultant brain fatigue, and on the exclusive attention to
intellectual with neglect of physical and moral training.

In regard of all these points the present system is in contradiction
to the teachings of scientific experience, and is accordingly to be
regarded as one of the most important social factors of insanity and
crime. Its dangers are, of course, greatest for the hereditarily unstable.

To remedy this evil the author suggests that teachers should be
instructed in anthropology and psychology, so as to be able to examine
intelligently the character and aptitudes of every pupil, their observa¬
tions being noted on the dossier of each individual. In this way it
would be possible to arrive at a sound system of classification, and to

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SOCIOLOGY.

787

1902.]

adopt for each category of pupils the most fitting conditions of instruc¬
tion. Notably the author would advocate special classes for the defec¬
tives and for the exceptionally brilliant pupils. Medico-pedagogic
inspectors, who should be trained alienists, would supervise the working
of the system.

In the discussion which followed there was a general agreement in
condemning the existing methods of education, but the author’s proposals
of reform appear to have come in for a good deal of criticism. Bianchi
in particular, in an eminently common-sense speech, deprecated the
tendency to exaggerate the value of anthropological data in the judgment
of mental qualities, and took exception to the suggestion of converting
schoolmasters into amateur anthropologists. In common with most of
the speakers, he was strongly opposed to the separation of children
showing exceptional aptitudes. On the other hand, the need of special
schools for defectives, and the desirability of instituting a psychiatric
inspection of education, were admitted by all. W. C. Sullivan.

The Training of Defectives; its Criteria and Methods [£#/ Criteri e
Metodiper V Educabilitd dei Deficienti\. (. Riv . Sper. di Freniatria .,
vol. xxviii, fasc. /, 1902.) De Sanctis.

One of the most interesting and important contributions to the
Psychiatric Congress of Ancona was this exhaustive report by De
Sanctis on the education of the w’eak-minded. The author divides his
matter under several heads.

1. Classification of the phrenasthenias .—It is not possible to classify
the defectives, as Sollier and others have attempted to do, by reference
to the presence or absence of cerebral lesions with the corresponding
absence or presence of neuropathic heredity. The biological factor
(neuropathic heredity) dominates in the aetiology of all the phrenas¬
thenias, whether paralytic or not, and even the presence of spastic
paralytic symptoms is no proof that the related brain lesion is also the
cause of the mental defect. Neither is the distinction into extra-social
and anti-social a valid one ; at some phase of their existence all defec¬
tives, paralytic or otherwise, become anti-social, unless their life of
relation is too narrowly restricted by their disease. To meet these
objections, De Sanctis would suggest that in addition to the (a) bio-
pathic (imbecility) and (b) cerebropathic (idiocy), a (r) bio-cerebropathic
form of phrenasthenia should be admitted (including epileptic idiocy),
different degrees (slight, moderate, extreme) of mental and moral defect
being recognised in each class.

2. Educational capacity .—The progress of the defectives under
training should be observed as far as possible by positive scientific
methods. De Sanctis, after unsatisfactory experience with various tests
of intelligence, has come to rely solely on the determination of the
power of voluntary attention by Griesbach’s sesthesiometric method.
The greater or less constancy of the degree of acuteness of tactile per¬
ception in a series of experiments is a measure of the greater or less
capacity of concentrating attention; the oscillations of this acuteness
under the influence of distracting stimuli acting on the various senses is
an inverse measure of tenacity of attention.

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788

EPITOME.

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Progress in spontaneous attention (in school, games, etc.), in pro¬
ficiency, in demeanour, conduct, and morality, have to be estimated in
a more or less arbitrary fashion. Comparison of the records of the
pupil at long intervals enables a judgment to be formed as to his capacity
and progress.

De Sanctis is satisfied that his observations by this method prove
the existence of a certain educational capacity in the defectives. He
points out, however, that there is a good deal of individual variation in
the degree of this capacity, and, further, that moral progress rarely
keeps pace with intellectual.

3. Arrests in educational progress. —Moreover in the course of
training there are frequent periods of arrest, or even of retrogression.
In the large majority of defectives a notable cessation of progress occurs
at puberty, mainly determined by the awakening of the sexual instinct;
but also furthered by other factors, social and bio-social. At this
period practically all defectives, save such as are reduced to impotence
by their disease, are actively anti-social; it is the moment when the
criminal disposition is formed.

Thus the training of the weak-minded during childhood does not
secure their future permanent adaptation to society. De Sanctis
specially notes the not infrequent occurrence of cases where puberty
appears to start a sort of progressive phrenasthenia—a rapid and extreme
mental failure without symptoms of true dementia praecox or of juvenile
general paralysis.

4. Care of defectives. —It is accordingly necessary to prolong the
care of the defective beyond adolescence, by means of adult industrial
schools, labour colonies, etc. This is a measure of social prophylaxis,
and, as such, interests the State ; though voluntary effort under proper
organisation can do much to help in the task. W. C. Sullivan.

Enrico Bailor , called “ the Hammerer ” [Enrico Bailor, detto “ il Mar-

tellatore”\ (Arch, di Psichiat ., voL xxiii, fasc. it , Hi.) Lombroso .

Enrico Bailor, sumamed “the Hammerer,” from the weapon which
he specially affected, was recently condemned at Turin for the murder
of an old man; he was further supposed on strong evidence to have
been the author of three other assassinations in which robbery was
associated with apparently sadist impulses; from the age of eighteen
he had been frequently in prison for thefts and wounding. Despite
this record, however, Bailor, like Musolino, did not present the ana¬
tomical characters which are supposed to distinguish the “criminal
type.” Lombroso’s note aims at showing that this fact is not as
damaging as it looks to the atavistic theory of crime.

An examination of the assassin showed, it is granted, very few and
unimportant somatic stigmata of degeneracy. On the other hand,
there were numerous functional anomalies—contraction of the visual
fields, with extensive scotoma on the right side, absence of most of the
skin and tendon reflexes, sluggish action of the pupils, deficiency of the
earthy phosphates in the urine (a condition noted by Audenino after
experimental removal of the prefrontal cortex). Further, Bailor showed
in a marked degree the vanity, laziness, and absence of moral sense

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1902.]

ASYLUM REPORTS.

789

usually met with in habitual criminals. Inquiry into the family history
disclosed alcoholism in the father, mental instability in the mother; a
sister committed suicide. The murderer himself appeared normal as a
child ; but at ten years of age had an attack of meningitis, on recover¬
ing from which he developed extremely vicious tendencies. At about
twenty-four years of age he had his testicles removed for tubercular
disease. He was of alcoholic habits.

Lombroso interprets this history as meaning that in Bailor the
criminal disposition was acquired as a result of the brain affection, and
was not congenital. This would explain the absence of the somatic
stigmata. W. C. Sullivan.

8. Asylum Reports, 1901.

Some English County and Borough Asylums.

Carmarthen. —An electric bath has been fitted. It will be interest¬
ing to hear later on from Dr. Goodall of the effect that its use may have
on patients. In more than half the admissions hereditary predisposi¬
tion from insanity or allied nervous diseases was found. Mention is
made of a case where a patient managed to squeeze herself through a
a very small window space, and to throw herself off. The act was not
suicidal, but because she wanted “ to fly about like a little bird.” Dr.
Goodall continues to remind his Committee of the necessity for a
pension scheme.

Derby Borough. —We note that a boarder from the Middlesex Asylum
was received in exchange for an imbecile child—we presume in order
that the latter should receive benefit from the special care bestowed on
such cases in Dr. Hill’s new annexe. Such a procedure is to be warmly
commended.

In Table X the results of careful investigation into the causes of the mental
disease are given in detail. The two chief ascertained causes are hereditary pre- (
disposition in one third of the cases, and a previous attack in one fifth. Public
opinion has not yet reached the stage when these can be considered preventable
causes. Seventeen cases, or 18 per cent., attributable to alcoholic excess appear a
large number, but the proportion is considerably less than the average of previous
years, which works out at 20 per cent. In connection with intemperance, which
may be placed in the foreground as the chief preventible cause of insanity, two
facts must be remembered in any deductions we are tempted to make from
statistics: the one is that insanity in some cases so lessens the self-control that
intemperance is the result and not the cause of the mental disease; the other is
that a large proportion—certainly one third—of our relapsed cases are alcoholic,
and the same patients recur over and over again, and swell the number in which
alcoholic excess is tabulated as the cause.

Dorsetshire. —In 1901 the male admissions exceeded the female, the
former having notably increased, the latter remaining stationary.

A separate house for private cases is in course of erection, Dr.
Macdonald finding that contiguity to pauper cases is a hindrance and
an objection.

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79 O EPITOME. [Oct.,

Glamorganshire .—In connection with the causation of insanity Dr.
Pringle remarks—

If the teachers in our board and Sunday schools who realise the terrible evils,
physical and moral, which result from this habit (intemperance) were to point them
out to their pupils, I think much good might be done. As a consequence of
excesses in the parents, large numbers of children are born with strong impulses
and weak wills, and they succumb to influences of a kind that those of a happier
heritage can easily resist, and from these classes we receive many of our imbeciles
and epileptics. The tendency of our age seems to be an increasing love of excite¬
ment and pleasure and a lessening sense of duty, and it is disappointing that
education seems to do so little towards the building up of character or the
promotion of self-control.

The new census enables him to form some conclusion as to the
relative frequency of insanity in his area. At the previous census
Glamorgan stood as 186 to 268 of all England per 100,000 of popula¬
tion. Now the proportion stands as 239 to 302.

The favourable position occupied by Glamorgan as regards lunacy I have
always ascribed to the mixed character of its population and the constant influx of
new blood, but this influence seems to be gradually decreasing.

Hampshire .—The following facts are worthy of noting and recording,
as showing to what unexpected extent symptoms of tangible bodily
disease may be marked in insane patients.

I extremely regret to have to report that after an interval of sixteen months’
immunity from typhoid fever it again appeared at the end of January, when seven
cases took place. Three more occurred in June, and one at the end of November.
In all, three male and six female patients and two nurses suffered from it, and
one male and three female patients died. Two of these deaths call for special
notice, as they were of a most unusual kind. The first, a male patient aged 35, an
epileptic idiot of a very low type, died in a fit. A post-mortem examination showed
that a typhoid ulcer had ruptured, and was the cause of his death. He had no
symptoms of fever during his life, and was up and about and took his food well the
day he died. The second was a female aged 62 who had been eighteen months in
the asylum, and was demented. It was well known that she had heart disease very
badly, and had been treated for it on several occasions. At a post-mortem
examination it was ascertained that her heart was greatly affected, and also that she
had three large typhoid ulcers in that portion of the intestine where they are
usually situated. She had not a single symptom of typhoid during life. She was
in the infirmary ward the whole time she was in the asylum, and the nurse in
charge of it has been specially trained, and has had two years’ experience in a fever
hospital.

Monmouthshire .—We are glad to note that the holders of the
Nursing Certificate are granted both medals and increase of pay by the
Committee.

Nottingham Borough. —Dr. Powell has to regret the first appearance
of colitis in Mapperley. One case which died came from a London
asylum a fortnight before his death, while the other death was that
of a patient who had been at Mapperley for some years.

This disease is said to be in a large measure due to overcrowding; if this is so,
it is curious that it made its appearance with us some time after the opening of the
new wings, and when our accommodation was ample. It is undoubtedly an infec¬
tious disease, so that every precaution was taken to prevent its spread, and with
satisfactory results, as we have not had another case. There has been no case of
any other infectious disease during the year.

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ASYLUM REPORTS.

791

Touching escapes, the subjoined remarks of Dr. Powell are very
much to the point. There is no art whatever in absolute prevention
of all escape, but there is large scope for art in providing that the right
patients only shall have a chance.

There were six escapes, all men ; they were retaken after short periods of absence.
It is not surprising that we get these escapes at times, because we allow most of
the patients a considerable amount of liberty; and as this is so important in securing
the comfort of the majority, I think it better to suffer an occasional escape than to
adopt a system of surveillance which would be irksome to so many.

Salop and Montgomery .—The medical superintendent's report is by
Dr. Rigden, Acting Superintendent. He speaks feelingly of the
death of Dr. Strange, which will be dealt with elsewhere.

Dr. Strange was universally beloved, both by the staff and by the patients, on
account of the kindliness of his heart, and those of us who have had the privilege
of serving under him for a number of years feel that we have lost a personal friend.

Symptoms of impatience are arising between the two owners of the
asylum, such as are often seen when counties are in union. Sooner or
later one contributor supplies more patients than are justified by con¬
tribution. A fresh arrangement may temporarily adjust difficulties, but
dissolution of union is a common result.

Surrey .—This county has also entered into a commendable agree¬
ment with Middlesex for the reception of ten improvable idiots by the
latter. The ultimate results of treatment of imbeciles at Tooting will
be looked for with the utmost interest. It is essential to remove all
idiots and juveniles from general wards, and it is therefore right for all
counties and boroughs to provide accommodation for all such cases,
either by themselves or in combination. But it would be an immense
mistake for each special idiot house to aim at anything like systematic
instruction and education. The arrangements necessary for this would
be expensive and complicating, and the success more than doubtful.
Middlesex seems to have provided not only for itself but for others the
right accommodation for the higher treatment of these juvenile incom¬
petents, and the willingness to receive such cases by this county lays
others under a very sensible obligation.

In dealing with the causation of his admissions Dr. Barton is able
to state that a history of syphilis was found in nine out of twelve cases
of general paralysis. This high proportion is not only very interesting
as supporting the idea that paresis is in the main of syphilitic origin,
but it is instructive as showing that persistent inquiry can evoke a larger
amount of valuable history than is ordinarily given. We find that in
Table X only two cases are attributable to syphilis, this being probably
the amount of information afforded on admission or soon thereafter. It
is a question which may well be considered when the present statistical
tables are revised, whether this table should not be recommended for
treatment in the same manner as the Commissioners treat causation in
their quinquennial averages, viz., to adopt the relieving officers'
statements only when later and more skilled inquiry has failed to elicit
a more accurate aetiology.

Dr. Barton points out that the new definition of “ seclusion ” by the
Commissioners has increased the number to be recorded under this

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792

EPITOME.

[Oct,

heading. It is a serious question whether, since the term “ seclusion ”
has a somewhat invidious meaning in the minds of lay readers, it would
not be wise to subdivide it rather than to include that form of treatment
which, in regard to wild uncontrollable patients, no present-day superin¬
tendent would adopt unless he were driven to it by mental exigencies,
under the same heading as is now applied to the desire to keep a weakly
patient a little longer in a state of bed-restfulness. To speak plainly, it is
well known that the original provision for recording seclusion formally
in the visitors* books was aimed at the wholesale shutting up of
patients by day, because the staff was too small or too lazy or too
benighted to give them a fair chance of responding to the better treat¬
ment. It is a serious matter to similarly docket and record as an
element in the management of an asylum a procedure adopted from
consideration of the physical condition of frail patients who are year by
year increasing in our institutions.

East Sussex .—Beer as part of the ordinary diet has been abolished
in the whole establishment. This, which in the opinion of the Com¬
mittee has been of benefit, was the cause of but slight expressed
discontent on the part of the patients, by whom the addition of more
cheese, cake, and jam to the dietary is much appreciated. The
Committee give jQ 2 extra wages to holders of the Nursing Certificate.

In the useful table of prospects on admission which is presented each
year (and which other asylums might well adopt), no less than 145 out
of 233 admissions presented bad or hopeless prognosis.

Mr. Mortlock, who had been steward since the opening of the asylum
in 1858, died suddenly. His services are mentioned with high appre¬
ciation both by the Committee and Dr. Walker.

The general paralytics admitted are numerous, being fifteen males
and four females.

Wiltshire .—The committee, we are glad to note, specially commend
the time given out of their leisure by the assistant medical officers, Drs.
Gordon and McRae, to improving the qualifications of the attendants,
and sending many up successfully for the Nursing Certificate and the
St John’s Ambulance Examination. We have before adverted to the
frequent visitation of this asylum by the Guardians of the contributing
Unions, and to the large amount of instructed interest shown in the
record of these visits. We cannot but think that the hands of the Com¬
mittee must be strengthened as against the querulous ratepayers by such
remarks as these—

After seeing the splendid new hall for recreative purposes, we were rather sur¬
prised to find the chapel so inadequate, only capable of seating about 250, whereas
Dr. Bowes assured us he could easily send in 500, and further expressed the opinion
that attendance at Divine worship is decidedly beneficial to many of the inmates;

and—

With much pleasure we note all that provides for the comfort and well-being of
the inmates, the wards being especially bright and cheerful. The chapel accommo¬
dation appeared to be quite insufficient for the requirements of the institution.

Worcestershire .—The duration of service here is noted by the Com¬
missioners as satisfactory, 56 per cent, of the male and 35 per cent, of

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ASYLUM REPORTS.

793

1902.]

the female attendants having over five years' service. T ( he great
majority of charge attendants have over ten years. Dr. Braine-Hartnell
makes remarks on the question of nursing male patients by female
attendants.

The nursing of the insane is the topic of the hour among asylum medical
officers. I think we are destined to see great and radical changes in this part of
the work. The desire is to bring asylum nursing into line with general hospital
nursing. This would necessitate an increased staff, especially by night. It is pro¬
posed to undertake the care of the male hospital wards with trained nurses. The
matter is as yet in a tentative stage. It has been chiefly tried in Scotland, and its
advocates are loud in their praise. I think we ought to be able to show that the
increased cost would give an increased recovery rate before we make such wide and
sweeping changes.

Some Registered Hospitals .

The Lawn , Lincoln—The Coppice , Nottingham .—We are glad to note
that both these hospitals have had a successful financial year. Neither
is in receipt of substantial assistance from endowments or accumulations,
but both apparently succeed in making their patients comfortable, and
in both the recovery rate is good, being 43 and 60 per cent, respectively.
The average payment of patients for maintenance, etc., and incidents is
about ^110 per annum.

The Retreat , York. —Dr. Bedford Pierce notes a recovery in a case of
dull, silent melancholia after seventeen years' residence.

A striking instance of the value of work as an aid to recovery occurred recently
in the case of a gentleman suffering from severe melancholia. As is commonly
the case, he thought his condition was utterly hopeless. At first fitfully, and later
on regularly and industriously, he assisted in the routine indoor domestic work,
and polished the brasses with great vigour, and in other ways he materially helped
the attendants. During this time he would say he was no better and had no hope
of recovery, although it was evident he was improving all round. Very soon he
began to exercise his influence on others, and he coaxed and bullied another gentle¬
man, also deeply depressed, into helping in the work, the result being that not only
did he himself perfectly recover but he contributed to the recovery of his com¬
panion. Both gentlemen are now filling important and responsible positions in life.

Patients doing regular work in the garden continue to be paid by the hour, an
arrangement which answers well. One patient admitted at the lowest rate earns
sufficient to pay for his maintenance, whilst others keep themselves in clothes and
pocket money.

Some Scotch District Asylums.

Hartwoody Lanark .—This is the first report make by Dr. Neil Kern
whom we congratulate on his appointment. Dr. Kerr has no doubt that
a certain number of alcoholic cases are erroneously returned as such,
intemperance being a symptom and not a cause. It would be highly
interesting if any one could give a series of cases in which abstainers
from birth had taken to drink in consequence of mental alienation.
A case of recovery from mania is recorded after thirteen years' resi¬
dence, the greater part of which was spent in noisiness, violence, and
threatening. Dr. Kerr, during the four months’ interval since discharge,
had heard from the man regularly, and knows that he is doing useful
work in the world. One case who escaped had to be discharged at
the end of twenty-eight days because, though it was known to the

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EPITOME.

794

[Oct.,

authorities in what neighbourhood he was, the people of the district
successfully baffled the efforts of the police to capture him.

Inverness .—Overcrowding to a serious extent is reported, and worse
in the immediate future is feared. Though the high percentage of 43
of the total insane of the district is resident in private dwellings (as
against 21 *3 per cent, for all Scotland) Dr. Keay thinks that another
eighty or ninety patients could be safely boarded out, but increased
allowance would have to be offered to the caretakers. The present
allowance of 5 s. per week seems to be prohibitively low, and is only
just one half of the asylum maintenance rate. The cost of food alone
in the asylum is, as we find from the Blue Book, just about 4^. per
patient per week. There can be very little margin left for other
expenses—care, etc.,—unless the quantity of food is reduced. Dr.
Keay seems to be justified in recommending an increase of is. or 2s.
per week in the allowance.

Roxburgh. —Dr. Carlyle Johnston shows by figures what a good effect
persistent pushing of the boarding-out system can have. Chiefly by
this means his average residence was brought down to 197 in 1888
from 241 in 1881. The allowance appears to be just under 7 s. per
week, or about two thirds of the asylum maintenance rate. Of late,
however, the population has seriously increased, being 313 for the year
under report. As he points out, this is not due to increase in admis¬
sions, for the yearly average in the last quinquennium is slightly below
that of the preceding. Subtraction by removal and death do not keep
pace with addition of fresh patients. The population of the con¬
tributing counties seems by the last census to have decreased in the
inter-censal period by about 10 per cent.

Some Royal Chartered Asylums.

Dumfries , The Crichton. —The directors, on the recommendation of
Dr. Rutherford, are about to erect a house for the special treatment of
phthisical patients. Dr. Rutherford states that tubercle was directly
responsible for 25 percent, of the deaths, while post-mortem examination
showed that another 30 per cent, had at one time or another been
infected. Dr. Rutherford does not find that the popular idea of
increased lunacy is borne out by the statistics of this institution—the
pauper lunatics in the asylum being now 309 as against 307 in 1882.
But he does find a marked change in the character of the cases
admitted, there being more persons beyond middle age, and in bad
health, and of broken constitution. Several of the voluntary patients
were addicted to drink or morphia, and he has a poor opinion of the
class.

My experience of such cases has not been very favourable. They are often dis¬
agreeable inmates, untruthful, and untrustworthy. They exercise a bad influence
on the other patients, and sometimes even try to corrupt the attendants. The
results of treatment, too, are generally unsatisfactory.

Montrose. —Dr. Havelock expresses a similar opinion to that of Dr.
Rutherford as to the increase of insanity, and as to the causation of
apparent increase by sending weakly dotards to the asylum, where they

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NOTES AND NEWS.

1902.]

795

can get well nursed now-a-days, in preference to keeping them at home
till the end.

Dr. Havelock points out that the ‘ hospital’ treatment of the insane was
in a sense existent at Montrose in the eighteenth century, a project
being formed in 1779 to combine a suitable house for the treatment of
the insane with an infirmary ward. The latter was removed in 1836
because the principal object of the institution, the care of the insane,
was impaired by the demands of the infirmary section.

Royal Edinburgh Asylum .—The pressure on the space is still
maintained. In July, 1897, the City Parish of Edinburgh agreed to
reduce the number of their patients to 105 at the end of five years, or
“ as soon thereafter as the new district asylum shall be fitted up.” At
the end of 1901, so far from this being done, there were 416 of their
patients in residence, or sixty more than when the agreement was made,
besides ninety-three others for whose boarding out in other asylums the
managers were responsible.

One fourth of the admissions were associated with gross brain disease.
Sixty-five cases of general paralysis form a record. Of these twelve
were females. Dr. Clouston considers that the occurrence of the
disease might be entirely prevented.

The mean age on admission continues to rise steadily ; it used to be
forty—it is now nearly forty-three. The mean age on death also rises—
it was 507 in 1899, it is now 54*3. A sum of jQi 10 s. yearly extra
pay is given to holders of the Nursing Certificate, who form one third of
the total staff.

To my great regret, and to the irreparable loss of the Institution, Mrs. Findlay,
who for twenty-eight and a half years has been the head of our Female Hospital in
the West House, has felt her strength no longer able for the arduous duties there,
and has resigned. She was the pioneer nurse of Scottish asylums, and no more
enthusiastic, strenuous, or unselfish woman did I ever meet. She lived for her
patients, and for them alone. Her heart was wholly in her work. I always knew
that things in her department were just as sure to be well looked after as if I were
there ana looking on all the time. " Well done, good and faithful servant,” is no
empty eulogy in her case.

Part IV—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

Annual Meeting.

The sixty-first annual meeting began at 11 a.m. on Thursday, July 24th, 1902,
in the Medical Institution, Liverpool. Dr. Oscar T. Woods, the retiring President,
occupied the chair.

Present: Drs. T. Stewart Adair, Robert Baker, Fletcher Beach, Charles H.
Bond, David Bower, Lewis C. Bruce, A. W. Campbell, D. M. Cassidy, T. S.
Clouston, H. Corner, Andrew Davidson, W. R. Dawson, P. Maury Deas, Thomas
O’C. Donelan, F. W. Edridge-Green, W. F. Farquharson, James F. Gemmel,
Stanley Gill, Thomas A. Greene, John G. Havelock, Charles K. Hitchcock, James
Hyslop, Theo. B. Hyslop, J. Carlyle Johnstone, Robert Jones, Walter S. Kay,

xlviii. S 5

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NOTES AND NEWS.

[Oct.,

Neil T. Kerr, Richard Legge, Stephen G. Longworth, H. C. MacBiyan, P. W.
Macdonald, T. W. McDowall, Charles A. Mercier, W. J. Mickle, Alfred Miller,
John Mills, C. S. Morrison, F. W. Mott, G. W. Mould, Gilbert Mould, H. Hayes
Newington, David Nicolson, M. J. Nolan, Conolly Norman, L. R. Oswald, Bedford
Pierce, Daniel Rambaut, Nathan Raw, Henry Rayner, J. Peeke Richards, George
M. Robertson, H. A. Robinson, James Rorie, James Rutherford, George H.
Savage, James Shaw, Francis O. Simpson, R. Percy Smith, J. B. Spence, James
Stewart, R. J. Stilwell, C. T. Street, A. R. Turnbull, A. K. Urquhart, L. A.
Weatherly, E. B. Whitcombe, J. Wiglesworth, Oscar T. Woods, David
Yellowlees.

Visitors: Dr. Edward N. Brush, Dr. Alexander Davidson, Prof. Sherrington,
Dr. W. B. Warrington, Mr. Darner Harrisson.

Apologies for absence were intimated from Dr. John Keay, Dr. Jules Morel,
Dr. M. Peeters, Dr. Antonio Ritti, Prof. R. Virchow, Dr. Ernest W. White, Dr.
Motet, Dr. Toulouse.

The minutes of the preceding annual meeting were taken as read, confirmed,
and signed.

Election op Officers and Council.

The meeting then proceeded to the election of officers and council, Dr. Hyslop
and Dr. Oswald acting as scrutineers. As the result of the scrutiny, they reported
that the candidates nominated by the Council had been almost unanimously
elected.

President ....
President Elect .

Treasurer ....
General Secretary
Registrar ....

Editors ....

Auditors ....

Divisional Secretary for —
Scotland
Ireland

South-Western Division
South-Eastern Division

, J. Wiglesworth, M.D.

. Ernest W. White, M.B.

H. Hayes Newington, F.R.C.P.Ed.
. Robert Jones.

. Alfred Miller.

( Henry Rayner, M.D.

. < A. R. Urquhart, M.D.

(.Conolly Norman, F.R.C.P.I.
f James M. Moody.

* j. E. B. Whitcombe.

. Lewis C. Bruce, M.B.

. W. R. Dawson, M.D.

P. W. Macdonald, M.D.

. A. N. Boycott, M.B.

Northern and Midland Division . C. K. Hitchcock, M.D.

Members of Council.

R. C. Stewart; F. W. Mott, M.D., F.R.S.; A. D. O’C. Finegan; G.
Braine-Hartnell; Maurice Craig, M.D.; David Yellowlees, M.D.

Election of Ordinary Members.

The following candidates were proposed for election as ordinary members:—
Campariole, Paul Clem, M.B., C.M.Ed., Junior Assistant Medical Officer, County
Asylum, Melton, Suffolk (proposed by J. R. Whitwell, Stephen E. Longworth,
and Robert Jones); Cassells, Alexander Henderson, M.B., Ch.B.Glasg., Senior
Assistant Medical Officer, Sunnyside, Montrose (proposed by J. G. Havelock,
John Cameron, and L. R. Oswald); Forster, Hermann Julius, L.K.C.P.I., L.S.A.,
Assistant Medical Officer, East Sussex Asylum, Haywards Heath (proposed by
Edward B. C. Walker, H. Hayes Newington, and Charles Planck); Higginson,
John Wigmore, M.R.C.S., L.R.C.P., Resident Medical Officer, Hayes Park
Asylum, Hayes Park, Middlesex (proposed by Theo. B. Hyslop, Maurice Craig,
and Robert Jones); Kelly-Patterson, William, M.D., M.Ch., R.U.I., Ballyemond,
Killowen, co. Down (proposed by Arthur Finegan, Oscar T. Woods, and Robert
Jones) ; Sodhi, D. M. S. Baba, M.B., Ch.B.Ed., Senior Assistant Medical Officer,
Portsmouth Borough Asylum, Portsmouth (proposed by T. S. Clouston, H.
Hayes Newington, and Robert Jones) ; Thomson, James, M.D.Glasg., Senior
Assistant Medical Officer, Gartloch Hospital for Mental Diseases, Gartcosh, N.B.

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NOTES AND NEWS.

797

1902.]

(proposed by L. R. Oswald, D. Yellowlees, and W. A. Parker) ; Trevelyan,
E. F., M.D.Lond., F.R.C.P.Lond., Assistant Physician to the Leeds General
Infirmary, 40, Park Square, Leeds (proposed by F. W. Eurich, C. K. Hitchcock,
and Robert Jones).

They were all unanimously elected.

Election of Honorary Members.

Dr. H. Rayner. —I beg, sir, to propose as an honorary member of the Asso¬
ciation Sidney Coupland, M.D.(Lond.), F.R.C.P., Commissioner in Lunacy,
16, Queen Anne Street, Cavendish Square, W., late Physician to the Middlesex
Hospital. It is hardly necessary to recommend Dr. Coupland to the members of
the Association. He has done a good deal of literary work, among which his
work on enteric fever has long been an authority. Besides his long experience
at the Middlesex Hospital, he was for a great many years lecturer on pathological
anatomy, and also lecturer on practical medicine. Both his literary and medical
records, which are very good indeed, qualify him for the post he now holds. In
that post many present can speak of the admirable way in which he fulfils his
duties. I can speak personally, and I have great pleasure in nominating him.

The Treasurer. — I have equal pleasure in seconding the nomination.

The President. —It is unnecessary to recommend Dr. Coupland. I am sure
that he will be a worthy member of the Association.

Dr. Urquhart then proposed the election of Dr. E. N. Brush, physician
superintendent of the Sheppard and Enoch Pratt Hospital for the Insane at
Baltimore. This nomination had been made bv the President, Drs. Savage,
Yellowlees, Rayner, Hayes Newington, and himself. Dr. Brush was well known
to those of their members who had visited America, and had taken special
interest in psychological medicine in the United States. He would honourably
and efficiently represent the Association among their colleagues of the great
republic.

Dr. Savage. —I have pleasure in seconding the nomination. Dr. Brush is not
only a very distinguished American physician, but has devoted his life to this
work, and is fully alive to all that is being done both in England and on the
Continent. I speak from personal knowledge when I say that any one going to
America and visiting Philadelphia will find in him a cordial friend.

Dr. Yellowlees. —I wish to support the nomination very emphatically. No
one going over to the United States and meeting Dr. Brush will fail to find in him
a helper, as well as delightful friendship.

The President. —Dr. Brush, one of the leading physicians of the United States,
is accredited to us by the Medico-Psychological Association of America, and
will make a very worthy member of this Association.

Both candidates were unanimously elected.

Election of Corresponding Member.

Dr. Percy Smith. —I beg, sir, to propose the election as a corresponding
member of Benedetto Giovanni Selvatico Estense, M.D. (Padua), of 116, Piazza
Porta Pia, Rome, Assistant at the Psychiatric Clinic of the University of Padua,
Lecturer at the Medical Pedagogic Institute (Rome) of the Italian National
League for Deficient Children. I have indeed pleasure in recommending the
Association to elect this gentleman. He is well known to myself and to Dr.
Savage, is a frequent visitor to English asylums, and has formerly taken part in
the discussions of this Association. His contributions to medical literature are
numerous and valuable.

Dr. Savage. —I second the proposition. I have a personal knowledge of this
distinguished gentleman. He is a man who has done extremely good work, and
will do further good work. His epitome of the opinions of Continental and
English writers on general paralysis is a very masterly compilation.

The President. —After the full report given by Dr. Percy Smith and Dr.
Savage it is not necessary for me to say anything, except to express my own
opinion that Dr. Estense will make a very worthy member of this Association.
His connection with this country makes his visits frequent. I hope they will be
equally as frequent in the future.

Dr. Estense was unanimously elected.

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798

NOTES AND NEWS.

[Oct., 1902.

Report of Council.

Membership .—The number of members of this Association for the year 1901
was as follows:

Ordinary members 580, honorary members 37, corresponding 11. Compared
with previous years, the membership for the quinquennium ending 1901 shows
the gradual growth and increased prosperity of the Association :

1897.

1898.

1899.

1900.

1901

Ordinary members

524 ••

. 540 ...

5^0 ..

. 568 ..

. 580

Honorary „

38 ..

. 38 ...

36 ..

. 38 ..

• 37

Corresponding members

12 ..

12 ...

12 ..

. 10 ..

Totals

574 ••

• 590 ...

608 ..

. 616 .,

,. 628

Two honorary members, Dr. Cleaton and Dr. Curwen, died during the year,
and one was elected. One corresponding member was elected. Eight ordinary
members died, among whom were Drs. Law Wade, J. F. Sutherland, Campbell
Clarke, and Alfred Aplin. This year also the Association has lost by death Drs.
A. Strange, W. C. Hills, Bonville Fox, and G. F. Bodington.

During the year forty-four members were elected, twenty-one resigned, and four
were removed for non-payment of subscription.

Meetings .—The Annual Meeting was held in Cork, in July, under the presidency
of Dr. Oscar T. Woods, and was most successful. It was well attended, and the
hospitality of Dr. and Mrs. Woods was greatly appreciated by the members.

Three General Meetings were held, one at Claybunr, in February, and the
others in London. Papers were read by Drs. Mercier, Percy Smith, Sir Lauder
Brunton, and others, much interest being evinced in the subsequent discussions.

The Divisions have held meetings, and those held in the South-western
Division, as last year, have materially added to the membership of the Association.

Committees .—Much work has been done by the various standing and special
committees, and the report of the Tuberculosis Committee has been published,
which emphasises the necessity for providing separate accommodation for the
phthisical insane.

The Educational Committee continues to devote time to the special recognition
of training nurses for the insane, and the Certificate of the Association for pro¬
ficiency in nursing the insane has become a recognised standard of efficiency, and
is much sought for. The Council thinks that the Association continues success¬
fully to carry out the scheme for the training and examination of attendants and
nurses, a responsibility which the Association undertook about ten years ago.

The Report was unanimously adopted.

Report of Treasurer.

The Treasurer. —My report, sir, is contained in the balance-sheet circulated
with the papers for the year. The Auditors’ report comes next. Unfortunately
neither is able to be present. I think most members have a print of their report.
They find that all is correct. They merely remark upon the satisfactory balance,
and I may be permitted to add that it is larger than we ever had before. We
made about ^125 net last year, and this balance was created in the best way,—
that is, by increasing subscriptions and by keeping the expenditure at a reason¬
able point. (Applause.) I beg to present my report.

Dr. Savage. —I move that the report be received and adopted.

The motion being duly seconded, it was put and carried unanimously.

Report of Auditors.

We, the undersigned Auditors of the Medico-Psychological Association, beg to
report as follows. We have duly examined the items of expenditure for the year
1901, and checked the entries in the cash-book with the vouchers. We have also
investigated the sources of income and duly checked the various items. We are
pleased to note an increase in the annual subscriptions and in the fees for the
Nursing Certificate. The certificate for medical men still fails to attract candi¬
dates. The balance upon the year’s working is quite satisfactory.

Ernest W. White,! a ...

July ijth, 1902. James M. Moody, j AU * ttors '

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HAVES NEWINGTON, Treasurer,

800

NOTES AND NEWS.

[Oct,

Qaskell Memorial Fund.

1901. Dr.

Aug. 16. Dr. Stoddart (Prize)
„ 30. A. Wyon (Medal)

„ 14. Examiners' Fees

Dec. 31. Balance.

... 5 5 0

... 4 4 ©

... 3*3

1901.

Jan. Balance

,, a. Dividend ...

July 1. Dividend ...

Cr.

£ s. d.

. 1 16 a

. aa 19 1

. aa 15 0

£41 10 3

■MMi

£47 10 3

1902.

July 36. Balance .

£ 1. d.

... 49 9 3

1902.

Jan. 1. Balance ...

' ,, a. Dividend ...

July a. Dividend ...

£ *. d.

. 3*3

. aa 13 0

. *3 «3 0

£49 9 3

I '

£49 9 3

N.B.—At the time of the Annual Meeting, in addition to the credit balance on the current
account as above, a sum of £vjt or. 6 d. on deposit stood to the credit of the Fund.

H. HAYES NEWINGTON, rnatunr.

Revision of the Rules.

The President read the notice which had appeared on the agenda; it was as
follows:—“ To receive and, if thought fit, to adopt the report of a Committee
appointed by the Council to consider the reprinting of the Rules and Regulations
of the Association with such alterations as have been made from time to time
therein at annual meetings, together with certain minor amendments which
appear to the Committee necessary for the better working of the Association.’*

Dr. Whitcombe. —Mr. President, the Rules Committee have met on several
occasions, and have done a large amount of work by correspondence. They
reported to the Council this morning in the following terms :—“ Your Committee
reports that in pursuance of the resolutions of the Council dated May 23rd. 1901,
July 23rd, 1901, and May 21st, 1902, they have considered—(a) the reprinting of
the Rules (the former issue being exhausted); (A) the homologation of amend¬
ments made therein from time to time; (c) the introduction of amendments
which would, in their opinion, lead to the better working of the Association.

“ Further, they have, as instructed, caused proofs of the Rules, with proposed
amendments, to be sent to each member of the Association with a view to the
matter being dealt with at the annual meeting. In order to bring the matter
forward the Committee have caused a notice of motion to be placed on the
agenda of the Council meeting.

“ The Committee have also, as empowered, taken the opinion of the Solicitor
on various points. One result has been the disclosure of the fact that even the
slightest alteration of the Articles of Association entails cumbrous formalities. If
the Association in annual meeting approves the proposed changes it will be
further necessary to hold two special meetings at statutory intervals, and to
circulate special notices, etc., etc. The Board of Trade has signified its readiness
to forego tne submission to it of the proposed alterations.

“Your Committee, having in view the beneficial character of several of the
proposed amendments, recommend that the Council should signify its approval of
the said amendments to the annual meeting, and that it should suggest to the
annual meeting that your Committee be empowered to take the necessary steps
for carrying the matter through.”

Not being a member of the Council I had no opportunity to submit this report,
and I am at the present time in ignorance of what the Council have done. I
therefore simply read the report made to the Council to the meeting here.

After a prolonged discussion the following was proposed by Dr. Whitcombe,
and seconded by Dr. Morrison :—" That a Committee be appointed to consider
and revise the Rules, to add such amendments as have been made from time to
time, and to report to the next Annual Meeting.” This was rejected, and the
following amendment to this motion proposed by Dr. Urquhart, seconded by
Dr. Conolly Norman, was carried as a substantive motion, vis.: “That the
Rules Committee appointed by the Council be thanked for their report, but that

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1902.]

NOTES AND NEWS.

8 oi

it be not adopted. That this meeting do appoint a Committee to continue the
work done by the Committee now dissolved, by submitting the amended Articles
of the Association to the Divisions of the Association for consideration at their
autumn meetings of the current year. That the reports of the Divisions be sent
to the Committee to-day appointed, who are hereby granted freedom to deal with
the whole question of Articles, Rules, and Bye-laws, with the instruction to prepare
a report for the Annual Meeting of 1903. That this Committee be constituted as
follows:—Drs. Hayes Newington, Mercier, Urquhart, Conolly Norman, Carlyle
Johnstone, Whitcombe, Weatherly, Robert Jones (Honorary Secretary).” Dr.
Whitcombe declined to act.

Report of the Tuberculosis Committee.

Dr. Weatherly.— It is now my privilege to bring forward the report of the
Committee which was appointed two years ago on this subject. With the
enormous amount of work we had, with members living in all parts of the
country, and not having more than one meeting every quarter, it will not be
difficult to understand why it should have taken two years to prepare this report.
There are one or two points on which, before proceeding to the general question,
I should like to touch. It will be observed that some of the answers have not
been embodied in the statistics. For that omission the Committee take the full
responsibility. The omission is due simply to this fact, that some of the answers
sent to us, although most valuable in some respects, were not so perfect that we
could embody them with the others, and draw proper inferences from them. The
Committee again wish me to emphasise the work of our honorary secretary, and
we owe a deep debt of gratitude to Dr. E. France for the labour he has under¬
taken. It is somewhat remarkable that this report should be placed before you
for adoption at Liverpool, because this town is in the forefront of Great Britain in
doing something for its poor consumptives. It has already started a grand
sanatorium at Delamere, and the Poor Law guardians are fully aware of the
importance of this great crusade. To the energy of Dr. Nathan Raw, a member
of our Association, is Liverpool indebted for the position she takes up in this
good work.

Some may smile at this report and stigmatise it as a mass of commonplace
platitudes, but from my experience of this crusade against consumption I am
satisfied that these truths cannot be too often repeated.

I trust that this Association will grant power to our Treasurer to provide
money for the wide circulation of this report. We are on the eve of a great good
resulting from this crusade, and I am confident that the statistics which we are
able to show the public now, and the improvement that must result from the
adoption of our suggestions in the mortality from consumption in our asylums
for the insane, will help forward a movement which science so clearly tells us
must ultimately be the means of eradicating this dreaded disease from amongst us.

On behalf of the Tuberculosis Committee I beg to move the adoption of this
report.

Dr. Percy Smith.—I beg, sir, to second the motion.

The resolution was carried.

Dr. Clouston. — I cannot allow the occasion to pass without referring to the
exemplary pains which, as Chairman of the Committee, Dr. Weatherly himself
has taken to make this report perfect. We know that a report of this kind is not
compiled without great interest and enthusiasm on the part of the Chairman, and
we ought to thank him very heartily. With the contents of the report we shall
not deal seriously, but, however commonplace it may appear to be, it is needed
to bring before us, as the heads of asylums, the responsibility which lies upon us
for the lives of our patients. I move—” That the best thanks of this Association be
given to the Committee for the great trouble they have taken, and for their able,
lucid, and instructive report.” (Applause.)

Dr. Nicolson. — I have great pleasure in seconding that motion. It is a
subject on which we have been working for many years in asylums.

The President. —I do not think we can be too grateful to the Committee, and
we ought to thank the Secretary as well as the General Committee.

The resolution was unanimously passed.

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802 notes and news. , [Oct.,

Circulation of the Report on Tuberculosis .—It was resolved that Dr. Weatherly
should submit the names of those to whom the report should be sent, and that the
President and Ex-President be authorised to pass the expenditure.

Parliamentary Committee.

Dr. Hayes Newington, on behalf of the Parliamentary Committee, stated that
as the Lunacy Bill had not yet made its appearance they had nothing to report.

Educational Committee.

Dr. Percy Smith. —There is very little to say about the Educational Committee.
We have got the new Nurses’ Examination arrangements completed, and have
settled many matters referred to us by the Council. We have the Medico-
Psychological Certificate Examination still under consideration, but we hope to
arrive at a definite conclusion at the meeting in the autumn.

The Library.

Dr. Morrison. —The Library Committee, Mr. President, made last year a
report which was referred for consideration to the Council, with instructions to
bring the matter before this meeting. Has the matter been submitted to the
Council, and if so have the Council reported ?

The President. —It has been under the consideration of the Council, and is
still in their hands; it has not been forgotten.

Dr. Hyslop. —It is very important that this question should not be shelved.

Dr. Urquhart. —In regard to the questions before the Annual Meeting at Cork
last year I undertook to submit a report to the following Council meeting in
London, and I did so.

Dr. Morrison. —May I propose that ^25 be put aside for additions to the
Library ?

Dr. Hyslop. —There have been no additions for the last ten or twelve years.
The Library has been at a standstill. It is of no use for reference. Something
to be done to provide more recent works.

The President. —Will Dr. Morrison put it in this way: that the matter be
referred to the Council as a suggestion that an annual grant be made for the
support of the Library ?

Dr. Morrison. —We could vote an annual grant of £25 at once. As a
suggestion I do not think it would do any good.

Reappointment of Committees.

The Parliamentary Committee were appointed for the ensuing year.

Dr. Carlyle Johnstone.— Will the members of the Education Committee who
are not, as teachers of insanity, members ex officio, and have not attended at least
one meeting, be reappointed ? I should like to propose that members, not being
members ex officio , who have attended at least one meeting be reappointed.

The following resolution was adopted, viz., ‘‘That those members of the
Educational Committee, not being teachers of insanity, who have attended at
least one meeting of the Committee during the year be reappointed, with the
addition of the names of Drs. Macphail and Robert Jones.”

The meeting then adjourned for lunch.

The meeting having reassembled—

The President said: My duties as your President are drawing to a close, but
before I leave the chair I have a pleasant office to fulfil. It is to propose in no
formal way a vote of thanks to the permanent officials of the Association.
(Applause.) On them the work of the Association depends, and they are almost
all of them old in its service. Your Treasurer has grown grey in your service.
He at all events spares himself no trouble to further the interests of the Associa¬
tion. In your Secretary I personally know you have a most valuable officer who
carries out his duties with a faithfulness ana an anxiety which few could emulate.
Unfortunately during the year our late Registrar was obliged through ill-health
to resign. He had most faithfully discharged his duties. I believe you have

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NOTES AND NEWS.

803

1902.]

found a very worthy successor in Dr. Miller, who has the interests of the Associa¬
tion at heart. I beg to propose a very warm vote of thanks to these gentlemen
for the great assistance they have given me, and for the time they have devoted to
the good of our Society.

With regard to the Editors, the whole work of the Association depends on the
Journal, and Drs. Rayner, Urquhart, and Norman have worked on it for years,
and very warm acknowledgment is due to them for their labours.

The motion was passed with applause.

Dr. Urquhart. —I have been asked to respond to this vote of thanks, and I do
so with great pleasure, because now I feel myself in a position of less responsi¬
bility and greater freedom, and can speak more freely with regard to the officers
of the Association than I might have done last year. I quite endorse what you
have said about our Secretary and Treasurer ; we could not be better served.
With regard to Dr. Benham, my old and valued friend, I am sure that the Asso¬
ciation deeply regrets that he has been laid aside by illness, and hopes to see him
soon restored to health. All our officers fully appreciate the confidence which
the Association reposes in them.

Dr. Mercier. —May I ask that a copy of the resolution be sent to our late
Registrar P

Dr. Newington. —Dr. Benham is back, and looking forward to a renewal of his
work.

Introduction of Dr. Brush.

Dr. Urquhart. —Mr. President and Gentlemen, I have the honour to present
to you Dr. Brush, of the Sheppard and Pratt Hospital at Baltimore. I spoke at
length this morning concerning Dr. Brush, and would merely add that he is the
bearer of a letter from our friends of the American Medico-Psychological Associa¬
tion, and I now present his credentials as their representative. (Applause.)

Dr. Brush (who was received with loud applause).—The credentials which my
friend Dr. Urquhart has presented to you were sent to me, and found me a few
months ago in Germany. A little later a letter came from the secretary of our
association, asking me to express to the British Medico-Psychological Association
their warm and most fraternal greetings. I have great pleasure in doing so.
(Applause.) We look to you, gentlemen, for example. As one of the editorial
committee of our journal, I may say we regard the Journal of this Association
as the model of what the journal of an association of this kind ought to be, and
we follow it as nearly as we can. For myself, nothing I can say or do in my
future professional life can in any way equal the honour which has been done me
to-day; I can simply thank you most sincerely.

Vote of Thanks to the President.

Dr. Savage. —Mr. President, you are about to leave the Chair, but for a
moment permit me to say we have had in you a president who has not only
represented your profession in this country in the genial and kindly way which
was reflected in the terms in which you spoke of your officers, but who has, as
helmsman, steered us well through this year. We feel now that the rest you have
obtained has been earned, and without arresting your descent any longer, I beg in
the most cordial way to propose a vote of thanks for the manner in which you
have performed your duties.

The motion was passed with applause.

The President. —Gentlemen, I am exceedingly obliged for the warm vote of
thanks you have passed, and for the acclamation with which you received it. In
accepting office I felt that, living so far away, I could not fill it as my predecessors
had done. It has, however, proved a work of pleasure. I have made many new
friends, and met many old ones. In retiring I have only to introduce to you my
successor, Dr. Wiglesworth. (Applause.) You have known him for many years
as an able and enthusiastic worker. Everything he has taken up he has done
thoroughly. With him the interests of the Association are in safe hands. We
do not doubt that he will follow in the footsteps of the best of his predecessors*
(Applause.)

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804 notes and news. [Oct.,

The President, Dr. Wiglesworth, then delivered his presidential address
(see page 611).

Mr. Damer H arrisson read a paper entitled “ Some Remarks upon the Surgical
Treatment of Insanity.” He showed a case on which he intended to operate.
The result of the operation is recorded in an appendix to his paper (see page 696).

Dr. Mercier proposed the following resolution “That in the opinion of this
Association further legislative measures are needed to protect the property of
those who, without being certifiably insane, are yet, by reason of disorder of mind,
unable to administer their affairs with ordinary prudence.” A report of the
discussion that ensued will appear in the January number of the Journal.

Second Day.

Dr. Mott read a paper entitled “ Stimulus in Relation to Decay and Repair of
the Nervous System” (see page 667). The paper was illustrated by lantern
slides and diagrams.

Dr. A. W. Campbell gave a lantern demonstration on the medullated nerve-
fibres of the cerebral cortex.

Dr. David Orr gave a lantern demonstration on nerve-cell and medullated
fibre changes in acute insanity.

Dr. Clouston introduced a discussion upon “ The Possibility of providing
suitable means of Treatment for Incipient and Transient Mental Diseases in our
Great General Hospitals” (see page 697).

Dr. Hubert C. Bond read a paper on “Medico-Psychological Statistics—the
Desirability of Correlation with a view to Collective Study ” (see page 709).

The following resolution was, on the motion of Dr. Newington, seconded by
Dr. Rayner, unanimously passed“ That Dr. Bond be thanked for his paper,
and that it be remitted for consideration to a committee. That the said committee
be requested to report to the next Annual Meeting upon the present statistical
tables of the Association as to whether, and if so in what direction, their altera¬
tion or amplification would be of advantage. That individual members of the
Association be hereby invited to communicate to the committee any views they
may have on the subject; and that such committee consist of Drs. Rayner, Hyslop,
Whitwell, Stewart (Glamorgan), Bond, Yellowlees, Easterbrook, Nolan, Dawson,
Bedford Pierce, and the Treasurer; that Dr. Yellowlees be appointed Chairman,
and Dr. Bond Secretary; that the quorum be three, and that the committee have
power to fill any casual vacancy.”

Drs. Urquhart and Ford Robertson contributed the clinical and pathologi¬
cal report of “A Case of Epilepsy with Glioma following on Traumatic Injury of
the Brain” (see page 751).

Dr. Dawson contributed a paper entitled “ Note on the Pathogenesis of
Diabetic Insanity ” (see page 735).

Votes of Thanks.

Dr. Rayner. —We ou^ht not to separate without passing a vote of thanks to
the medical authorities in Liverpool who have lent us this building, so well
adapted to the purpose of our meeting. I beg to move that the best thanks of the
Association be given to the members of the Medical Institution.

Dr. Mott seconded the resolution.

The motion was carried with acclamation.

Dr. Newington. — I beg to propose a vote of thanks to our President for his
services in the chair. No one deserves it more.

Dr. Raw. —I have much pleasure in seconding this proposal. The medical
profession in Liverpool are gratified that Dr. Wiglesworth has attained to the
position of President of this important Association.

The motion was carried amid applause.

The President. —I thank you, gentlemen, for the manner in which ^ou have
supported the Chair. I desire, in parting, to congratulate the Association on
the high quality of the work presented to us. The original work might have been
laid before any society in the kingdom. It docs the Association great credit,
and promises well for the future.

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805

The Annual Dinner.

The Annual Dinner of the Association took place at the Adelphi Hotel on
Thursday evening, the 24th July. The President occupied the chair, and there
was a large attendance of members, amongst whom were no less than fifteen past
presidents. Amongst the visitors were Sir William Mitchell Banks, Sir Edward
Russell, Mr. W. Scott Barrett, Dr. Brush (Baltimore), Mr. Edgar Browne, Mr.
Darner Harrisson, etc. Dr. Savage, in proposing “ The Liverpool University
College," alluded to the fact that the present college was formerly, in part, the
old Lunatic Hospital of Liverpool; and Dr. Clouston, in proposing “The
Guests,” twitted the inhabitants of Liverpool with having abolished the Lunatic
Hospital of the town without putting any similar institution in its place.

The speeches were of an exceptionally lively character, that of Sir William
Banks being especially witty, while Mr. Edgar Browne delighted his audience by
his happy humour. Both the meeting and the dinner may be said to have been
of the most successful character, giving strongest evidence of the vigour of the
scientific spirit, together with the cordial feeling of fellowship in the members of
the Association.

Council and Committees.

In connection with the Annual Meeting there were meetings of Educational,
Rules, and Parliamentary Committees. The Council met on the 24th July, the
following members being present:—Oscar T. Woods (President), J. Wiglesworth
(President-elect), H. Hayes Newington (Treasurer), Alfred Miller,]. G. Havelock,
P. W. Macdonald, J. Beveridge Spence, L. A. Weatherly, Fletcher Beach, R.
Percy Smith, T. Stewart Adair, A. R. Turnbull, A. R. Urquhart, L. C. Bruce,
T. B. Hyslop, Henry Rayner, D. M. Cassidy, W. R. Dawson, Conolly Norman,
and Robert Tones (Hon. General Secretary).

The usual official reports were received and dealt with.

The Educational Committee recommended that the following gentlemen be
appointed Examiners for the Medico-Psychological Certificate Examinations:—
England: Dr. Theo. B. Hyslop. Scotland : Dr. John Carswell. Ireland: Dr.
Michael J. Nolan.

IRISH DIVISION.

A meeting of the Irish Division of the Medico-Psychological Association was
held in the College of Physicians, Kildare Street, Dublin, on Friday, May 23rd,
1902.

Dr. Oscar Woods presided, and there were also present Drs. Frank O’Mara,
Henry M. Eustace, M. J. Nolan, O’Neill, Thomas Drapes, W. R. Dawson, Tohn
Mills, Richard Leeper, Michael Curran, Conolly Norman, Daniel F. Rambaut,
J. O’C. Donelan, J. A. Oakshott, and Arthur Finegan, Hon. Sec.

The minutes of the last meeting as published in the Journal were taken as
read and confirmed.

Dr. Nolan expressed surprise and regret that a proof of his remarks in the
discussion at the previous divisional meeting had not been sent to him.

Dr. O’Neill said that unfortunately he was not able to be present at the
discussion that took place on the resolution standing in his name at the last
meeting. Had he been present he would have corrected some of the statements
that were there made. He felt that it was only due to himself and the Associa¬
tion that the matter should be cleared up. He then briefly referred to the action
he had taken in the pension question in the interests of the Association and of
every one connected with the service.

Dr. Oscar Woods. —I am, as is every one here, perfectly satisfied that the
action which Dr. O’Neill took was for the best interests of all asylum officials.
I think that Dr. O’Neill was perfectly justified in bringing forward his resolution
at the general meeting in England. He did so in consultation with the per¬
manent officials of the Association. As it was a matter purely in connection with
Irish asylums it would have been better, if possible, to have brought it before the

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NOTES AND NEWS.

[Oct.,

Irish Branch; we must not forget, however, that the whole subject was brought
before the annual meeting at Cork, and that it was owing to an oversight that
the resolution was not then proposed.

The Honorary Secretaryship.

The Chairman. —We are all very sorry to hear that Dr. Finegan has decided to
resign the secretaryship of our division. He asked me to bring the matter before
the meeting in London the other day. 1 brought it before the Council, and the
Council passed a resolution that any name sent forward by to-day’s meeting
would be put forward for the secretaryship of the Branch.

It was unanimously decided to nominate Dr. Dawson for the position of
Honorary Secretary.

Nomination for Election to the Council.

On the motion of Dr. Conolly Norman, seconded by Dr. Drapes, it was
unanimously decided to nominate Dr. Finegan.

Examinership for the Medical Certificate of the Association.

On the motion of Dr. Mills, seconded by Dr. Dawson, it was unanimously
resolved to nominate Dr. Nolan.

Dr. Richard Leeper read a paper entitled “ Observations on the Neuroglia
Cell and its Processes.” He showed a series of microscopic preparations of
neuroglia fibres from the brain of an epileptic.

Dr. Rambaut read a paper entitled 11 Case-taking in Large Asylums.” This
paper will appear in the January number of the Journal.

Dr. Dawson read a paper entitled " Note on a New Case-book Form.” This
will appear in the January number of the Journal.

Dr. Conolly Norman read a paper on “ Obsessions.” This will appear in an
early number of the Journal.

BRITISH MEDICAL ASSOCIATION.

Annual Meeting, Manchester, 1902.

Section of Psychology.

President: George Wrn. Mould, M.R.C.S. Vice-Presidents: Judson Sykes
Bury, M.D.; Thomas Steele Sheldon, M.B. Honorary Secretaries: John Sut¬
cliffe, M.R.C.S.; Ernest Septimus Reynolds, M.D.

The section was well attended, and the subjects discussed were of exceptional
interest.

President’s Address.

Mr. Mould, in his presidential address, referred to the recent advances in the
accommodation provided for the insane, and mentioned especially the system of
having detached blocks or villas. He said that this plan had been adopted at
Cheaale since 1862, and that it was now in extensive use in Europe and America,
and had the support of the most advanced and enlightened psychiatric physi¬
cians. He contrasted the present-day treatment of the insane with that in vogue
forty years ago, and he mentioned some of the heroic measures which were
formerly adopted, and which with the advance of knowledge had disappeared.
He referred to the meeting that had been held in Manchester twenty-five years
ago, and he paid a high tribute to the memories of some of the distinguished
alienists who were then present.

The Care and Treatment of Persons of the Poorer Classes in the
Early Stages of Unsoundness of Mind.

Sir John Sibbald, in opening a discussion on this subject, said that the present
position of the matter might be summed up in two propositions: first, persons
suffering from mental disorders in their early stages were not, and under British

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807

lunacy law could not be, provided for in asylums; and secondly, such patients
were at present, as a rule, unprovided with hospital treatment of any kind. All
that he desired was that general hospitals should do for mental disease in its
early phases what they did for disease in general, viz., they should receive
patients of the poorer classes who suffered from incipient mental disorder, and
who could not be properly treated under the conditions usual in the homes of the
poor, but could be suitably treated in special wards in general hospitals. He
considered that it was desirable that the mental wards which he proposed should
be in charge of physicians who had devoted their special attention to the care and
treatment of mental disease. He referred to the rival proposal of providing
separate special hospitals—institutions apart from general hospitals and public
asylums—for the reception and treatment of incipient cases of mental disorder.
An insuperable objection to this scheme, however, was that bv whatever attrac¬
tive name such hospitals might be designated, they would be classed by the
public as *• asylums,” and the patients whom it was wished to benefit would
accordingly shrink from entering them. He pointed out that the educational
value of such an arrangement as he proposed would be very great, and he added
that, above all considerations, there rose the supreme fact that the establishment
of such wards would render possible the special treatment of mental diseases in
the early stages.

The Hospital Treatment of the Insane at the Bexley Heath Asylum,
and the Value of Villas for the Housing of Convalescing and
Quiet Chronic Patients.

Dr. Hubert Bond, in his paper on this subject, gave details of the system of
nursing at Bexley Heath, and stated that it was similar to that adopted in the
medical wards of general hospitals. Plans of the villas and gardens were shown.

The Relation of Functional Neuroses (Hysteria, Neurasthenia,
Hypochondriasis, etc.) to Insanity.

Prof. Clifford Allbutt opened the discussion on this subject. While admit¬
ting that the morbid states to which one gave such names as hysteria, neuras¬
thenia, and hypochondriasis were somewhat arbitrary conceptions at the best,
he was of opinion that a discriminating diagnosis was frequently possible. He said
that the confusion which arose generally depended not upon identity, but upon a
similarity between two or more of these maladies in certain phases of their course.
He gave a very clear and exhaustive account of the characteristics of these con¬
ditions, and laid special stress on the differential diagnosis of neurasthenia from
insanity. He stated that for the most part it was wrong to say that neurasthenia
“ drifted into ” this, that, or the other morbid process; neurasthenia was not a
general quality common to many diseases, but a particular process having its
own causes and its own events. Diagrammatically they might conceive of the
nervous system as a vertical pile of centres, the lowermost of which presided over
the earliest of the functions, each higher centre in its turn being occupied with
functions later and later in the order of development. Not only so, but each
later centre was not only attached directly to its predecessor, but was co¬
ordinated also with all its predecessors, so that the pile became a system of
mutual interdependence. Thus every later centre modified, or, in other words, con¬
trolled or inhibited, not only the one immediately below it, but also each and all
the earlier centres, certain cardinal inhibitions being provided for by special
short circuits. But a nervous centre was not a mere change-house; it was also
an accumulator of energy, whereby it was prepared not only for mean demand,
but also for extremes of effort or rest. The neurasthenic had never much reserve
for time of stress; he needed inordinate time for repair, and was apt to be
exhausted beyond the possibility of full repair. In this lowering of nervous
potential not only did output soon run down, but inhibition was slackened, so that
energy was prematurely set free in what they called “ irritable weakness.” This,
however, was not insanity; it was not perversion, but poverty. Hysteria, on the
other hand, was the interference of inhibition out of season. It consisted in
intrusive suggestion; the patient could not take the break off; so it was often
remediable by counteracting suggestions and by disciplinary exercises, neither of

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NOTES AND NEWS.

[Oct.,

which were of much service in neurasthenia. The neurasthenic sought each new
physician with fresh prospects of relief; the hypochondriac sought him only to
consume another man’s time and sympathy upon the altar of himself. Of late
years he had formed the opinion that neurasthenia was apt to follow surgical
operations—sometimes even the smaller operations—when done under an anaes¬
thetic. He believed it to be genuine neurasthenia, and allied to that which
followed some railway accidents.

Apprehensiveness, Stupor, and Katatonia.

Dr. Robert Jones read a paper on this subject. He thought that katatonia
was not a separate variety of insanity, but was a symptom which occurred in the
cyclic forms of insanity. The essential feature was a tendency to the recurrence
or repetition of motor and mental impulses followed by negativism, i. e. t by a con¬
dition of passive resistance to every movement. He gave a detailed account of
the prominent symptoms in the various stages of this affection, and said that the
greater number of katatonic cases became chronic and passed into mild dementia
of a sluggish type. Overstrain and anxious responsibility were important factors
in the causation, and masturbation aggravated the condition. It had not yet been
possible to correlate the symptoms during life with the lesions observed in post¬
mortem investigations.

Syphilis as a Cause of Insanity.

Dr. Mott, in opening the discussion, said that the poison of syphilis was
remarkable for its persistency, its potency, and its prevalence, and that it acted in
many ways as a cause of insanity. During the secondary stage the anaemia and
toxaemia which it produced acted as exciting causes of insanity in predisposed
subjects, but over-dosage with mercury was also a possible factor in some cases.
The worst forms of brain syphilis were those which occurred within the first four
years after infection. Such cases usually ran a rapid course, and were intractable
to treatment. Those forms of the disease in which there was a combination of
endarteritis with gummatous meningitis simulated very closely general paralysis;
they were, however, amenable to treatment by drugs, and the symptoms in great
measure coincided with the post-mortem findings. The relation of general
paralysis to syphilis was now an established fact of great importance. The action
of syphilis in producing general paralysis was limited to the brain of the civilised
man, for in savage races syphilis might be, and often was, common, while general
paralysis was rare. The factors which in civilised life favoured the development
of neurasthenia were capable, in co-operation with syphilis, of producing general
paralysis. Acquired or congenital syphilis was equally potent to cause general
paralysis. The occurrence of syphilitic infections could by careful investigation
be traced in from 70 to 80 per cent, of cases of general paralysis. The symptoms
of general paralysis, however, began to be apparent only several years after
infection, the average interval being fifteen years. General paralysis was un¬
known where syphilis was unknown, and was rare in the rural districts of Ireland
and Sweden. It was also rare among priests, Quakers, and women of the upper
classes. General paralytics were immune to syphilitic inoculation. Juvenile
general paralysis was almost invariably found to be a result of congenital
syphilis, and in 20 per cent, of the cases observed it was found that the fathers of
the patients had had general paralysis. Dr. Mott concluded by adopting, for the
purpose of raising a discussion, the thesis, “ No syphilis, no general paralysis.”

At the close of this discussion the following motion was carried unanimously:—
“ That the Section of Psychological Medicine thinks it ought to point out that
general paralysis, a very grave and frequent form of brain disease, is largely due
to syphilis, and is therefore preventable. We therefore, the members, strongly
recommend that greater efforts should be made to arrest the transmission of
syphilis and to stamp it out, and we further urge that the attention of the Legis¬
lature and of public bodies should be called to this important matter.”

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809

RECENT MEDICO-LEGAL CASES.

["The editors request that members will oblige by sending full newspaper reports
of all cases of interest as published by the local press at the time of the
assizes.]

An Appeal by Mrs. Cathcart.

Cathcart v. Jacobs and another .

This was an appeal by the plaintiff, Mrs. Mary Cathcart, and the committee of
her estate, who had been made a party to these proceedings since the trial of the
action, from an order of Mr. Justice Day, whereby he entered judgment in favour
of the defendants on the claim and judgment for them also on their counter-claim
for ^2387 10s. —Mr. Montague Lush, K.C., and Mr. Morton Smith appeared for
the plaintiffs ; Mr. Minton Senhouse and Mr. Emery for the defendants.

Mr. Morton Smith, in stating the facts to the court, said this action was a good
sample of Mrs. Cathcart’s litigation. The action came on just before the Long
Vacation of 1900, and he believed the lady was represented by counsel during the
two days when it was then argued. After the Vacation it again came into the
list, and Mrs. Cathcart conducted her case in person—or, perhaps it would be
more correct to say, she was not represented by counsel, as she was constantly
away from the court. The action was brought by the plaintiff claiming to have
three agreements signed by her in 1898 cancelled, on the ground that the
defendants had obtained one of them by misrepresentation, and that her sig¬
natures to the other two were forgeries.

The Master of the Rolls.—What did the learned judge find as to the alleged
forgeries ?

Mr. Morton Smith.—That the signatures were not forgeries. Continuing, the
learned counsel said the defendants were Mr. Julius Jacobs and his son, Mr.
Morris Jacobs, who were described as financial agents in the city. They denied
the allegations in the claim, and counter-claimed for ^12,000 as the commission
due to them under the documents the subject of the action. Mrs. Cathcart’s
case was that in 1898 her mother, a Mrs. Unwin, having recently died, she asked
the defendants to try to find out what property her mother died possessed of,
representing to them that she did not know anything about her mother’s affairs.
The defendants, in consideration of 15 per cent, on all the money they might
discover that the lady had died possessed of, undertook, on the contract note
being signed, to make the necessary investigations. As a matter of fact, the
lady’s estate was all known to her bankers, and the getting together of the
information was a very simple affair. The lady died possessed of many
thousands, and the commission on her property was out of all proportion to the
labour expended; but at the trial the defendants offered to accept a quantum
meruit , and the judge acted on that offer. As a defence to this part of the
counter-claim Mrs. Cathcart said the property discovered was already standing
in her name, and was not property that passed to her on her mother’s death at
all, but the learned judge ruled otherwise. The second document was to the
effect that in the event of the defendants letting certain lands of hers in
Worcestershire, on building leases, at a ground rent of ^50 a year, and a
premium of ^1500, the money over and above that premium was to be retained
by the defendants for their trouble. The third document purported to be an
agreement to sell to the defendants, in consideration of the sum of ^1500, a
ninety-nine years’ lease of the “ Horse and Groom ” public-house at Hayley, and
some other property, subject to a rental of ^55 a year, the defendants to retain
all they got for this property over and above the *1500 for their trouble. The
learned counsel submitted that the defendants knew perfectly well that Mrs.
Cathcart was not able to manage her affairs, and had taken unfair advantage of
this fact to get her to enter into contracts which were so to her disadvantage that
the courts could not allow them to stand. He asked for a new trial. The real
issue—the insanity of the plaintiff—was not before the court when the action was
heard.

Mr. Montague Lush, K.C., having been heard on the same side, Mr. Minton
Senhouse, for the defendants, said there was no evidence on which this court

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NOTES AND NEWS.

[Oct,

could set aside the judgment entered for the defendants. Everything they had
done was done aboveboard and was regular. The commission the lady was
willing to pay was in writing. The defendants had incurred substantial out-of-
pocket expenses, and if a new trial was ordered on the ground that the lady was
insane when she entered into these agreements the defendants should have their
expenses paid and their costs. The only ground on which the court could order
a new trial—namely, the incapacity of the plaintiff to contract—was not before the
court when the action was tried. The lady had failed in the action, and the
defendants had won on their counter-claim. He submitted, as the defendants
had acted bond fide in the matter, a new trial could only be ordered if the
plaintiff placed the defendants in the same position as the parties were as
regarded money matters before the trial was commenced.

Mr. Emery followed, and at the close of his argument the Master of the Rolls
said the point the court had to decide was whether Mrs. Cathcart was in a
position at the time of the trial to conduct her own case and instruct counsel
properly. The facts spoke for themselves, and showed that by the lady’s conduct
the real issue was not tried when the action was heard. As to the merits of the
case he would say nothing; but the judgment entered for the defendants for
£2.2 87 could not stand, and there must be a new trial; the costs of the first trial
and of this appeal to be left to the discretion of the judge who re-heard the
action.

The Lords Justices concurred.—Court of Appeal, before the Master of the
Rolls and Lords Justices Mathew and Cozens-Hardy.— Standard t July 19th,
1902.

In re Isaiah Meechan , who assaulted Dr. Anderson at West green Asylum , Dundee .

Before Sheriff Campbell Smith and a jury at Dundee yesterday, Isaiah
Meechan, at present an inmate of the institution, was charged with having, on 24th
June, on the terrace at Westgreen Asylum, assaulted Dr. William Lockhart
Gibson Anderson by beating him on the face with his hand, and by stabbing him
with a knife on the left side.

Mr. Lawrence Melville, solicitor, who appeared on behalf of Meechan, submitted
a special defence, in which he stated that accused denied the charge, and pled that
at the time the crime was said to have been committed he was and still is insane.

Dr. Anderson, examined by Mr. Melville, stated that he was Junior Assistant
Medical Officer at Westgreen Asylum, having held that post since March, 1901.
Meechan came to Westgreen as an ordinary pauper lunatic in April last, and had
been there ever since. His condition had not improved. Meechan imagined that
Westgreen Asylum belonged to him, and that he was tormented by various people
who spoke to him by means of a telephone. Dr. Anderson, he believed, was one
of his tormentors.

Mr. Lawrence Melville.—Did he mention any other body P

Witness.—Yes, he thought Sheriff Campbell Smith and myself were working
an infernal machine against him. Meechan refused to take his food, and witness
was preparing to administer it compulsorily when accused volunteered to partake
of it. On several occasions Isaiah had used violence towards the doctor. He had
refused to go to exercise on the terrace, and he had had to be carried out by the
attendants. He first attacked the doctor about the middle of May. One of the
attendants warned witness, and he watched accused carefully. On 24th June,
while witness was on the terrace, Meechan suddenly rushed at him, and struck
him on the right cheek, while almost simultaneously he dealt him a blow on the
left side of the body. Dr. Anderson did not pay particular attention to the latter,
but on looking under his waistcoat he saw a small patch of blood. He then
examined his side, and found a wound from one third to half an inch in length
between the seventh and eighth ribs. One of the attendants closed with Meechan,
and a knife was found in his possession. The witness had no doubt that Meechan
was insane and dangerous.

William Mitchell, head attendant at the asylum, corroborated as to the assault.
He recovered the knife, which he found had been brought into the house by some
relations of another patient.

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1902.] NOTES AND NEWS. 8ll

Dr. Rorie, Medical Superintendent, Westgreen Asylum, stated that Meechan
had been quite insane ever since he came into the institution. He was suffering
from delusions that people were working an infernal machine upon him. He
appeared to improve a little, and the doctor was hopeful that the delusions were
leaving him, but unfortunately they returned. He had examined accused on
several occasions, including that day, and he was still suffering from these
delusions.

The Procurator Fiscal.—He is not a fit subject for an ordinary lunatic asylum?

Dr. Rorie.—No, he is exceptionally dangerous, and not at all suitable for treat¬
ment in an ordinary asylum.

In answer to the Sheriff, accused said he had got witnesses in Lochee and the
asylum attendants. He wished them to be examined against these doctors. He
must get justice as well as other people.

The Sheriff.—Did I torment you as well as the doctors ?

Meechan.—I never mentioned your name to them.

The Sheriff said he had no doubt that Meechan was not a fit subject to be at
large, and the best thing for him and for others was that he should be taken care
of. He would grant the ordinary interlocutor.

Meechan, as he was leaving the dock, exclaimed, I am entitled to get pro¬
tection as well as other people.

His Lordship.—You will get protection.

Meechan was then ordered to be confined in Perth Penitentiary during His
Majesty's pleasure.— Dundee Advertiser , August 8th, 1902.

REVISION OF THE RULES.

The following communication has been sent by the Honorary General Secretary
to the Divisional Secretaries :

Dear Sir, —The Rules of the Medico-Psychological Association being out of
print, it has been thought desirable- before a reprint is issued to consider any
suggestions which might be made for the better working of the Society, and a
committee—Drs. Carlyle Johnstone, Mercier, Hayes Newington, Conolly Nor¬
man, Urquhart, Weatherly, and the Honorary General Secretary—was appointed
at the last Annual Meeting in Liverpool to report upon the Rules to the next
Annual Meeting. It was also referred to the various Divisions to consider the
Rules at their next Autumn Meetings, and I write to request that you will kindly
bring the matter forward for consideration, and that you will also kindly let me
know what suggestions—if any—may be made by your Division, so that I can
report to the Rules Committee.

The following is a record of action taken by the Council and Annual Meeting
in regard to the Rules:

May 23rd, 1901.—A committee, consisting of Drs. Whitcombe, Mercier,
Weatherly, Newington, and the Secretary, was appointed to consider the printing
of the new Rules, and to report to the next Council.

July 25 th % 1901 (Annual Meeting in Cork). —It was resolved, on the motion
of Dr. Hayes Newington, seconded by Dr. Urquhart—" That it be further remitted
to the Rules Committee to report to the Council showing what rules have been
passed by the Association since last printing, what rules have been passed by the
Council, and what suggestions they would submit for the better working of the
Association."

July 24th, 1902 (Annual Meeting in Liverpool). —The following was proposed
by Dr. Whitcombe, and seconded by Dr. Morrison!—" That a committee be
appointed to consider and revise the Rules, to add such amendments as have been
made from time to time, and to report to the next Annual Meeting." This was
rejected, and the following amendment to this motion, proposed by Dr. Urquhart,
seconded by Dr. Conolly Norman, was carried as a substantive motion, viz.:—
" That the Rules Committee appointed by the Council be thanked for their report,
but that it be not adopted. That this meeting do appoint a Committee to con-
XLVIII. 56

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812

NOTES AND NEWS.

[Oct.,

tinue the work done by the Committee now dissolved, by submitting the amended
Articles of the Association to the Divisions of the Association for consideration
at their autumn meetings of the current year. That the reports of the Divisions
be sent to the Committee to-day appointed, who are hereby granted freedom to
deal with the whole question of Articles, Rules, and Bye-laws, with the instruc¬
tion to prepare a report for the Annual Meeting of 1903. That this Committee
be constituted as follows:—Drs. Hayes Newington, Mercier, Urquhart, Conolly
Norman, Carlyle Johnstone, Whitcombe, Weatherly, and Robert Jones (Honorary
Secretary).” Dr. Whitcombe declined to act.

A copy of the Rules, with proposed amendments, was forwarded by post to
every member of the Association before the last Annual Meeting. Further copies
may be obtained from the printers of the Journal.

Yours faithfully,

Robert Jones,

Honorary General Secretary.

COMMITTEE FOR THE REVISION OF THE STATISTICAL TABLES
OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.

The Committee on Statistical Tables appointed at the last Annual Meeting
(1902) are anxious to ascertain the views of asylum physicians as to the twelve
tables that are now in use, some of which were adopted nearly forty years ago.
The Committee have before them the labour involved in the compilation of these
tables, and the advantage of retaining simplicity of form as far as is consistent
with accuracy and utility. They earnestly ask the co-operation of their fellow-
members, and that replies to the following questions be sent before November 1st
to the Secretary of the Committee, Dr. Bond, London County Asylum, Bexley,
Kent.

1. Do you think that the present series of tables requires modification or
addition ?

2. If so, what tables require alteration, and in what respect ?

3. What additions do you suggest ?

N.B.—The form of the official tables as originally recommended by the Asso¬
ciation is set forth in vols. xi and xiii of the Journal of Mental Science.

Suggestions of Possible Amendments .

1. The points of information afforded by the tables in their present form
number rather more than fifty. Several occur in more than one table. By
avoiding this repetition, space may be found for many of the additional points
already supplied by some asylums.

2. Several of the items of information are read and interpreted diversely. This
lack of definition has been recognised by many asylums, and attempts to correct
it have been made by the addition of explanatory foot-notes. Particularly is there
often confusion as to the interpretation of the word “ admissions,” and as to
whether or not transfers have been included in the figures.

3. The advantage of greater correlation between the tables.

(a) The age at death, with the cause of death (Table V); and

( b ) The duration of insanity on admission with the existence of any prior

attack (Table VII), are examples of existing attempts at this by the
present tables.

was in operation), with a cross-index to associate them, e.g. enabling
it to be seen into how many deaths from general paralysis, phthisis
entered;

(d) The association of the duration of the mental disease with the cause of

death;

( e) The inclusion of the ages in a similar manner with the form of mental

disorder (Table XI); and

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NOTES AND NEWS.

813

1902.]

(/) The cross-indexing of the causes of insanity (Table X), e.g. enabling
it to be seen into how many alcoholic cases heredity entered, or how
many puerperal cases were also adolescent, etc.,
are examples of possible further efforts in this direction.

4. Supplementary tables. For instance, one detailing the degree of insane
heredity, and associating it with neurotic, phthisical, and alcoholic heredities.

5. Any revision of the present nomenclature of mental diseases in Table XI,
and the separation therein of symptomatological from aetiological terms.

THE HYPODERMIC ADMINISTRATION OF MORPHIA.

Dr. J. B. Mattison, Medical Director, Brooklyn Home for Narcotic Inebriates,
offers a prize of 400 dollars for the best paper on the subject:—

Does the habitual subdermic use of morphia cause organic disease ?

If so, what ?

Contest to be open two years from December 1st, 1901, to any physician, in
any language.

Award to be determined by a committee: Dr. T. D. Crothers, Harford, Conn.,
Editor Journal of Inebriety t Chairman; Dr. J. M. Van Cott, Prof, of Pathology,
Long Island College Hospital, Brooklyn; and Dr. Wharton Sinkle, Neurologist
to the State Asylum for the Chronic Insane, Philadelphia.

All papers to be in the hands of the Chairman by or before 1st December,
1 9 ° 3 ; to become the property of the American Association for the Study and
Cure of Inebriety; and to be published in such journals as the committee may
select.

CORRESPONDENCE.

44 F. S. S.” v. " Resartor ”

Gentlemen, —I have to inform 44 F. S. S.” that no collaboration was practised
in preparing my strictures; indeed, none was wanted. I thank him for his recogni¬
tion of care on my part. Perhaps it was due to this care that he was not able,
in his rejoinder, to make a frontal attack on the positions taken up by myself.
44 F. S. S.” is aggrieved by my assuming that he recommended the adoption of
average residence in place of residence on January 1st of each year as a basis for
statistical computations. He bids me read his review again. I have done so, and
in the light of his recent translation of the first paragraph I must congratulate him
on the production of a fine cryptogram. I have gone further, and re-read his
review of the previous year^ 1 ) ana find that he advocated therein this same basis of
average residence. But on that occasion he added that if the Commissioners
adopted it they might safely work out percentages to two places of decimals.
Where, then, is the grievance? and why should he now write that a tyro in
arithmetical reasoning could see that such a summation could not possibly be taken
as a basis for working ratios and proportions ?

However, it now turns out that 14 F. S. S.,” in recommending this 44 only fair
estimate,” only meant to give the Lord Chancellor a better estimate (to two places
of decimals ?) of the amount of work the Commissioners have to do annually. But
even on this footing, why should not the Commissioners tell their own tale of work
in the way they may think best ?

I still think that 44 F. S. S.” is mixed on the subject of recovery rates. 44 1
merely desired to emphasise the fact that such a yearly aggregate increase must in
a measure affect the calculation, be it the average number resident or the admission
rate which may be chosen.” That is just where he is mixed. This crisp state¬
ment exactly confirms my reading of his original review. How can yearly aggre¬
gate increase affect recovery rate on admission P It is a fact that yearly aggregate
increase depends largely on failure to recover; in other words, recoveries affect

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8 x 4

NOTES AND NEWS.

[Oct.,

aggregate increase. If, at the same time and for the same purpose of estimating
the amount of curative work done, we are to reverse the position of cause and
effect, and to look upon aggregate increase as having active control of recoveries,
we are landed in a parlous statistical maze. I maintain confidently that the two
methods of estimating recoveries are so diverse that they can have nothing in
common.

He asks for my authority for stating as a patent fact that there are fewer cases of
general paralysis than there were. Here it is:

Lunacy Reports , 1896 and 1901.— Table XX.

Annual
averages of

Total

admissions.

General paralytics
admitted.

Proportion per cent,
of general paralytics
in total admissions.

1890-94

{ Private
Pauper

2,109 ... 150

14,977 ... 1,299

7’ 1

Total

1895-99

{ Private
Pauper

17,086 ... 1,449

2,144 ... 156

16,600 ... 1,207

3-5

7*3

Total ... 18,744

'.363

" F. S. S.” follows up his challenge with this most remarkable question:" Because
the Commissioners show statistically that there are fewer general paralytics in
asylums, does * Resartor ’ imagine that there are fewer in the community P ” He
must well know that the Commissioners’ report under review dealt only with
officially known lunatics, and he must equally well know that in the paragraph of
his review in which he himself dealt with the question not a suspicion of " the
community ” was raised. He debated the question on stated figures applying only
to known insanity. One may well ask why he has touched the blue-book statistics
at all if he is going to import an element which must vitiate all, even his own, cal¬
culations. It would have been more to the point if he had opened his review with
the remark made by him in this very paragraph, " It is not apparently appreciated
that rational proportions of quinquennial averages are totally different from pure
aggregates; ” and then, after having demonstrated the impossibility of obtaining a
pure aggregate in the face of existent but unascertainable insanity outside asylums,
treated all statistics to a righteous and dignified silence.

“ F. S. S.,” after all, does believe that syphilis is the sole factor of general paralysis.
I am with him to a certain extent in his belief that it is a prime factor, but I cannot
conscientiously go so far as he does, since the denial of all other causation, direct or
contributive, entails the discomforting proposition that every person who contracts
syphilis, which is not arrested or modified by treatment, is bopnd to fall to the
other disease,—a sort of penny-in-the-slot aetiology which is simple but very
frightful.

I am, Gentlemen,

Your obedient servant,

Resartor.

( l ) J. M . S. t January, 1901, p. 119.

To the Editors of the * Journal of Mental Science *

Gentlemen, —Tactically it is recognised that to make a frontal attack against
an insidious foe can be of but small avail if one desires to convince him of the
pregnability of his position. I therefore very properly made a flank attack in the
hope of satisfying" Resartor’s ” scruples, and I adopted plain and simple reasoning
as my movement; direct denials and refutations would never have persuaded one
who argues as does he. Unfortunately, with blind unreason he returns to the
encounter, and by further misinterpretations and misreadings of my meaning
attempts to pass off as fair argument a perverted view of any opinion of mine he
can fasten upon, if only for the sake of establishing his earlier erroneous conten¬
tions, and to justify himself in his own sight and in the eyes of your readers. I

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1902.]

NOTES AND NEWS.

815

feel that no further arguments, corrections, or interpretations of what I have
written will help him out of the “ statistical maze ” into which he has so rashly
wandered, or wean him of the self-satisfaction he feels in the plausibility of his
own deductions.

I generously grant him, therefore, the supposititious victory!for which he craves.
I yield. I am everything that is wrong. I remain mixed on the subject of
recovery rates. General paralysis is dying out. Syphilis is not the sole cause of
general paralysis, and so forth. Ainsi soit-il — qu'importe ?

But if " Resartor ” thinks I am retreating from my position, or covering an
apparent retreat by assuming the cloak of indifference, he is vastly mistaken. As
I hope to contribute a paper to your Journal dealing with the whole matter of
lunacy statistics, an opportunity will no doubt be afforded him of entering the lists
against me and my doctrines. He will, perhaps, by very careful reading, find
some verbal construction at which to tilt his hypercritical lance—or is it his
shears ? or his goose P

" Resartor,” I note, withdraws the other lines of his attack without one word of
comment, covering the confusion in his ranks by further involved disquisitions on
certain opinions and suggestions of mine—opinions which he distorts, and sugges¬
tions which he cripples and warps so that the victory may be his. To me it seems,
however, that the flank movement above alluded to has not been quite so unsuc¬
cessful after all.

My thanks are due to you for forwarding me a proof copy of the above letter.
So far as I am concerned the correspondence ends.

I am, your obedient servant,

F. S. S.

The Insane in Jerusalem.

Dr. Cecil Beadles has forwarded us a letter from Dr. P. D’Erf Wheeler,
Medical Superintendent of the English Hospital at Jerusalem, in which the
writer states:

" I had not forgotten to make inquiries, and to visit and inspect personally the
only institution here approaching to the name of * Lunatic Asylum. 1 This insti¬
tution, called ‘The Aid for Women,’ has a threefold object. 1. The nursing and
support of poor women in childbirth. 2. The support of a certain number of
deserving 1 incurables.’ 3. The looking after the insane. .

41 I visited this institution accompanied by Mr. Wiseman and Mr. Penash, the
head of the establishment.

44 There were only six lunatics proper, and these were well looked after, and
treated regularly by the doctor of the institution. They are fairly well supplied
with a * douching apparatus,’ and have a good supply of water for washing and
hydropathic purposes. There were two acute cases of mania. During the last
year there were thirteen lunatics treated in the institution.

44 I know of no other properly organised * Lunatic Asylum ’ in the country,
except the new one near Beyrout.

44 The crude—I was going to say barbarous treatment of the insane at the
Church of St. George’s (Greek Orthodox) is well known to you. I have seen a
patient chained to the altar almost nude, undergoing treatment (or ill-treatment ?);
they are supposed to be forty days there. Some few years ago I attempted to
establish a 1 lunatic room * in connection with our new hospital, but the Committee
would not give their permission.

44 We sadly need in Jerusalem a proper institution for the insane, and any help
I can render towards such an object will be most willingly given.”

OBITUARY.

George Micklby.

We much regret to announce the death, on August 10th last, of George Mick-
ley, late Medical Superintendent of St. Luke’s Hospital. Born in November,

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8i6

NOTES AND NEWS.

[Oct,

1843, he received his education at Clare College, Cambridge, and Guy’s Hospital,
graduating B.A. in 1864, M.B. 1865, C.M. 1866, and M.A. 1867. In 1867 he also
became a Licentiate of the Society of Apothecaries, being elected a member of
that body in 1895. After leaving Guy’s Hospital he was appointed Clinical
Assistant at Bethlem Hospital, which post he held for a year, being then elected
Assistant Medical Officer to the Three Counties Asylum, where he remained for
seven years and became Senior Assistant. In 1875 he was elected Medical
Superintendent of St. Luke’s Hospital, from which post he retired in 1898 owing
to failing health. His whole life was spent in the practice of Lunacy, and he was
a member of the Medico-Psychological Association for thirty-five years. Many
improvements and alterations were made at St. Luke’s during his time for the
welfare of the patients. He was a devoted Mason, interesting himself especially in its
educational and benevolent institutions, and attained a high degree in the craft.
His death was due to organic heart disease, which was started by a severe attack
of influenza some years ago. He will be remembered by all who knew him as a
sincere, honest, and kindly gentleman, and by those who worked with him in any
capacity as a friend.

Neil Harrismith Macmillan.

** He whom the gods love dies young.”

A most promising and brilliant career has been suddenly cut short at its very
outset. Just over thirty years of age, and whilst absent on leave, Dr. Macmillan
has passed away. The sad and unexpected news of his death has caused very
deep and real grief to the service at Claybury Asylum. At the last meeting of
the South-eastern Division of the Medico-Psychological Association he read a
paper upon “ The History of Asylum Dysentenr at Claybury ” (to which malady,
with the irony of fate, he himself has succumbed), recording his experience on
the female side of the asylum, and suggesting methods of treatment; he was
greatly complimented by the Division upon his careful, clear, and most
suggestive contribution. Born in South Africa (Harrismith), educated in the
south of France, he took his degree at Edinburgh, where he filled the resident
appointments after qualifying, and he subsequently studied in Vienna. He was
acquainted with French ana German, and served as a most helpful assistant at
Claybury, where he endeared himself to patients and staff. He was an excellent
clinician, devoted to his work; he spent hours in the wards daily, and was most
observant, careful, and earnest. His case-books and general work were always
marked with thoroughness, and in his social relations he was courteous, urbane,
and essentially conscientious.

It is the first occasion upon which a medical officer at Claybury has died in
active service, and, as the chaplain at a memorial service observed, “ as an honour¬
able gentleman his memory will always be held in endearing affection.”

NOTICES BY THE REGISTRAR.

The following gentlemen were successful at the examination for the Certificate
in Psychological Medicine, held on July 17th, 1902.

Examined at Bethlem Hospital, London: James E. H. Sawyer, James F.
Cunningham, George H. Grills.

Examined at Glasgow: Harry E. Brown.

The following is a list of the questions which appeared on the paper:

x. Mention briefly the various types of progressive paralysis occurring in the
insane. 2. Describe the various pupillary changes met with in the insane, and
state their clinical significance. 3. State briefly the premonitory symptoms of an
attack of insanity, and your mode of treatment. 4. Describe a case of puerperal
mania, your prognosis, and treatment. 5. Discuss the relative influence of the
hereditary factor in the causation of insanity, and mention the most important
stigmata of degeneration. 6. Morbid anatomy .—Describe in detail chromatolysis
of the nerve-cell. 7. Describe the physical symptoms met with in melancholia

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NOTES AND NEWS.

817

1902.]

and mania. 8. What are the pharmacological actions of sulphonal, trional, and
the bromides ? What dangers attend their use ? 9. Enumerate the chief forms
of syphilitic insanity; and briefly describe the rdle of intoxication, and infection
in its pathogenesis. 10. Describe a case of sexual hypochondriasis. Give prog¬
nosis and treatment. 11. Discuss the doctrine of Kraepelin that melancholia is
essentially a disease of early senility. 12. Mention the leading theories which
have been formed to account for the existence of hallucination, and discuss the
arguments in favour of that one to which you adhere.

Examination for the Nursing Certificate.

The next examination for the Certificate of Proficiency in Nursing will be held
on Monday, November 3rd, 1902, and candidates are earnestly requested to send
in their schedules, duly filled up, to the Registrar of the Association not later than
Monday, October 6th, 1902, as that will be the last day upon which, under the
rules, applications for the examination can be received.

For further particulars respecting the various examinations of the Association,
apply to the Registrar, Dr. Alfred Miller, Warwick County Asylum, Hatton, near
Warwick.

NOTICES OF MEETINGS.

Medico-Psychological Association.

General Meeting. —The next General Meeting will be held in the rooms of the
Association, 11, Chandos Street, W., on 20th November, 1902.

South-western Division. —The Autumn Meeting will be held at the Devon
County Asylum, Exminster, on Tuesday, 28th October, 1902. Business meeting
at 2.45 p.m.

South-eastern Division .—The Autumn Meeting will be held, by the courtesy of
the Drs. Tuke, at Chiswick House, Chiswick, on Wednesday, 29th October, 1902.

APPOINTMENTS.

Ellerton, Henry B., M.R.C.S.Eng., L.R.C.P.Lond., appointed Senior Assistant
Medical Officer to the Leavesden Asylum.

Macfarlane, Aylmer A., M.D., appointed Resident Medical Officer to the
Parkside Lunatic Asylum, Adelaide, South Australia.

Rambaut, Daniel F., M.D. Univ. Dub.l, Third Assistant Medical Officer and
Pathologist, Richmond Asylum, Dublin, appointed Resident Medical Superinten¬
dent, Salop and Montgomery Counties Asylum, Shrewsbury, vice Dr. Arthur
Strange, deceased.

Robinson, Harry A., M.D., B.Ch.Vict., appointed Senior Assistant Medical
Officer to the Darenth Asylum.

Walker, Ernest C. D., M.B., C.M., appointed Assistant Medical Officer of the
Seacliff Lunatic Asylum, New Zealand.

Wilkinson, Miss Ada, M.B., appointed Assistant Medical Officer to the Isle of
Wight County Asylum, vice W. M. P. Keogh, M.B., B.Ch., R.U.I., deceased.

Digitized by tjOOQle

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INDEX TO VOL. XLVIII.

Pabt I.—GENERAL INDEX.

Alcohol and tobacco, influence on work, 351
„ duration of psychic action of, 164
,, influence on handwriting, 163
„ question as a cultural and race problem, 350
,, total abstinence question, 190
Alcoholics, asylum treatment of, 185
Alcoholism as a cause of general paralysis, 168
Ambidexterity, 348
American psychiatry, 124
Anthropology, 142 , 344 , 660
Aphasia, mental condition in, 575
Apprehensivencss, stupor, and katatonia, 808
Argyll-Robertson pupil, clinical value and relation to syphilis, 570
Army, insanity in, 125
Art and artists, 120

Asylum accommodation in Lancashire, 384
,, at Lujan, Buenos Ayres, 361

„ Bangour, 539

„ dysentery, 509

„ for London (ninth), 764

„ reports, 192 , 366 , 789

„ workers* association, 540

Asylums, Continental and British, notes of a visit to, 761
,, night nursing and supervision in, 289
,, political management of, 125
Audition, 1 ’, 549

Bangour asylum, 639
Bed treatment of insanity, 186
Belgium psychiatry, 127
Boarding out system, 136
Brain, abnormal, 323
Brain, circulation of blood in, 555
„ lipoma of, 64

„ traumatic lesion of, with epilepsy, 66
„ of a criminal, 585 , 773

British Medical Association, section of psychology, 806
Bromides, action of, during hypochlorisation, 359 , 361
Bureau of information, 202, 207

Care and treatment of persons of the poorer classes in the early stages of unsound¬
ness of mind, 806
Cathcart case, 536
Catatonia, 356

XLVIII. 57

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820

INDEX.

Children, mentally deficient, 558
Chloral-hydrate poisoning, 784
Choreas, psycho-mechanical treatment of, 785
Chromatolysis, 151

Classification of the psychopathies, 778
Circular insanity, value of dreams in, 578
Cocalnomaniac father and idiot children, 132
Consanguine marriages and consequences, 569
Consanguinity in the ©tiology of epilepsy, 569
Copenhagen hospital, psychiatric wards, 525
Corpus callosum, deficiency of, 146
Correspondence, 207 , 386 , 598 , 813
Crime in general paralysis, 28

Criminal asylums and sections for insane in prisons, 584
„ lunatics, female, 13

„ i, statistics, 127

Criminals, abnormalities in brains of, 585
Croonian lectures on the chemical side of nervous activity, 148
„ „ „ degeneration of the neuron, 150

Cross-education, 156
Cutaneous sensibility, 135

Czolgosz, the assassin of President McKinley, 125 , 336

Danger of discharge of insane patients by the judicial authority, 335
Defectives, training of, 786

Delusions in some cases of melancholia, evolution of, 495
Dementia praecox, 779
Denmark, psychiatry in, 129
Diabetic insanity, 735

Dietiug of pauper lunatics in Scotland, report on, 33 i
Dispensary treatment of mental diseases, 187
Dreams and their meaning, 122
„ case of prolonged, 180

„ importance of, as symptoms of disease, 180
„ projection of, into waking state, 161

„ semeiology of, 564

„ symptomatic value of, 578

„ systematised delusional insanity from dream to dream, 179
Drug therapeutics, 760
Dysentery, asylum, 609

Education and psychiatry, 786
Electric bath, 789
Emotions, 550

„ psycho-physiology of, 159

Encyclopedia medica, 545
Enrico Bailor, called “ the hammerer,” 788
Epidemic irrationality, 542

„ and cysticerci of brain, 184

„ dietetic treatment of, 784

„ following traumatic lesion of brain, 66, 139
,, and hysteria, 578

„ hysteria, idiocy, etc., 569 , 547

,, observations on, 135

„ original research in, 76

„ pathogenesis and pathology of, 109

„ psycho-motor, syphilitic, 182

„ treatment of, public aid, aud jurisprudence, 110
„ „ practical, 111

„ with glioma, following traumatic injury of brain, 751

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Google

INDEX.

821

E pileptics, treatment of, 385

„ new toxic and therapeutic properties of the blood-serum of, 782
Ereuthophobia, case of, 159

Faradisation of head for insomnia, 188

Female criminal lunatics, 13

Finger-prints of normal and insane patients, 560

Flagellatio puerorum as an expression of masked sadism, 189

France, psychiatry in, 131

General paralysis, tetiology and symptoms of, 573
„ „ crime in, 28

„ „ early symptoms of, 574

„ „ genital sense in, 174

„ „ normal posterior root ganglia and their degenerative phases, 369

,, „ polyclonus in, 173

„ „ psycho-motor hallucinations in, 174

„ „ sense of smell in, 572

„ „ simulating cerebral syphilis, 574

„ ,, spontaneous fracture in, 355

„ „ stigmata of degeneration in viscera, 354

„ „ topography of degeneration in cortex, 583

Germany, psychiatry in, 133
Glioma and epilepsy, 751

Gynecological observation at the asylum of Ville-Evrajd, 186

Hematoma of the cerebral dura mater, 531
Hallucinations, 45

„ and allied mental phenomena, 226

„ of hearing, unilateral, 54

Hallux, shortness of, in epileptics, criminals, and idiots, 142
Head, measurements of, 558
Hearing, 549

„ hallucinations of, 54
Heart and circulation in feeble-minded, 176
Heating and ventilation as regards tuberculosis, 406
Hemicephale, nervous system of, 145
Heredity of endogenous psychoses, 567
„ and insanity, 611
Holland, psychiatry in, 134
Homicide, mental conditions resulting in, 313
Hospital ideals in the care of the insane, 261, 598

„ treatment of incipient and transient mental disease, 697
Hunger, action on psychic processes, 165
Hydrotherapy, 782, 788
Hysteria and its treatment, 114

„ and katatony, diagnosis, 582
„ definition of, 576
Hysterical psychoses and myoclonus, 577

Ideas, fixed, 175
Idiocy and athetosis, 172

„ and cerebral paralysis, 178
„ clinical and peuatomopathological studies, 780
„ with diplegia, 575
„ pathological studies in, 112
Idiot and imbecile, psychology of, 111
Idiots and imbeciles, care of, 738
Imbecile children, 564
Imbeciles, prostitution and vagrancy in, 586
Incipient mental disorder, treatment of, 215
Index to Brain , 836

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822

INDEX.

Infanticide. 366
Influenza. 387

Insane before the courts, 340
„ care of, in hospitals, 261
„ criminals, disposal of, 341
„ modern advances in treatment, 187
,, treatment of, without isolation, 133
Insanity, delusional, 179

„ „ surgical treatment of, 460

,, legislation for limitation of, 192

„ of adolescence, 177, 178

,, text-book of, by Dr. Mercier, 643
„ with rigidity of muscles, 183
Italy, psychiatry iu, 137

Jealousy, delusions resulting from, 133

Jerusalem, insanity in, 764, 816

Judicial condemnations of unrecognised lunatics, 584

Katatony and hysteria, diagnosis, 582

Kernig's sign as a symptom of focal brain disease. 776

Kleptomania and death from cerebral unemia, 181

Laboratory of the Scottish asylums, 697
Lipoma of the brain, 64

Localisation of mental faculties in left prefrontal lobe, 561
Lunacy, the burden of, 198
„ increase of certified, 763

„ law, flaw in, 312, 335

„ „ reform of, 190

„ legislation, 541

„ statistics, 71

Malaria, psychical disorders in, 579

Mania, delirious, acute, 580

Maniac, autobiography of a, 171

Marriages, consanguine, and their consequences. 569

Materialistic psychiatry, 162

Medico-legal cases, 205, 380, 536, 591, 809

Medico-psychological research, organisation, 74

„ ,, Association meetings, 196, 198, 201, 202, 369, 371, 372, 586,

587, 589, 590, 591, 757, 795, 805
„ „ presidential address, 611

„ ,, statistics, 709

Melancholia and the toxemia theory, 352
„ evolution of delusions in, 495
Memory, 552

„ development in children, 153

,, negation of, 680

„ in the normal, neurasthenic, and insane, 153
Mental and motor ability, correlation between, 156
„ »* physical tests, correlation of, 106

„ health and the war, 73
„ state of the subjects of tics, 581

„ symptoms, relation to bodily disease and treatment, 748
„ work and dynamometrical effort, 653
Merck's annual report, 766
Messiah, another, 765
Military crime, 786
Mind!, 75
Morals, 551

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INDEX.

823

Morphia, criminal assault to secure, 132
,, hypodermic administration of, 813
Morphinomania, 478

Nails, transverse ridging of, in the normal, criminal, and insane, 344
National mental health and the war, 73
Nerve-cells, alteration of, in acute confusional psychoses, 184
Nerves, peripheral, restoration of, 147
Nervous organs in health and disease, anatomy of, 118
„ system, stimulus in repair and decay of, 667
Neurasthenia, symptoms of, 116
„ auto-suggestive, 181

,, treatment of, 548

Neuroglia cell and its processes, 732
Neuron, degeneration of, 150
Neuroses, functional, relation to insanity, 807
Neurosis of the end of the century, 166
Norway, psychiatry in, 141

Obituary notices—Bodiugton, Dr. G. F., 604; Clark, Dr. Campbell, 209, 371;
Fox, Dr. Bonville. 690, 602; Hills, Dr. W. C., 388 ; Macmillan, Dr. N. H.,
816; Mickley, Dr. G., 815; Shaw, Dr. J. S., 126; Strahan, Dr. S. A. K., 389;
Strange, Dr. A., 603; Sutherland, Dr. H., 208; Wade, Dr. Ij., 193, 201;
Worcester, Dr., 126
Obsessions of scruples, 154

Onanism and treatment by hypnotic suggestion, 785
Open-door and bed treatment in Argentine Republic, 361
Optic thalami, degeneration of, 58

Pachymeningitis interna hmmorrhagica, 531
Pain, 347

Paralysis, general, tee General paralysis
„ pseudo-bulbar, 161
Paralytics, degeneration in cortex of, 383
Parricide and mental degeneration, 132
Pathological study of insanity, 383, 641
Pathology, human and comparative, 107
Pellagrous insanity, 1
Pelvis in criminals, 143
Penal science, 339
Pensions, 197, 373
Pericardium, calcification of, 529
Photographing of insane patients, 203
Pigott, Mr., another Messiah, 765
Pituitary gland, physiology and pathology of, 119
Plans of villa at Perth Royal Asylum, 588
Polydactylism, 346

Prefrontal lobes and localisation of mental functions, 9
Pregnancy, insanity of, 17

„ and nervous diseases, 668
Presidential address by Dr. Wiglesworth, July, 1902, 611
Primitive offenders and offences, 346
Private insane patients, 331

Progressive paralysis, changes in the cerebellar neuroglia, 582
„ „ genesis and nosographic position of, 775

„ „ in the German Tirol, 168

Psychiatric clinique in Edinburgh, proposed, 329, 381
Psychological investigations in psychiatry and criminal anthropology, 566
Psychology, evolution of, 162

„ normal and morbid, 76, 95
Puberty, 122, 137

Pupillary symptoms in the insane, 501

Digitized by v^,ooQLe

824

INDEX.

Recurrent insanity, etiology and morbid anatomy, 167
Report of Tuberculosis Committee, 393
„ on heating and ventilation, 405
Resartor, reply to, 600
Responsibility, diminished, 585
Roll of honour for asylum workers, 75
Rules, revision of, 811

Saint-Simon, mental condition of, 665
Santonin, action of, on colour-sense, 563
Science and medieval thought, 103
Sex, influence on anthropological characters, 143
Sexual impulse in women, 773

Sleep in relation to narcotics in the treatment of mental disease, 460
Smell, sense of, in general paralysis, 572

Social class and creed, influence on anthropological characters, 345

Statistical tables, revision of, 812

Stimulation and fatigue, 349

Sulphonal poisoning, 755

Superannuation, 373

Surgical treatment of delusional insanity, 460
» „ insanity, 687

Swindler, an international, 191
Syphilis and Argyll-Robertson pupil, 570
„ and the nervous system, 337
„ as a cause of insanity, 808
Syphilitic insanity, prevention of, 758

Tabes dorsalis in the pre-ataxic stage, 571

„ „ new theories concerning the etiology of, 308

Tactile impressions, perception of, 774
Taste sensations in the larynx, 157
Thermic applications in nervous diseases, 137
Thompson, Dr., letter on hospital ideals, 598
Tics, mental state of subjects of, 581
Toxsomia in the aetiology of mental disease, 434
Toxemic theory and melancholia, 352
Traumatic lesion of prefrontal lobe, epilepsy, 66
„ neurosis, disturbed sensation, 571
Treatment without isolation cells by hydropathic measures, 782
„ of mental disorders by the continuous bath, 783
Tubercular patients in asylums, isolation, 191
Tuberculosis Committee, report, 393
Tumour of the frontal lobes of cerebrum, 327
Twins, insanity in, 135

Uraemia and acute delirious mania, 358

Ventricles, lateral, of brain, topography, 149
Vertigo, 155

Vision of natives of Torres Straits, 667
Visual area, localisation of, 148
Voluntary control, development of, 168

„ mydriasis and epilepsy in a man of genius, 775

War and the national mental health, 78
Warneford Asylum, 70
Woman, bodily and mental individuality, 169
„ sequestrated, 131
Women, sterilisation of, plea for, 189

Yellowlees, Dr., resignation of, 208

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INDEX.

825

Part II.—ORIGINAL ARTICLES.

Alexander, H. de M., M.D., a case of sulplional poisoning, 755

Baker, J., M.D., female criminal lunatics, 13
Bar, Dr., unilateral hallucinations of hearing, 55
Blackford. J. B., M.D., degeneration of the optic thalnmi, 58
Bond, C. H., D.Sc., M.D., medico-psychological statistics: the desirability of defini¬
tion and correlation with a view to collective study, 709
Brunton, Sir Lauder, hallucinations and allied mental phenomena, 226

Clouston, T. S., M.D., toxaemia in the aetiology of mental disease, 434

„ the possibility of providing suitable means of treatment for

incipient and transient mental disorders in our great
general hospitals, 697

Cowen, T. P., M.D., tumour of the frontal lobes of the cerebrum in which sleep was
a marked symptom, 827

„ pupillary symptoms in the insane and their import, 501

Dawson, W. R., M.D., note on the pathogenesis of diabetic insanity, 785

Elkins, F. A., M.D., night nursing and supervision in asylums, 289

Qreenlees, T. D., M.D., a statistical contribution to the pathology of insanity, 645

Harrisson, D., F.R.C.S., surgical treatment of insanity, 687

Jones, R., M.D., cases of morphinomania, 478

Deeper, Dr., observations on the neuroglia cell and its processes, 732
Longworth, S. G., L.R.C.P., ham atom a of the cerebral dura mater associated with
hemorrhage from the colon, 531

MacDonald, P. W., M.D., note on the prefrontal lobes and the localisation of mental
functions, 9

Macmillan, N. H , M.D., prophylaxis and treatment of asylum dysentery, 509
Mott, F. W., F.R.S., M.D., importance of stimulus in repair aud decay of the
nervous system, 667

Norman, Dr. Conolly, notes on hallucinations, 45

Pontoppidon, Prof. Knud, psychiatric wards in the Copenhagen Hospital, 525

Raw, N., M.D., the relation of mental symptoms to bodily disease and their treat¬
ment, 748

Rayner, H., M.D., sleep in relation to narcotics in the tre&tmeut of mental disease,
460

Revington, G. T., M.D., mental conditions resulting in homicide, 313
Robertson, A., M.D., unilateral hallucinations of hearing, chiefly musical, with re¬
marks on the formation of psycho-cerebral images, 54
„ G., M.D., hospital ideals in the care of the insane, 261

,, W. Ford, M.D., epilepsy following traumatic lesion of brain, 66

„ „ „ „ „ with glioma, 751

Rows, R. G., M.D., the bearing of recent research in the posterior root ganglia
upon the new theories concerning the etiology of tabes dorsalis, 308

Shaw, T. Clay, M.D., surgical treatment of delusional insanity based upon its
physiological study, 450

Sibbald, Sir J., M.D., the treatment of incipient mental disorder and its clinical
teaching in the wards of general hospitals, 215

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826

INDEX.

Simpson, F. 0., L.R.C.P, calcification of the pericardium, 529
Sproat, J. H., M.B., the care of idiots and imbeciles, 738
Steiger, Ad6le de, M.B., two cases of lipoma of the brain, 64
Sullivan, W. C., M.D., crime in general paralysis, 28
Sutcliffe, J., L.R.C.P., an abnormal brain of excessive weight, 323

Urquhart, A. R., M.D., a case of epilepsy following traumatic lesion of prefrontal

lobe, 66

>» „ „ with glioma following on traumatic

injury of brain, 751

Warnock, J., M.D., some cases of pellagrous insanity, 1

Weatherley, L., M.D., evolution of delusions in some cases of melancholia, 495
White, E. W., M.B., a flaw in the English lunacy law, 312
Wiglesworth, J., presidential address—heredity and insanity, 611

Paet III.—REVIEWS.

Allbutt, T. Clifford, M.A., M.D., Science and medimval thought: the Harveian oration
for 1900, 103

Berger, Dr. Hans, Zur Lehrc von der Blut'/irk illation in der Schadelhohle des
Menschen namentlich den Einfluss von Mcdikamcnten, 555
Biervliet, Prof. J. J. van, La memoire, 552
Binet, Dr. A., L’ann£e psychologique, 552

Bonfigli, Prof. C., Inaugural address on the opening of the institution for mentally
deficient children at Rome, 558
Bonnier, Dr. P., L’audition, 549

Bourneville, D., Recherches cliniques et therapeutiques sur l’4pilepsie, l’hystdrie, et
l’idiotie, 547

Brooks, Mr. H. S., The elements of mind; being an examination into the nature of
the first divisiou of the elementary substance of life, 767

Caselli, Dr. A., anatomical and experimental studies upon the physiology and
pathology of the pituitary gland, 119
Centralblatt fur Anthropologie, Ethnologie, und Urgeschichte, 123
Clinique des maladies du septifctne nerveux, 772

Dupratt, Dr. G. L., La morale, 651

Elmira Reformatory, year-book of, for 1901, 342

Ferrari, Prof. G. C., On the league for protection of deficient children, 558
Fleury, Dr. M. de, Les grauds symptflmes neurasthSniques (pathogenic et traite-
raent), 116

Gianelli, A. D., On the education of deficient children, 558

Gilles de la Tourette, Prof., Le traitement pratique de l’£pilepsie. 111

Hutchinson, Dr. H. G., Dreams and their meaning, 122

„ Dr. W., Studies in human and comparative pathology, 107

Jahresbericht der Neurologie und Psychiatrie, 554

Kovalesky, Dr. P., iSpilepsie: traitement, assistance, et inedecine legale, 110

Leonardo, Prof. B., Trattato di Psichiatria, 558

Marro, Dr. A., La puberty, 122

Mercier, Dr. C. A., A text-book of insanity, 543

„ „ Psychology, normal and morbid, 95

Merck’s annual report, 766
Mdbius, Dr. D. J., On art and artists, 120

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INDEX.

827

Nacke, Dr. P., The disposal of insane criminals, 341
„ „ Ueber die sogenannte “moral insanity,” 768

Nonne, Dr. M., Syphilis und Nervensystem, 337

Obersteiner, Dr. H., Introduction to the study of the anatomy of the central nervous
organs in health and disease, 118

Oppenheim, Dr. H., Lehrbuch der Nervenkranklieiten fur Aerzte und Studirende,
771

Pactet et H. Colin, Drs., Les alienes dans les prisons, 340
„ „ ,, devant la justice, 340

Pellizzi, Dr. G. B., Clinical and pathological studies upon idiocy, 112
Pini, Dr. P., L* epilessia: eziologia, patogeuesi, e cura, 343

Pontoppidon, Dr. K., Medico-legal reports on insanity : a collection of cases for the
use of physicians and jurists, 343

Proust and Ballett, Drs., The treatment of neurasthenia, translated by Dr. P.
Campbell Smith, 548

Relazione finanziaria de 1’ Istituto Medico-Pedngogico, 558
Reports of the Cambridge anthropological expedition to Torres Straits, 556
„ Commissioners in Lunacy, England, 76
„ „ „ Ireland, 89

„ „ „ Scotland, 84

Rcsoconto finanzinrio della Lega Nazionnle, 1899—1901, 558

Sergi, Prof. G., Les Emotions, 550

„ „ The Aryans in Europe and Asia, 770

Sollier, Dr. P., L'hysteric et son traitement, 114

„ „ Psychologic de l’idiot etde l’imb5cile, 111

Vaschide, N., et Vurpas, Cl., Psychologic du delire dans les troubles psycho-
pathiques, 769

Watson, Dr. C., Encyclopadia medica, 545

Weber, Dr. L. W., Contributions to the pathogenesis and pathological anatomy of
epilepsy. 109

Whiteway, A. R., M.A., Object lessons in penal science, 339
Wissler, C., M.A., The correlation of mental and physical tests, 106

AUTHORS REFERRED TO IN EPITOME.

Agostini, 786
Alter, 782
Angiolella, 580
Audiffrent, 366
Audinino, 775

Babinski, 576
Bagley, 156
Bair, 158
Bechterew, 571
Benedikt, 182,190
Bergson, 563
Berrillon, 785
Bethe, 147

Bianchi, 191, 166, 775
Biervliet, 348
Bolton, 148

Bourneville, 178,575, 569
Brissaud, 574
Buvat, 580

Cardamatis, 579
XLVIII,

Cauria, 184
Ceni, 782

Cestan et Dupay-Du
temps, 570
Channing, 187
Coscia, 143
Crothers, 359
CulleiTe, 358

Davis, 156
Del Greco, 169
Dumas, 565
Dunton, 779

Eisath, G., 168
Ellis, Havelock, 773

F5r5, 349, 351
Forel, 360
Fdrster, 571

Gabred, 361

Gamier, 686
Grandis, 774
Grasse), 155
Guidi, 181
Guizzatti, 151

Halliburton, 148
Havelock, 187
Henneberg, 171

Janet, Pierre, 154
Juliusburger, Otto, 162

Kaiser, 582

Kiesow, F., and Hahn,
R., 157

Klippel, 179, 180
Krafft-Ebing, 189

Ladame, 151
Lalanne, 355
Lambranzi, 178

Digitized by v^,ooQLe

828 Vi

INDEX.

Laufer, 359

Paris, 186

Schaffer, 583

Lobsien, Marx, 153

Parnisetti, 585

Schule, 183

Lombroso, 142, 182, 775,

Peipers, 569

Seppile, 168

778

Pellizzi, 780

Shafer, 784 %

Luckerath, 784

Penta, 346, 584, 585

Sloan, 188

Lui, 184

Pfitzner, 143, 345

Phelps, 561

Taylor, 175

Marie et Buvat, 174, 191

Pickett, 177

Picqu 6 , 186

Tomasini, 172

Marondon, 174

Toulouse, 162, 361, 572

Mayer, 163

Pilez, 167

Treves, 344

Meige et Feindel, 581

Portigliotti, 345

Tschisch^347

Meunier, 181

Probst, 146

Moeli, 185

Vaschide, et P., 159, 161

Mondia, 577

Raecke, 582

180, 564, 578

Mongeri, 568

Ranschburg, 153

Vigouraux, 575

Moravesik, 574

Rasche, 573 4

Vor 8 ter, 667

Mott, 150

Raymond, 578

Murault, 145

Rudin, 164

Wacb 8 muth, 173

Waldeyer, 773

Nacke, 354

Sailer, 776

Weygandt, 165

Nagel, 563

Sanctis, 560, 778, 787

Sauo, 357

Zuccnrelli, 189

Puctet, 584

Saporito, 786

ILLUSTRATIONS.

Photographs of cases of pellagrous insanity to illustrate Dr. Waruock's paper, 6 , 8
„ of brain to illustrate Dr. MacDonald’s paper, 10

„ of portion of brain to illustrate Drs. Urquhart and Ford Robertson’s

paper, 68

Woodcut diagrams to illustrate Sir Lauder Brunton’s paper, 237, 238, 242
Lithographs of scotoma and retinal haemorrhage, 246
Woodcut diagrams of arteries of brain, 261

Lithographs showing distribution of arteries and function of the cerebrum, 252
„ of procession of spirits from Dante’s Inferno and Paradiso , 253
„ of visual appearance preceding sick headache, 254
Photographs of brain and brain sections to illustrate Mr. J. Sutcliffe and Prof.
Del£pinc’s paper, 326

Tables and charts showing statistics respecting tuberculosis, 426
Woodcuts of pulse tracings in morphinomania and alcoholic neuritis, 489, 490
Woodcut representing nervous system to illustrate Dr. Mott’s paper, 671
Tables suggested for medico-psychological statistics, illustrating Dr. Bond’s article
730

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Messi's. J. H. Booty & Son , 30 , Holbom , E.C.

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JOURNAL OF MENTAL SCIENCE, OCTOBER, 1902 . iii

Telegram*: “ATKINSON COMPANY, LONDON." Telephone: TOT HOP.

ATKINSON & CO.,

GOVERNMENT CONTRACTORS,

I98, 200, 202, 204, 206, 208, 210, 212,

WESTMINSTER BRIDGE ROAD, LONDON,

Have the honour to hold some of the largest Contracts in the Kingdom from
Asylums, Unions, Hospitals, and Government Departments. The magnitude of
their Contracts enables them to employ Manufacturers solely for their demands,
thus affording a direct charge to the Consumer.

NUMEROUS SPECIALITIES IN

HOSPITAL BEDSTEADS, CHAIRS, SEATS, MATTRESSES, LOCKERS,

Ac. Ac.

NAPIER MATTING, LINOLEUMS, AND VARIOUS FLOOR COVERINGS
Made in Special Widths and Qualities to meet exceptional wear.

“ATKINSON’S” PINE FIBRE MATTRESS i* specially

recommended because of its healthful and antiseptic properties.

PRICES ON APPLICATION.

ATKINSON & CO. undertake to supply any quantity of Goods as
specified below by the quarter, half-year, or year, viz.:

Bedsteads in Wood or Iron, Iron Bedsteads with Patent Spring
Mesh Bottoms, Woven Wire and other Mattresses, Coir, Fibre,
Horsehair, riocks, and every other Material for Bedding.
Blankets, Bugs, Counterpanes.

Sheeting, Waterproof ditto.

Flannels, Calicoes, Prints, Woollen Cloths of all qualities.
Corduroys, Fustians, &c.

Men and Women’s Under and Upper Clothing.
Heady-made Garments, in all Sises and for both Sexes.

Hats, Caps, Bonnets, fcc.

Hosiery and Haberdashery.

Uniforms, fee.

FURNITURE, CARPETS, and every Requisite supplied on the Shortest
Notice for Board Rooms, Offices, Masters' Houses, &c.

ILLUSTRATED CATALOGUES AND ESTIMATES FREE.

Secretaries and Clerks of Institutions are respectfully requested, when issuing
Contracts, to forward a Form of Tender to Atkinson & Co.

SPECIAL CATALOGUE POST FREE ON APPLICATION.

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THE THYROID TREATMENT

and the Preparations Manufactured by

ALLEN & HANBURYS Ltd.

MyxOftflema*—The relief afforded to eases of Myxcedema by the use of the Thyroid Gland
during the last five years has marked a totally new departure in the history of medicine. We arc
beginning to understand the physiological importance of Internal Secretions to the animal economy.

Myxcedema has been recognised as long ago as 1874 by Sir Wm. Gull as a distinct disease", and
before that time it had been found that animals invariably succnmbed after total extirpation of the
Thyroid.

Cretinism, too, had long been recognised to be connected with congenital absence or deficiency in
the glandular structure of the Thyroid.

Time enough has now elapsed to prove that those cases of Myxcedema which have been restored to
health maintain that condition as long as they continue to take the gland or efficient preparation of its
extract.

Sporadic Cretinism*— As regards Sporadic Cretinism, wc cannot do better than refer

the reader to an original article which appeared in the Lancet , with Photographs, by W. W. 0-,

M.D. Oxon., M.R.C.P. London, November 4th, 1893, p. 1113.

All these cases were treated by Allen and Hanburys’ Thyroidiir Tablets. The

results are perhaps more remarkable than those obtained in the allied condition of Myxcedema.

The writer observes that these Preparations have given entire satisfaction. The
Photographs speak for themselves.

The success attending the use of Thyroid Extract in the Myxoedcmatous condition of the skin
and its appendages has suggested its employment in various skin lesions.

Psoriasis.— Very good results have been attained in some oases of obstinate
psoriasis by using Thyroidin Tablets.

In a recent number of the Lancet three of these cases are reported. After treatment with iodide
of potassium and arsenic internally, and chrysophatiic acid ointment locally, showed no improvement,
hut, on the other hand, the disorder was in some cases aggravated, developing a general dermatitis of
the face with febrile disturbance.

But on the treatment being changed, and Tablkts or Tiiyboid Gland (Am.rn and Hanburys'}
being administered, the writer observes:

Cate 1.—“The improvement was very striking, . . . the scnles were completely gone, and all that
was left was a slight discoloration of the skin where the disease had appeared.”

Case 2.—“ The scalp and limbs were nearly clear. . . . The patient, who has suffered from the
disease for nineteen years past, 1ms had no discomfort from the remedy, and says that nothing has ever
acted so rapidly upon his disease."

Case 3.—“The result was astonishing, for in three days there was a marked improvement, and no
further spread of the disease had taken place. No discomfort was experienced from tne remedy.”

For full details of the above quotations see the Lancet, January 6th, 1894, p. 19.

Whilst formerly liquid extracts and the raw gland were used, Allkn and Hanburys were the first
to offer the active princinles of the Thyroid Gland in the compressed form, whivh is now the favourite
mode of administration. The glands are dissected and carefully examined nnd separated from all blood ,
fat , and inert tissue, which readily decompose and produce gastric disturbances, vomiting, &c., an d

which give to some preparations on the market a most repulsive smell, especially
when they have been kept for a short time.

THYROIDIN TABLETS

Readily disintegrate when swallowed, and from their shnpe and size arc taken without difficulty. If
preferred, they may be dissolved in a little water before being swallowed.

One Tablet equals 5 grs. of Gland. Dose: 1 or 2.

THYROIDIN CACHETS

Contain 5 grs. of Thyroidin in each. Dose: 1 or 2. A very suitable and convenient mode of takiug

Thyroidin.

ELIXIR THYROIDIN

Is a very palatable, slightly sweet preparation, of which one fluid ounce represents one Gland (average).
It will be found to keep well without change. Dose : 1 to 4 fluid drachms.

The above are put np in Is., 2s. 6d., and 4s. 6d packages (retail), or 8s., 21s., and 40e.
per doz. to the Profession.

SAMPLES SUPPLIED TO THE PROFESSION ON APPLICATION.

ALLEN & HANBURYS LTD.,
Plough Court, Lombard Street, LONDON.

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SOUTH BEACON,” HADLOW DOWN, BUXTED, SUSSEX

S'** ^ 0 ^ . ° £* c-2

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enough to be v —— ------ Servants

Certified, jfyr full particulars apply to PHILIP H. HARMER. ^

JOURNAL OF MENTAL SCIENCE, OCTOBER, I 902 V

J. Swift & Son,

1 *

MANUFACTURING OPTICIANS,

Solely appointed to H.M. Dept., War Office.

NEW HISTOLOBICAL MICROSCOPE,

with coarse adjustment by
rack and pinion, fine adjust¬
ment by micrometer screw,
2/3" and 1/6" objectives, one
ocular and iris diaphragm, in
Cabinet. £6 ISSm

Double nose-piece as figured
(extra). USSm

Microscope as above, but
with sliding tube, coarse
adjustment £8 BSm

These microscopes have
been supplied to the following
medical schools, viz.—St.
Bartholomew’s, St. Mary’s,
Guy’s, Westminster, Charing
Cross, Middlesex, London
Hospital, University College,
and most of the provincial
Colleges.

Illustrated Circular on Application.

University Optical Works,

81, TOTTENHAM COURT ROAD, W.

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JOURNAL OF MENTAL SCIENCE

Books and Pamphlets Received (continued).

Richmond ; Le Criminal R£cidiviste, Morel; Nervous and Mental Diseases, Church
and Peterson ; XHIe Congr&s International de Medecine, Paris, 1890 (De Psychiatrie),
Ritti.

Asylum Reports have been received for 1900-1901 from those marked with an
asterisk:— County. —Beds, Berks, Bucks, Cambridge, Carmarthen,*

Chester, Chester (Parkside), Cornwall, Cumberland,* Denbigh, Derby
(Mickleover),* Devon,* Dorset,* Durham, Essex, Glamorgan,*
Gloucester,* Hants,* Isle of Wight, Hereford,* Hertford,* Kent
(Barming), (Chartham), Lancashire (Lancaster), (Rainhill), (Prestwich),*
(Whittingham), Leicester,* Lincoln (Kesteven),* London* (Colney Hatch),
(Hanwell), (Banstead), (Canehill), (Claybury), (Wandsworth), Middlesex,*

Monmouth,* Norfolk, Northampton, Northumberland,* Nottingham,
Oxford, Salop,* Somerset (Wells),* (Taunton), Stafford (Stafford),
(Lichfield),* Leek,* Suffolk,* Surrey, Sussex (East* Chichester,
West),* Warwick,* Wilts,* Worcester,* Yorkshire (Wake¬

field*), (Wadsley*), (Menston*), (Clifton), (Beverley); Borough.— Birming¬
ham* (Winson Green), (Rubery Hill),* Bristol,* Derby,* Exeter,
Hull, Ipswich, Leicester, London,* Middlesbrough,* Newcastle,*

Norwich, Nottingham,* Plymouth, Portsmouth, Sunderland.* Hospitals.
—Manchester, Wonford,* Barnwood,* Albert, Lincoln, St. Luke’s,*

St. Andrew’s, St. Ann’s,* Coppice,* Warneford,* Coton Hill, Bethlem,*
Earlswood, Bootham, Retreat,* Colchester,* Broadmoor, Isle of

Man, Aberdeen,* Argyll,* Ayr, Dumfries, Edinburgh,* Midlothian,*
Fife,* Dundee,* Montrose,* Inverness,* Lanark,* Barony,* Glasgow
Royal,* Lenzie, Govan,* Gartloch,* Kirklands,* Perth,* Murthly,*
Roxburgh,* Stirling,* Baldovan, Armagh, Ballinasloe, Belfast,*
Carlow, Castlebar, Clonmel, Cork, Downpatrick, Ennis, Ennis-
corthy, Kilkenny, Killarney, Letterkenny, Limerick,* Londonderry,

Maryborough, Monaghan, Mullingar, Omagh, Dublin, Richmond,
Sligo, Waterford, Famham.*

The following Asylum Reports have also come to hand:—Egypt, Cape of Good

Hope, Nova Scotia,* New Brunswick, Victoria,* New York Massa¬
chusetts Hospital,* Ontario, Verdun, Warren, Pennsylvania,* Phila¬

delphia Friends,* Binghampton,* Willard, Northampton, Long View,
South Australia,* Cleveland, Matteawan, New South Wales,* Assam,

Madras, Bengal, Bombay,* Central Provinces, Rangoon,* Punjaub,
Mississippi, Pennsylvania Hospital,* Washington,* Utica,* Long Island,*
Virginia Central,* Illinois West,* New Hampshire,* Butler, Maryland,*
Pennsylvania West,* South Mountain, Manhattan,* Indiana East,* Con¬
necticut, Carolina N.,* Dakota N., Ohio, Carthage,* Buffalo,*
Lebanon, Michigan East,* Missouri,* Alt Scherbitz, Massachusetts
Board,* Virginia West,* Pennsylvania, Danville,* Sheppard and Pratt
Hospital, Baltimore,* Pennsylvania, Harrisburgs,* Pennsylvania, Norristown,*
Aarhus, Lebanon,* Hudson River,* Rochester.*

Authors of Original Papers receive 25 reprints of their articles free of cost, if
application be made on the slips when returning proof. If any extra reprints are
required, notice should be at the same time sent to the Printers, Messrs. Adlard and
Son, Bartholomew Close, London, E.C., who will supply them at a fixed charge.
Unless instructions are sent by authors of Papers when the proofs are returned, no
copies can be guaranteed.

The copies of the Journal of Mental Science are regularly sent by carrier, who in
every case obtains a receipt of delivery, to the Ordinary and Honorary Members of the
Association. Complaints of non-receipt of the Journal should be sent to Messrs.
Adlard. Any change of address should be intimated to the General Secretary.

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JOURNAL OF MENTAL SCIENCE.

CONTENTS FOR JANUARY, 1902.

Original Articles.— Page*

Some Cases of Pellagrous Insanity; by John Warnock, M.D.—Note on
the Prefrontal Lobes and the Localisation of Mental Functions; by P. W.
MacDonald, M.D.—Female Criminal Lunatics: a Sketch ; by John Baker,

M.D.—Crime in General Paralysis; by W. C. Sullivan, M.D.— Notes on
Hallucinations: I; by Conolly Norman .... i— 53

Clinical Notes and Case*.—

Case of Unilateral Hallucinations of Hearing, chiefly Musical; with
Remarks on the Formation of Psycho-cerebral Images ; by Alex. Robert¬
son, M.D., F.F.P.S.G.— Degeneration of the Optic Thalami (Preliminary
Note); by J. B. Blachford, M.D.—Two Cases of Lipoma of the Brain-)
by Adele de Steiger, M.B.—A Case of Epilepsy following Traumatic
Lesion of Prefrontal Lobe; by A. R. Urqnhart, M.D., and W. Ford
Robertson, M.D. . . . . . 54—70

Occasional Notes.—

Warnet'ord Asylum—Lunacy Statistics—The National Mental Health
and the War—Organisation of Medico-Psychological Research—Roll of
Honour for Asylum Workers—Mind !—Original Research in Epilepsy—
Psychology, Normal and Morbid ..... 70—76

Reviews.—

The Fifty-fifth Report of the Commissioners in Lunacy for England,

July 1 st, 1901 .—Forty-third Annual Report of the General Board of
Commissioners in Lunacy for Scotland ( 1901 ).—Fiftieth Report of the
Inspectors of Lunatics (Ireland), for the year ending December 31 st,

1900. — Psychology, Normal and Morbid; by Charles A. Mercier,

M.B., M.R.C.P., F.R.C.S.—Science and Mediajval Thought: the
Harveian Oration of 1900 ; by Thos. Clifford Allbutt, M.A., M.D.,

F.R.S.—The Correlation of Mental and Physical Tests; by Clark
Wissler, A.M.—Studies in Human and Comparative Pathology; by
Woods Hutchinson, A.M., M.D.—BeitrSge zur Pathogenese und
pathologische Anatomie der Epilepsie [Contributions to the Pathogenesis
and Pathological Anatomy of Epilepsy]; by Dr. L. W. Weber.—
Epilepsie: Traitement, Assistance, et Medecine legale [Epilepsy: Treat¬
ment, Public Aid, and Jurisprudence]; by Paul Kovalesky, M.D.—

Le Traitement pratique de l’Epilepsie [Practical Treatment of Epilepsy] ;
by Professor Gilles de la Tourette.— Psychologie de 1’Idiot et de
l’Imb£cile [Psychology of the Idiot and Imbecile]; by Dr. Paul Sollier.

—Studii Clinici ed Anatomo-patologici sull* Idiozia [Clinical and Patho¬
logical Studies upon Idiocy]; Pel Dottor G. B. Pellizzi. — L’Hyst^rie
et son Traitement; par le Dr. Paul Sollier. —Les grands Symptomes
neurasthfcniques (Pathog^nie et Traitement); by Dr. Maurice de
Fleury. —Anleitung beim Studium des Baues der nervosen Central-
organe im gesunden und kranken Zustande [Introduction to the Study
of the Anatomy of the Central Nervous Organs in Health and Disease];
von Dr. Heinrich Obersteiner, K.K.O.O.—Studii anatomici e speri-
mentali sulla Fisiopatologia della Glandola pituitaria (Hypophysis
Cerebri) [Anatomical and Experimental Studies upon the Physiology
and Pathology of the Pituitary Gland; Dott. Arnoldo Caselli. —Ueber
Kunst und Kiinstler [On Art and Artists]; von D. J. Mobius. —Dreams
and their Meaning ; by H. G. Hutchinson. —La Puberte ; parA.M.\RRO.

—Centralblatt fur Anthropologie, Ethnologie, und Urgeschichte . 76—123

Epitome ......... 124—196

Note* and News ........ 196—213

ADLARD AND SON, PRINTERS, BARTHOLOMEW CLOSE, E.C.; 20, HANOVER SQUARE, W. ;

AND DORKING.

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