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THE JOURNAL

MENTAL SCIENCE.

EDITORS >

Henry Rayner, M.D. A. B. Urquhart, H.D.

J. Chambers, M.D.

ASSISTANT EDITOR:

J. B. Lord, M.B.

VOL. LIV.

LONDON:

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCVIII.

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i.4 ixuy

’If. b

" 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 may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to a certain extent, attains immediate practical results of the greatest utility
to the welfare of mankind ; we therefore maintain that our Journal is not 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.P.S.

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THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS, 1907-8.

president.— P. W. MACDONALD, M.D.
president ELECT.— CHAS. A. MERCIEB, M.D., F.R.C.P., F.R.C.S.
ex-president.— ROBERT J0NE8, M.D., F.R.C.P., F.R.C.S.
treasurer.— H. HATES NEWINGTON, F.R.C.P.Eil.

/HENRT RATNER, M.D.

editors OP journal J A - E - URQ0HART, M.D.

RDrroBS op journal, -j C0N0LLY NORMAN, F.R.C.P.I.

VJAMES CHAMBERS, M.D.

assistant editor (not Member of Council).—JOHN R. LORD, M.B.

DIVISIONAL SECRETARY FOR SOUTH-EASTERN DIVISION.— R. H. STEEN, M.D.
DIVISIONAL SECRETARY FOR SOUTH-WESTERN DIVISION.— H. T. S. AVELIN K.L.R.C. P.
DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION.

BEDFORD PIERCE, M.D., F.R.C.P.

DIVISIONAL SECRETARY FOR SCOTLAND.— HAMILTON C. MARR, M.D.
DIVISIONAL SECRBTARY FOR IRELAND.— WILLIAM R. DAWSON, M.D.
GENERAL SECRETARY.— C. HUBERT BOND, M.D., D.Sc.
secretary of educational committee.— MAURICE CRAIQ, M.D. (appointed by
Educational Committee, but with seat on Council).
registrar.— ALFRED MILLER, M.B.

MBMBBK8 OF COUNCIL.

REPRESENTATIVE.

A. N. BOYCOTT
C. H. FENNELL
H. WOL8ELEY LEWIS
ERNEST W. WHITE
F. StJ. BULLEN
EDWIN GOOD ALL
JOHN A. EWAN
T. W. McDOWALL
DAVID ORR
LEWIS C. BRUCE
A. R. TURNBULL

8.E. Div.

8.W. Div.

N. & M. Div.
Scotland.

REFERS BNTATJVR.

T1IOMA8 DRAPE8
MICHAEL J. NOLAN

} Ireland.

nominated.
JOSEPH 8. BOLTON
THOMA8 8. CLOUSTON
THEO. B. HYSLOP
GEORGE H.SAVAGE
JOHN TURNER
T. OUTTERSON WOOD

[The abore form the Council.]

AUDITORS

THEO. B. HYSLOP, M.D.
D. G. THOMPSON, M.D.

BXAMINBR8.

ENGLAND

MAURICE CRAIG, M.D.
ROBERT JONES, M.D.

fLANDEL R. OSWALD, M.B
1 W. FORD ROBERTSON, M.D.

IRELAND

WILLIAM R. DAWSON, M.D.
WILLIAM GRAHAM, M.D.

Examiners for the Nursing Certificate of the Association :

ADAM R. TURNBULL; CONOLLY NORMAN; BEDFORD PIERCE.

PARLIAMENTARY COMMITTEE.

FLETCHER BEACH.

GEO. F. BLANDFORD.

C. HUBERT BOND.

DAVID BOWER {Chairman).
LEWIS C. BRUCE.

JOHN. CARSWELL.

TH08. S. CLOUSTON.

WM. R. DAWSON.

THOS. DRAPES.

H. GARDINER HILL.

CHAS. K. HITCHCOCK.

THEO. B. HYSLOP.

J. CARLYLE JOHNSTONE.
ROBERT JONES.

H. WOL8ELEY LEWIS ( Secretary).
P. W. MACDONALD.

T. W. McDOWALL

W. F. MENZIES.

CHAS. A. MERCIER.

H. HAYES NEWINGTON.
M. J. NOLAN.

CONOLLY NORMAN.
EVAN POWELL.

HENRY RAYNER.

GEO. H. 8AVAGE.

R. PERCY SMITH.

J. BEVERIDGE SPENCE.
DAVID G. THOMSON.

T. SEYMOUR TUKE.
ALEX. R. URQUHART.

E. B. WHITCOMBE.
ERNEST W. WHITE.

T. OUTTERSON WOOD.
DAVID YELLOWLEES.

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EDUCATIONAL COMMITTEE.

FLETCHER BEACH.

J. 8. BOLTON.

C. HUBERT BOND.

LEWIS C. BRUCE.

TH08. 8. CLOUSTON.
MAURICE CRAIG {Secretary).
WILLIAM R. DAWSON.
THOS. DRAPES.

EDWIN GOODALL.

W. GRAHAM.

F. A. ELKINS.

J. A. EWAN.

THEO. B. HY8LOP.

J. CARLYLE JOHNSTONE.
ROBERT JONES.

WALTER 8. KAY.

P. W. MACDONALD.

TH08. W. McDOWALL.

S. R. MACPHAIL.
HAMILTON C. MARR.
WILLIAM F. MENZIE8.

C. A. MERCIER {Chairman).

JAMES MIDDLEMASS.
ALFRED MILLER.

H. HAYES NEWINGTON.
MICHAEL J. NOLAN.
CONOLLY NORMAN.

L. R. OSWALD.

BEDFORD PIERCE.
WILLIAM RAWES.

HENRY RAYNER.

GEORGE M. ROBERTSON.
GEORGE H. SAVAGE.

R. PERCY SMITH.

J. BEVERIDGE SPENCE.
ROBERT H. STEEN.
FREDERIC R. P. TAYLOR.
T. SEYMOUR TUKE.

ADAM R. TURNBULL.
EDMUND B. WHITCOMBE,
ERNEST W. WHITE.

T. OUTTERSON WOOD.
DAVID YELLOWLEES.

LIBRARY COMMITTEE.

FLETCHER BEACH. I T. 0UTTER80N WOOD.

HENRY RAYNER. | ROBERT H. COLE

LIST OF CHAIRMEN.

1841. Dr. Blake, Nottingham.

1842. Dr. de Vitrl, Lancaster.

1843. Dr. Conolly, Han well.

1844. Dr. Thurnam, York Retreat.

1847. Dr. Wintle, Warneford House, Oxford.

1861. Dr. Conolly, Han well.

1862. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS

1864. 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 Winslows M.D., Sussex House, Hammersmith.

1858. John Conolly, M.D., County Asylum, Hanwell.

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

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

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

1862. John Kirkman, M.D., Suffolk County 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.

IS72. 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.

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1875.

1876.

1877.

1878.

1879.

1880.
1881.
1882.

1883.

1884.

1885.

1886.

1887.

1888.

1889.

1890.

1891.

1892.

1893.

1894.

1895.

1896.

1897.

1898.

1899.

1900.

1901.

1902.

1903.

1904.

1905.

1906.

1907.

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

W. H. Parse?, M.D., Warwick County Asylum.

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

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

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

G. W. Mould, M.R.C.S., Royal Asylum, Cheadle.

D. Hack Tuke, M.D., London.

Sir W. T. Gairdner, M.D., Glasgow.

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

Henry Rayner, M.D., County Asylum, Hanwell.

J. A. Barnes, M.D., District Asylum, Cork.

Geo. H. Sarage, M.D., Bethlem Royal Hospital.

Fred. Needham, M.D., Barn wood House, Gloucester.

T. S. Clous ton, M.D., Royal Edinburgh Asylum.

H. Hayes Newington, M.R.C.P., Ticehurst, Sussex.

Darid Yellow lees, M.D., Gartnavel Asylum, Glasgow.

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

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

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

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

David Nicolson,M.D., C.B., State Criminal Lunatic Asylum, Broadmoor.
William Julius Mickle, M.D., Grove Hall Asylum, Bow.

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

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

J. B. Spence, M.D., Burntwood Asylum, nr. Lichfield, Staffordshire.
Fletcher Beach, M.B., 79, Wimpole Street, W.

Oscar T. Woods, M.D., District Asylum, Cork, Ireland.

J- Wiglesworth, M.D., F.R.C.P., Rainhill Asylum, near Liverpool.
Ernest W. White, M.B., City of London Asylum, Dartford, Kent.

B. Percy Smith, M.D., F.R.C.P., 36, Queen Anne Street, Cavendish

Square, London, W.

T. Outterson Wood, M.D., F.R.C.P., 40, Margaret Street, Cavendish
Square, London, W.

Robert Jones, M.D., Claybury Asylum, Woodford Bridge, Essex.

P. W. MacDonald, County Asylum, Dorchester.

1896.

1881.

1907.

1900.

1881.

1876.

1902.

1887.

HONORARY MEMBERS.

Allbutt, 8ir T. Clifford, K.C.B., M.D., F.R.C.P., Regius Professor of
Physic, Univ. Camb., St. Radegund's, Cambridge.

Benedikt, Prof. M., Franciskaner Platz 6, Vienna.

Bianchi, Prof. Leonardo, Manicomio Provincials di Napoli. ( Carr. Mem .
1896.) *

Blnmer, G. Alder M.D., L RC P.Edin., Butler Hospital, Proridence,
U.S.A. (Ord. Mem,, 1890.)

Bresler, Johannes, M.D. ( Carr. Mem., 1896.)

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

Browne, Sir J. Crichton-, M.D.Edin., P.R.S., Lord Chancellor’. Visitor.
New Law Courts, Strand, W.C. (Pbxsidbwt, 1878.)

Brush, Edward N., M.D., Sheppard and Enoch Pratt Hospital, Towson,
Maryland, U.S.A. r ’

1002.

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

Coupland, Sidney, M.D., F.R.C.P.Lond., Commissioner in Lunacy, 16
Queen Anne Street, Cavendish Square, London, W. *

m2 , Courtenay E. Maziere A.B., MJB., C.M.T.C.D., M.D., Inspector of
1 * 1876^87 ) d> LunaCy 0ffice * Dubli “ Castle. {Secretary for

1891.

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iv Honorary and Corresponding Members .

1879. Echeverria, M. Q., M.D.

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

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Commissioner in Lunacy, 13,

Heriot Row, Edinburgh.

1898. 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.

1887. Lentz, Dr., Asile d’Alilnls, Tournai, Belgique.

1898. Magnan, V., M.D., Asile de Sfce. Anne, Paris.

1866.1 Mitchell, Sir Arthur, M.D.Aberd., LL.D., K.C.B., late Commissioner in
1871. J Lunacy for Scotland; 34, Drummond Place, Edinburgh.

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

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

1889. Needham, Frederick, M.D.SL And., M.R.C.P.Edin., M.R.C.S.Eng.,
Commissioner in Lunacy, 19, Campden Hill Square, Kensington,
W. (Pbbsidskt, 1887.)

1891. O'Farrell, 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.

1873. Pitman, Sir Henry A., M.D. Can tab., F.R.C.P.Lond., Registrar of the

Royal College of Physicians, Enfield, Middlesex.

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

Mem., 1890.)

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

1881. Tamburini, A., M.D., Beggio-Emilia, Italy.

1901. Toulouse, Dr. Edouard, Directeur du Laboratoire de Psychologie experi¬

mental k l’Ecole des Hautes Etudes Paris et M6decin en chefde
l'Asile de Villcjuif, Seine, France.

1904. Tuke, Sir John Batty, M.D., M.P., 20, Charlotte Square, Edinburgh.

CORRESPONDING MEMBERS.

1904. Bierao, Caetano, 48, Rua Formosa, Lisbonne, Portugal.

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

1904. Caroleh, Wilfrid, Manicomia de Sta. Crur, St. Andreo de Palamar,
Barcelona, Spaiu.

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

1902. Estense, Benedetto Giovanni Selvatico, M.D., 116, Piazza Porta Pia, Rome.

1907. Ferrari, Giulio Cesare, M.D., Director of the Institute Medico-pedagogico,
Emiliano, Bestalia, Bologna, Italy.

1904. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.
1880. Komfeld, Dr. Hermann, Gleiwitz, Silesia, Germany.

1889. Kowalowsky, Professor Paul, Kharkoff, Russia.

1895. Lindell, Emil Wilhelm, M.D., Sweden.

1901. Manheimer-Gomm&s, Dr., 32, Rue de l’Arcade, Paris.

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

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

1890. Regis, Dr. E., 64, Rue Huguerie, Bordeaux.

1893. Semelaigne, Dr. Rene, Secretaire des Stances de la Society Medico-
Psychologique de Paris, 16, Avenue de Madrid, Neuilly, Seine, France.

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MEMBERS OF THE ASSOCIATION.

Alphabetical List of Members of the Association , with the year in which they
joined. The Asterisk means Members who joined between 1841 and 1855.

1900. Abbott* Henry Kingsmill, M.D.Dublin, D.P.H. I reland. Hants County

Asylum* Far eh am.

1891. Adair, Thomas Stewart, M.D., C.M.Edin., Storthes Hall Asylum, Kirk-
burton, near Huddersfield.

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

Clapton, London.

1886. Agar, S. Hollingsworth, jun., B.A.Cantab., M.R.C.S., Hurst House,
Henley-in-Arden.

1901. Ahern, John M., M.B., B.Ch., L.R.C.P.&S.I., Assistant Medical Officer,

18, Walton Park, Liverpool.

1905. Alcock, Benjamin James, M.B.Aberd., Ch.B., James Murray’s Royal

Asylum, Perth.

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

1906. Alexander, Edward Henry, M.B., M.R.C.S., Physician Superintendent,

Ashbourne Hall Asylum, Dunedin, New Zealand.

1899. Alexander, Hugh de Maine, M.D., Medical Superintendent, Aberdeen
City District Asylum, Kingseat, Newmachar, Aberdeen.

1890. Alexander, Robert Reid, M.D.Aber., 31, Royal Parade, Eastbourne.
1905. Allen, Robert George, L.R.C.P.&S.I., The Rectory, Little Bytham,

Grantham.

1883. AUiott, A. J., M.D., The Vine, Sevenoaks.

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

Officer, District Asylum, Armagh.

1885. Amsden, Geo., M.B., Medical Supt., County Asylum, Brentwood, Essex.

1900. Anderson, John Sewell, M.R.C.S., L.R.C.P., Hull City Asylum, Willerby,

near Hull.

1901. Anderson, William C., M.B., C.M., 15, King Street, Dundee, N.B.

1904. Archdale, Mervyn Alex., M.B., B.S.Dur., East Riding Asylum, Beverley,

Yorks.

1905. Archdall, Mervyn Thomas, L.S.A.Lond., L.R.C.P.&S.Edin., Brynn-y-

Nenadd Hall, Llanfairfechan, N. Wales.

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. (Son.
Sec. for 8.W. Division since 1905.)

1903. Bailey, William Henry, M.B., M.R.C.S., L.S.A., Featherstone Hall,

Southall, Midd.

1894. Baily, Percy J., M.B.Edin., Medical Superintendent, London County
Asylum, Hanwell, W.

1906. Baird, Harvey, M.D., Ch.B. Ed in.. Assistant Medical Officer, London

County Asylum, Colney Hatch.

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

1888. Baker, John, M.D., Deputy Superintendent, State Asylum, Broadmoor,
Berks.

1904. Barham, Guy Foster, M.B., B.A., B.C., M.R.C.S., L.R.C.P., Senior Assis¬

tant Medical Officer, London County Asylum. Long-Grove, Epsom.
1901. Barnett, Horatio, M.B., B.C.Cantab., M.R.C.S., L.R.C.P.Lond., Medical,
Superintendent, Stretton House, Church Stretton, Salop.

1878. Barton, James Edward, L.R.C.P.Edin., L.M., M.R.C.S., Medical Superin¬
tendent, Surrey County Lunatic Asylum, Brook wood, Woking.

1904. Barton, Samuel J., M.D.Dubl., Physician to the Norfolk and Norwich
Hospital, Surrey Street, Norwich.

1901. Baskin, J. Lougheed, L.R.C.P.&S.Edin., L.F.P.S.Glas., Fisherton

House, Salisbury.

1902. Baugh, Leonard D. H., M.B., C.M., Gsrtloch Asylum, Gartcosh,Glasgow,

N.B.

1864. Bayley, Joseph, M.R.C.S., Medical Superintendent, St. Andrew’s Hos¬
pital, Northampton.

Digitized by L^ooQle

vi Members of the Association .

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

St. Andrew’s Hospital, Northampton.

1907. Bazalgette, Sidney, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
Fishponds Asylum, Bristol.

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

1892. Beadles, Cecil F., M.R.C.S., L.R.C.P., The Clergy House, Englefield
Green, Surrey.

1902. Beale-Brown e, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., Medical
Staff, South Nigeria, West Africa ; Dowdeswell House, Andovers-
ford R.S.O., Glo8.

1896. Beamish, George, L.R.C.S.I., L.R.C.P.E., L.M., c/o New Club, 4, Grafton

Street, New Bond Street, W.

1899. Beresford, Edwyn H., M.R.C.S. & M.R.C.P.Lond., Medical Superinten¬

dent, Tooting Bee Asylum, Tooting, S.W.

1894. Blachford, James Vincent, M.D., B.S.Durham, Medical Superintendent,

Bristol Asylum, Fishponds, near Bristol.

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

1883. Blair, Robert, M.D., Braefort, Crookston, Paisley.

1901. Blake, Thomas Frederick Hillyer, D.P.H., L.Ii.C.P.&S.Edin., Isolation
Hospital, Norwich.

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

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

L.R.C.P.Lond., Senior Assistant Medical Officer, County Asylum,
Whittingham, Preston, Lancs.

1904. Bodvel-Roberts, Hugh Frank, M.A.Cantab., M.R.C.S., L.R.C.P., Middle¬
sex County Asylum, Napsbury, near St. Albans, Herts.

1900. Bolton, Joseph Shaw, M.D., B.S., B.Sc.Lond., Senior Assistant Medical

Officer, County Asylum, Rainhill, Liverpool.

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

London County Asylum, Long-Grove, Epsom. (Hon. General
Secretary.)

1877. 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, Ivybridge, Devon.

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

1896. Boycott, Arthur N., M.D.Lond., M.R.C.S.Eng., L.R.C.P.Lond., Medical
Superintendent, Herts County Asylum, Hill End, St. Albans, Herts.
(Hon. Sec. for S.-E. Division, 1900-05.)

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. Br&ine-Hartnell, George, M. P., L.R.C.P.Lond., M.R.C.S.Eng., Medical
Superintendent, County and City Asylum, Powick, Worcester.

1904. Branthwaite, Robert Welsh, M.D. (Inspector under the Inebriates Act),

Home Office Chambers, 55, Whitehall, S.W.

1881. Br&yn, R., L.R.C.P.Lond., Medical Superintendent, Broadmoor Asylum,
Crowtborne, Berks.

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

Westbrooke House Asylum, Alton, Hants.

1905. Brown, Harry Egerton, M.D., M.P.C., The Asylum, Pretoria, S. Africa.
1904. Brown, Josephine, M.B.Lond., 28, John Street, Bedford Row, W.C.
1898. Bruce, Lewis C., M.D.Edin., Druid Park, Murthly, N.B. (Hon. Div t-

sional Secretary for Scotland since 1901.)

* Brushfield, Thomas N., M.D.St. And., The Cliff, Budleigh Salterton, Devon.

Digitized by L^ooQle

Members of the Association . vii

1896. Babb,William, M.R.C.S., L.R.C.P.Lond., 8, Cloverdale Lawn,Cheltenham.
1882. Bollen, Frederick St. John, M.R.C.S.Eog., 12, Pembroke Road, Cliftou,

Bristol.

1807. Burpitt, Harry Reginald, M.D.Brnx, M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Metropolitan Asylum, Durenth, Hartford.

1904. Barrell, Arthur Ambrose, M.B., B.Ch., St. Edinundsbary, Lacan, Co.
Dublin.

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

1889. Calico tt f James T., M.D., Medical Superintendent, Borough Asylum, New-
caatle-on-Tyne.

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

1902. Campariole, Paul Clem, M.B., C.M.Ed., Junior Assistant Medical Officer,
County Asylum, Melton, Suffolk.

1894. Campbell, Alfred Walter, M.D.Edin., Macquarie Chambers, 183, Mac¬
quarie Street, Sydney, New South Wales.

1880. Campbell, Patrick E., M.B., C.M., Medical Superintendent, District
Asylum, Caterham.

1897. Campbell, Robert Brown, M.B., C.M.Edin., Medical Superintendent,

Inverness District Asylum, Inverness.

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

1906. Carre, Henry, L.R.C.P., L.M., Woodilee Asylum, Lenzie, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.F.P.S.Glasg., Certifying Medical Officer,

Barony Parish, 5, Royal Crescent, Glasgow.

1896. Cushman, James P., M.B., B.Ch., 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.

1888. Chambers, James, M.A., M.D., The Priory, Roehampton. ( Co-Editor qf
Journal since 1905, Assistant Editor 1900-05.)

1865. Chapman, Thomas Algernon, M.D.Glas., L.R.C.S.Edin., Betula, Reigate.

1907. Cbislett, Charles G. A., M.B., Ch.B.Glasgow, Second Assistant Medical

Officer, Woodilee Asylum, Lenzie.

1880. Christie, J. W. Stirling, L.R.C.P.Edin., Medical Superintendent, County
Asylum, Stafford.

1878. Clapham, Wm. Crochley 8., M.D., F.R.C.P.Ed., The Five Gables, May-

field, Sussex. (Hon. Sec. N. and M. Division , 1897—1901.)

1907. Clarke, Geoffrey, M.D.Lond., Senior Assistant Medical Officer, London
County Asylum, Long-Grove, Epsom.

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

1907. Clarke, Sidney Herbert, M.A., M.B., B.C.Cantab., M.R.C.S.,

L.R.C.P.Lond., Assistant Medical Officer, County Asylum, Leicester.
1907. Clarkson, Robert Durward, M.D., B.Sc., M.R.C.P.Edin., Medical Officer,
Scottish National Institution for Education of Imbecile Children at
Larbert.

1901. Cleland, William Lennox, M.B., B.Ch.Edin., Park Side, Adelaide, South
Australia.

1862. (Houston, T. S., M.D., LL.D.Edin., F.R.C.P., F.R.S.E., Physician Super¬
intendent, Royal Asylum, Morningside, Edinburgh. (Editor of
Journal , 1873—1881.) (Pbesidiwt, 1888.)

1900. Coffey, Patrick, L.R.C.P.&S.I., District Asylum, Maryborough, Queen’s
Co., Ireland.

1892. Cole, Robert Henry, M.D.Lond., M.R.C.P.Lond., 25, Upper Berkeley

Street, W.

1900. Cole, Sydney John, M.A., M.D., B.Ch.Oxon., Senior Assistant Medical
Officer, Wilts County Asylum, Devizes.

1906. Collen, Edward Victor, M.D., B.Ch., B.A.O.Dubl., Killycomain,
Portadown, Ireland.

Digitized by L^ooQle

riii Members of the Association .

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Kent County Asylum, Maidstone.

1903. Collins, Michael Abdy, M.B., B.S., M.R.C.S. & P.Lond., London County

Asylum, Bexley, Kent.

1888. Cones, John A., M.R.C.S., 2, Portland Place, Kemp Town, Brighton.

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

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

1899. Cooke, J. A., M.R.C.S., L.R.C.P., Medical Officer and Co-Licensee, Tue
Brook Villa, near Liverpool.

1908. Cormac, Harry Dove, M.B., B.S.Mndras, Parkside Asylum, Macclesfield.
1891. Corner, Harry, M.D.Lond., M.R.C.S., L.R.C.P., M.P.C., 87, Harley
Street, W.

1905. Cotter, James, L.R.C.P.&S.E., L.F.P.S.Glas., Down District Asylum,

Downpatrick.

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

1893. Cowen, Thomas Philip, M.D., B.S.Lond., Assistant Medical Officer,
County Asylum, Lancaster.

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

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

Medical Officer, Bethlem Royal Hospital, Southwark.

1904. Crawford, William Thomson, M.B.Lond., M.R.C.S., L.R.C.P., East

Sussex Asylum, Hellingly, Sussex.

1906. Creighton, John Alexander, M.B., C.M., West Riding Asylum, Wakefield.

1897. Cribb, Harry Gifford, M.R.C.S.Eug., L.R.C.P.Lond., Senior Assistant

Medical Officer, London County Asylum, Cane Hill, Coulsdon,
Surrey.

1898. Crookshank, F. G., M.D.Lond., M.R.C.S., L.R.C.P., 27, The Terrace,

Barnes. S.W.

1904. Cross, Harold Robert, L.S.A., Storthea Hall Asylum, Kirkburton, near

Huddersfield.

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

Officer, Richmond District Asylum, Dublin.

1905. Cummins, Edmund Joseph, L.R.C.P.&S.Edin., Old Rectory House, Low

Street, South Essex.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Can tab., M.R.C.S., L.R.C.P.Lond.

Senior Assistant Medical Officer, London County Asylum, Han well, W.
1905. Derbyshire, Harold Stewart C., M.R.C.S.Eng.,L.R.C.P.Lond., Grosvenor
House, West Ealing, W.

1899. Daunt, Elliot, M.R.C.S., L.R.C.P., D.P.H., The Glen, Bursledon,

Hampshire.

1896. Davidson, Andrew, M.D., C.M.Aber., Callan Park, Sydney, N.S.W.

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, Farnbam House Asylum, Finglas, Dublin. (Hon. Divisional
Soc.for Ireland since 1902.)

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

1900. Despard, Rosina C., M.D.Lond., The Dell, Colden Common, Winchester.
1883. De Lisle, Samuel Ernest, L.R.C.P., L.R.C.S.I., Three Counties Asylum,

Stotfold, Herts.

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

1905. Devine, Henry, M.B., B.S., M.R.C.P.Lond., M.R.C.S., London County

Asylum, Long-Grove Asylum, Epsom, Surrey.

Digitized by L^ooQle

1004.
1003.

1906.

1070.

1886.

1889.
1802.
1809.
1202 .
1800.

1906.

1897.

1903.

1905.

1884.

1005.

1907.
1002 .

1890.
1905.

1008.

1007.

1899.

1003.

1874.

1006.

1873.

1881.

1891.

1008.
1907-

Members of the Association. ix

Devon, James, L.R.C.P. k S.Edin., 6, Cathedral Square, Glasgow.

Dickson, Thomas Graeme, L.R.C.P. k S.Edin., Assistant Superintendent,
Wye House, Bax ton.

Dixon, J. Francis, M.D., B.Cb., B.A.O., B.A.Dubl., Three Counties
Asylum, Arlesley, Hitchin.

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

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

Donaldson, William Ireland, B.A., M.D., B.Ch.Univ. of Dubl., Medical
Superintendent, County of Loudon Manor Asylum, Kpsom, Surrey.

Donelan, John O’Conor, L.R.C.P.I., L.R.C.S.I., M.P.C., Deputy Super¬
intendent, Portrane Asylum, Donabate, co. Dnblin.

Donelan, Thomas O'Conor, L.R.C.P. & L.R.C.S.I., Middlesex County
Asylnm, Napsbury, near St. Albans, Herts.

Douglas, Archibald R., L.R.C.P.&S.Edin., L.F.P.S.Glas., Royal Albert
Asylum, Lancaster.

Douglas, William, M.D.Queen’s Uuiv. Irel., M.R.C.S.Eng., Brandfold,
Goudliurst.

Dove, Augustus Charles, M.D.Durh., M.B., B.S., “ Brightside,” Crouch
End Hill, N.

Dove, Emily Louisa, M.B.Lond., The School, Durham.

Dow, William Alex., M.D.Durh., M.R.C.S.&P.Lond., H.M. Prison, Lewes.

Drake-Brockman, Henry George, M.K.C.S., L.R.C.P., Middlesborough
Asylum, Cleveland, Yorks.

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

Drew, Charles Milligan, M.A., M.B., Ch.B.Glas., Lt. R.A.M.C., c/o
Messrs. Holt k Co., 3, Whitehall Place, S.VV.

Dry den, A. Mitchell, M.6., Ch.B.Edin., Assistant Medical Officer,
Woodilee Asylum, Lenzie.

Dudgeon, Herbert Wm., M.D.Durh., M.R.C.S.Eng., L.R.C.P.Lond.,
Medical Officer to the Egyptian Asylum, Abassieh, Cairo, Egypt.

Dudley, Francis, L.R.C.P.&S.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

Dunlop, James Craufurd, M.D.Edin., L.R.C.P.Edin., M.R.C.S.E., Super¬
intendent of Statistical Department, H.M. General Registry of
Births, Marriages, and Deaths, Scotland, 33, Chester Street, Edin¬
burgh.

Dunston, John Thomas, M.D., B.S.Lond., Senior Assistant Medical
Officer, The Asylum, Pretoria.

Dwyer, Patrick J., M.B., B.Cb., R.M.I., Clinical Assistant, Richmond
District Asylum, Dublin.

Eades, Albert I., L.R.C.P. k S.I., North Riding Asylum, Cliftou, Yorks.

Eady, George John, M.D., M.R.C.P.Edin., M.R.C.S.Eng., 78, Drayton
Gardens, S. Kensington, S.W.

Eager, Reginald, M.D.Lond., M.R.C.S.Eng., North woods, near Bristol.

Eager, Richard, M.B., Ch.B.Aber., Assistant Medical Officer, Devon
County Asylum, Ezminster.

Eager, Wilson, L.R.C.P.Lond., M.R.C.S.Eng., Northwoods, Winter¬
bourne, Bristol.

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

Earls, James Henry, M.D., M.Ch., Moyalton, Fairlawn Park, Chiswick,
S.W.

East, Guy Rowland, M.B.Durh., Northumberland County Asylum,
Morpeth.

Esst, Wm. Norwood, M.D., Loud., M.R.C.S., L.R.C.P., Deputy Medical
Officer, H.M. Prisori, Brixton.

Digitized by

Google

Members of the Association .

1895. Easterbrook, Charles C., M.A., M.D., F.R.C.P.Ed., Physician Superin¬
tendent, Crichton Royal Institution, Dumfries.

1895. Edgerley, Samuel, M.D., M.A., C.M.Edin., Assistant Medical Officer, We»t
Riding Asylum, Menston, nr. Leeds.

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

1897. Edwards, Francis Henry, M.D.Brux., M.R.C.P.Lond., Medical Super¬

intendent, Camberwell House, S.E.

1901. Elgee, Samuel Charles, L.R.C.P., L.R.C.S.I., London County Asylum,

Horton, Epsom, Surrey.

1889. Elkins, Frank Ashby, M.D., Medical Superintendent, Metropolitan

Asylum, Lenvesden.

1898. EUerton, Henry B., M.R.C.S., L.R.C.P., Leavesden Asylum, King's

Langley R.S.O., Herts.

1873. Elliot, G. Stanley, M.R.C.P.Edin., F.R.C.S.Edin., 31, Belvedere Road,
Upper Norwood, S.E.

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

Singapore.

1899. Ellison, F. C., M.D., B.Ch., T.C.D., Assistant Medical Officer, District

Asylum, Castlebar.

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

1895. Enrich, Frederick Wilhelm, M.D., C.M.Edin., 7, Liudum Terrace, Man-
ningham, Bradford, Yorks.

1894. Eustace, Henry Marcus, M.D., B.Ch., B.A.T.C.D. Assistant Physician,
Hampstead and Hielifield Private Asylum, Glasnevin, Dublin.

1901. Evans, James Wm., M.R.C.S., L.S.A., Lieut.-Col. Indian Medical Service
(retired), East India United Service Club, 16, St. James's Square,
S.W., and Martinstown, Dorchester.

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

1891. Ewan, John Alfred, M.A., M.D., Medical Superintendent, Kesteven

County Asylum, Sleaford, Lines.

1884. Ewart, C. T., M.D., C.M.Aberd., Senior Assistant Medical Officer,
Claybury Asylum, Woodford Bridge, Essex.

1906. Ewens, George Francis William, Major I.M.S. Bengal, c/o Messrs.

Grindlay & Co., 54, Parliament Street, S.W.

1907. Exley, John, L.R.C.P.I., L.M., M.R.C.S., Medical Officer, H.M. Prison,

Grove House, New Wortley, Leeds.

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

1907. Farvics, John Stoddart, L.R.C.P., L.R.C.S.Edin., Assistant Medical
Officer, Royal Albert Asylum, Lancaster.

1903. Fennell, Charles Henry, M.A., M.D.Oxon, M.R.C.P.Lond., Senior
Assistant Medical Officer, East Sussex Asylum, Hellingly, Sussex.
1907. Fergusson, J. J. H&rrower, M.B., Ch.B.Edin., Senior Assistant Medical
Officer, Fife and Kinross Asylum, Cupar, Fife.

1905. Ferris, William, M.D., B.S.Lond., Middlesex County Asylum, Tooting,

S.W.

1397. Fielding, James, M.D., Victoria Univ., Canada, M.R.C.S.Eng., L.R.C.P.
Edit)., Medical Superintendent, Bethel Hospital, Norwich.

1906. Fielding, Saville James, M.B., B.S.Durh., Bethel Street, Norwich.

1873. Finch, John E. M., M.D., Medical Superintendent, Borough Asylum,

Leicester.

1889. Finch, Richard T., B.A., M.B.Cantab., Manor House, llminster, Somerset.
1882. Finegan, A. D. O'Connell, L.R.C.P.I., Medical Superintendent, District
Asylum, Mullingar, Ireland. (Son. JDioutonal Sec. for Ireland ,
1898-1902.)

1889. Finlay, David, M.D.Glasg., Medical Superintendent, County Asylum,
Bridgend, Glamorgan.

1906. Firth, Arthur Harcus, M.A., M.B., B.Ch.Edin., Wadsley Asylum, near
Sheffield.

Digitized by L^ooQle

Members of the Association. xi

1908. Fitigenld, Alexis, L.R.C.P. & 8.L, L.M., District Asylum, Waterford.
1894. Fitigerald, Charles E., M.D., F.R.C.S.I., Surgeon-Oculist to the King in
Ireland, 27, Upper Merrion Street, Dublin.

1888. Fitx-Gerald, Gerald C., M.D., B.C.Cantab., M.P.C., Medical Superin¬
tendent, Kent County Asylum, Chartham, nr. Canterbury.

1899. Fitigerald, James J., M. D., B.Ch., B.A.O.R.U.I., Assistant Medical Officer,
Cork District Asylum, Carlow.

1901. Fitigerald, John J., M.D.Brox., L.R.C.P.&S.Edin., Assistant Medical

Officer, District Asylum, Cork.

1907. Fleming, Geo. A., L.U.C P.AS.Irel,, Assistant Medical Officer, Camber¬
well House Asylum, Camberwell.

1904. Fleming, Wilfrid Louis Remi, M.R.C.S., L.R.C.P., Suffolk House, Pir-
bright, Surrey.

1899. Flemming, Arthur L., M.R.C.S.Eng., L.R.C.P.Lond., 34, Alma Road,
Clifton, Bristol.

1894. Fleury, Eleonora Lilian, M.D., B.Ch., R.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

1902. Forde, Michael J., M.D., M.Ch., R.U.I., Assistant Medical Officer, Rich¬

mond Asylum, Donabate, Dublin.

1902. Forster, Hermann Julius, L.R.C.P.I., L.S.A., Assistant Medical Officer,
Brighton Borough Asylum, Hayward’s Heath.

1906. Forster, R. A., M.B., Ch.B.Aber., Valhewbury Asylum, Mowbray, Cape
Town, U.S.A.

1906. Fortune, John, M.B., Ch.K.Edin., Senior Assistant Medical Officer,
Devon County Asylum, Exminster.

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

1896. France, Eric, M.B., B.S.Durb., Dutch Chambers, Adderley Street, Cape
Town, South Africa.

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

1906. Fraser, Thomas Peppd, M.B., Ch.B.Aberd., 93, Beaconsfield Place,
Aberdeen.

1901. French, Louis Alexander, M.R.C.S., L.R.C.P., H.M. Prison, Wakefield,

Yorks.

1902. Fuller, Lawrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Eastern Counties

Inebriates Reformatory, East Harling, Norfolk.

1906. Oane, Edward Palmer Steward, M.R.C.S.Eng., L.R.C.P.Lond., Borough
Asylum, Ryehope, Sunderland.

1904 Garden, W. Sim, M.B., Manston Asylum, W. Riding, Yorks.

1893. Garth, Henry C., M.B., C.M.Edin., 36, Chowringee, Calcutta, India.
1890. Gaudin, Francis Neel, M.R.C.S., L.S.A., M.P.C., Medical Superintendent,
The Grove, St. Lawrence, Jersey.

1906. Gavin, Noel John Hay, M.B., Ch.B.Edin., Pathological Department,
The University, Manchester.

1885. Qeyton, Francis C., M.D., Brook wood Asylum, Woking, Surrey.

1896. Geddes, John W. f M.B., C.M.Edin., Medical Superintendent, County

Borough Asylum, Berwick Lodge, Middlesbrough, Yorks.

1892. Gemmel, James Francis, M.B.Glasg., Medical Superintendent, County
Asylum, Whittingham, Preston.

1904. Gibb, James Alex., M.B., Ch.B., Pitmedden, Udny, Aberdeenshire, N.B.
1899. Gilfillan, Samuel James, M.A., M.B.Edin., Senior Assistant Medical
Officer, London County Asylum, Colney Hatch.

1904 Gillespie, Daniel, M.B. (R.U.I.), Wadsley Asylum, near Sheffield.

1897. Gilmonr, John Rutherford, M.B., F.R.C.P.Edin., Medical Superintendent,

West Riding Asylum, Scalebor Park, Burley-iu-Wharfedale, Yorks

Digitized by L^ooQle

xii Members of the Association.

1906. Gilmour, Richard Withers, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,

Assistant Medical Officer, St. Luke’s Hospital, E.C.

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

1907. Gloag, Alfred M. f M.B., Ch.B.Edin., Senior Assistant Physician,

Inverness District Asylum, 9, Barnton Terrace, Edinburgh.

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

Assistant Physician, Royal Asylum, Gartnuvel, Glasgow.

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., B.S.Lond., F.R.C.P., Medical Superintendent,
City Asylum, Cardiff.

1899. Gordon, James Leslie, M.B., Ch.B., Tooting Bee Asylum, Tooting,

London, S.W.

• Gordon, William S., M.A., M.B., T.C.D., District Asylum, Mullingar.
1905. Gordon-Munn, John Gordon, M.D., F.R.S.E., Heigham Hall, Norwich.

1901. Goatwyck, C. H. G., M.B.,Ch.B., Stirling District Asylum, Larbert.

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

1888. Graham, Thomas, M.D.Glasg., 3, Garthland Place, Paisley.

1887. Graham, William, M.D., R.U.I., Medical Superintendent, District Lunatic
Asylum, Belfast.

1886. Greenlees, T. Duncan, M.D., Fenstanton, Christ Church Road, Streatham
Hill, S.W.

1904. Griffin, Ernest Harrison, B.A.Cantab., L.S.A.Lond., Camberwell House,

Peck ham Road, S.E.

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

County Asylum, Chester.

1900. Grove, Ernest George, M.R.C.S., L.R.C.P., Bootliam Park, York.

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

Whitchurch, Salop.

1905. Hallett, H. G., M.R.C.S., L.R.C.P.Lond., Darenth Asylum, Dartford,

Kent.

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

1908. Hanbury, Langton Fuller, M.R.C.S.Eng., L.R.C.P.Lond., West Ham
Borough Asylum, Ilford, Essex.

1902. Hanbury, Saville Waldron, M.R.C.S.Eng., L.R.C.P.Lond., Assistant

Medical Officer, London County Asylum, Banstead, Surrey.

1896. Hanbury, William Reader, M.R.C.S., L.R.C.P., Senior Assistant Medical
Officer, West Ham Borough Asylum, Goodmayes, Ilford.

1903. Hankin, Chella Mary, M.B.Durh., Borough Asylum, Portsmouth.

1901. Harding, William, M.D., M.R.C.P.Lond., Medical Superintendent,

Northampton County Asylum, Berry Wood, Northampton.

1906. Harman, George James, L.R.C.P.&S.Edin., L.F.P.S.Glasg., Assistant

Medical Officer, Chester County Asylum, Chester.

1899. Harmer, W. A., L.SA., Resident Superintendent and Licensee, Redlands
Private Asylum, Tonbridge, Kent.

1904. Harper-Smith, George Hastie, M.R.C.S., L.R.C.P., B.A.Cantab., Claybury,

Woodford Bridge, Essex.

1898. Harris-Liston, L., M.D., M.R.C.S., L.R.C.P.Lond., L.S.A., Middleton
Hall, Middleton St. George, Co. Durham.

1905. Hart, Bernard, M.B.Lond., M.R.C.S.Eng., Long-Grove Asylum, Epsom,

Surrey.

1886. Harvey, Bugenal Crosbie, L.R.C.P., L.R.C.S., Assistant Medical Officer,
District Asylum, Clonmel.

Digitized by L^ooQle

Members of the Association . xiii

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

1891. Havelock, John G., M.D., C.M.Edin., Physician Superintendent, Montroee
Royal Asylum.

1890. Hay, Frank, M.B., C.M., Inspector-General of Asylums for New Zealand,
Government Buildings, Wellington, New Zealand.

1900. Haynes, Horace E., M.R.C.S., L.S.A., 32, Brunswick Terrace, Hore,
Sussex.

1895. Hoarder, Ifrederic P., M.D., C.M., Medical Superintendent, Yorkshire
Inebriate Reformatory, Cattal, Whixley, near York.

1906. Hector, George W. K., M.D., L.R.C.P.&S., New Herrington, Co. Dublin.
1909. Hefferain, Patrick, M.B., B.Ch., B.A.O., R.U.I., Rathkenny, Fethard,
oo. Tipperary.

1906. Henderson, George, M.A., M.B. (Address uncommunicated.)

1885. Henley, Edward W., M.R.C.S., L.R.C.P., Medical Superintendent,
County Asylum, Barn wood, Gloucester.

1906. Herbert, Thomas, M.R.C.S.Eng., L.R.C.P., York City Asylum, Fulford,

York.

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

Denbigh, North Wales.

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

1908. Hewitt, David Walker, M.B., B.Ch., R.U.I., Surgeon R.N., H.M.S.
Powerful, Australia.

1877. Hewion, R. W., L.R.C.P.Edin., Medical Superintendent, Coton Hill,
Stafford.

1902. Higginson, John Wigmore, M.R.C.S., L.R.C.P., Resident Medical Officer,

Hayes Park Asylum, Hayes Park, Middlesex.

1882. Hill, H. Gardiner, M.R.C.S., Medical Superintendent, Middlesex County
Asylnm, Tooting.

1907. Hine, T. Goy Macaulay, M.A., B.C.Cantab., 19, Lower Seymour Street,

Portman Square, W.

1905. Hines, Arthur, M.B., County Asylum, Stafford.

1871. Hingston, J. Tregelles, M.R.C.S.Eng., Red cote, St. Mark’s Road,
Leamington.

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

1900. Hollinder, Bernard, M.D., M.R.C.S.. L.R.C.P., 35 a, Welbeck Street,

London, W.

1903. Hopkins, Charles Leighton, M.B., B.C.Cantab., York City Asylum, Ful¬

ford, York.

1686. Hotchkis, Robert D., M.A., M.D., Renfrew Asylum, Dykebar, N.B.
1907. Howard, S. Carlisle, M.B., Ch.B.Aberd., Assistant Medical Officer, Perth
District Asylum, Murthly.

1900. Hughes, George Osborne, M.D*.Virginia, M.R.C.S., L.R.C.P. (Travelling.)
1900. Hughes, Percy T.. M.B., Ch.M.Edin., D.P.H.Lond., Medical Superinten¬
dent, Worcestershire Couuty Asylum, Barnseley Hall, Bromsgrove.

1904. Hughes, William Stanley, M.R.C.S., L.R.C.P., Claybury Asylum, Wood¬

ford, Essex.

16^7- Humphry, John, M.R.C.S.Eng., Medical Superintendent, County Asylum,
Stone, near Aylesbury, Bucks.

1897- Hunter, David, M.A., M.U., B.C.Cantab., Medical Superintendent, West
Ham Borough Asylum. Goodmayes, Ilford, Essex.

1^04. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., East Sussex County
Asylum, Hellingly, Sussex.

1906. Hutchinson, Joseph Armstrong, M.D., M.S.Durli., Northallerton, York¬

shire.

Digitized by L^ooQle

xiv Membei 8 of the Association.

1906. Huxley, Charles Rodney, L.R.C.P.&S.Edin., L.F.P.S.Glas., Kent House
Road, New Beckenham, Kent.

1882. Hyslop, James, D.S.O., M.D., Natal Government Asylnm,Pietermaritz¬
burg.

1888. Hyslop, Theo. B., M.D., C.M.Edin., M.R.C.P.E., M.P.C., Bethlem Royal
Hospital, S.E.

1871. Ireland, William W., M.D.Edin., 1, Victoria Terrace, Musselburgh, N.B.
1906. Irwin, Peter Joseph, L.R.C.P.&S.I., L.M., District Asylum, Limerick.

1905. Jackson, Arthur Molyneux, M.D.Oxon., Medical Superintendent, Notts
County Asylum, Radcliffe-on-Trent.

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.

1907. Jex-Blake, Bertha, M.B., Ch.B.Edin., Assistant Medical Officer, County
and City Asylum, Hereford.

1905. Johnson, Smeeton, M.B.Lond., L.R.C.P., M.R.C.S., Rainhill Asylum,
near Liverpool.

1893. Johnston, Gerald Herbert, L.R.C.S. and L.R.C.P.Edin., Brooke House,
Upper Clapton, N.

1905. Johnston, Thomas Leonard, L.R.C.P.AS.Edin., L.F.P.S.Glas., Brace-
bridge Asylum, Lincoln.

1905. Johnstone, George A., M.B., Ch.B.Aberd., Femdene, Craigleith,
Edinburgh, N.B.

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

1903. Johnstone, Thomas, M.D.Edin., M.R.C.P.Loud., 32. Park Square, Leeds.

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

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

1882. Jones, Robert, M.D.Lond., B.S., F.R.C.P., F.R.C.S., Medical Superinten¬
dent, London County Asylum, Claybury, Woodford, Essex. (Gen.
Secretary from 1897 to 1906. President 1906-7.)

1898. Jones, W. Ernest, M.R.C.S.Eng., L.R.C.P.Lond., The Old Treasury
Buildings, Spring Street, Melbourne.

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

1886. Keay, John, M.D., Bangour Village, Uphall, Linlithgowshire.

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

1902. Kelley-Patterson, VVm., M.D., M.Ch., R.U.I., Tod Pedu, South Godstone,
Surrey.

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

1907. Keene, George Henry, M.D. (T.C.D.), Camberwell House, Peckham Road.

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

District Asylum, Enniscorthy, Wexford.

1902. Kennedy, Patrick Gabriel, L.R.C.P.&S.Edin., L.F.P.S.Glasg., Assistant
Medical Officer, London County Asylum, Banstead, Surrey.

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

1902. Kerr, Neil Thomson, M.B., C.M.Ed., Medical Superintendent, Lanark

District Asylum, Hartwood, Shotts, N.B.

1893. Kershaw, Herbert Warren, M.R.C.S.Eng., L.R.C.P.Lond., Dinsdale Park,
near Darlington.

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

1903. King, Frank Raymond, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Northumberland House, Finsbury Park, N.

Digitized by L^ooQle

Members of the Association. xv

1897 Kingdon, Wilfred Robert, M.B., B.S.Durh., 160, Goldhawk Road, W.

1905. Kingsbury, William Neave, M.R.C.S., L.R.C.P., 15, Blackbeath Rise,
Lewisham, S.E.

1908. Kingsford, Arthur Beresford, M.R.C.S., L.R.C.P.Lond., D.P.H.Camb.,
19, Upper George Street, Bryanston Square, W.

1902. King-Turner, A. C., M.B., C.M.Edin., The Retreat, Fairford, Gloucester¬
shire.

1899. Kir wan, James St. L., B.A., M.B., B.Ch., B.A.O.Roy. Univ. Irel.,
Medical Superintendent, District Asylum, Ballinasloe, Ireland.

1908. Kough, Edward Fitzadam, M.B., B.Ch., County Asylum, Gloucester.

1896. Labey, Julius, M.R.C.S., Medical Superintendent, Public Asylum, Jersey.
1902. Langdon-Down, Percival L., M.A., M.B., B.C.Cantab., Dizland, Hampton
Wick, Middlesex.

1896. Langdon-Down, Reginald L., M.A., M.B., B.C.Cantab., M.R.C.P.Loud.,
Normansfield, Hampton Wick.

1902. Laval, Evariste, M.B., C.M.Edin., Langbo, nr. Blackburn.

1896. Lavers, Norman, M.D., M.R.C.S., Medical Superintendent, Bailbrook
House, Bath.

1899. Law, Charles D., L.R.C.P.&S.Edin., L.F.P.G.S., c/o Manager, Bank of
Victoria, 10, King William Street, E.C.

1892. Lawless* George Robert, F.R.C.S.I., Medical Superintendent, District
Asylum, Armagh.

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

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

1699. Leeper, Richard R., F.R.C.S.I., Medical Superintendent, St. Patrick's
Hospital, Dublin.

1905. Le Fanu, Hugh, M.B., C.M.Aber., 145, Leinster Road, Rathmines,

Dublin.

1683. Legge, Richard J., M.D., Medical Superintendent, County Asylum,
Mickleover, Derby.

1906. Leggett, William, B.A., M.B., B.Ch.Dubl., Assistant Medical Officer,

Kent County Asylum, Maidstone.

1894. Lentaigne, John, B.A., F.R.C.S.I., Medical Visitor of Lunatics to the
Court of Chancery, 42, Merrion Square, Dublin.

1899. Lewis, H. Wolseley, M.D.Brux., F.R.C.S.Eng., Medical Superintendent,
Kent County Asylum, Banning Heath, Maidstone.

1879. Lewis, William Bevan, M.R.C.S., L.R.C.P., Medical Superinrendent,
West Riding Asylum, Wakefield.

1863. Ley, H. Rooke, M.R.C.S.Eng., Beaulieu, Westhy Road, Boscombe,
Hants.

1859. Lindsay, James Murray, M.D.St.And., F.R.C.S. and F.R.C.P.Edin.
53, Victoria Road, Aldershot. (Pbksidknt, 1893.)

1903. Logan, Thomas Stratford, L.R.C.P.&S.Edin., L.F.P.S.Glas., County of

London Epileptic Colony, Ewell, Surrey.

1906. Long, Sydney Herbert, M.D.Cantab., Physician to Norfolk and Norwich
Hospital, 37, St. Giles Street, Norwich.

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

1898. Lord, John R., M.B., C.M., Medical Superintendent, London County
Asylum, Horton, Epsom. ( Assistant Editor of Journal since 1900.)
1906. Lowry, James Arthur, M.B., B.Ch., B.A.O., R.U.I., Assistant Medical
Officer, Middlesex County Asylum, Napsbury.

1904. Lyall, C. H. Gibson, L.R.C.P.&S.Edin., Leicester Borough Asylum,
Leicester.

1906. Lyell, John Hepburn, M.D.Glasg., M.B., C.M., Assistant Medical Officer
to H.M. Prison, the Royal Infirmary, and Parish Council, Perth,
15, Marshall Place, Perth.

Digitized by L^ooQle

xvi Members of the Association.

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

1906. Macarthur, John, M.R.C.S., L.R.C.P.Lond., The Hut, Manor Road,

East Molesey.

1899. Macartney, William H. C., L.R.C.P.&S.I., River head House, Sevenoaks.
1880. MacBryan, Henry C., L.R.C.P. & S. fidin., Kingsdown House, Box, Wilts.
1902. McCarthy, Owen F., L.R.C.P.&S.I., District Lunatic Asylum, Cork.

Ireland.

1900. McClintock, John, L.R.C.P. & L.R.C.S.Edin., Resident Medical Super¬

intendent, Qrove House, Church Stretton, Salop.

1900. McConaghey, John C. t M.B., C.M.Edin., Parkside Asylum, Macclesfield,

Cheshire.

1886. McCreery, James Vernon, L.R.C.S.I., Medical Superintendent, “Or¬
monde,” Walpole Street, Kew, Victoria.

1901. MaeDouald, James H., M.B., Ch.B.Glasg., Govan District Asylum, Hawk-

head, Paisley, N.B.

1907. Macdonald, Peter Horne, M.B., Ch.B.St.Andrews, Pathologist, Gartloch

Hospital, Gartcosh.

1884. MacDonald, P. W., M.D., C.M., Medical Snperintendent, Dorset
County Asylum, Herrison, Dorchester. (Hon. Sec. S. IF. Division
1894 to 1905.)

1905. MacDonald, William Fraser, M.B., Ch.B.Ediu., 18, Buckingham Ter¬
race, Glasgow.

1905. McDougall, Alan, M.D.Vict., M.R.C.S., L.R.C.P.Lond., Medical Director,

The David Lewis Colony, Sandle Bridge, near Alderley Edge,
Cheshire.

1906. McDowall, Colin Francis Frederick, M.B., B.S.Durh., Assistant Medical

Officer, City Asylum, Newcastle.

1870. McDowall, Thomas W., M.D.Edin., L.R.C.S., Medical Superintendent,
Northumberland County Asylnm, Morpeth. (Pbxsidsitt, 1897-8.)
1893. Macevoy, Henry John, M.D., B.Sc.Loud., M.P.C., 41, Buckley Road,
Brondesbury, London, N.W.

1895. Macfarlane, Neil M., M.D.Aber., Medical Superintendent, Government
Hospital, Thlotae Heights, Leribe, Basutoland, South Africa.

1883. Macfarlane, W. H., M.B. and Ch.B.Univ. of Melbourne, Medical Super¬
intendent, Hospital for the Insane, New Norfolk, Tasmania.

1902. McGregor, John, M.B., Cb.B.Edin., Assistant Medical Officer, County

Asylum, Bridgend, Glam.

1906. Macllraith, Alex. Robert MacIntyre, Brownlie Place, Cathcart, Renfrew¬

shire.

1905. Macllraith, W. MacLaren, L.R.C.P. & S.Edin., L.F.P.S.Glasg.,
L.DS.R.C.S.Edin., Assistant Medical Officer, Brownlie Place,
Cathcart, N.B.

1899. McKelvey, Alexander Niel, L.&M.P.C.P.&S.I., The Asylnm, Auckland,
New Zealand.

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

1903. Mackenzie, Theodore Charles, M.B., Ch.B.Edin., Royal Asylum, Aberdeen.
1899. Mackeown, William John, A.B., M.B., B.A, O.R.U.I., A.M.O., County

Asylum, Fareham, Hants.

1907. MacLeod, John A., M.B., Cli.B., Assistant Medical Officer, Lochmore,

Lairg, Sutherlandshire.

1901. Macleod, Neil, M.D., C.M.Edin., H.B.M. Consular Surgeon and Surgeon
to the General Hospital, Shanghai, China, 12, Whangpoo Road,
Shanghai.

1904. Macnamara, Eric Danvers, M.A., M.B., 9, Welbeck Street, W.

1898. Macnaughtou, George W. F., M.D., F.R.C.S., 33, Lower Belgrave Street,
Eaton Square, London, S.W.

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

1882. Macphail, S. Rutherford, M.D.Edin., Derby Borough Asylum, Rowditcb,
Derby.

Digitized by L^ooQle

Members of the Association. xvii

189®. Maepberson, Charles, M.D.Glas., Deputy Commissioner in Lunacy, 193,
Bruntsfield Place, Edinburgh.

188®. Macplienoo, John, M.D., F.R.C.P., 8, Darn a way Street, Edinburgh.

1901. McRae, G. Douglas, M.6., C.M.Edin., Medical Superintendent, District

Asylum, Ayr, N.B.

1902. Macrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin., Lynwood,

Marrayfield, Edinburgh.

IffiH. Me William, Alexander, M.A., M.B., C.M.Aber., Waterval, Odiham,
Winchfield, Hants.

1907. Meek, Andrew Alexander Robertson, M.B., Cb.B. Glas. Univ., Assistant
Physician, Gartlocb Hospital, Gartloch.

1865. Manning, Henry J., B.A.Lond., M.R.C.S., Laverstock House, Salisbury.
1900. Manning, Herbert C., M.R.C.S., L.R.C.P., County Asylum, Cambridge.

1903. Maraan, John, M.B., B.Ch., Fishponds Asylum, Bristol.

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

Asylum, Lenzie.

1897. Marshal], John, M.B., C.M.Glasg., 2, Hartingdon Gardens, Edinburgh.

1905. Marshall, Robert Macnab, M.B., Ch.B., Oak lands, 21, Maxmill Drive,

Pollokshields, Glasgow.

1896. Martin, James Charles, L.R.C.S.I., L.M., L.R.C.P., Assistant Medical
Officer, District Asylum, Letterkenny, Donegal.

1907. Martin, Mary Edith, L.R.C.P.AS.Edin., L.F.G.S.Glas., L.S.A.Lond.,
Fenst&nton, Christchurch Road, Streatham Hill, S.W.

1904. May, George Francis, M.D., C.M. (McGill), L.S.A., Win ter ton Asylum,

Ferry hill, Durham.

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

County Asylum, Cheddleton, near Leek.

1891. Mercier, Charles A., M.D.Lond., F.R.C.P., F.R.C.S.Eng., Lecturer on

Insanity, Westminster Hospital; Flower House, Catford, S.E.
(Pbbbidbkt-elbct.)

1877. Meraon, John, M.A., M.D.Aber., Medical Superintendent, Borough

Asylum, Hull.

1871. Mickle,William Julius, M.D., F.R.C.P.Lond. (Address uncommunicated.)
(Pbbsidbht, 1896-7.)

1893. Middlemans, James, M.D., C.M., B.Sc.Edin., F.R.C.P., Medical Superin¬
tendent, Borough Asylum, Ryhope, Sunderland.

1898. Middlemist, George Edwyn, M.B., Keelby, Brocklesby, Lines.

1883. Miles, George E., M.R.C.P., Ac., Medical Superintendent, Hospital for
the Insane, Rydalmere, New South Wales.

1887. Miller, Alfred, M.B. and B.C.Dubl., Medical Superintendent, Hatton
Asylum, Warwick. (Registrar since 1902.)

1904. Miller, James Webster, The County Asylum, Herrison, Dorchester.

1893. Mills, John, M.B., B.Ch., and Diploma in Mental Diseases, R.U.I.,
District Asylum, Ballinasloe, Ireland.

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

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

intendent, County Asylum, Cane Hill, Coulsdon, Surrey.

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

1906. Moore, Francis Joseph, L.R.C.P.AS.Irel., Ivy House, Ardee, Co. Louth.

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

Sanatorium, Virginia Water, Surrey.

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

intendent, County and City Asylum, Burghill, Hereford.

Digitized by L^ooQle

xviii Members of the Association .

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

1896. Mott, F. W., M.D., B.Sc., B.S., F.R.C.P.Lond., F.R.S., 25, Nottingham
Place, London, W.

1896. Mould, Gilbert E., M.R.C.S., L.R.C.P.Lond., The Grange, Rotherham,

Yorks.

1862. Monld, George W., M.R.C.S.Eng., Oak Mount, Colvin Bay, N. Wales.
(Pbbsidbbt, 1880.)

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Overdale, Whitefield,

near Manchester.

1907. Mules, Bertha Mary, M.B., B.S.Durli., Court Hall, Kenton, S. Devon.
1897. Mumby, Bonner Harris, M.D.Aber., D.P.H.Cantab., Medical Superin¬
tendent, Borough Asylum, Portsmouth.

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.I., L.M., L.R.C.S.I., Assistant Medical
Officer, Prestwich Asylum, Manchester.

1905. Murrell, Christine Mary, M.D.Lond., B.S., Royal Free Hospital, 86,
Porchester Terrace, Hyde Park, W.

1903. Navarra, Norman, M.R.C.S., L.R.C.P., 61, Upper Bedford Place, W.C.

1880. Neil, James, M.D., M.P.C., Medical Superintendent, Warneford Asylum,
Oxford.

1903. Nelis, William F., M.D., Newport Borough Asylum, Caerleon, Mon.

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., The Gables, Tice-
hurst, Sussex. (Pbbbident, 1889.) (Treasurer,)

1869. Nicolson, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courts of Justice, Strand, W.C. (Pbbbidbht, 1895-6.)

1893. Nobbs, Athelstane, M.D., C.M.Edin., Layton House, Upper Richmond
Road, S.W., and 337, Queen’s Road, Battersea Park.

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

1880. Norman, Conolly, F.R.C.P.I., M.D.Dubl., S. Dymphna’s, North Circular
Road, Dublin, Medical Superintendent, Richmond District Asylum,
Dublin, Ireland. (Hon. Secretary for Ireland, 1887 —1894.)
(Pbesidbnt, 1894-5.) (Co-Editor of Journal since 1895.)

1885. Oakshott, James A., M.D., Medical Superintendent, District Asylum,

Waterford, Ireland.

1906. O’Brien, Mary, L.S.A., 7, Wimborne Gardens, W. Ealing, W.

1903. O’Doherty, Patrick, B.A. and M.B.Irel., District Asylum, Omagh.

1904. Q* Downey, Augustine Francis, L.R.C.P.AS. Edin., Salop aud Mont¬

gomery County Asylum, Bicton Heath, nr. Shrewsbury.

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

Officer, London County Asylum, Horton, nr. Epsom, Surrey.

1892. O’Mara, Francis, L.R.C.P.&S.I., District Asylum, Ennis, Ireland.

1886. O’Neill, Edward D., M.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. (Pbbbidbnt, 1883.)

1907. O’Reilly, Arthur Edward, L.R.C.S. AP.I., L.M., Assistant Medical

Officer, North Riding Asylum, Clifton.

1902. Orr, David, M.B., C.M.lSlin., Pathologist, County Asylum, Prestwich,

Lancs.

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

Digitized by L^ooQle

Members of the Association. xix

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

Asylum, Gartnavel, Glasgow.

1899. Owen, Corbet W., M.B., C.M.Edin., 31, Victoria Place, High Street,
Bangor, North Wales.

1905. Paine, Frederick, M.R.C.S., L.R.C.P., Clay bury Asylum, Woodford
Bridge, Essex.

1907. Parker, James, L.R.C.S.&P. and L.M.Irel., Assistant Medical Officer,
West Riding Asylum, Wakefield.

1898. Parker, William Arnot, M.B., C.M., Medical Superintendent, Gartloch

Asylum, Gartcosh, N.B.

1896. Pasmore, Edwin Stephen, M.D.Lond., M.R.C.P.Lond., Croydon Mental
Hospital, Warlingham, Surrey.

1901. Passmore, Win. Edwin, L.S.ALond., Forest View, Woodford Bridge,
Essex.

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

Wormwood Scrubbs, London, W.

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

1892. Patterson, Arthur Edward, M.D., C.M.Aber., Senior Assistant Medical

Officer, City of London Asylum, Dartford.

1905. Paul, Maurice Eden, M.D.Brux., M.R.C.S., L.R.C.P., Moorcroft, Park-

stone, Dorset.

1907. Peachell, George Ernest, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistant
Medical Officer, West Sussex County Asylum, Chichester.

1903. Pearce, Francis H., M.B., B.C.Cantab., Earlswood Asylum, Redhill,

Surrey.

1893. PerceTal, Frank, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superintendent,

County Asylum, Prestwich, Manchester, Lancashire.

1878. Philipps, Sutherland Rees, M.D., C.M. Queen’s Univ. Irel., F.R.G.S.,
4, The Beacon, Exmouth.

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

Eldon Square, Newcastle-on-Tyne.

1906. Phillips, Nathaniel Richard, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, County Asylum, Abergavenny, Monmouthshire.

1905. Phillips, Norman Routh, M.D.Brux., M.K.C.S., L.R.C.P., St. Andrew’s
Hospital, Northampton.

1891. Pierce, Bedford, M.D.Lond., F.R.C.P., Medical Superintendent, The

Retreat, York. (Hon. Sec. N. and M. Division.)

1888. Pietersen, J. F. G., M.R.C.S., Ashwood House, Kingswinford, near

Dudley, Stafford.

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

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

Medical Superintendent, Somerset and Bath Asylum, “ Westfield,”
near Wells, Somerset.

1876. Powell, Evan, M.R.C.S.Eng., L.S.A., Medical Superintendent, Borough

Lunatic Asylum, Nottingham.

1904. Pringle, Archibald Douglas, Government Asylum, Pietermaritzburg,

Natal, South Africa.

1875. Pringle, Henry T., M.D.Glasg., Hawtree, Ferndown, Wimborne.

1901. Pugh, Robert, M.D.Edin., Ch.B., Medical Superintendent, Brecon and

Radnor Asylum, Talgarth, S. Wales.

1904. Quin, Henry C. E., L.R.C.P., L.R.C.S.Edin., Camberwell House,
Peckbam Road, S.E.

1904. Race, John Percy, M.R.C.S., L.R.C.P., L.S.A., Assistant Medical
Officer, London County Asylum, Colncy Hatch, N.

1899. Rainsford, F. E., M.D., B.A., Resident Physician, Stewart Institute,
Palmerston, co. Dublin.

1894. Rambaut, Daniel F., M.A., M.D.Univ. Dubl., Salop and Montgomery

Asylum, Bicton Heath, Shrewsbury.

1902. Rattray, A. Mair, M.B., C.M.Edin., City Asylum, Gosforth, Newcastle*

on-Tyne.

Digitized by L^ooQle

Members of the Association .

1889. Raw, Nathan, M.D., F.R.C.S., 66, Rodney Street, Liverpool.

1893. R&wes, William, M.D.Durh., 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.Edin., 16,Queen Anne Street, London,

W. (Pbbbident, 1884.) ( General Secretary , 1878-89.) ( Co-
Editor of Journal since 1895.)

1903. Read, George F., L.R.C.S., L.R.C.P.Edin., Hospital for the Insane,
New Norfolk, Tasmania.

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

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

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

Medical Superintendent, Central Criminal Asylum, Dundrum,
Ireland.

1907. Reynolds, Ernest Septimus, B.Sc.Vict., M.D., F.R.C.P.Lond.,
2, St. Peter's Square, Manchester.

1903. Rhodes, John Milson, M.D.Brux., L.R.C.P.&S.Edin., Ivy Lodge, Barlow

Moor, Didshury, Manchester.

1899. Rice, David, M.R.C.S., L.R.C.P., City Asylum, Hillesdon, Norwich.

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

1899. Richards, John, M.B., C.M.Edin., Joint Counties Asylum, Carmarthen.
1905. Ridley, Edward Hope, M.D.Edin., 4, Columbia Street, London, N.E.

1904. Rigden, Alan, M.D.Durh., Salop and Montgomery Asylum, nr. Shrewsbury.

1907. Rivers, William Gregory, M.B., Ch.B.Edin., Assistant Medical Officer,
Cornwall County Asylum, Bodmin.

1893. Rivers, William H. R., M.A., M.D.Lond., St. John's College, Cambridge
University.

1903. Roberts, Norcliffe, M.B., B.S.Durh., London County Asylum, Cane Hill,
Coulsdon, Surrey.

1871. Robertson, Alexander, M.D.Edin.. 11, Woodside Crescent, Glasgow.

1905. Robertson, Constance C., M.D.Durh., B.S., Seinmercote, Darlington.

1887. Robertson, Geo. M., M.B., C.M. and F.R.C.P.Edin., M.P.C., Medical

Superintendent, District Asylum, Larbert, Stirling.

1895. Robertson, William Ford, M.D., C.M., 9, Priestfteld Road, Edinburgh.

1905. Robertson-Milne, Major Charles John, M.B., C.M. Aberd., Superintendent,
Bengal Criminal Asylum, Berampore, Bengal.

1900. Robinson, Harry A., M.D., Ch.B.Vict., 67, Canning Street, Liverpool.

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

1895. Rolleston, Lancelot W., M.B., B.S.Durh., Medical Superintendent, Mid¬
dlesex County Asylum, Napsbury, near St. Albans.

1879. Ronaldson, J. B., M.D.St.And., FR.C.S.AL.R.C. P.Edin., Medical Officer,
District Asylum, Haddington, N.B.

1879. Roots, William H., M.R.C.S., Canhury 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., 4, Roxburgh Terrace, West
Park Road, Dundee. {Late Mon. Secretary for Scotland .)

1888. Ross, Chisholm, M.D., 147, Macquarie Street, Sydney, New South Wales.

1905. Ross, Sheila Margaret, M.B., Holloway Sanatorium, Virginia Water,
Surrey.

Digitized by L^ooQle

Members of the Association . xxi

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Medical Superintendent,

Darenth Asylum, Dartford, Kent.

1906. Rowan, Marriott Logan, B.A., M.D., R.M.I., Assistant Medical Officer,

Derby County Asylum, Mickleover.

1884. Rowe, Edmund L., L.R.C.P.AS.Edin., Medical Snperintenaent, Borough
Asylum, Ipswich.

1883. Rowland, E. D., M.B., C.M.Edin., The Public Hospital, George Town,
Demerara, British Guiana.

1902. Rows, Richard Gundry, M.D.Lond., M.R.C.S., L.R.C.P., Pathologist,
County Asylum, Lancaster.

1877. Russell, Arthur P., M.B., M.R.C.P.Edin., The Lawn, Lincoln.

1907. Rutherford, Henry Richard Charles, L.R.C.P.&S.Irel., L.M., Ballinasloe,

Co. Galway.

1866. Rutherford, James, M.D.Edin., P.R.C.P.Edin., F.F.P.S.Glasgow. (Hon.
Secretary for Scotland , 1876-86.)

1896. Rutherford, James Mair, M.B., C.M.Edin., Assistant Physician, Royal
Edinburgh Asylum, Morningside.

1907. Rutherford, James Whigham, L.R.C.P.&S.I., L.M., Assistant Medical

Officer, Ballinasloe, Co. Galway.

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

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

1908. Ruttledge, W. E., M.R.C.S., L.R.C.P.Lond., County Asylum, Wells,

Somerset.

1902. Sail, Ernest Frederick, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬
intendent, Borough Asylum, Canterbury.

1894. Sankey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medical
Licensee, Boreatton Park Licensed House, Buschurch, Salop.

• Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Road, Oxford.
1873. Savage, Geo. H., M.D.&F.R.C.P.Lond., 26, Devonshire Place, W.

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

1906. Scanlan, John, L.R.C.S.Edin., 7, Park Villas, Victoria Road, Cork.

1896. Scott, James, M.B., C.M.Edin., 19, Raleigh Gardens, Brixton Hill,
London, S.W.

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

1880. Seccombe, George S., M.R.C.S., L.R.C.P., Port of Spain, Trinidad, W.I.
1879. Seed, William Hy., M.B., C.M.Edin., The Poplars, 110, Waterloo Road,
Ashton-on-Ribble, Preston.

1906. Sepbton, Robert Poole, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.Lond.,
County Lunatic Asylum, Lancaster.

1882. Seward, William J., M.B.Lond., M.R.C.S., Medical Superintendent,
Colney Hatch Asylum, London, N.

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

1905. Shaw, Charles John, M.B., Ch.B., M.R.C.P.E., Montrose Asylum.

1891. Shaw, Harold B., B.A., M.B., D.P.H.Camb., Medical Superintendent,
Isle of Wight County Asylum, Whitecroft, Newport, Isle of Wight.
1904. Shaw, Patrick, L.R.C.P.&S.Edin., Ararat Hospital for the Insane,
Ararat, Victoria, Australia.

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

1882. Sheldon, Thomas S., M.B., Medical Superintendent, Cheshire County
Asylum, Farkside, Macclesfield.

1900. Shera, John E. P., M.D., Somerset County Asylum, Wells, Somerset.

Digitized by L^ooQle

xxii Members of the Association.

1877. Shuttleworth, George E., M.D.Heidelb., M.R.C.S. and L.S.A.Eng., R.A.

Lond., late Medical Superintendent, Royal Albert Asylum, Lan¬
caster ; Parkholme, East Sheen, S.W.

1809. Sibley, Reginald Oliver, M.B.Lond., M.R.C.S., L.R.C.P., Assistant
Medical Officer, London County Asylum, Cane Hill, Coulsdon,
Surrey.

1906. Sievwright, Henry Gates, M.R.C.S., L.R.C.P.Lond., Tor Glas, Whit¬

church, nr. Cardiff.

1901. Simpson, Alexander, M.A., M.D.Aber., Medical Superintendent, County
Asylum, Winwick, Newton *le-Willows, Lancashire.

1905. Simpson, Edward Swan, M.B., Ch.B.Edin., East Riding Asylum,
Beverley, Yorks.

1888. Sinclair, Eric, M.D.Glasg., Richmond Terrace, Demain, Sydney, New
South Wales.

1891. Skeen, James Humphry, M.B., C.M.Aber., Medical Superintendent,
Kirklands Asylum, Bothwell.

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

hill, Durham.

1900. Skinner, Ernest W., M.D., C.M.Edin., Mansfield, Rye, Sussex.

1901. Slater, George 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.

1907. Smith, Ch. Mollyson, M.B., Cli.B.Aberd., Assistant Medical Officer,

County Asylum, Prestwich, Manchester.

1905. Smith, George William, M.B., Holloway Sanatorium, Virginia Water,

Surrey.

1907. Smith, Henry Watson, M.B., Ch.B., Assistant Medical Officer, Durham

County Asylum, Winterton, Ferryhill.

1899. Smith, John G., M.D., Herts County Asylum, Hill End, St. Albans, Herts.

1904. Smith, Peter Campbell, L.R.C.P.AS.Edin., 4, Upper Grosvenor Road,

Tunbridge Wells.

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.) (President,
1904-5.)

1884. Smith, W. Beattie, F.R.C.S.Edin., L.R.C.P.Lond., 4, Collins Street,

Melbourne, Victoria.

1908. Smith, William Maule A., M.B., CliB.Edin., M.R.C.P.Edin., Senior

Assistant Medical Officer, Worcester County Asylum, Barnsley
Hall, Bromsgrove.

1901. Smyth, Robt. B., M.A., M.B., Ch.B., Senior Assistant Medical Officer,
County Asylum, Gloucester.

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

1885. Soutar, James Grieg, M.B., Barn wood House, Gloucester.

1906. Spark, Percy Charles, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

The Colony, Ewell, Surrey.

1883. Spence, John Buchan, M.D., M.C., The Asylum, Colombo, Ceylon.

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

1891. Stansfield, T. E. K., M.B., C.M.Edin., Baldwyn’s Park, Bexley, Kent.
1901. Starkey, William, M.B., B.Ch., B.A.O.Roy. Univ. Irel., Assistant Medical
Officer, Lancashire County Asylum, Prestwick, near Manchester.

1907. Steele, Patrick, M.B., Ch.B.Edin., Assistant Medical Officer, Edinburgh

District Asylum, Bangour, Uphall.

1898. Steen, Robert H., M.D.Lond., B.A., R.U.I., Medical Superintendent,

City of London Asylum, Stone, Dartford.

1905. Stevenson, William Edward, M.B., B.S.Durh., c/o P. k O. S.N. Co.,

122, Leadenhall Street, E.C.

1905. Stewart, Frederick William, B.A., M.D., B.Ch., B.A.O.I., Dipl. Ment.

Dis., R.U.I.,Keut County Asylum, Barming Heath, near Maidstone.

Digitized by L^ooQle

Members of the Association. xxiii

1907. Stewart, Helen C., M.B., Ch.B.Birm., Edala, Chigwell, Essex.

1868. Stewart, James, F.R.C.P.Edin., L.R.C.S.lrel., Junior Constitutional Club,
Piccadillj, S.W.; 40, South Hill Park, Hampstead Heath.

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

1905. Stillwell, Henry Francis, L.R.C.P.&S.E., Barnwood House, Gloucester.
1862. Stilwell, Henry, M.D.Edin., M.R.C.S.Eng., Hanover Lodge, Compton
Road, Eastbourne.

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

Middlesex.

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

1897. Stoddart, William Henry Butter, M.D., B.S.Lond., M.R.C.S.Eng.,

M.R.C.P.Lond., Bethlem Royal Hospital, London, S.E.

1905. Strathearn, John, M.B., Ch.B., British Ophthalmic Hospital, Jerusalem.

1903. Stratton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., The Royal
Societies Club, St. James's Street, S.W.

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

Willows, Lancashire.

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

Asylum, Rosslynlee, N.B.

1886. ~Suffern, Alex. C., M.D., Medical Superintendent, Ruberry Hill Asylum

near Bromsgrove, Worcestershire.

1894. Sullivan, William C., M.D.R.U.I., 444, Camden Road, London, N.

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

chester.

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

51, Queen Street, Edinburgh.

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

1901. Sykes, Arthur, M.R.C.S., L.R.C.P., Medical Superintendent, 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.

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

1904. Tate, Robert George H., M.D., D.P.H., Lt. R.A.M.C., c/o Messrs. Holt
& Co., 3, Whitehall Place, S.W.

1857. Tate, William B., M.D.Aber., M.R.C.P.Lond., M.R.C.S.Eng., Medical
Superintendent, 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., Medical Superintendent, East Sussex Asylum,
Hellingly.

1907. Taylor, John Archibald, M.B., Ch.B.Edin., Assistant Medical Officer,
County and City Asylum, Powick, Worcester.

1904. Thompson, Alexander D., M.B., Ch.B.Glasg., “Parkburst," Edinbro*

Road, Dumfries, N.B.

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

1903. Thomson, Herbert Campbell, M.D., F.R.C.P.Lond., Assist. Physician
Middlesex Hospital, 34, Queen Anne Street, W.

1905. Thomson, James Hutcheon, M.B., Ch.B.Aberd., Powick Asylum,

Worcester.

1905. Thwaites, Harry, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
Lebanon Hospital, Asfuriyeh, near Beyrout, Syria.

1905. Tidbury, Robert, M.D., R.U.I., M.Ch., L.M., The Borough Asylum,
Ipswich.

1901. Tighe, John Y. G. B., M.B., B.Ch., B.A.O.Irel., North Riding Asylum,
Clifton, Yorks.

1900. Tinker, William, M.R.C.S., L.R.C.P., Hordle House, Brockenhurst,
Hants.

Digitized by L^ooQle

xxiv Members of the Association .

1898. Todd, Percy Everard, M.B., Medical Superintendent, Pretoria Asylum,
Transvaal, South Africa.

1903. Topham, J. Arthur, B.A.Cantab., M.R.C.S.&P.Lond., County Asylum,

Chart ham, Kent.

1896. Townsend, Arthur A. D., M.D., Assistant Medical Officer, Hospital for
Insane, Bamwood House, Gloucester.

1904. Treadwell, Oliver Fereira Naylor, M.R.C.S.Eng., L.S.A., H. M. Prison,

Parkhurst, I. of W.

1903. Tredgold, Alfred F., M.R.C.S., L.B.C.P., 6, Dapdune Crescent, Guild¬
ford, Surrey.

1902. Trevelyan, Edmund Fauriel, M.D.Lond., F.R.C.P.Lond., Assistant

Physician to the Leeds General Infirmary, 40, Park Square, Leeds.
1881. Tuke, Charles Molesworth, M.R.C.S.Eng., Chiswick House, Chiswick.

1888. Tuke, John Batty, jun., M.D., F.R.C.P.Edin., Resident Physician,

Saughton Hall, Edinburgh; Linden Lodge, Loanhead, Midlothian.
1886. Tuke, T. Seymour, M.A., M.B., B.Ch., 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. (Late Son, Secretary for
Scotland.)

1906. Turnbull, Peter Mortimer, M.B., B.Ch.Aberd., Tooting Bee Asylum,
Tooting, S.W.

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

1906. Turner, Frank Douglas, M.B.Lond., M.R.C.S., L.R.C.P., Medical Officer,

Eastern Counties Asylum for Idiots, Colchester.

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

County Asylum, Brentwood.

1903. Turner, Oliver P., M.R.C.S., L.R.C.P., Peck ham House, Peckham, S.E.

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

James Murray’s Royal Asylum, Perth. (Co-Editor of Journal eince
1894.) (Hon. Secretary for Scotland , 1886-94.) (President,
1898-9.)

1907. Urquhart, Annie Davidson, M.B., B.Ch.Edin., Assistant Medical Officer,

Northumberland County Asylum, Morpeth.

1904. Vincent, George A., M.B., B.Ch.Edin..Assistant Medical Superintendent,

St. Ann’s Asylum, Trinidad, B.W.I.

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

Asylum, near Sheffield.

1884. Walker, Edw. B. C., M.D., C.M.Edin., Medical Superintendent, East
Sussex Asylum, Haywards Heath.

1896. Walker, William F., L.R.C.S.&L.M.Edin., L.S.A.Lond., Plas-yn-Dinas,

Dinas Mawddwy, Merionethshire.

1900. Walters, John Basil, M.R.C.S.Eng., L.R.C.P.Lond., 61, Devonshire Street,
Portland Place, London, W.

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

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

85, Parliament Street, Box 78, Cape Town, South Africa.

1902. Watson, Frederick, M.B., C.M.Edin., The Grange, East Finchley,
London, N.

1891 Watson, George A., M.B., C.M.Edin., M.P.C., County Asylum, Rainhill,
Liverpool.

1885 Watson, William Riddell, L.R.C.S. and L.R.C.P.Edin., Govan District
Asylum, H&wkhead, Paisley.

1897. Welsh, Gilbert Aitken, M.D., 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 Bancks, M.R.C.S., Medical Superintendent, Winson
Green Asylum, Birmingham. (President, 1891.)

1884. White, Ernest William, M.B.Lond., M.R.C.P.Lond., Fenstanton, Christ¬
church Road, Streatham'Hill, S. W.; and Ferndale, Sevenoaks. (Son.
Sec. South-Eastern Division , (1897-1900. (President 1903-4.)

Digitized by L^ooQle

Members of the Association. xxv

1906. White, Robert George, M.A., M.B., B.Sc., Ch.B., Pathological Depart¬

ment, School of Medicine, Cairo, Egypt.

1903. Wbittingham, George M., M.R.C.S., L.R.C.P., West Ham and East
London Hospital, Stratford, E.

1905. Whittington, Richard, M.A., M.D., 1, Sillwood Place, Brighton, Sussex.

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

Suffolk County Asylum, Melton Woodbridge.

1903. Wigan, Charles Arthur, M.D.Durh., M.R.C.S.Eng., Deepdene, Portis-

head, Somerset.

1883. Wigleeworth, Joseph, M.D., F.R.C.P.Lond., Rainhill Asylum, Lancashire.
(Pbbsidbht, 1902-8.)

1895. Wilcox, Arthur William, M.D., C.M.Edin., 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.A., M.D., C.M., Bethnal House, Cambridge
Road, N.E.

1907. Williams, Charles E. C., B.A., M.B., B.Ch.Dubl., Assistant Medical

Officer, Holloway Sanatorium, Virginia Water, Surrey.

1905. Williams, David John, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
The Asylum, Kingston, Jamaica.

1901. Wilson, Albert, M.D.Edin., 22, Langham Street, Portland Place, W.

1904. Wilson, Geoffrey Plumpton, M.R.C.S., L.R.C.P.Lond., Kesteven Asylum.

Sleaford, Lines.

1890. Wilson, George R., M.D., C.M., M.P.C., 8, Rutland Square, Edinburgh.

1896. Wilson, Robert, M.B., C.M.Glasg., Nailsworth, 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., 11, Burwood Place,
Connaught Square, Hyde Park, W.; and Little Combe, Charlton.
1894. Wood, Guy Mills, M.B.Durh., 49, Gordon Square, London, W.C.

1904. Wood, Martin Stanley, M.B., Ch.B.Viet., Royal Asylum, Cheadle,

Cheshire.

1903. Wood, Maurice Dale, M.D.Durh., B.S., Assistant Medical Officer,
Brighton Borough Asylum, Haywards Heath, Sussex.

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. (Pbbsidbvt, 1906-6.)
1885. Woods, J. F., M.D„ M.R.C.S., 7, Harley Street, Cavendish Square, W.

1905. Worsley, Richard Le Geyt, M.R.C.S., L.R.C.P., H.M. Prison, Liverpool.
1900. Worth, Reginald, M.R.C.S., L.R.C.P., Middlesex Asylum, Tooting, 8.W.
1877. Worthington, Thomas Blair, M.A., M.D., and M.C.Trin. Coll., Dubl.,

95, Breoonsfield Villas, Preston Park, Brighton.

1862. Yellowlees, David, LL.D., M.D.Edin., F.F.P.S.Glasg., 6, Albert Gate,
Dowan Hill, Glasgow. (Pbbsidbht, 1890.)

Obdivaby Mbvbbbs . 646

Hohobaby Mb mb bbs . 30

COBBBBFOHDING MXMBEBS . 15

Total. 691

Members are particularly requested to send changes of address, etc ., to Dr.
C. Hubert Bond, the Honorary Secretary, 11, Chandos Street, Cavendish
Square, London, W., and in duplicate to the Printers of the Journal ,
Messrs. Adlard and Son, 22\ Bartholomew Close, London, B.C.

Digitized by L^ooQle

List of those who have 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 0.

Cook, William Stewart.

Adkins, Percy, R.

Cooper, Alfred J. S.

Ainley, Fred Shaw.

Cope, George Patrick.

Ainslie, William.

Corner, Harry.

Alexander, Edward H.

Cotton, William.

Anderson, A. W.

Couper, Sinclair.

Anderson, Bruce Arnold.

Cowan, John J.

Anderson, John.

Cowie, C. G.

Andriezen, W.

Cowie, George.

Armour, E. F.

Cowper, John.

Attegalle, J. W. S.

Cox, Walter H.

Aveline, H. T. S.

8 Craig, M.

Ballantyne, Harold S.

Cram, John.

Barbour, William.

Crills, G. H.

Barker, Alfred James Glanville.

Cross, Edward John.

Bashford, Ernest Francis.

Cruickshank, George.

Begg, William.

Cullen, George M.

Belben, F.

Cunningham, James F.

Bird, James Brown.

Dalgetty, Arthur B.

Blachford, J. Vincent.

Davidson, Andrew.

Black, Robert S.

Davidson, William.

Black, Victor.

6 Dawson, W. R.

Blackwood, John.

De Silva, W. H.

Blandford, Henry E.

Distin, Howard.

7 Bond, C. Hubert.

Dixon, J. F.

Bond, R. St. G. S.

Donald, Wm. D. D.

Bowlan, Marcus M.

Donaldson, R. L. S.

Boyd, James Paton.

Donellan, James O’Conor.

Bristowe, Hubert Carpenter.

Douglas, A. R.

Brodie, Robert C.

Downey, Augustine.

Brough, C.

Drummond, Russell J.

Browne, Hy. E.

Eames, Henry Martyn.

Bruce, John.

Earls, James H.

Bruce, Lewis C.

East, W. Norwood.

Brush, S. C.

Easterbrook, Charles C.

Bulloch, William.

Eden, Richard A. S.

Calvert, William Dobree.

Edgerley, S.

Cameron, James.

Edwards, Alex. H.

Campbell, Alex Keith.

Elkins, Frank A.

Campbell, Alfred W.

Ellis, Clarence J.

Campbell, Peter.

English, Edgar.

Carmichael, W. J.

Eustace, J. N.

Carruthers, Samuel W.

Eustace, Henry Marcus.

Carter, Arthur W.

Evaus, P. C.

Chambers, James.

Ewan, John A.

Chapman, H. C.

Ezard, Ed. W.

Christie, William.

Falconer, A. R.

Clarke, Robert H.

Falconer, James F.

Clayton, Frank Herbert A.

Farquharson, Wm. Fredk.

Clayton, Thomas M.

Fennings, A. A.

Clinch, Thomas Aldous.

Ferguson, Robert.

Coles, Richard A.

Findlay, G. Landsborough.

Collie, Frank Lang.

Fitzgerald, Gerald.

Collier, Joseph Henry.

Fleck, David.

Conolly, Richard M.

Fox, F. G. T.

Conry, John.

Fraser, Donald Allan.

Digitized by L^ooQle

XXV11

Fraser, Thomas.

Frederick, Herbert John.

Gandhi. Francis Neel.

Gawn, Ernest K.

Gemmell, William.

Genney, Fred. S.

Gibb, H. J.

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilmour, John R.

Goldie, £. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Wemyss.

Grant, Lachlan.

Gray, Alex. C. E.

Griffiths, Edward H.

Hall, Harry Baker.

Hals ted, H. C.

Haslam, W. A.

Haslett, William John Handfteld.
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hen nan, George.

Hewat, Matthew L.

Hewitt, D. Walker.

Hicks, John A., jun.

Hitchings, Robert.

Holmes, William.

Horton, James Henry.

Hotchkis, R. D.

How den, Robert.

Hngbes, Robert.

Hntchinson, 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 Truby.

Laing, C. A. Barclay.

Laing, J. H. W.

Law, Thomas Bryden.

Leeper, Richard R.

Leslie, R. Murray.

Livesay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Low, Alexander.

McAllum, Stewart.

Macdonald, David.

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

Macdonald, W. F.

Macevoy, Henry John.
McGregor, George. ,

Maclnnes, Ian Lamont.
Mackenzie, Henry J.

Mackenzie, John Cumming.
Mackenzie, T. C.

Mackenzie, William H.
Mackenzie, William L.

Mackie, George.

McLean, H. J.

Macmillan, John.

5 Macnaughton, 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, Wra. Lewis.

Masson, James.

Meikle, T. Gordon.

Melville, Henry B.

Middlemass, James.

Miller, R. H.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Monteith, James.

Moore, Edward Erskine.

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

Murison, T. D.

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, Landel R.

Owen, Corbet W.

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.

Digitized by L^ooQle

XXV111

Pitcairn, John James.

Porter, Charles.

Price, Arthur.

Fring, Horace Reginald.

Rainy, Harry, M.A.

Ralph, Richard M.

Rannie, James.

4 Raw, Nathan.

Reid, Matthew A.

Renton, Robert.

Rice, P. J.

Rigden, Alan.

Ritchie, Thomas Morton.

Rivers, W. H. R.

3 Robertson, G. M.

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

Rose, Andrew.

Rowand, Andrew.

Rudall, James Ferdinand.

Rust, James.

Rust, Montague.
lORutherford, J. M.

Sawyer, Jas. E. H.

Scott, George Brebner.

Scott, J. Walter.

Scott, William T.

Seuwright, H. G.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skae, F. M. T.

Skeeu, George.

Skeen, James H.

Slater, William Arnison.

Slattery, J. B.

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.
Stoddart, John.

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

Strong, D. R. T.

Stuart, William James.
Symes, G. D.

Thompson, A. D.

Thompson, George Matthew.
Thomson, Eric.

Thomson, George Felix.
Thomson, James H.

Thorpe, Arnold E.

Trotter, Robert Samuel.
Turner, W. A.

Umney, W. F.

Walker, James.

Wallace, J. A. L.

Wallace, W. T.

Warde, Wilfred B.
Waterston, Jane Elizabeth.
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. O.
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 awnrded.
10 To whom the Gaskell Prize (1906) was awarded.

Digitized by L^ooQle

THE

\\v>\

JOURNAL OF MENTAL SCIENCE

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

No. 224 [ m, n w „"£.“] JANUARY, 1908. Vol. LIV.

Part I.—Original Articles.

Amentia and Dementia: a Clinico-Pathological Study.
By Joseph Shaw Bolton, M.D., M.R.C.P., Fellow of
University College, London; Senior Assistant Medical
Officer, Lancaster County Asylum, Rainhill.

PART III.—DEMENTIA {continued).

PAGE

[Introduction .LH. 22i]

[The general pathology of mental disease and the functional regions of

the cerebrum .LI I. 224 ]

[.Mental confusion and dementia .LII. 428 ]

[Varieties of dementia .LII. 711 ]

[Group /—Primarily neuronic dementia .LII. 716 ]

Group II—Progressive and secondary dementia . 2

(a) Progressive senile dementia . 10

Morbid anatomy and pathology. 12

Symptomatology.* . 19

(b) Dementia paralytica . 22

Heredity of insanity and of parental and family degeneracy . 26
Death-rates in mental disease (including and excluding

dementia paralytica). 32

Morbid anatomy of dementia paralytica. 37

Regional cortical wasting in dementia paralytica . . 41

Cerebral under-development in certain types of dementia

paralytica . 48

Clinical types of dementia paralytica. 49

Summary. 55

[Group III—Special varieties of dementia .]

LIV. I

Digitized by L^ooQle

AMENTIA AND DEMENTIA,

[Jan.,

Group II.— Progressive and Secondary Dementia.

The present portion of this paper deals with the subject of
progressive and secondary dementia. It includes the con¬
sideration of those cases of mental disease which, owing to the
existence of certain extra-neuronic encephalic morbid states,
do not develop a practically stationary condition of mental
enfeeblement consequent on the loss of a proportion of the
higher cortical neurones, but undergo a more or less rapidly
progressive process of neuronic dissolution, which, if the patient
survives to such a stage, finally ends in gross dementia.

As has already frequently been stated, the necessary pre¬
cursor to dementia, in the opinion of the writer, is the symptom-
complex which he has already exhaustively considered under
the term “ Mental Confusion ” ( Journal of Mental Science , July,
1906).

When referring to the causes of mental confusion, he has
expressed the view that the necessary precedent to this psychic
state is, in at least all severe cases, a deficient durability of the
higher cortical neurones , which ranks, therefore, as the essential
physical basis.

Further, he has dealt with the non-pathological and secon¬
dary or exciting causes of this symptom-complex, namely, the
various forms of physical and mental stress , which, especially at
the “ critical ” periods of life, often excite morbid changes in
cortical neurones of deficient durability, although they would
be relatively or absolutely without prejudicial influence on
normal cortical neurones. This factor merely causes temporary
mental disturbances (unassociated with any considerable degree
of mental confusion) in such individuals as possess cortical
neurones of average durability but of subnormal or abnormal
development and of imperfect functional stability.

Lastly, he has referred to the chief exciting or secondary
causes of mental confusion which are pathological in nature,
and has classed these into two groups. In the first of these
groups has been considered the direct action of toxines 9 especially
alcoholic excess and the toxaemia which frequently follows
childbirth, but also, though more rarely, the different toxaemias
and infections.

Whether the cases of mental confusion which arise in con¬
sequence of the action of one or more of these causative agents

Digitized by L^ooQle

BY JOSEPH SHAW BOLTON, M.D.

1908.]

recover, or develop a mild or moderate grade of dementia,
depends on the resistance of the affected neurones and on the
extent and severity of the pathological changes which are
produced. In the latter case, the result is an example of the
“primarily neuronic dementia” which has been considered in
the last division of this paper, and the patient may remain in a
stationary condition of mild or moderate mental enfeeblement
for many years, or even for life.

In the case of the second group of pathological and secondary
causes of mental confusion the results are different, and it is to
the consideration of these that the present portion of this paper
is devoted. These causes are, in essence, consequences of the
indirect action of toxines, which results in imperfect nutrition of
the cortical neurones and therefore tends to interfere with their
vitality and functional stability.

This indirect action of toxines will be considered under two
main headings, the contents of which present much similarity
as regards pathology but differ considerably in details of pro¬
cedure and in symptomatological consequences. They are
responsible respectively for the types of case described under
the terms “ Progressive Senile Dementia ” and “ Dementia
Paralytica.” In both groups pathological changes exist in the
cerebral vessels. These changes in the first group are chiefly
of a degenerative or “ wearing out ” nature, and in the second
are partly degenerative and partly of the nature of a reparative
reaction. In the first the vascular changes are chiefly the
result of natural decay, and in the second they are largely the
consequences of an enhanced capacity of reparative reaction
which is due to the previous occurrence of a severe and pro¬
longed systemic toxaemia. In the first group general non¬
neuronic reparative reaction is feeble, and in the second it is
variable, and in many cases very marked. In both groups the
effect on the neurones is partly caused by imperfect nutrition
and partly by secondary toxaemia. In both groups there is a
tendency to the formation of a “ vicious circle,” but in the
second this is much the more marked owing to the greater
capacity of reparative reaction which exists. In the first group
the patients are senile or presenile; in the second they are
usually adult, but may be of any age from puberty to advanced
senility.

Digitized by L^ooQle

AMENTIA AND DEMENTIA,

[Jan.,

Group A.—Degeneration of the Cerebral Vessels accompanying
Senility or Premature Senility .

As has been shown in the first part of this paper and also in
greater detail in a previous paper (Archives of Neurology , vol. ii),
there is a direct relationship between the presence of degenera¬
tion of the cerebral vessels and the development of severe
dementia.

The chief facts bearing on this relationship are as follows :

(1) Simple senility (i.e., old age) is not necessarily associated
with gross degeneration of the cerebral vessels.

(2) In the insane, gross degeneration of the cerebral vessels
may exist without dementia.

(3) Dementia, except in rare cases of slowly progressive pre-
senile involution of the cortical neurones, does not progress
beyond a moderate stage, if gross degeneration of the cerebral
vessels does not coexist.

(4) In the 200 cases of Series A, and in the 233 cases ot
Series B, the percentage amount and also the severity of naked-
eye degeneration of the cerebral vessels vary directly with the
degree of dementia present.

(5) Severe degeneration of the cerebral vessels occurs before
the development of gross dementia. In recent senile cases,
with the mildest grade of dementia, but with considerable
mental confusion, which, had they lived, would on clinical
grounds have been expected to develop gross dementia, the
percentage of naked-eye degeneration of the cerebral vessels is
as great as it is in Groups IV and V (severe and gross dementia).
On the other hand, in chronic and recurrent senile cases, with
a mild grade only of dementia, naked-eye degeneration of the
cerebral vessels is rarely present and is then relatively slight.

Hence the relationship between the presence of degeneration
of the cerebral vessels and the development of dementia may
be thus summed up: In a cerebrum which has begun to break
down , or where degeneration has progressed to the “ moderate ” stage ,
(Group III, the chronic lunatic with moderate stationary
dementia), the presence or incidence of gross degeneration of the
cerebral vessels will cause more or less rapid progress of the neuronic
dissolution , with resulting gross dementia .

In such cases the pathological process in the neurones is

Digitized by

Google

1908.] BY JOSEPH SHAW BOLTON, M.D. 5

caused on the one hand by imperfect nutrition and on the
other by secondary intoxication from incomplete removal of
the waste products of metabolism and dissolution, and relatively
little encephalic extra-neuronic reparative reaction occurs
owing to the degenerative or “ wearing out ” nature of the
whole process.

The dementia which supervenes progresses rapidly or slowly
until death occurs.

It may be added that, whilst “ wearing out ” of the cerebral
arteries ensues at different ages in different individuals, and as
a rule only occurs when old age is reached, the premature in¬
duction of this by such devitalising agents as prolonged alcoholic
excess and by organic affections, particularly of the heart and
kidneys, is fairly common. The writer is of the opinion that
usually rather more extra-neuronic reparative reaction occurs
in the latter cases than in those in which the “ wearing out ”
is due to simple senile decay.

Group B.—Certain Vascular and Neuroglial (and chiefly Secon¬
darily Neuronic) Changes which Follow the Prolonged Action
o/Toxines, etc.

These appear to be largely of the nature of secondary pro¬
liferation after, or of reaction to the injury produced by the
poison, toxine or pathogenic micro-organism; and their onset,
in the opinion of the writer, is not necessarily coincident
in time with its exhibition, but ensues as the result of adverse
influences occurring at any subsequent period of life. That
this statement is in accord with general pathology can readily
be illustrated. Prolonged immunity is common after many
of the severe specific infections, which induce profound and
more or less permanent protective modifications of general
metabolism. Excessive local reparative reaction often occurs
after diphtheria, scarlet fever, and syphilis, and results in
intractable strictures of orifices. On the other hand, a similar
local reparative reaction in the arteries after an attack of
syphilis is later on followed by dilatation and the formation
of aneurysms. Further, injuries in the subjects of former
syphilis frequently result in the occurrence of excessive local
reparative reaction, and dense fibrous scars often follow
abscesses, vaccination, etc., in the case of such persons. This

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AMENTIA AND DEMENTIA,

[Jan.,

fact is as readily explicable on the ground that the tissues, in
consequence of a former attack of syphilis, possess a per¬
manently enhanced capacity for reparative reaction to injury,
as on the commonly accepted thesis that the Spirochata
pallida still exists in the body, after perhaps as long a period as
twenty-five years.

The chief variety of mental disease which falls under the
above heading is the dementia paralytica (general paralysis)
which is a frequent sequela of systemic syphilis in degenerates
and which rapidly or slowly passes on to a fatal issue.

As various authors give the percentage of ascertained pre¬
vious syphilis in cases of dementia paralytica as anything from
50 or less to 100, and as several writers deny any direct causal
relationship between syphilis and dementia paralytica, it would
be futile to introduce such diverse and extraneous conclusions
into this paper. The writer therefore purposes to confine him¬
self to the repetition of his own previously published statistics
on the subject, and especially so as prolonged experience has
convinced him of their substantial accuracy.

These statistics deal with 19 private and 83 rate-paid patients,
in the case of whom, in the course of a systematic inquiry into
their histories, he was able to obtain trustworthy personal
details.

In 15 of the 19 private cases there was a history or clear
clinical evidence of former syphilis, and the date of infection,
where it could be ascertained, was from four to twenty-five
years before the onset of mental symptoms. The following
details were obtained concerning the remaining four cases:

Case 3.—Tabetic general paralysis. Was twelve years in
the Army, and was then in the police force. Had been married
for twelve years without children.

Case 4.—Tabetic general paralysis. Was an Indian Govern¬
ment official for over thirty years, and at the age of thirty-
seven married a half-breed, with whom he lived a jealous and
unhappy life.

Case 8.—Patient stated that he had had several gonorrhoeas
and orchitis in each testicle on separate occasions.

Case 15.—Patient stated that he had had several gonorrhoeas
and gleets, and had also suffered from orchitis.

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1908 .] BY JOSEPH SHAW BOLTON, M.D. 7

Hence, of the 19 cases, syphilis was certain in 15 (79 per
cent.), and probable in the remaining 4 (21 per cent.).

Of the 83 rate-paid cases, syphilis was proved to have existed
in 59. The information was obtained from the histories, or
from clinical or post-mortem evidence, and in some instances
from all these sources. Syphilis had also probably existed in
another 11 cases, there was no evidence for or against in 11,
and it was definitely denied by the relatives in 2 cases. In the
latter cases the only evidences against the disease were the
direct negatives of the friends and the absence of clinical signs.
In other cases where syphilis was proved to have existed an
equally definite denial was given by the friends. Of the 59
cases in which it had certainly existed, it was probably “ con¬
genital ” in 4, and was probably acquired after puberty in the
remainder. Where the information was available, the date of
syphilisation varied from nine to twenty-five years before the
onset of dementia paralytica.

Hence, of the 72 cases which it is possible to employ, syphilis
had existed in 59 (82 per cent.), and had probably existed in 11
{iS per cent.).

The writer therefore considers himself justified in concluding
that syphilis is a necessary antecedent to, and is causally related
to the development of dementia paralytica.

On the basis of this conclusion it is possible to demonstrate
that the course taken by cases of dementia paralytica depends
largely on their respective degrees of cerebral degeneracy, and
also, as will be shown later in this section, that dementia para¬
lytica is not a special organic disease of the cerebrum, but is a
branch of ordinary mental disease.

In the under-developed and poorly-constructed neurones of
the imbecile variety of juvenile general paralysis, the process of
dissolution is slow, and the neuronic changes, as has been shown
by Watson, are proportionately more extensive than are the
vascular and neuroglial.

On the other hand, in the better-developed cerebra of the
ordinary juvenile general paralytic, who is infected with syphilis
at birth or thereabouts, the process of dissolution is more rapid,
and vascular and neuroglial proliferation is more pronounced.

Further, in adult cases of general paralysis the course is
usually chronic in degenerates, who readily break down under
the influence of external “ stress,” and who, therefore, require

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8 AMENTIA AND DEMENTIA, [Jan.,

early segregation, with the consequent relative absence of this
factor; and it is commonly more rapid in the less degenerate
subjects, who, before breakdown occurs, are frequently subjected
to the severest forms of mental and physical “stress,” and
whose neurones are therefore strained to the utmost before
asylum rigime becomes necessary. In both these types, as the
syphilitic infection at the time of its occurrence had acted on
already developed neurones, and therefore had not induced
still further developmental disabilities in these, vascular and
neuroglial proliferation is pronounced.

Finally, in senile cases of general paralysis, in which
reparative reaction is naturally more feeble, the course of the
process of dissolution is variable, and the general type of the
symptomatology and of the morbid anatomy and histology
approximates towards that which exists in progressive senile
dementia.

Though a former attack of syphilis, as has been stated, is
usually the important extraneous factor in the production of
progressive (secondary) non-senile dissolution of the higher
neurones of the cerebrum, and is responsible for the develop¬
ment of the clinical entity termed “ dementia paralytica,” other
influences, particularly certain of the slowly-acting metallic
poisons— e.g., lead—produce a progressive cerebral dissolution
of similar character.

Further, of the insane who are the subjects of epilepsy, about
25 per cent, suffer from a similar progressive disintegration of
the higher neurones of the cerebrum, which, in well-marked
cases, presents a clinical symptomatology and a morbid anatomy
which in many important details resemble those existing in
dementia paralytica.

It may be added that such devitalising factors as prolonged
alcoholic excess, etc., play an important secondary part in the
development of many of the cases referred to under this heading,
by producing morbid changes, not only in the higher neurones
of the cortex, but also in the cerebral blood-vessels.

As dementia paralytica consists in essence, as will be seen
later, of a dissolution of the (human) centre of higher association,
it is necessarily impossible to reproduce this clinico-pathological
entity by experiment on the lower animals. Watson has, how¬
ever, shown that the prolonged exhibition of certain virulent
neurone toxines— e.g., abrin and ricin—produces in the cerebrum

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1908.] BY JOSEPH SHAW BOLTON, M.D. 9

of the guinea-pig or rabbit dissolution of cortical neurones and
proliferation of the neuroglia and blood-vessels. There is no
doubt that the former is the direct result of neurone intoxication,
and that the latter is a reparative reaction to the injury pro¬
duced. Though such experimental results present no true
homology to human dementia paralytica and progressive
dementia, they nevertheless indicate that the non-neuronic
elements of the encephalon react to neurone destruction, as do
the local mesoblastic elements of other parts of the body to
destruction of glandular epithelium. From this aspect they
are therefore of great importance in that they experimentally
support the soundness of the thesis, based on grounds of general
pathology and advocated by the writer in the present and
previous papers, that the morbid process in dementia paralytica
is the pathological ally of that occurring in the different types
of progressive dementia, and is, in essence, in no way dissimilar
(differences in structure and function being allowed for), from
the morbid process which occurs in, for example, certain forms
of renal cirrhosis.

It may further be added that the results of these experiments
indicate the likelihood that the morbid process in acute or
advanced cases of dementia paralytica may be much aggravated
by such secondary microbic invasions as necessarily occur
owing to the decreased resistance of such patients to the
attack of organisms, which, under normal conditions, might
not be pathogenic.

The cases belonging to the present group of " progressive
and secondary dementia” amount to 47 only, thus forming
io # 6 per cent, of the total of 445 cases of dementia, and 6*5 per
cent, of the total of 728 cases of amentia and dementia.

They will be divided in accordance with the pathological
considerations just adduced, into the following classes :

M. F. T.

Class (a ).—Progressive senile dementia . 9 15 24

Class (b ).—Dementia paralytica . . . 14 9 23

Total 23 24 47

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IO AMENTIA AND DEMENTIA, [Jan.,

Class (a).

Progressive Senile Dementia.

The cases to be referred to under the term “ Progressive
Senile Dementia ” differ from the contents of the preceding
group of “ Primarily Neuronic Dementia ” in the fact, as has
already been indicated, that the dementia is not stationary, but
progresses rapidly or slowly until death occurs.

In the case of the preceding group, as the result of morbid
changes in the higher neurones of the cerebral cortex in
association with (acute) symptoms of mental alienation and
such a degree of mental confusion as is the necessary con¬
comitant of these morbid changes, a certain degree of neuronic
dissolution results. This finds its symptomatological expres¬
sion in a grade of dementia which varies in degree from “ mild ”
to “ moderate/’ and it exhibits from the physical aspect certain
intra-cranial morbid changes which have been described in the
first part of this paper (Journal of Mental Science , April, 1905),
under Groups II and III, namely “ cases with slight morbid
changes and where the pia-arachnoid strips rather more readily
than natural,” and “ cases with moderate morbid changes, with
subdural excess to the level of the tentorium, and where the
pia-arachnoid strips readily.” Such cases, as the acute morbid
changes, which constitute the physical basis of the “acute”
symptoms presented, result in the maiming or death of numbers
of the affected higher cortical neurones, pass into, and then for
long periods remain in, a stationary condition of mild or
moderate dementia.

In the case, however, of the class at present under considera¬
tion, that of progressive senile dementia, no such stationary
condition of dementia ensues, but dissolution of the higher
neurones of the cortex progresses more or less rapidly until the
centre of higher association is practically non-existent, exten¬
sive dissolution of many of the regions of lower association has
resulted, and the patient is consequently in a condition of gross
dementia.

This result is due, as has already been shown in summary at
the commencement of this section and demonstrated at length in
the first part of the present and also in a previous paper, to the
existence of gross degeneration of the cerebral vessels. In some

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1908.]

BY JOSEPH SHAW BOLTON, M.D.

cases this morbid condition is present at the time of onset of the
attack of insanity, and in others gross degeneration of the cere¬
bral vessels gradually develops in stationary cases of moderate
dementia* In all such cases, however, whether the cerebrum
is beginning to break down or dissolution has already progressed
to the “ moderate” stage (Group III), the determining cause
of a more or less rapidly progressive dissolution of the centre of
higher association is the presence or incidence of gross degenera¬
tion of the cerebral arteries.

Whilst, as a rule, at any rate in comparison with dementia
paralytica, relatively little reparative reaction occurs in the
extra-neuronic elements of the encephalon owing to the
degenerative or “ wearing out ” nature of the whole process, in
many cases a xt vicious circle,” similar to that commonly
occurring in dementia paralytica, undoubtedly develops—
neuronic dissolution being followed by reparative reaction and
this by further and secondary neuronic dissolution—and increases
the rapidity with which the final result is attained. The pro¬
gress of the dissolution is also in many cases assisted by tem¬
porary and local thromboses, which frequently find symptoma-
tological expression in “ seizures ” accompanied by temporary
paresis and homologous, in the opinion of the writer, with the
“seizures” which so commonly occur in dementia para¬
lytica.

Progressive senile dementia thus differs markedly, both in its
pathology and in its termination, from the types of dementia
which have already been considered. As, however, the essential
feature of progressive* senile dementia is a senile dissolution of
the higher neurones and of many of the lower neurones of the
cortex cerebri, the correctness of the inclusion of this type of
dementia under the terms “ mental disease,” or “ insanity,”
may be taken for granted.

It is, however, necessary, as will be seen later, to adopt a
different course in the section dealing with dementia paralytica.
It will consequently be found that the greater portion of the
section referred to deals with evidence which, in the view of the
writer, conclusively shows that dementia paralytica is also a
branch of insanity or-mental disease, and is not a specific
organic disease of the cerebrum. In other words, whilst
progressive senile dementia requires no justification for its
inclusion in the present group of “ Progressive and Secondary

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12 AMENTIA AND DEMENTIA, [Jan.,

Dementia,” such justification is needed, and will be produced,
in the case of dementia paralytica.

Certain of the more important features of the morbid
anatomy, pathology, and symptomatology of progressive senile
dementia will now be referred to. As, however, the morbid
anatomy of mental disease has already been considered at
length in Part I {Journal of Mental Science y April, 1905), and in
Part II {Journal of Mental Science , April, 1906), and as the
symptomatology of mental confusion and its relationship to
that of dementia have been fully discussed in Part II {Journal
of Mental Science , July, 1906), only those details of morbid
anatomy and symptomatology in which progressive senile
dementia differs from primarily neuronic dementia will be
introduced.

Morbid Anatomy and Pathology of Progressive Senile Dementia .

Though naked-eye degeneration of the cerebral arteries is not
one of the morbid changes which necessarily occurs in primarily
neuronic dementia, it is, as has already been stated, a necessary
factor to the development of progressive senile dementia.
Cerebral vascular degeneration may exist in the absence of
dementia. Though evidence of senility or prematurely produced
senility of the cerebral arteries, it is not a necessary consequent
of old age. On the other hand, the grosser forms of dementia
never exist in the absence of macroscopic, or, at the least, of
microscopic, signs of severe degeneration of the cerebral arteries,
even in cases which have not attained to the senile period of
life. Finally, in recent senile cases, with the mildest dementia
but considerable mental confusion, which, had they lived,
would on clinical grounds have been expected to develop gross
dementia, the percentage of naked-eye degeneration of the
cerebral vessels is so high as to justify the assumption that,
were it possible to invariably make a certain diagnosis, this
morbid change would be found to be a constant feature of such
cases.

Such, in brief, are the chief facts on which is based the
conclusion that a causal relationship exists between degeneration
of the cerebral arteries and the development of the grosser
forms of dementia; and the writer therefore places degeneration
of the cerebral arteries first on the list of the morbid appearances
which are found in senile progressive dementia.

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1908.] BY JOSEPH SHAW BOLTON, M.D. 13

As has been pointed out in the first part of this paper, the
intra-cranial morbid appearances which are found in such cases
of mental disease as during life exhibited a greater or a lesser
amount of dementia, namely, chronic degeneration and fibrosis
of the dura mater, excess of intra-cranial fluid, subdural deposits,
chronic thickening of the pia-arachnoid, etc., are the macro¬
scopic equivalents of, and vary in degree with, the grade of
dementia which is present, and are otherwise independent of
the duration of the insanity.

In the several types of “ primarily neuronic dementia,” such
morbid appearances, in agreement with the amount of dementia,
are not as a rule present in more than a moderate grade of
severity (Group III). On the other hand, in the two classes
of “ progressive and secondary dementia,” namely, “ progressive
senile dementia” and “dementia paralytica,” these morbid
appearances in advanced cases attain their maximum intensity
(Groups IV and V), in association with the existence of gross
dementia and more or less complete dissolution of the cortical
neurones of higher association and of many of those of lower
association.

These morbid appearances are the physiological results of
the loss of cerebral substance, caused by the degeneration of the
cortical neurones, which is the physical expression of dementia,
reacting on the mechanical conditions existing within the
cranial cavity. The skull is a closed bony chamber, and were
the neuronic dissolution ever so slow in its progress, replace¬
ment of the lost cerebral tissue could not well be fully per¬
formed by a chronic hypertrophy of the inner wall of the
skull-cap and of the cerebral membranes. The progress of neu¬
ronic dissolution is, as a rule, however, by no means slow, and
in cases of progressive dementia it is relatively rapid, and often
very rapid. In consequence of this, the cerebral membranes,
especially the pia-arachnoid, make a hopeless attempt at the
formation of replacement or scar-tissue, and what space cannot
be filled up in this way is replaced by cerebro-spinal fluid.

The writer feels that he cannot too strongly or too frequently
insist on the importance of excess of intra-cranial fluid in the
pathology of dementia. This excess is so commonly neglected
in descriptions of intra-cranial morbid changes in favour of
gross or fine changes in the dura mater, the pia-arachnoid, or
the cerebrum, that it might almost be supposed to be value-

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14 AMENTIA AND DEMENTIA, [Jan.,

less as a criterion of the degree of cerebral wasting which is
present.

Under normal conditions, as has been shown by Leonard
Hill, the intra-cranial fluid is minimal in amount, and this is
also the case in all types of uncomplicated amentia or cerebral
sub-evolution.

In cases, however, in which but a moderate grade of dementia
exists, there is in the majority of cases such an excess of intra¬
cranial fluid as extends up to, or even above, the level of the
tentorium, as well as considerable cerebro-spinal fluid in the
pia-arachnoid and the ventricles; and a much greater excess
exists in cases of progressive dementia, even when these are
only reasonably advanced.

In the case of sub-dural excess alone in senile progressive
dementia, for example, in the ninety-two cases contained in
Group IV and the seventy-nine cases contained in Group V,
which are referred to in the first part of this paper, excess of
subdural fluid exists in all. In Group IV it is “ slight ” in
5*4 percent., “ moderate” to the level of the tentorium)
in 27*2 per cent ., and “ great ” in 67*4 per cent .; and in Group
V it is “ moderate ” in 177 percent . and “ great ” in 82 '$per cent.

This excess of intra-cranial fluid, which primarily occurs to
replace loss of cerebral substance in the closed bony chamber,
interferes with the normal relationship of the pia-arachnoid
to the dura mater, and converts a potential space into an
actual one full of cerebro-spinal fluid. This fluid, which is
often abnormal in composition, necessarily predisposes to the
development of a chronic degenerative process in both the
dura mater and the pia-arachnoid, as does also the hopeless
attempt at the formation of replacement or scar-tissue which
is made by these membranes. Hence, any more or less sudden
alteration of intra-cranial tension, due, e.g., to a convulsion, a
trauma, etc., or even to the change in blood-content from the
arterial to the venous side, which occurs at or shortly after
death, tends to cause an effusion of blood from the degenerate
and often dilated vessels (arteries or veins) of the dura mater,
the pia-arachnoid, or both. This effusion, whether recent or
partially organised, single or multiple, constitutes the “sub¬
dural deposit” which is so relatively common in cases of well-
marked dementia, and particularly so in cases of advanced
progressive dementia.

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1908.] BY JOSEPH SHAW BOLTON, M.D. 15

In the 433 cases referred to in the first part of this paper,
for example, in Group I (no dementia), sub-dural deposits
existed in 3*1 per cent., and in Group II (slight dementia) they
existed in 5*2 per cent. All these deposits were of an accidental
nature or were recent and sufficiently explicable on general
pathological grounds by the cause and mode of death.

In Group III (moderate dementia) these deposits existed in
17*8 per cent. of the cases; in Group IV (severe dementia) they
existed in 17^4 per cent., and in Group V (gross dementia) they
existed in no less than 22*8 per cent, of the cases.

Extensive morbid changes in the pia-arachnoid are a constant
feature in progressive senile dementia, and the relative severity
of these is well illustrated by the following data.

In cases without dementia (Group I) the pia-arachnoid,
except in cases of cerebral oedema due to systemic causes, strips
naturally. In cases of mild dementia (Group II) this membrane
is slightly thickened and strips rather more readily than natural
in 74 per cent, of the cases, and readily in another 20 per cent.
In cases of moderate dementia (Group III) it is thickened and
at times slightly opaque, and it strips readily in 82 per cent, of
the cases and very readily in another 16 per cent. In cases of
severe dementia (Group IV) it is opaque and much thickened
and it strips readily in 13 per cent, of the cases, very readily in
83 per cent, and like a glove in 4 per cent. Finally, in cases of
gross dementia (Group V), it is very opaque and markedly
thickened, and it strips readily in 1 per cent., very readily in 41
per cent., and like a glove in 58 per cent.

The final important morbid appearance in senile progressive
dementia, namely cerebral wasting, will now be considered.

It is usual, even in relatively recent cases in which incom¬
plete removal of the products of neuronic dissolution has
occurred, to find the cerebral wasting quite pronounced, and
this is still more evident in cases of chronic type. In many of
the latter, however, before the hemispheres have been stripped,
the wasting is by no means evident, in consequence of the
opacity of, and still more, of fibrotic contraction of the pia-
arachnoid. The difference in the appearance of a hemisphere
before and after stripping is, in fact, in many cases, quite
remarkable.

Whilst individual variations in the relative degrees of wasting
exist, which may by future study be associated with differences

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16 AMENTIA AND DEMENTIA, [Jan.,

in symptomatology, the regions of wasting are on the whole
very definite, and by practice can be determined with consider¬
able accuracy.

In uncomplicated cases there is a clear relationship between
the grade of dementia and the degree of wasting present, and,
therefore, cases of progressive senile dementia, as a rule,
present the most clearly-marked examples of the cortical
wasting which has developed pari passu with dissolution of the
higher neurones of the cerebrum.

These regions of wasting are as follows :

(1) The greatest amount occurs in the prefrontal region
(the anterior two-thirds or so of the first and second frontal
convolutions, including the neighbouring mesial surface, and
the anterior third or so of the third frontal convolution).

(2) The wasting is next most marked in the remainder of
the first and second frontal convolutions. [In dementia
paralytica Broca’s convolution should, as a rule, be included
here, and (2) and (3) should follow (4)].

(3) It is, perhaps, next most marked in the ascending frontal
and Broca’sconvolutions, though this grade should, in many
cases at least, follow (4).

(4) It is next most marked in the first temporal convolution
and the insula, and in the superior and inferior parietal lobules.
In practically all cases it is more marked in the two former
than in the two latter.

(5) It is least marked in the remainder of the cerebrum
(including the orbital surface of the frontal lobes), particularly
the inferio-internal aspect of the temporo-sphenoidal lobe and
the posterior pole of the hemisphere.

In the experience of the writer exceptions to this general
order are invariably due to vascular or traumatic causes, and
should, therefore, be excluded from the ordinary and normal
wastings of dementia.

Such exceptions, however, occur not uncommonly in pro¬
gressive senile dementia, owing to the extensive degeneration
of the cortical arteries, which is a constant feature of these
cases. The writer here refers not to definite old or recent soften¬
ings, but to more or less extensive atrophies of convolutions,
which commonly exhibit vermiform or cross-striated markings,
and are obviously due to local ischaemias in the distribution of
(chiefly) the anterior and middle cerebral arteries. Such

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BY JOSEPH SHAW BOLTON, M.D.

1908.]

exceptional regions of wasting are, however, quite readily
separable from the normal wasting caused by dissolution or
retrogression of the centre of higher association.

They are chiefly found in cases in which acute exacerbations
of symptoms, in the form of severe mental confusion with or
without convulsions followed by temporary paresis, have
occurred; and they are usually absent from cases which have
undergone a steady progress to gross dementia. Further, these
local wastings are, in the experience of the writer, absent from
cases which have for years exhibited stereotyped and repeated
motor phenomena, and from the occasional cases of Huntington’s
chorea which have come under his observation. It is probable
that such motor exhibitions are homologous with such normal
phenomena of senility as lower jaw and manual movements.

Cases presenting such local atrophies form, in fact, a half-way
house between cases of ordinary gross dementia and cases of
gross dementia which also exhibit gross lesions of the cerebrum
of vascular origin.

The regions of wasting, which have been described above
will now be further demonstrated by means of illustrative cases.

On Plate IV are exhibited photographs of two hemispheres
from well-marked cases of progressive senile dementia. In
both instances the regions of wasting are obvious, but they are
especially evident when the figures are compared with the
illustrations on Plates I, II, and III. It may be remarked that
all the hemispheres illustrated on the plates are of exactly
the same relative size.

On Plate I are shown the small and very simply convoluted
hemispheres of a case of imbecility with epilepsy. In this case
there were no dementia, no cerebral wasting, and no excess of
intra-cranial fluid, and the stripped right and left hemispheres
weighed respectively 475 and 470 grm.

On Plate II are illustrated the very small and simply convo¬
luted hemispheres of a normal degenerate who died of the
secondary intra-cranial effects of middle-ear disease. In this
case there were no dementia, no cerebral wasting, and no
excess of intra-cranial fluid. The stripped hemispheres weighed
but 430 grm. each, a weight which is almost incompatible with
continued existence outside an asylum. This patient would
probably, in fact, have died at home or in a hospital had he
possessed a cerebrum large enough to withstand the stress of

Liv. 2

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PLATE I. Fig. i.

Cerebrum small and very simply convoluted; no morbid appearances .

(Group I.)

Photograph of the hemispheres of a case of imbecility with epilepsy. The
hemispheres are small and very simply convoluted, but are otherwise of normal
appearance.

History. —Male, aet. 47, single, organ blower. He is stated to have got on fairly
well at school, and to have suffered from fits since the age of fifteen years. In
Claybury Asylum during the last five years of his life. He was simple and childish,
and unable to give a connected account of himself. He was unintelligent, and
possessed deficient reasoning powers. He was untidy in his appearance, and took
little interest in his surroundings.

Post-mortem. —Dura and S.D.: Natural; no excess. Pia: Natural; strips
naturally. S.A.: No excess. Vents.: L., normal; IV, a few granulations in
the lateral sacs. Vessels: Natural. Encephalon: 1,143 gnn. Cerebellum,etc.:
163 grm. R.H.: 485 grm.; stripped 475 gnn. L.H.: 490 grm.; stripped 470
grm. Cause of death : Congestion of right lung; cardiac failure.

[Note. —The illustrations on this and the following plates are all of exactly
the same relative size.]

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Plate I.

To illustrate Dr. J. S. Bolton’s paper.

Dale it Daniehtoii, Ltd.

Digitized by

Google

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Plate II.

JOURNAL OF MENTAL SCIENCE, JANUARY, 1908.

Fig. 2.

To illustrate I)r. J. S. Holton’s paper.

hole (l Iktnielsgon, l.til

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Google

PLATE II. Fio. 2.

Cerebrum simply convoluted and very small; no morbid appearances beyond oedema
due to the local disease . (Group I.)

Photograph of the hemispheres of a case of extra-dural and cerebellar abscess.
The hemispheres are very small; the right is fairly and the left simply^convoluted.
The brain is otherwise normal in appearance.

History. —Male, aet. 39. Father suffered from paralysis. Married nineteen
years, eight children alive. Had lead poisoning six years ago. He exhibited
symptoms for a month before, and died thirteen days after his admission to
Claybury Asylum. He exhibited physical symptoms which suggested general
paralysis. He was confused, helpless, and defective in his habits. He had a
convulsion five days after his admission.

Post-mortem .—Dura and S.D.: Natural; no excess. Pia: Much oedema; strips
like a glove everywhere. S.A.: No excess. Vents.: L., slightly dilated; IV,
granulations in lateral sacs. Vessels: Natural. Encephalon: 855 grm. Cere¬
bellum, etc.: 125 grm. R.H.: 430 grm.; stripped 408 grm. L.H.: 430 grm. 5
stripped 410 grm. Cause of death: (a) Pneumonia; (6) abscess of cerebellum,
local meningitis, extra-dural abscess, necrosis of petrous bone, middle-ear disease.

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Plate III.

JOURNAL OF MENTAL SCIENCE, JANUARY, 1908.

To illustrate Dr. J. S. Bolton’s paper.

Bale Danielesan , Ltd.

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Fig. 5.

To illustrate Dr. J. S. Bolton’s paper.

Bale it Daniclsson , Ltd.

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PLATE IV. Fig. 4.

Cerebrum exhibits the morbid appearances associated with severe dementia (Group
IV). Hemispheres were probably , in their original state, of average sixe and
convolutional pattern .

Photograph of the left hemisphere of a case of marked dementia (Group IV).
The figure shows wasting, which is very marked in the prefrontal region, marked
ia the rest of the frontal region, the superior parietal lobule, the anterior part of
the inferior parietal lobule and the first temporal gyrus, and less marked elsewhere.

History. —Female, aet. 89, widow. No family or personal history. Died in
Claybury Asylum after a residence of five and a half years. On admission was
talkative and reacted well to questions. She had delusions of persecution by
electricity. Her memory was very good for her age. Two years later she was
noisv and troublesome, had delusions on the subject of marriage, worked in the
needle-room, and had developed dementia. Later on she constantly heard voices,
and she was at times very noisy, and she became very demented before her death.

Post-mortem. —Dura: Adherent in the left frontal region. S.D.: Moderate
excess. Deposit: Large recent film, as thick as brown paper, in the left middle
and posterior fossae above the tentorium ; scattered blood-flakes elsewhere. Pia:
Fronto-parietal opacity and considerable thickening; strips very readily. S.A.:
Considerable excess. Vents.: L., moderately dilated; IV, lateral sacs slightly
granular. Vessels: Markedly atheromatous. Encephalon: 1,150 grm. Cere¬
bellum, etc.: 135 grm. R.H.: 492 grm.; stripped 455 grm. L.H.: 485 grm.;
stripped 446 grm. Cause of death: Broncho-pneumonia, senile decay, marked
renal cirrhosis, vascular degeneration, and cardiac hypertrophy.

Fig. 5.

Cerebrum exhibits the morbid appearances associated with gross dementia (Group
V). Hemispheres were probably, in their original state , of average sixe and
convolutional pattern.

Photograph of the left hemisphere of a case of gross dementia (Group V). The
figure shows wasting which is extreme in the prefrontal region, very marked in
the fronto-parietal region, and less marked elsewhere.

History. —Female, aet. 75, milliner. No family or personal history. Died in
Claybury Asylum after a residence of five years. On admission was confused and
had no idea of time or place. Was restless, fearful and somewhat resistive, and
was of defective habits. Two years later she did not know her name or age, was
unable to look after herself, and was wet and dirty. At the time of her death she
was at times restless and noisy, and was quite helpless and grossly demented.

Post-mortem. —Dura: Some congestion in occipital region. S.D.: Enormous
excess. Pia: Considerable fronto-parietal opacity and thickening, nearly natural
elsewhere ; strips like a glove in the frontal region and the first temporal gyrus,
readily over the parietal lobules, and nearly naturally on the orbital surface, the
lower temporo-sphenoidal region, and the occipital pole. S.A.: Great excess,
largely under arachnoid. Vents. : L., much dilated ; IV., granulations in lateral
sacs. Vessels: Considerable atheroma throughout. Encephalon : 1,045 grm.
Cerebellum, etc.: 145 grm. R.H.: 410 grm.; stripped 370 grm. L.H.: 418 grm.;
stripped 383 grm. Cause of death : Gangrene of the right lung, recurrent carci¬
noma of breast, vascular degeneration.

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18 AMENTIA AND DEMENTIA, .[Jan.,

the disease. Under the circumstances, however, he presented
such mental symptoms as relatively obscured those of his
physical disease and suggested that he was suffering from
early and acute general paralysis. This case, in fact, is an
illustration of a truth which the writer considers to be beyond
the range of controversy, namely that whilst great individual
variations in the weight of the cerebrum are compatible with
permanent sanity, a minimum weight (probably about 500 grin,
per hemisphere) nevertheless exists, below which this is difficult
or impossible to preserve.

It will be noted that whilst the hemispheres of this case are
simply convoluted, those of the case illustrated on Plate I are
still more so. In agreement with this detail the latter patient
was an imbecile organ-grinder who suffered from epilepsy, and
who resided in an asylum for the five years preceding his
death.

On Plate III is shown the left hemisphere of a merchant of
considerable business ability who suffered from presenile
melancholia with a mild grade of dementia. In association
with this there existed some excess of intra-cranial fluid. The
unstripped right and left hemispheres weighed respectively
720 and 705 grm., and the left hemisphere in its stripped condi¬
tion weighed no less than 680 grm. The slight degree of
cortical wasting which exists is not obvious in the illustration.
The convolutional pattern is exceptionally complex and the
hemisphere contrasts markedly with those illustrated on
Plates I and II, and especially so when it is borne in mind that
all are of exactly the same relative size.

On Plate IV are illustrated the left hemispheres of two cases
of progressive senile dementia. These illustrations present very
different appearances from those exhibited by the other
figures, which, for purposes of comparison, are shown in the
preceding plates.

Fig. 4 is a photograph of the left hemisphere of a case of
marked dementia (Group IV). The patient, a female, died at
the age of eighty-nine years, after a residence of five and a half
years, during which dementia gradually developed. She died
before the final stage of cerebral dissolution had been reached.
The cerebral arteries were markedly atheromatous. There was
considerable excess of intra-cranial fluid and also a large recent
subdural deposit. The stripped right and left hemispheres

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1908 .]

BY JOSEPH SHAW BOLTON, M.D.

weighed respectively 455 and 446’grm., and they had probably
originally been of average size and of nearly average convolu¬
tional pattern. The wasting is very marked in the prefrontal
region, marked in the rest of the frontal region, the superior
parietal lobule, the anterior part of the inferior parietal lobule
and the first temporal gyrus, and less marked elsewhere.

Fig. 5 presents a still greater contrast to the hemispheres
illustrated on Plates I, II, and III. It represents the left
hemisphere of a case of advanced progressive senile dementia
(Group V). The patient, also a female, died at the age of
seventy-five years, after a residence of five years, in the final
stage of cerebral dissolution. The cerebral vessels were athero¬
matous. There was enormous excess of intra-cranial fluid.
The stripped right and left hemispheres weighed respectively
370 and 383 grm. The cerebellum, however, weighed 10 grm.
more than did that of the last case, and therefore, presumably,
the cerebral hen^pheres had also originally been of greater
weight than those of the last case. It is hence probable that
the hemispheres of the present case had been originally of at
least average size and convolutional pattern. The wasting is
extreme in the prefrontal region, very marked in the fronto¬
parietal region and in the first temporal gyrus, and quite evident,
though less marked, elsewhere.

Judging from his general experience as well as from these
two individual brains, the writer considers the former to be the
more degenerate and the latter to be the less durable cerebrum.
The progress of the cerebral dissolution in the first case was
relatively slow, in spite of the great age of the patient, and of
the presence of gross degeneration of the cerebral vessels. This
indicates the existence of a certain degree of neuronic durability.
The cerebral hemispheres had also, in their original condition,
probably been the smaller and rather the more simply convo¬
luted of the two. On the other hand, in the latter case, cere¬
bral dissolution had, when the patient died, progressed to about
the maximum degree which is compatible with life.

Symptomatology of Progressive Senile Dementia.

It is unnecessary to introduce here a detailed description of
the symptomatology of progressive senile dementia, as the
subjects of mental confusion and dementia have already been

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20 AMENTIA AND DEMENTIA, [Jan.,

considered at length in a previous section (Joum . Ment. Sci.,
July, 1906). On reference to this section it will be seen that
both the symptomatological differences between simple and
presumably recoverable mental confusion and the mental
confusion of progressive senile dementia, and also the more
complex phenomena of lower association which are frequently
presented by the latter type of mental disease, have been fully
referred to.

The present purpose of the writer will therefore be served by
the repetition of a case which illustrates with exceptional
clearness the chief characteristics of the mental confusion of
progressive senile dementia. The interest of this case is
increased by the fact that the exciting cause is stated to be
intemperance, for this factor has not in any way obscured the
details of symptomatology to which it is necessary to draw the
attention of the reader.

Case 21.— Admitted September 22nd, 1904 (Hellingley Asylum).
Exciting cause, intemperance. Duration prior to admission
said to be fourteen days.

Female, married, nurse, set. 75. Admitted four days ago.

A wrinkled old woman who says that her name is “ Sarah C—x,
a large family we are.” This is her married name and her
maiden name was H—s. She then states that she married
again and that her present name is W—m. (Isn’t your name
Mrs. B—d ?) “ I am, sir, because I was a widow and married

Mr. R. B—-d.” She recognises the nurse as “ Mrs. W—m’s
daughter. Mrs. P—r it was once I know. Weren’t your
grandmother’s name P—r ? ” She then tells me that the nurse
is “ Mrs. P—r’s grand-daughter, isn’t it ? I know the old lady
and I know your mother.” She states that she has seen me
before at Bishopstoke. She does not know whether my name
is P—r or not. “ I know Mr. P—r and Mrs. P—r and thought
you were Mr. P—r.” She calls a patient named M. B—d
“ Mrs. T—r,” and another named S. P—x “ Mrs. P—r,” and a
nurse “ Mrs. P—r’s daughter.” She thinks to-day is Sunday
(Monday), and that the date is the 25th or 26th (26th). She
replies that the month is “ not February is it ?” (September),
and that the year is “ I don’t know whether it is 101 or 102 ”
(1904). (Age ?) “ I’m getting on for forty. It’s a nice little

age, isn’t it ? I suppose you’re beginning to shave it, aren’t

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1908.] BY JOSEPH SHAW BOLTON, M.D. 21

yon ? ” (Out to-day ?) “ Yes, I’ve been out to see the cricket
match to-day.” She states that she saw her husband at
Bishopstoke this morning. She brought her husband’s break¬
fast home with her—bread, butter, and oysters. I tell her that
I don’t know a soul in Bishopstoke, and she remarks, “ A soldier
there, are you?” She replies that she has children at home.
The youngest is five or six, and she has twenty-five living, and
thinks it likely that she will have another to make twenty-six.
When asked where she is she replies that it is “ about one mile
from Bishopstoke Station here.” When again asked the same
question she remarks, " Very nice place, I like it very well. I
should think it was a bonny place myself.” I then ask her if
she is a countrywoman, andshe replies, “ Southampton woman.”
She answers questions quickly and apparently rationally, but
as a whole does not volunteer much information about herself.
She laughs and looks about slyly from face to face as if she
thinks that she is amusing. She has evidently lived a rather
dissolute life, as she says, “ I went to Bishopstoke this morn¬
ing. I enjoyed myself I can tell you. I always do when I go
on the spree. I was along with your nephew last time I saw
you, and with his father this morning.” She is very erotic.
When I touch her chin to get her to open her mouth she tells
me I am a rascal, and that “ he thought he’d tickle me under
the chin.” She is wet and dirty in her habits, but is quiet and
no trouble, and she takes her food well.

This patient died two and a-half months after admission in
a condition of advanced dementia.

The chief details of importance which are exhibited by this
case are the following:

(1) The patient does not know the time of year.

(2) She gives her first married name instead of her present
one.

(3) She states that she is “ getting on for forty,” whereas
she is seventy-five years of age.

(4) She confabulates readily, but the psychic phenomena which
are evolved are , on the whole , impossible as statements of fact, and
are largely based on groups of memorial units dealing with her
early life .

(5) She has well-marked illusions of identity, but she continually
employs the same name , “ P —r,” in her identifications.

In all these points the case differs from one of presumably

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AMENTIA AND DEMENTIA,

[Jan.,

recoverable mental confusion, and shows evidence of the mental
confusion of progressive dementia. Other similar examples
have also been cited and discussed in the section referred to—
e.g., Case 3, pp. 437-438, and Case 12, pp. 452-455.

As the various phenomena of lower association which
frequently occur in cases of progressive senile dementia are, in
reality, closely connected with, and, in fact, part of, the existing
mental confusion, and as they are thus the symptomatological
expression of active neuronic dissolution, the writer has not
employed them as a basis for the elaboration of clinical types.

The cases falling into the group of progressive senile dementia
have therefore been grouped as follows:

Sub-class (1): Melancholia with dementia

• 3

Sub-class (2): Mania with dementia

. —

Sub-class (3): Simple dementia

. 6

Total .

• 9

The cases of progressive senile dementia thus form the small
proportions of 5*4 per cent, of the 445 cases of dementia under
consideration, and 3*3 per cent, of the total of 728 cases of
amentia and dementia.

This point is interesting in view of the fact that the cases are
derived from the largely agricultural population of East Sussex.
Though the writer has no statistics at his disposal, he is never¬
theless quite certain that progressive senile dementia is much
more common amongst the insane derived from the great
centres of population, and he is also inclined to think it more
common in Lancashire than in the County of London.

As would be expected, very few cases of progressive senile
dementia are capable of useful work. Of the nine males, seven
were unemployed and two did a little work; and of the fifteen
females, thirteen were unemployed and two did a little work.

Class (b).

Dementia Paralytica (General Paralysis).

Though earlier in this section the writer has indicated the
existence of certain types of progressive dementia, which are,
from the aspect of general pathology, homologous with dementia

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1908 .]

BY JOSEPH SHAW BOLTON, M.D.

paralytica, these types are so unimportant from the clinical
aspect owing to their rarity, and they are consequently at
present so undefined, that he proposes to confine his attention
in the following description to dementia paralytica alone.

It is not his intention to discuss, or even to enumerate, the
various views which have been enunciated with regard to the
causation and general pathology of this clinical entity.

The question as to whether dementia paralytica is primarily
a meningo-encephalitis or a primary degeneration of the
cortical neurones is now chiefly of historical interest, as it is
very generally accepted that the essential histological features
present consist on the one hand of a proliferation of the extra-
neuronic elements, which is of different ages and of different
degrees of severity according to the stage and type of the case,
and on the other of a mixture of acute and chronic nerve-cell
changes which also vary in type and extent in accordance with
the clinical symptomatology manifested by the patient. It is
probably quite unimportant to seriously discuss whether the
former or the latter occurs the first, for, in the established
morbid state, a “ vicious circle” exists in which each factor in
turn causes the other; and the writer hopes to make clear that
there is every reason to believe that, under the influence of
different exciting causes, either may originally form the starting
point of the morbid process.

The opinion that syphilis, i.e . 9 active infection by the Spirochceta
ballida , is the cause of dementia paralytica, owing to the fre¬
quency, or it may even be said the constancy, with which
evidence is obtainable that the subjects of dementia paralytica
have previously suffered from this disease, though widely held,
is opposed by facts which, in combination, appear to be quite
crucial. For example, on a liberal estimation probably only
about 2 per cent . of the persons who have suffered from syphilis
later on develop dementia paralytica. Again, general paralysis,
even in the earliest stages, is quite intractable under anti¬
syphilitic treatment. Further, this symptom-complex develops
at very variable periods after infection with syphilis, e.g . 9
from four to twenty-five years in the personal experience of
the writer.

A serious attempt has recently been made by Ford Robertson
to demonstrate that the essential cause of dementia paralytica
is a type of diphtheroid bacillus to which he has applied the

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AMENTIA AND DEMENTIA,

[Jan.,

generic name of “ Bacillus paralyticans” and of which he
describes at least two varieties. The writer does not propose
to discuss the views of Ford Robertson, as his investigations
are not yet completed, as his conclusions are at present
so entirely sub judice , and as these are diametrically opposed by
the pathological, etc., considerations contained in the present
paper. He thinks it desirable, however, without expressing
any opinion, to draw the attention of the reader to the remarks
he has already made with reference to Watson’s experiments
with abrin and ricin on the guinea-pig and rabbit, for these
experiments have afforded results which, as far as it is possible
to judge from Ford Robertson’s descriptions, resemble those
obtained by this investigator from his injection experiments.

The writer has already, earlier in this section, indicated his
views as to the relationship, from the aspect of general pathology,
which exists between dementia paralytica and progressive senile
dementia, and as to the part played by a previous attack of
syphilis in the development of the former of these types of pro¬
gressive and secondary dementia.

In the following description, therefore, the aetiology of
dementia paralytica will be considered mainly from the point
of view of whether this clinical entity is a subdivision of mental
disease, or is an organic disease of the cerebrum which merely
in its symptomatology resembles insanity. If the latter were
true the frequently expressed opinion that no anxiety need be
felt regarding the future of the offspring of general paralytics
would be justified, and dementia paralytica would bear no closer
a relationship to mental disease than does cerebral tumour
or cerebral abscess.

In the opinion of the writer, however, dementia paralytica is
an integral part of mental disease, and, were syphilis non¬
existent, the majority of the existing cases of dementia para¬
lytica would merely be replaced by cases of the primarily
neuronic dementia which has already been considered. Of these
cases the majority would remain in asylums as permanent
inmates, and the rest would possess a sufficient remainder of
intelligence to be discharged as “ recoveries ” or to the care of
their friends. The writer thus hopes to demonstrate that the
general paralytic is a lunatic who differs from the ordinary case
of primarily neuronic dementia solely in having earlier in life
suffered from syphilis.

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1908.] BY JOSEPH SHAW BOLTON, M.D. 25

He believes that the ordinary sane individual and the
ordinary psychopath or potential lunatic, who possesses cortical
neurones of average durability, may suffer from syphilis with
impunity as regards the later onset of dementia paralytica;
and he would express the same opinion with regard to the
syphilised lunatics with little or no dementia who are fairly
common in asylums.

On the other hand, he thinks that a psychopath, who
possesses cortical neurones of subnormal durability, and who,
apart from an attack of syphilis, would develop a moderate
grade of dementia as the result of one or more attacks of mental
alienation, would, after an attack of this disease, sooner or
later suffer from one or other of the types of dementia paralytica.

Further, since he considers, as has already been remarked,
that the extra-neuronic reaction, which constitutes the essential
feature of cases of dementia paralytica, is allied to, and only
differs in type and degree from that occurring in cases of progres¬
sive senile dementia, he is of the opinion that whilst in ordinary
life many psychopaths with deficiently durable cortical neurones
manage to survive without the onset of an attack of insanity,
all or nearly all such psychopaths would, if previously infected
with syphilis, sooner or later develop (chronic) dementia
paralytica.

This latter suggestion is founded on a basis of general
pathology, but it is not contradicted by the estimate that about
2 per cent . of general paralytics occur amongst the former sub¬
jects of syphilis, as this probably roughly represents the
percentage of psychopaths in the general population, this
certainly being several times greater than the existing proportion
of certified lunatics in England and Wales (1 in 282 in January,
1907).

Such an estimate is naturally not to be considered as other
than suggestive, for even an approximate determination of the
incidence of syphilis in England is impossible, and it is quite
likely that the percentage of psychopaths amongst the subjects
of syphilis may differ somewhat from that in the general
population.

In the following description an attempt will be made to
record in compact but intelligible form such data as the
writer is able to produce with reference to the relationship ot
dementia paralytica to mental disease.

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AMENTIA AND DEMENTIA,

[Jan.,

The subject will be considered under the following headings:

(1) Evidence as to the existence of heredity of insanity and
of parental and family degeneracy in the subjects of dementia
paralytica.

(2) Evidence as to the relationship between dementia para¬
lytica and mental disease, derived from the study of the death
rates in mental disease (including and excluding dementia
paralytica) at different ages, and from the comparison of these
death rates with the homologous death rates in the correspond¬
ing general population.

(3) Pathological evidence as to—

(а) The relationship between the morbid anatomy and the

regional cortical wasting of dementia paralytica and
of progressive senile dementia.

(б) The existence of cerebral under-development in certain

types of dementia paralytica.

(4) Evidence as to the relationship between dementia para¬
lytica and mental disease, derived from a study of the clinical
types of dementia paralytica.

(1) Evidence as to the Existence of Heredity of Insanity and of
Parental and Family Degeneracy in the Subjects of Dementia
Paralytica.

As has already been stated, the writer is of the opinion that
the presence or absence of heredity of insanity in any case or
series of cases possesses merely a relative value, as family and
social conditions so largely decide whether any particular in¬
dividual should be sent to an asylum or not. The equally and
often more important evidence of family or parental degeneracy
is frequently not available, and is usually not easy to obtain.

He thinks it more probable that isolated cases of insanity
arise from the intermarriage of ill-assorted couples and mild
degenerates, and that the severer grades of family degeneracy
follow the intermarriage of definite degenerates, rather than
that isolated examples of insanity in either parental stock will
be followed by insanity in the offspring of such parents.

He would, in other words, place the percentage of heredity
at 100 with regard to the offspring of either degenerate or
“ normal ” individuals, and, without going so far as to assert
that non-traumatic cerebral under-development or dissolution

Digitized by L^ooQle

1908.] BY JOSEPH SHAW BOLTON, M.D. 27

cannot occur in the absence of hereditary causes, would
emphatically express his doubts with regard to its occurrence
with any degree of frequency.

On the thesis that dementia paralytica were an integral part
of mental disease, it would be expected therefore that a high
percentage of heredity of insanity and of parental or family
degeneracy would be obtained in a series of carefully taken
cases, although this percentage, for the reasons stated, would
necessarily fall far short of zoo.

In a series of 85 cases of dementia paralytica which were
published some years ago by the writer {Arch, of Neurol., vol.
ii), satisfactory family histories were obtained. These histories
were the outcome of several hundred personal interviews with
all the available relatives or friends of the patients, and of
information collected by other means.

Much labour was expended on the subject, for the difficulties
in the way of obtaining information concerning the family
histories of cases of dementia paralytica are often very great,
and particularly so in the case of patients of the male sex.
The wife is frequently the only visitor, and it is quite common
for the family of the patient to be unknown to her. This is
more often the case with patients suffering from dementia
paralytica than in other forms of insanity, for the former
patients, owing to their previous dissipated and often wander¬
ing life, are frequently entirely out of touch with their relatives.
The usual age of the subjects of dementia paralytica is again a
serious drawback, as the older the patient is, the fewer are
the available relatives who can give trustworthy information
regarding the family history. Lastly, it is common for relatives
to be informed that the disease is not insanity but is due to the
former dissipated life of the patient, in order that their natural
apprehensions concerning the future of the offspring may be
relieved. They therefore tend to hide many facts of family
history which they would otherwise have mentioned. The
writer has in fact met with several instances in which the
relatives, until definitely taxed regarding the correctness of
some specific fact of history which had been accidentally
acquired from other sources, stoutly denied the existence of
any insanity in the family, and deliberately suppressed the
name of the subject of this when first giving the history.
Whilst such deliberate mis-statements are at times met with

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AMENTIA AND DEMENTIA,

[Jan.,

during ordinary history-taking, the writer is convinced that
they are more frequently found in the case of the histories of
general paralytics, the friends of whom are often only too
anxious to accept former syphilis as the cause of the disease.

Of the eighty-five cases which will now be referred to, thirteen
were private and seventy-two were rate-paid patients.

In 8 of the 13 private cases there was direct or collateral
insanity; in 3 there were allied disorders, including epilepsy;
in the twelfth the father died of cerebral haemorrhage, and the
mother of paralysis, and the patient was the youngest of a
family of eight; and in the thirteenth the mother and sister
died of phthisis, a brother was delicate, and eleven out of
fourteen in the family were dead.

In one instance the parents were first cousins, and a paternal
uncle and two female cousins were insane; four patients were
the youngest in the family; and in three families there was a
very high death rate. In four cases there was phthisis in the
family (mothers and sisters), in two diabetes, and in one
asthma.

Of the 72 rate-paid cases, actual insanity existed in 45 families
(62*5 per cent.), and in 4 of these true epilepsy also existed,
apart from the cases of insanity. True epilepsy existed in 5
other families without insanity (6‘g per cent.), though in one
case it was probably associated with melancholia of pregnancy.
Histories of insanity and epilepsy consequently existed in 50 of
the 72 families (69*4 percent.). In these fifty families, as further
evidence of family degeneracy, there were disorders allied to
insanity in at least sixteen instances (nervous diseases not
being included).

In the 45 histories containing actual insanity there existed
65 insane relatives. These included 10 brothers, 10 sisters,
11 mothers, 7 fathers, 3 maternal grandfathers, 1 maternal
grandmother, 2 paternal grandfathers, 1 maternal great-grand¬
father, 2 maternal uncles, 5 maternal aunts, 4 paternal uncles,
1 paternal aunt, and 8 collaterals (1 half-sister, 1 half-brother,
4 cousins, 1 father’s maternal cousin, and 1 sister’s son).
Several of these insane relatives suffered from fits, and a few
may have been cases of general paralysis, but no stress can be
laid on this point, as the details available are insufficient.

Of the remaining 22 of the 72 cases, psychopathy (equals
“ border-land cases,” and does not include examples of nervous

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1908.] BY JOSEPH SHAW BOLTON, M.D. 29

disease) existed in 9 (12*5 per cent.), 2 brothers, 2 sisters,
3 mothers, and 3 sons being affected.

Of the remaining 13, there was an abnormally high death-rate
amongst relatives in no less than 7 cases (97 per cent.).

Finally, of the remaining 6, in 3 there was paralysis; in one
the patient was the delicate child of the family and did not walk
until he was four years of age ; and in the remaining 2 there
was merely a history of alcoholic excess in the parents.

Hence, of the 72 histories of rate-paid patients, there was
psychopathic heredity in no less than 8rg per cent., and an
abnormally high family death rate in another 97 per cent. In the
remaining 8*4 per cent, less important aetiological factors existed.

Phthisis existed in 19 of the 72 families (26*4 per cent.), in
8 affecting brothers and sisters, and in 6 the father's, in 4 the
mother’s, and in 1 both families.

Intemperance in alcohol existed in 26 of the 72 families (36*1
per cent.), both sides of the family suffering from the disorder
in 7 cases, the paternal side in 12, and the maternal in 5 ; the
remaining 2 cases occurred in sisters of the patients.

General or nervous diseases were ascertained to have existed in
19 cases (26*4 per cent.).

In 13 families (18 per cent.) there was an abnormally high
death rate, it being so high in 7 of these that very few family
details could be obtained.

The figures given above illustrate the high percentage of
heredity of insanity and of parental and family degeneracy
which occurs in dementia paralytica, and form the first part
of the evidence which the writer is able to produce in support
of the thesis under consideration.

He is, of course, aware that comparative observations on
normal individuals and on ordinary cases of mental disease
would be necessary in order that exact conclusions might be
drawn regarding the respective degrees of degeneracy in these
two classes and in dementia paralytica. Such observations
would, however, necessarily have had to be made on exactly
similar samples of population, and for these he had neither the
time nor the opportunity. It is also extremely doubtful
whether the results would have been of sufficient value to justify
the expenditure of the necessary time and labour, even if it had
been possible, as for practical purposes the only question it was
necessary to settle was whether or not a high heredity of

liv. 3

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30 AMENTIA AND DEMENTIA, [Jan.,

insanity and of parental and family degeneracy were obtainable
in dementia paralytica.

The writer considered it desirable to carry out this investi¬
gation as there are few subjects on which greater differences of
opinion exist than with regard to the question of the percent¬
age of heredity of insanity in dementia paralytica.

That the figures he has given are higher than thpse published
by most observers he admits, but he judges this to be due to
the fact that in, at any rate, the majority of cases, the histories
employed are such as are provided by ordinary case-book
entries, and are not obtained as the result of laborious
individual investigation.

In Table XXII of the Sixty-first Report of the Commis¬
sioners in Lunacy are given the proportions ( per cent.) of the
yearly average number of the total patients admitted to the
asylums in England and Wales during the five years, 1901-5,
in which certain assigned causes of insanity were found to exist.
Those data which bear on the question under consideration
are as follows:

Causes of insanity.

Proportion {percent.) to the yearly
average number admitted during
the five years.

Hereditary influence ascertained .

108

25*3

Congenital defect ascertained

As at least a large proportion of the histories of admissions
to asylums are not taken at all, these figures are naturally
much lower than such as would be obtained from the data pro¬
vided by asylum case-books.

In his presidential address ( Journal of Mental Science , October,
1902) Dr. Wiglesworth provides statistics of great interest in this
connection. “ My statistics deal with a series of 3,445 insane
patients who have been admitted into Rainhill Asylum under
my care during a period of twelve years, 1,693 of these patients
being males and 1,752 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 ante¬
cedents it is impossible to obtain any trace, but every patient

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1908.] BY JOSEPH SHAW BOLTON, M.D. 3 I

has been included of whose family history any details whatever
were obtainable.”

These are shown in the following table:

Form of insanity.

Number of cases.

Number of these
showing heredity.

Percentage of hereditary
cases on total numbers.

Congenital insanity (idiocy
and imbecility) with or
without epilepsy .

37‘14

5151

44 *ii

; Epileptic insanity

120

1948

5348

31*66

General paralysis

363

433

16 52

31*42

1893

Ordinary insanity (non-
congenital) —mania,
melancholia, dementia,
etc. ....

1,218

1,606

2,824

331

484

2717

30 13

28*85

| All cases together

419

546

96s

2474

3116

| 28 01

It will be noted that the percentage of hereditary cases
amongst the female general paralytics is slightly higher than
that amongst the examples of ordinary insanity, whereas
amongst the male general paralytics it is much lower. From
the considerations already adduced it seems to the writer of
the present paper to be at the least probable that this sex differ¬
ence is largely or entirely due to the less satisfactory nature of
the information which is usually obtainable regarding the
personal and family history of male general paralytics. This
explanation is supported by the fact that no such sex-difference
existed in the case of the eighty-five histories referred to above.
The private patients, for example, were all of the male sex.

It is true that in the above table a similar sex-difference
exists in the case of the epileptics, the hereditary cases forming
an extremely high percentage in the case of the females and
a low one in the case of the males, in comparison with the
respective percentages in the cases of ordinary insanity. Epi¬
leptic insanity, however, is so frequently the result of organic
and traumatic causes that it falls into a different category from
other cases of mental disease, and the number of cases (120),
even when recruited from the cases of congenital insanity, forms

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32 AMENTIA AND DEMENTIA, [Jan.,

an unusually low proportion of the total of 3,445 cases. Dr.
Wiglesworth expressed this opinion as follows: “ 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.”

The percentages given in the case of congenital insanity are
also of relatively slight value, for “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 over¬
crowded for many years past, a restriction has been put upon
the admission of this class of cases,” and Dr. Wiglesworth adds
“ These cases have, however, been taken indiscriminately, and
no endeavour has been made to exclude 1 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 excluded, it would tend to make
the difference between the two sexes somewhat less pronounced.”

The important sex difference in the table/therefore, concerns
the general paralytics, and this is, in the opinion of the writer,
susceptible of the explanation he has given.

Hence Dr. Wiglesworth’s statistics may be considered not
to contradict the conclusions drawn from the personally
obtained data which the writer has provided with reference to
the existence in dementia paralytica of a high percentage of
heredity of insanity and of parental and family degeneracy.
Further, they are susceptible of the interpretation that the
percentage in dementia paralytica does not substantially differ
from that in ordinary mental disease.

(2) Evidence as to the Relationship between Dementia Paralytica
and Mental Disease , derived from the Study of the Death Rates in
Mental Disease {including and excluding Dementia Paralytica)
at Different Ages , and from the Comparison of these Death Rates
with the Homologous Death Rates in the corresponding General
Population .

The writer has calculated the death rates at different ages

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1908.] BY JOSEPH SHAW BOLTON, M.D. 33

amongst the insane of a certain asylum population. These
death rates on the one hand refer to the whole of the asylum
population, and on the other to the subjects of mental disease
apart from dementia paralytica.

The object of the writer is two-fold. He proposes in the
first place to compare the death rates of the insane with those
of the corresponding general population, and in the second to
determine what modifications of the former rates result from
the exclusion of the cases of dementia paralytica.

The data employed with reference to the general population
are the corrected death rates per 1,000 living in the County of
London for the year 1905 ( Sixty-eighth Report of the Registrar -
General, Tables 16 and 17). The margin of error owing to
the use of these data is inconsiderable, as the rates for neigh¬
bouring years are practically constant. It is necessary to
assume that the death rates for the whole County of London
and for its several larger sub-districts are the same, and
this assumption may appear likely to cause a serious error.
Such an error, however, if it exists, cannot be considerable,
as the death rates in the County of London do not, as
regards the present purpose of the writer, differ greatly
from those of the total general population of England and
Wales.

The data regarding the insane refer to the inmates of the
London County Asylum, Claybury. The deaths employed are
those included in Series B ( Journal of Mental Science , April,
1905), together with the cases of dementia paralytica dying
during the same period of twenty months, from October, 1901,
to May, 1903, inclusive.

The number of deaths during the period under consideration
was 311. Of these, 16 special cases (8 male and 8 female)
suffered from gross lesions, etc., and were unclassified. These
deaths are excluded, and an error of about 5 per cent . is thereby
introduced throughout the death rates, as it is impossible to
correct these by also excluding the living portion of the asylum
population from which such “ accidental ” cases arise. This
general lowering of the death rates, however, applies to all the
tables, and is fairly evenly distributed through the decades,
the eight male cases dying at ages varying from 21 to 77 years,
and the eight female cases dying at ages varying from 27 to 67
years. This error, therefore, as will be seen, does not pre-

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34 AMENTIA AND DEMENTIA, [Jan.,

judicially affect the conclusions which will be drawn from the
death rates.

The cases employed thus include 127 males, of whom 83
are ordinary cases and 44 are general paralytics; and 168
females, of whom 150 are ordinary cases and 18 are general
paralytics.

The annual death rates per 1,000 living at the eight age-
periods which are dealt with are worked out from the estimated
average population of the London County Asylum, Claybury,
at these age-periods during the twenty months referred to.

In the first instance the rates are prepared from the total
numbers of male and female deaths respectively and from the
estimated total average male and female populations respec¬
tively, at the eight age-periods under consideration.

Further death rates are then prepared from the numbers of
non-general-paralytic male and female deaths respectively, and
from the estimated non-general-paralytic average male and
female populations respectively, at these age-periods.

The estimated average population of the London County
Asylum, Claybury, at the eight age-periods during the twenty
months under consideration, is based on the returns of patients
resident on December 31st, 1902.

The average general paralytic population during these twenty
months is estimated by the writer, from data at his disposal, to
be 121, of which 90 (or 9 per cent . of estimated average total
male population) are males, and 31 (or 2*2 per cent . of estimated
average total female population) are females.

Of the 90 males, 12, 29, 37, 8, 3, and 1 are estimated to
belong to the second to the seventh age-periods respectively;
and of the 31 females, 7, 15, 7, and 2 are estimated to belong to
the second to the fifth age-periods respectively.

The estimated average general paralytic male and female
populations are subtracted from the estimated average total
male and female populations, in order to obtain the average
non-general-paralytic male and female populations, which are
employed for the preparation of the series of death rates on the
fourth lines of Tables I and II respectively.

These death rates are shown on the following tables:

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BY JOSEPH SHAW BOLTON, M.D.

1908 .]

Table I.— Death-rates per 1,000 Living Males .

Age

periods.

15 -

ao-

a$-

35-

45“

55“

65-

75“

85 and
upwards.

A. London County, 1905

3-8

5-8

io *6

194

358

70*3

>35*9

3*3*7

B. Series B + G.Ps on
estimated total aver¬
age population at
the several age-pe¬
riods

121

129

280

600

Ratio of B to A

About 8

5*2

3*3

3*4

r 8

2*1

i*9

C. Series B, on estimated
total average popu¬
lation less estimated
G.P. population at

1 the several age-pe-

| riods

1 26

XIO

126

257

600

1 Ratio of C to A

1 1

About 8

7*6

2*45

i*3

3*i

r 8

i*9

Table II. — Death-rates per 1,000 Living Females .

boO

< £

if-

JO-

*45“

75-

85 and
upwards.

A. London County, 1905

B. Series B + G.Ps. on

estimated total aver¬
age population at the

2*3

2*8

4*2

14*0

35*9

55*i

II7‘I

288*0

several age-periods .

About

io *6

199

315

600

Ratio of B to A

C. Series B, on estimated
total average popu¬
lation less estimated
G.P. population at
the several age-pe¬

9*8

6*2

3*4

2*3

3*6

2*7

2-0

riods

About

199

315

600

Ratio of C to A

xo -6

7*4

i «

2*9

2*2

2*7

2-0

It will be noticed that the death rate in the normal popula¬
tion nearly doubles itself at each decade, the rise being slightly
more rapid throughout in the case of the males than in that of
the females.

In the case of the total male insane population, as is shown
both by the death rates (Table I, B) and by their ratios to the
normal death rates, which are shown on the next line of the
table, a rise also occurs throughout the age-periods, but this

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36 AMENTIA AND DEMENTIA, [Jan.,

rise after the second decade becomes progressively less in
comparison with the normal.

In the case of the total female insane population (Table II, B),
a similar rise in the death rates occurs throughout the'decades,
but it is somewhat less than in the males in the earlier decades,
and somewhat greater than in the males in the later.

The average total insane male death rate (not shown in the
table) is 76*5, and the average female is 72*2. These thus
differ slightly only, but this difference is in the same direction
as that of the normal population, though it is less marked.

The death rates of the total insane of both sexes thus
resemble those of the general population in forming an
ascending series, the increments to which are, however, much
greater than in the latter at first, but become proportionately
less marked as the ages increase, this being especially evident
in the case of the male sex.

In line C of the tables the death rates of the non-general-
paralytic male and female insane population are given.

In the case of the females (to whom in the total number the
general paralytics form a relatively small proportion), the
ascending series of death rates (Table II, C, and also the ratios
on the following line) is not markedly affected, though the
death rates in the second and third, and to a less extent in the
fourth, of the given decades are decidedly low.

In the case of the males, however (to whom in the total
number the general paralytics form a relatively large pro¬
portion), the ascending series is entirely broken up at the third
and fourth of the given decades, and the unexpected and
curious result appears that male lunatics have an extraordinarily
low death rate between the ages of 35 and 54. (Table I, C, and
also the ratios on the following line.)

This result is so grossly marked that the only possible
inference from the figures is that exclusion of the general
paralytic members of the lunatic population is unjustifiable,
and that therefore cases of general paralysis form an integral part
of mental disease .

In other words, it is impossible to avoid the conclusion that,
whatever be the cause of the particular symptom-complex
known as general paralysis, the cases which exhibit this are
nevertheless lunatics, and not merely the subjects of a disease
of the brain of microbic or syphilitic origin.

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1908.]

BY JOSEPH SHAW BOLTON, M.D.

(3) Pathological Evidence as to (a) the Relationship between the
Morbid Anatomy and the Regional Cortical Wasting of
Dementia Paralytica and of Progressive Senile Dementia , and
(b) the Existence of Cerebral Under-development in Certain Types
of Dementia Paralytica .

In its essentials the morbid anatomy of dementia paralytica
is that of ordinary progressive dementia. Certain important
differences, however, exist, and these the writer considers to be
largely or entirely due to the higher degree of reparative pro¬
liferation on the part of the non-neuronic elements of the
encephalon which is present in dementia paralytica.

As in progressive senile dementia, so here, the grossly obvious
features are cerebral wasting, and replacement of the lost cerebral
tissue to some extent by reparative proliferation of the non¬
neuronic elements, but chiefly by a large quantity of intra¬
cranial fluid.

The following description will largely be confined to those
appearances in which the morbid anatomy of dementia para¬
lytica differs from that of progressive senile dementia, with the
view of illustrating how these are due to differences in the
immediate aetiology and in the course of these different types of
dementia.

The cerebra of certain selected cases will then be illustrated
and described with the object of demonstrating (a) that the
wasting in dementia paralytica bears a close resemblance in
distribution and degree to that occurring in progressive senile
dementia, such a resemblance, in fact, as renders it impossible
to avoid the conclusion that in both cases this wasting is the
result of dissolution of the last evolved and functionally highest
regions of the cortex, and (6) that cerebral under-development
occurs in dementia paralytica just as it exists in ordinary
mental disease, and that the naked-eye anatomy of the cere¬
brum gives as important evidence regarding the unity of
dementia paralytica and ordinary mental disease as will next
be produced with regard to the clinical types of dementia para¬
lytica, and as has already been detailed from other aspects in
the preceding sub-sections.

(a) Morbid anatomy of dementia paralytica .—In early and
moderately developed, but less often in very advanced cases,
the venules, etc., of the intra-cranial membranes and encephalon

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38 AMENTIA AND DEMENTIA, [Jan.,

are intensely congested, a morbid appearance usual in status
epilepticus, but not often seen in progressive senile dementia.

Even in relatively early cases the excess of subdural fluid is
large, and in advanced cases it is as great as, or greater than,
occurs in ordinary gross dementia.

In the 44 male cases already referred to, great or very great
excess existed in 37, excess just over the tentorium in 2,
moderate excess in 2, slight excess in 1 early case, and no
excess in 2. Of the two without subdural excess, one was very
recent and acute, and in the case of the other the subdural
space contained 205 grm. of recent blood-clot.

Of the 18 female cases already referred to, a very great excess
of subdural fluid existed in all.

This sex-difference is in all probability associated with the
greater chronicity of the female cases.

A similar sex-difference exists with regard to the frequency of
the subdural deposits , which are somewhat more common in
dementia paralytica than in progressive senile dementia, except
in the case of the severer grades.

Of the 44 male cases, subdural deposits occurred in 12, or
27 per cent., and of the 18 female in 2, or n per cent., the per¬
centage in the case of the total of 62 being 22*6.

Of 85 male cases published in a previous paper, these deposits
occurred in 25, or 29*4 per cent., and of 38 female in 4, or 10*5
per cent., the percentage in the case of the total of 123 being
23-6.

The percentages in these two series of cases are thus sub¬
stantially the same. In both series also in each sex, half of
the deposits were of recent date and the remaining half were
more or less organised, and in several instances multiple.

In progressive senile dementia subdural deposits are rather
less common, except in the very advanced cases.

In the case of the combined series A and B referred to in the
first part of this paper, and including in all 433 cases of ordinary
mental disease, these deposits existed in 17*4 per cent, of the 92
cases in Group IV (severe dementia) and in 22*8 per cent, of the
79 cases in Group V (gross dementia), the latter percentage
being about the same as that indicated above as occurring in
dementia paralytica.

In early cases there is little or no excess of sub-arachnoid
fluid; in slow chronic cases there is often considerable excess.

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1908.] BY JOSEPH SHAW BOLTON, M.D. 39

frequently in the form of scattered “ arachnoid cysts ” ; and in
advanced cases there is great excess, the prefrontal pia-arachnoid
being in many instances ballooned out by the subjacent fluid.

In early cases the pia-arachnoid may superficially present few
abnormal characters beyond a larger or smaller amount of con¬
gestion ; in later cases it is, as a rule, immensely thickened and
opaque, and stretches as a continuous sheet over and often
entirely hides the subjacent sulci. The thickening and opacity
are, usually, most marked over the fronto-parietal regions and
the neighbouring median parts of the hemispheres, and also over
the first temporal gyri. They are often not so marked in the
prefrontal region, where the pia-arachnoid is raised up by sub¬
jacent fluid. The opacity may, however, be more widespread,
and may even occupy the whole cerebrum except, apart from
rare cases, the orbital surfaces of the frontal lobes, the lower
and inner occipito-temporal regions, and the posterior poles of
the hemispheres.

In progressive senile dementia the distribution of the opacity
and thickening is similar to that described, but the fibrosis (and
also the contraction) of the pia-arachnoid is commonly much
less marked than in dementia paralytica.

Even in early cases of dementia paralytica the pia-arachnoid
is granular in the mid-line prefrontal region below the falx
cerebri, and pia adheres more or less firmly to pia in this
position, the actual area of adhesion depending on the size and
shape of the falx cerebri. In more advanced cases the adhe¬
sions in this region are dense, and the hemispheres cannot be
separated without tearing the subjacent cortex. It is worthy
of note in this connection that the region under consideration
is the only part of the encephalon where pia meets pia, as else¬
where the pia lies in contact with the dura, to which, however,
it only rarely forms adhesions.

Particularly in early cases, but also in later ones in the
regions into which the morbid process is extending, the pia is
adherent to the subjacent cortex. Later on, when the pia-
arachnoid has become much thickened and the cortical wasting
is pronounced, the membrane strips like a glove from the
underlying cortex. Decortication on stripping is usually laid
much stress on in descriptions of dementia paralytica, but it is
an uncertain sign. The more chronic or the more advanced
the case happens to be, the less is the decortication, and viu-

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40 AMENTIA AND DEMENTIA, [Jan.,

versd. Decortication, on the other hand, is much increased by
oedema of the brain, and especially by post-mortem decom¬
position. It is largely obviated by the absence of these latter
factors, but in early cases it very often occurs in the mid-line
prefrontal region below the falx cerebri.

The peculiarly localised areas of adhesion between the pia
and the cortex, which are usually situated on the flat external
surfaces of the convolutions and do not reach to the fissure
lips, strongly suggest a vascular causation. This is almost con¬
clusively proved by the occasional occurrence, particularly in
acute cases, of fairly extensive areas of adhesion which approxi¬
mate very closely to known areas of arterial distribution.

This is finally proved by the fact that exactly similar regions
of pial adhesion occasionally occur in cases of gross senile
vascular degeneration (with or without dementia) and also in
cases of progressive senile dementia. (Archives of Neurology ,
vol. ii, pp. 483-4, Case 201.)

The lateral ventricles in dementia paralytica are dilated, and
often extremely so, and, with the third , are much more fre¬
quently granular than are these regions in progressive senile
dementia. The fourth ventricle , however, exhibits, as a rule,
the most characteristic naked-eye sign of dementia paralytica.
Granularity of the lateral sacs of the fourth ventricle is common
in all varieties of insanity, and in progressive senile dementia
granules also at times exist on each side of the mid-line in the
upper half of the lozenge. They, however, rarely or never
occur in the lower half or calamus except in dementia para¬
lytica, in which, even if the granularity is general, it is usually
most marked in this situation.

The smaller cortical arteries , even in very early cases of
dementia paralytica, are invariably fibrous, and in toughness
resemble strands of thread or fine wire.

The basal vessels at times show no obvious naked-eye abnor¬
mality, but in many cases, and especially in such as have
acquired syphilis at or after maturity, they are dilated and
irregularly thickened owing to patches of pearly white fibrosis.
They are occasionally small and fibrous. They are less fre¬
quently calcareous.

Of the 44 male cases of dementia paralytica referred to above,
the basal arteries were affected to a greater or a lesser degree in
28, or 64 per cent . 9 and were apparently normal in 16, or 36

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BY JOSEPH SHAW BOLTON, M.D.

1908.]

per cent . In the 28 cases the affection was slight in 11, moderate
in 10, and severe in 7. The average age of these 28 cases was
49 years, whereas in the case of the remaining 16 the average
age was 38 years.

Of the 18 female cases, the basal arteries were more or less
affected in 9, or 50 per cent. In these the affection was slight
in 4, moderate in 2, and severe in 3. The average age of these
cases was 47 years, whereas in the case of the 9 with apparently
normal basal vessels the average age was 38 years.

The basal vessels were therefore more frequently affected in
the case of the male sex. In the case of both sexes the average
age of the patients with affected basal vessels was about ten
years higher than that of the patients with apparently normal
vessels.

These morbid appearances in the cerebral arteries resemble
in their characters the dense, almost cartilaginous, pearly-white
fibrosis of the often-dilated aorta which frequently occurs in
dementia paralytica, and particularly so in cases over the age
of forty years. These vascular changes, and particularly that
in the aorta, are, in the experience of the writer, practically
diagnostic of a former attack of syphilis, in that they represent
an intense reparative reaction to previous severe injury, and at
the same time are found in syphilised but not in non-syphilised
subjects.

The vascular degeneration and nodular atheroma of the
cerebral arteries which occur in senility and premature senility
show, on the other hand, no such fibrotic appearances. In
these cases, in association with and probably owing to the
exceedingly feeble reaction of repair which they possess, a
deposition of lime salts occurs and results in the better known
calcareous degeneration.

As has already been stated, this condition of the cerebral
arteries is practically constant in progressive senile dementia.
On the other hand, in dementia paralytica, though naked-eye
pearly fibrosis is not a constant feature, it is, when present, a
highly characteristic morbid appearance.

The cerebral wasting in dementia paralytica often differs in
degree from that found in progressive senile dementia. In ful¬
minating cases of dementia paralytica death frequently occurs
so rapidly that no time is allowed for the removal of the pro¬
ducts of neuronic dissolution. On the other hand, in more

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42 AMENTIA AND DEMENTIA, [Jan.,

chronic cases of dementia paralytica, the relative finality of the
dissolution of the region of higher association and the organisa¬
tion of the results of extra-neuronic reparative reaction more
often result in very marked grades of cerebral wasting than is
the case in progressive senile dementia.

As a preliminary to the description of certain selected cases
of dementia paralytica which illustrate * the more important
appearances found in its different types and stages, the writer
proposes to briefly refer to four cases which exhibit in the
different sexes the essential features presented by the ordinary
rapid and slow types of dementia paralytica.

These cases were published in full in the second volume of
the Archives of Neurology as Nos. 212-215, and their morbid
anatomy, in summary, is as follows :

The encephala of the females (Nos. 213 and 215) weighed
respectively 985 and 782 grm. (average normal 1,275 grm.),
and both in their remarkably low weights and in the simplicity
of their convolutional patterns were markedly the brains of
degenerates. Those of the males (Nos. 212 and 214) were
much below the average normal weight of 1,400 grm., scaling
respectively 1,205 and 1,225 grm., but they differed from
the brains of the females in being convoluted in a fairly average
manner.

Nos. 214 and 215. Rapid spastic cases with very small and
alternating pupils. —In both cases there existed relatively little
opacity and thickening of the pia-arachnoid, this occupying the
fronto-parietal region ; and there was only a moderate amount
of wasting, which was chiefly visible in the prefrontal region.

Nos. 212 and 213. More chronic cases without knee-jerks.

No. 212. Male. —There was considerable fronto-parietal
opacity and generally marked thickening of the pia-arachnoid,
except at the occipital pole and on the under and inner part of
the temporo-sphenoidal region and the orbital surface of the
frontal lobe. In the region of the marked thickening, the pia-
arachnoid stripped like a glove from the brain. The wasting
was extreme in the prefrontal region, marked in the first temporal
gyrus and the inferior and superior parietal lobules , rather less
marked in Broca's gyrus , and the posterior thirds of the first and
second frontal gyri , moderate in the ascending frontal gyrus, slight
only in the outer part of the temporo-sphenoidal and pre-occipital
regions, and almost absent in the occipital lobe , the lower and

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1908 .] BY JOSEPH SHAW BOLTON, M.D. 43

inner part of the temporo-sphenoidal region and the orbital surface of
the frontal lobe .

No. 213. Female .—The pia-arachnoid showed considerable
opacity and marked thickening, which was most obvious in the
frontal lobe, the first temporal gyrus, and the superior and
inferior parietal lobules. The wasting was extreme in the
prefrontal region , marked in the first temporal gyrus and the
superior and inferior parietal lobules , moderate in Broca's gyrus
and the posterior thirds of the first and second frontal gyri, much
less in the ascending frontal gyrus , and slight or absent else¬
where.

[Note. —The terms employed for the cortical regions in the
above summary overlap somewhat, but are convenient for
brevity of description.]

The above-mentioned morbid appearances agree closely with
the clinical course of the dementia paralytica in the several
cases. In the two which rapidly broke down, the total amount
of intra-cranial fluid, the morbid state of the pia-arachnoid,
and the grade of the cerebral wasting were all much less
marked than in the two cases of chronic type, in which it may
be presumed had occurred a more complete removal of the
results of neuronic dissolution, and a greater degree of finality,
as regards cell-death, in the degenerative process.

Though such morbid appearances as those just referred to are
in average cases very definite and quite readily visible, the
determination of regional grades of wasting, and also of the
type of convolutional pattern as regards relative simplicity or
complexity, is at times attended with much difficulty. This is
especially the case when sub-development and wasting occur
together, though experience and practice enable error to be
largely eliminated.

The writer has, therefore, illustrated on Plates V to VIII,
figs. 6 to 11, certain hemispheres of cases of general paralysis,
which demonstrate the chief types of wasting and under¬
development which have come under his notice. In order that
they may be the more readily compared with one another and
also with the hemispheres of under-developed cerebra and of
cases of progressive senile dementia which have already been
illustrated, all the photographs are of exactly the same relative
size.

As has already been insisted on in both the present and pre-

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44 AMENTIA AND DEMENTIA, [Jan.,

vious papers, the most useful preliminary criterion of both the
existence and the approximate amount of wasting is the
quantity of intra-cranial fluid which is present, as this is
practically non-existent in the normal cranium, and as it can
only occur in quantity in association with loss of cerebral tissue.
The writer here excludes certain grossly obvious pathological
conditions unassociated with mental disease in which the blood
normally contained in the cerebral vessels and sinuses is largely
replaced by intra-cerebral fluid, and also ordinary local gross
lesions of the cerebrum in which loss of brain tissue is re¬
placed by intra-cranial fluid, as none of these morbid states form
part of the subject which is under consideration.

In the cases figured on Plates I and II, for example, there
was no excess of intra-cranial fluid, and there is no cerebral
wasting. In the first of these plates are shown the small and
very simply convoluted hemispheres of an imbecile with epi¬
lepsy, and in the second the very small and simply convoluted
hemispheres of a normal degenerate.

In the case figured on Plate III, some excess of fluid existed
in association with slight cerebral wasting, and, from the clinical
aspect, a mild grade of dementia in an intelligent individual
suffering from presenile melancholia. The cerebrum is very
large, and is extremely well convoluted, in these details
markedly contrasting both with the preceding and the following
illustrations.

In the case figured on Plate IV, fig. 4, there existed in the
subdural space moderate, and in the sub-arachnoid consider¬
able, excess of fluid. The case is one with a marked grade of
progressive dementia, and the wasting depicted in the photo¬
graph is obvious.

In the case shown on Plate IV, fig. 5, there existed in the
subdural space enormous, and in the sub-arachnoid great,
excess of fluid. The case is one of gross progressive senile
dementia, and the wasting exhibited in the photograph is
grossly obvious. In the preceding case the encephalon weighed
1,150 grm. and the cerebellum, etc., 135 grm., and in the
present one the encephalon weighs 1,045 g rm « and the cere¬
bellum, etc., 145 grm. It is, therefore, likely that the latter
brain was, in its original condition, greater than the former.
If, on this basis, the hemispheres in Figs. 4 and 5 were re¬
modelled, the latter would be the larger, and the apparent

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1908.] BY JOSEPH SHAW BOLTON, M.D. 45

great complexity of the prefrontal region which shows so
clearly in the photograph would become less obvious.

These hemispheres clearly illustrate the first of the important
points to which the writer wishes to draw attention, namely that
gross wasting markedly increases the apparent complexity of the
convolutional pattern . If they are compared gyrus by gyrus with
the hemisphere shown on Plate III, fig. 3, it will be evident at
once that neither possesses anything like either the frontal or
the parietal complexity which is exhibited by this case, although
on casual inspection they both appear to be more complex.

A further important fact is also shown by the comparison of
these hemispheres, namely that larger actual size of a hemi¬
sphere decreases the apparent complexity of the convolutional
pattern . Hemispheres, when studied one by one as they occur
at post-mortem examinations, are unconsciously inferred to be of
about the same size, unless they should happen to be grossly large
or very small. Even if certain selected hemispheres are later
on compared side by side, the smaller and more wasted examples
often appear to be the more complex, although actual detailed
examination may demonstrate the reverse to be the case. The
writer has, therefore, systematically supplemented his examina¬
tion of cerebral hemispheres by the study of a series of photo¬
graphs, all taken exactly to scale and of such a size as enabled
several to be examined at the same time.

As might be expected, the converse of the last point to which
attention has been drawn is also true. Smaller actual size of
a hemisphere increases the apparent complexity of the convolutional
pattern . This detail is well exhibited by certain hemispheres,
which will now be referred to.

The writer would finally draw attention to the point that
whilst in many hemispheres wasting is associated with an
unfolding of the affected convolutions, which results in rela¬
tively little apparent increase of complexity, in other cases which
exhibit gross wasting the convolutions may lie so closely together that
great apparent increase of complexity results. This detail is
especially evident in the hemispheres illustrated on Plate VIII,
fig. 11. These, though very simply convoluted, appear, through
the gross wasting and close packing of the convolutions, to be,
on first inspection, little inferior in complexity of pattern to the
well-developed hemisphere illustrated on Plate III, fig. 3. It
is difficult, indeed, even when the fact is known, to believe that
Liv. 4

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AMENTIA AND DEMENTIA,

[Jan.,

the magnification is exactly the same and that the convolutional
pattern is so grossly different in the two cases. In reality the
hemisphere shown in Fig. 3 weighed 680 grm., whereas the
hemispheres illustrated in Fig. 11 scaled but 330 and 290 grm.
respectively, their combined weight being less by 60 grm. than
that of the first hemisphere.

After the above preliminary remarks, the necessity of which
will be seen when the different illustrations are compared with
one another, the writer will now proceed to describe the hemi¬
spheres of the cases of dementia paralytica which are shown
on Plates V to VIII.

On Plate V, figs. 6 and 7, are figured the right hemisphere
of a chronic case, and the left hemisphere of a more acute case
of dementia paralytica. In the former of these (Fig. 6) the
pia-arachnoid stripped readily from the hemisphere illustrated,
whereas in the case of the left hemisphere, which was the less
severely affected of the two, this membrane stripped with con¬
siderable difficulty on the postero-inferior aspect. In the
hemisphere illustrated in the figure both the regional distribu¬
tion and the degree of the cortical wasting are well shown.

In the latter (Fig. 7) the pia-arachnoid was very adherent to
the subjacent cortex, and decortication occurred on the second
temporal gyrus and the pre-occipital region. The distribution
and the degree of the wasting, which are stated in the descrip¬
tion, are readily visible in the illustration.

A cursory examination of these hemispheres by no means
suggests that the former (Fig. 6) possesses a greater complexity
of convolutional pattern than the latter.

These cases indicate what is still more clearly demonstrated
in the cases illustrated in the next plate, namely, that the
degree and the regional distribution of the wasting are the same
as is found in progressive senile dementia, and figured on Plate
IV, figs. 4 and 5. They also show that, in the absence of post¬
mortem decomposition, the pia-arachnoid is especially adherent
in those regions in which, at the time of death, recent and
active dissolution of the cortical neurones is occurring, whereas
this membrane becomes less adherent to, or readily strips from,
the convolutions which have already undergone considerable
dissolution, and in which more or less complete organisation
of the proliferated non-neuronic elements of the cerebrum has
occurred.

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1908 .] BY JOSEPH SHAW BOLTON, M.D. 47

On Plate VI are shown two cases, which are unique owing
to the clearness with which they illustrate these details.

Fig. 8, in fact, depicts the different functional regions of the
cerebrum with almost diagrammatic clearness. The anterior
centre of association is grossly wasted, and the pia-arachnoid
over it stripped very readily. This is the region in which,
in mental disease, dissolution first occurs, and in which, in
advanced cases of dementia, it is the most marked. Further,
as has already been stated, it is the only region of the convex
aspect of the cerebrum in which, in very early cases of dementia
paralytica uncomplicated by post-mortem decomposition, adhesion
of the pia-arachnoid to the cortex occurs. The psycho-motor
area shows some, but much less, wasting, and the pia-arachnoid
over this area stripped readily. In the case of the parietal,
temporal, and insular centres of association externally, and of
the precuneus and the inner part of the temporo-occipital region
internally, the pia-arachnoid was very adherent to the cortex,
and extreme decortication resulted from stripping {post-mortem
four and a half hours after death). There was also decortication
scattered in irregular patches throughout the callosal convolu¬
tion, but the visuo-sensory area (projection sphere) was
practically intact. It was, unfortunately, impossible to obtain
a clinical history of this case for a longer period than one month
before death.

On Fig. 9, the same distribution of the cortical wasting, and
also a similar distribution of the decortication, are visible, but
the differences in the appearance of the several regions are still
more gross. The prefrontal region, especially, was to all
intents and purposes little more than a firmly organised scar,
and cut like soft wood. The case presented an unusual course
in having started with a long series of epileptiform convulsions
after which the patient rapidly became grossly demented; and
this history exactly agrees with the morbid appearances
exhibited in the cerebrum. The unusually severe involvement
of the sensori-motor area has its clinical counterpart in the
series of convulsions which ushered in the disease. In the
majority of the cases of dementia paralytica which have come
under the writer’s observation, the temporal and parietal centres
of association are, however, more severely affected than in the
sensori-motor area, and this distribution agrees with the usual
clinical course of the cases. Such a distribution has also been

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PLATE V. Fig. 6 .

Chronic dementia paralytica.

Photograph of the right hemisphere of a case of chronic dementia paralytica,
who died after a series of 198 epileptiform convulsions. The figure shows wasting,
which is very marked in the prefrontal region (anterior two-thirds of the first and
second, and anterior part of the third frontal gyri); marked in the first temporal
gyrus, the inferior parietal lobule, Broca’s gyrus, and the lower part of the
ascending frontal gyrus; fairly marked in the remainder of the sensori-motor area
and the superior parietal lobule; and relatively slight in the remainder of the
hemisphere, including the orbital surface of the frontal lobe.

History. —Male, aet. 53. Married eighteen years, no children. No family or
personal history. In Claybury Asylum suffering from chronic dementia paralytica
for nearly three years, during the greater part of which time he was lost to time
and place, and wet and dirty in his habits. During the last two years of his illness
he had several series of convulsions, and eventually died after a succession of 198
epileptiform fits. Knee-jerks absent. Left pupil greater than right, and both
inactive to light. Tremor.

Post-mortem. —Dura: Slightly thickened. S.D.: Recent subdural haemorrhage
and excess of blood-stained fluid. Pia: Fronto-parietal opacity and marked
thickening and congestion ; strips readily except on the postero-inmrior aspect of
the left hemisphere. S.A.: Excess. Vents.: L., markedly dilated and granular;
IV, granular throughout. Vessels: Considerable thickening of basal arteries.
Encephalon: 1,225 Cerebellum, etc.: 145 grm. R.H.: 500 grm.; stripped

460 grm. L.H.: 520 grm.; stripped 480 grm. The right hemisphere was more
severely affected than the left. The aorta was exceedingly dilated, of cartilaginous
density, and contained a large amount of pearly-white fibrosis and some calcareous
deposit. Liver, spleen, and kidneys dense.

Fig. 7 .

More acute dementia paralytica.

Photograph of the left hemisphere of a more acute case of dementia paralytica.
The figure shows wasting, which is very extreme in the prefrontal region; extreme
in Broca’s and the first temporal gyri and the inferior parietal lobule; marked in
the rest of the sensori-motor area and the superior parietal lobule; and less marked
elsewhere, including the orbital surface of the frontal lobe. Decortication exists
in the second temporal gyrus and the pre-occipital region, into which parts the
morbid process appears to be rapidly spreading.

History. —Female, aet. 38, married. No family or personal history. In Claybury
Asylum suffering from dementia paralytica for thirteen months. On admission
she was quiet and somewhat lost. She collected rubbish, and she was dirty
in her habits. During her residence she had several (chiefly left-sided) con¬
vulsions. The pupils were unequal. The right knee-jerk was absent and the
left was exaggerated. Facial and lingual tremors. Speech slightly slurred.
Died in the last stage of dementia paralytica.

Post-mortem. —Dura: Natural. S.D.: Great excess. Pia: Fronto-parietal
opacity; extremely thickened and gelatinous, and very adherent to the cortex.
S.A.: Excess. Vents.: L., immensely dilated, the left more than the right, and
very granular; IV, dilated and granular, especially in the lower part. Vessels:
Natural. Encephalon: 1,045 grm. Cerebellum, etc.: 160 grm. R.H.: 393 grm.:
stripped 360 grm, L.H.: 355 grm.; stripped 320 grm. The left hemisphere was
more severely affected than the right. Cause of death: Chronic tuberculous
pneumonia. Aorta natural. Liver, spleen, and kidneys dense.

Digitized by L^ooQle

Plate V.

JOURNAL OF MENTAL SCIENCE, JANUARY, 1008.

Fig. 7.

To illustrate Dr. J. S. Bolton’s paper.

Bole £ I Hi nielsaon, Ltd.

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Plate VI.

JOURNAL OF MENTAL SCIENCE, JANUARY, 1908 .

PLATE VI. Fig. 8.

Dementia paralytica t showing the order of progress of the morbid process.

Photograph of the left hemisphere of a case of dementia paralytica. The ante¬
rior centre of association is grossly wasted. The psycho-motor area shows some,
but much less, wasting. The temporal and parietal and insular centres of associa¬
tion are acutely changed {post-mortem four and a half hours after death). The
upper part of the temporal centre of association, and the anterior part of the
parietal, show less acute change and more lasting. The visual projection centre,
and the visuo-psychic cortex around it, are intact.

History . —Male, single, private in rifle brigade, stated to be act. 26. No satis¬
factory personal or family history, but heredity of insanity denied. Died in
Claybury Asylum after a residence of four weeks. Was admitted in a feeble and
helpless condition. Tongue tremulous. Right pupil greater than left, and both
irregular. The pupils react neither to light nor to accommodation, undergo
irregular rhythmic movements, and become eccentric at irregular intervals. Knee-
jerks + +. All the limbs undergo clonic contractions, and at times enter into a
pseudo-clonus. There are continual masticatory movements of the lower jaw.
Patient is somewhat resistive, grossly demented, and wet and dirty.

Post-mortem. —Dura: Natural. S.D.: Remarkable excess. Deposit: Non-
hxmorrhagic film, the thickness of tissue paper, on the right vault. Pia:
Extremely opaque and almost universally thickened; marked mid-line prefrontal
adhesions below the falx cerebri; strips very readily over the frontal region.
S.A.: Great excess, especially in the pre-frontal region. Vents.: L., immensely
dilated, granular; III, granular; IV, very granular throughout, but especially
so in calamus. Vessels: Apparently natural. Encephalon : 975 grm. Cerebellum,
etc.: 157 grm. R.H.: 395 grm. L.H.: 395 gran.; stripped 350 grm. Density
of liver, spleen, and kidneys increased. Cause of death : Right lobar pneumonia,
dementia paralytica.

Fig. 9.

Dementia paralytica, showing the order of progress of the morbid process.

Photograph of the left hemisphere of a case of dementia paralytica. The
wasting is very extreme in the prefrontal region, and extreme in the whole sensori¬
motor region (posterior thirds of the first and second frontal, Broca’s, and the
ascending frontal gyri), and in the first temporal gyrus, the superior parietal
lobule, and the ascending parietal gyrus. The acute degeneration is most marked
in the outer surface of the temporo-sphenoidal lobe, the inferior parietal lobule,
and the pre-occipital region, but it is marked elsewhere. This distribution shows
fairly well in the photograph, but it was much more clear in the actual hemisphere.

History. —Male, aet. 41, clerk. Uncleinsane. Mother died of phthisis. Family
intemperate. Married six years, no children. Suffered from syphilis in early
life, and " took enough mercury to kill a horse.” One year before admission to
Claybury Asylum patient had a series of convulsions, and was unconscious after
the first for twenty-four hours. He had forty-two in four days, and he had fifty or
more during the year. He has been in two asylums, with an interval of two weeks at
borne, during this time. Slight hypospadias. Old scar on glans penis. Resists exa¬
mination as if afraid of being hurt. Is grossly demented. Does not speak. Is wet
and at times dirty. During his residence he rarely spoke, and suffered at times
from auditory and visual hallucinations. He had several right-sided and mixed
convulsions. He continued helpless and resistive, and wet and dirty, until his
death fourteen months after admission.

Post-mortem. —Dura: Natural. S.D.: Great excess; a little lymph between
pons and occipital bone. Pia: Marked fronto-parietal opacity and thickening;
extreme mid-line prefrontal adhesions. Both on the median surface in the pre¬
frontal regjon, to some extent in the prefrontal region externally, and also in the
post-central region and the whole of the temporo-sphenoidal lobe, there is marked
decortication on stripping. In the remainder of the fronto-parietal region the pia-
arachnoid is ballooned out with fluid and strips like a glove from the subjacent
cortex. S.A.: Great excess. Vents.: L., considerably dilated ; many scattered
granulations; IV, granular throughout. Vessels: Apparently natural. The
prefrontal region, after hardening in formalin, cuts like soft wood. Encephalon :
1,280grm. Cerebellum,etc.: 198grm. R.H.: 535 grm. L.H.: 527 grm.; partially
stripped 475 grm. Cause of death : Broncho-pneumonia, dementia paralytica.

Digitized by L^ooQle

PLATE VII. Fig. io.

Dementia paralytica . Cerebrum very small and very simply convoluted .

Photographs of the hemispheres of a case of dementia paralytica. Duration
about two and a half years. There is much wasting of the fronto-parietal region
and of the first temporal gyrus, but this is imperfectly shown in the figure. The
hemispheres are very small and very simply convoluted.

History. —Female, aet. 37, married. Father intemperate. Father and sister
committed suicide. Patient suffered from tingling of the hands and feet for six
months before her admission to Claybury Asylum, where she died of dementia
paralytica after a residence of two years. On admission she exhibited marked
physical signs of dementia paralytica, and was dull and lethargic and lost to her
surroundings. She soon became defective in her habits. She had her first con¬
vulsions a year after her admission. She died helpless and grossly demented.

Post-mortem. —Dura : Natural. S.D.: Great excess. Pia : Much fronto¬
parietal opacity and thickening; marked mid-line prefrontal adhesions. S.A.:
Moderate excess. Vents.: L, somewhat dilated, granular; III, granular; IV,
markedly granular throughout. Vessels : Natural. Encephalon : 985 grin.
Cerebellum, etc. :i38 grm. R.H.: 415 grm.; stripped 385 grm. L.H.: 400 grm.;
stripped 373 grm. Wasting : Chiefly marked in the prefrontal region, less severe
and fairly general in the rest of the fronto-parietal region and in the first temporal
gyrus, and slight or absent elsewhere. Cause of death: Dementia paralytica,
cystic kidneys, and secondary morbus cordis.

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Plate VII.

JOURNAL OF MENTAL SCIENCE, JANUARY, 1908.

Fio. 10.

To illustrate I)r. J. S. Bolton’s paper.

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Fig. 11.

To illustrate Dr. J. S. Bolton’s paper.

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PLATE VIII. Fig. ii.

Dementia paralytica. Cerebrum simply convoluted and very small . Subdural

deposit.

Photographs of the cerebral hemispheres and of a subdural deposit from a case
of chronic dementia paralytica. The illustrations exhibit the essentials of the
following description. The right hemisphere shows extremely marked wasting in
the fronto-parietal region and in the first temporal gyrus. Of these parts the pre¬
frontal region is the most wasted, and the psycho-motor area, with the exception
of Broca’s gyrus, is the least. The left hemisphere, which was compressed by the
deposit photographed below it, exhibits scattered bronzing and very extreme
wasting in the prefrontal region. The anterior part of the first temporal gyrus
shows much bronzing and marked wasting. The wasting is otherwise as in the
right hemisphere. The hemispheres, apart from the wasting, are very small and
simply convoluted (R.H. = 330 grm., L.H. = 290 grm., average normal male —
589 grm.), and the small size, in association with the wasting and the close
packing of the convolutions, tends in the photographs to obscure the simplicity of
the convolutional pattern.

History. —Male, set 41, insurance agent. Intemperance on paternal side.
Father’s cousin is at present in an asylum. Patient had syphilis at the age of
twenty years. Married seven years, six children. The first, fourth, and fifth were
stillborn, the second is alive, and the third and sixth died when infants. For two
years before his admission patient was excitable and curious in his behaviour, and
talked and raved about his business. He had been intemperate, but latterly he
was often queer and erratic, although he had had no drink. He slept badly during
the last four months, and was eventually certified owing to sudden violence. He
resided in Claybury Asylum for three and a half years, and then died of dementia
paralytica. On admission he was excited and grandiose and confused, and
thought that he was Emperor of the World. Knee-jerks absent. Speech charac¬
teristic. Pupils irregular, and left greater than right. A year afterwards he was
cheerful and industrious, but was beginning to go downhill. A year later he still
exhibited delusions of wealth and strength, but was demented and wet and dirty.
He gradually became lost, untidy, destructive, shaky, and feeble, and died in an
advanced stage of dementia paralytica.

A monthly record of reflexes and pupillary changes was taken from the sixth to
the fifteenth month of his residence. The knee-jerks were absent. Hypotonus
(85°) developed in the fourteenth month and continued. Both pupils were very
irregular and were absolutely fixed to light. The right gradually decreased during
the above period from 3$ to 2$ mm., accommodating to 3 and 2 mm. respec¬
tively, and the left gradually decreased from 5 to mm., accommodating to
4! and 3 mm. respectively. At this time his tongue was only moderately
tremulous and his speech was not grossly characteristic. By the twelfth month
of residence patient was distinctly more stolid in his behaviour, but he continued
to be grandiose. He devoured pheasants, partridges, bullocks’ brains, jellies,
honey, and port wine daily. He was as strong as a lion. His mother was a
beautiful lady and his father a lawyer’s clerk with a carriage and pair.

Post-mortem. —Dura: Natural. S.D.: Enormous excess of clear fluid. Deposit:
When the dura is reflected it tends to adhere over the left side, but strips readily;
the whole left hemisphere, except for the median half inch about the posterior
half, is covered with an old greyish-green deposit, which is ballooned out anteriorly
by fluid; the right hemisphere possesses a large amount of loculated S.A. fluid,
but there is less on the left side. On removing the brain the deposit readily
separates from the dura at the base. It is very loosely attached to the pia. The
deposit contains fluid in its anterior part and is here in places haemorrhagic. The
weight of the deposit and contained fluid is 45 grm.; it is dense and pale and
fibrous, and behind the cystic cavity it varies from | to in. in thickness. Pia :
Almost generalised opacity and extremely marked mid-line prefrontal adhesions.
Vents.: L., enormously dilated, granular throughout; 111, granular throughout;
IV, extremely granular, especially in calamus. Vessels: Slightly fibrous and
very small. Encephalon: 812 grm. Cerebellum, etc.: 108 grm. R.H.: 362 grm.;
stripped 330 grm. L.H.: 310 grm.; stripped 290 grm. Cause of death, etc.:
Gangrene of right lung; dementia paralytica; very chronic tuberculosis of the
small intestine and the mesenteric glands. Severe pigmented scars on the left shin
and unpigmented papery scars on the right shin; extremely marked scar on the
glans penis just to the left of the urethral orifice. Glands in groins very shotty.

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AMENTIA AND DEMENTIA,

[Jan.,

independently described by Schaffer and by Watson. On the
other hand, in ordinary cases of dementia, in which the process
of neuronic dissolution is neither so fulminating nor so severe,
and in which the centres of lower association are frequently
less severely affected than is the pre-Rolandic portion of the
cortex, it is less common to meet, during their clinical course,
with the grossly aberrant psychic phenomena of lower associa¬
tion which are common in dementia paralytica,' and which have
already been considered in the present paper ( Journal of Mental
Science , July, 1906, pp. 456-465).

(b) Cerebral under‘development in dementia paralytica .—In the
remaining cases to which reference will be made and which are
illustrated on Plates VII and VIII, the question of cerebral
under-development in relation to dementia paralytica will be
considered. All the cases of dementia paralytica which so far
have been described may, for practical purposes, be considered
to have possessed cerebra of, at the least, average development.

For comparison with the clinical account of the varieties of
dementia paralytica in which it will be shown that not only
“ normal ” individuals, but also high grade aments and even
imbeciles exhibit this symptom-complex, it is now necessary to
produce cases of dementia paralytica which possess the small
and simply convoluted cerebra of mental degenerates.

In Plate VII, fig. 10, are shown the right and left hemi¬
spheres of a woman possessing a markedly under-developed
cerebrum. These hemispheres are very small and also very
simply convoluted, and these details become especially obvious
when the photographs are compared with the equal-sized illus¬
tration on Plate III, fig. 3. The weights of the right and left
hemispheres, after stripping, are respectively 385 and 373 grm.,
whereas the weight of the average normal stripped hemisphere
of the female (based on Huschke’s ratio and on F. Marchand’s
statistics) is about 534 grm.

The hemispheres of this case are so simply convoluted that
the marked wasting which exists is not obvious, in spite of the
fact that in any, but particularly in small, hemispheres the
apparent complexity of convolutional pattern is increased by
wasting. Were the hemispheres of this case in their original
condition, it is not an exaggeration to remark that the simplicity
of their convolutional pattern would appear extraordinary.

In Plate VIII, fig. 11, are shown the hemispheres of a similar

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1908.] BY JOSEPH SHAW BOLTON, M.D. 49

(male) case of dementia paralytica with an under-developed
cerebrum. The central photograph is that of a subdural
deposit of long standing, which entirely covered the left hemi¬
sphere. Though the patient was of the male sex, the stripped
hemispheres weighed respectively but 330 and 290 grm., the
pair thus totalling less by 60 grm. than the 680 grm. scaled
by the single hemisphere illustrated on Plate III, fig. 3 (average
male normal 589 grm.).

Here, again, the simplicity of convolutional pattern is so
marked that the very gross wasting which exists is far from
obvious. On the other hand, the close packing of the convolu¬
tions, in association with the gross wasting, tends to hide the
remarkable simplicity of convolutional pattern, and makes it
difficult to conceive that the hemispheres are of exactly the
same relative size as is that illustrated on Plate III, fig. 3.

(4) Evidence as to the Relationship between Dementia Paralytica
and Mental Disease , derived from a Study of the Clinical
Types of Dementia Paralytica.

In the preceding sub-sections evidence has been adduced as
to the frequency of heredity of insanity and of family and
parental degeneracy in dementia paralytica, and as to the
modification of the death rates of the insane at different ages
which results from the exclusion of the cases of dementia
paralytica. Further, the writer has indicated the relationship
which exists between the morbid anatomy of dementia para¬
lytica and that of progressive senile dementia, and he has
drawn attention to the existence of cerebral under-development
in certain types of dementia paralytica.

The final evidence, which he purposes to produce in support
of the thesis that dementia paralytica is an integral part of
mental disease, is derived from a comparison of the clinical
types of dementia paralytica with the homologous types of
ordinary mental disease, which have already been considered
under the heading of “ Primarily Neuronic Dementia.”

Further experience has confirmed him in the opinion that
the following classification of the varieties of dementia paraly¬
tica, which was suggested in a previous paper (Archives of
Neurology, voL ii), is on the whole satisfactory. It is based on
the different grades of cerebral degeneracy which are presented

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AMENTIA AND DEMENTIA,

[Jan.,

by the several types, and thus follows on the lines already
adopted in the description of primarily neuronic dementia,
though for convenience the order is inverted.

The classification is as follows:

(1) Dementia paralytica.

(а) Juvenile dementia paralytica.

(1) In imbeciles (low-grade aments).

(2) In high-grade aments, etc.

(б) Ordinary chronic dementia paralytica in adult high-

grade aments.

associated with extensive degeneration of (usually
afferent) lower neurones.

(d) Acute or subacute dementia paralytica in the highest

grade degenerates (general paralysis of the text¬
books). ^

(2) General paralysis

Cases of dementia n|(^ytica form a smSIW^oportion only of
the series of cases unftiD coj^kteratiolQOfliere Jbeing but 23, of

o are
xases

whom 14 are males a
5*17 per cent, of the 44*
the total of 728 cases of
These cases fall into the following classes:

ire females. TWfej
f demen^

mpihiL;

thus amount to
r 3-16 per cent, of
entia.

Dementia paralytica.

(а) Juvenile.

(1) In imbeciles .

(2) In high-grade aments, etc.

(б) Ordinary chronic in high-grade

aments.

(d) Acute or subacute in highest

grade degenerates .

M. F. T.

1 — 1

9 8 17

4 1 5

Total . . . 14 9 23

In spite of the small number of cases it will be seen that in
the acute or subacute type there is the usual preponderance of
male cases, whereas the chronic cases show but a slight
difference in sex-frequency.

The practically equal sex-incidence in chronic dementia
paralytica was noted some years ago by the writer in a previous

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BY JOSEPH SHAW BOLTON, M.D.

1908.]

paper. Whilst dementia paralytica is more common in the
male than the female sex owing to the greater frequency of
syphilis in the former, “stress 1 ’ is also a more important
factor in the male sex, owing to the conditions of civilised life.
Acute cases of dementia paralytica therefore preponderate in
the male sex and chronic cases in the female sex, with the
accidental result that an approximately equal number of
chronic cases exist in the two sexes.

On the other hand, the approximately equal sex-incidence in
juvenile general paralysis, which was first noted in 1893 by
Dr. Wiglesworth, is the natural consequence of the equal sex-
incidence of “ congenital ” syphilis and of the more equal
sex-incidence of “ stress ” in such juvenile cases.

As typical examples of the several varieties into which
dementia paralytica has been classified were published by the
writer in the paper already referred to, and as their existence is
now probably proved beyond dispute, his purpose will be served
by an explanatory amplification of the classification, without
the insertion of any cases beyond those already briefly sum¬
marised in the illustrations.

Juvenile dementia paralytica .—In the imbecile type the patient
is a well-marked degenerate of congenitally deficient intelli¬
gence. At or before the age of puberty a slowly progressive
dementia develops under the influence of the “stress” of
normal environment. In spite of the deficient durability of the
cortical neurones of these cases the development of the dementia
is usually slow, as the “ stress ” which has determined their
incarceration in an asylum is so slight that a relatively small
amount of immediate injury to the cortical neurones has been
produced. It is probable that accident of environment or
physical disease has a good deal to do with the exacerbation of
symptoms which at times occurs. In one case, for example,
the writer has little doubt that the exertion of acting as a golf
caddie was the exciting cause of a more rapid progress of
the disease, for the patient had for a long time previously
remained in a practically stationary condition. In the writer’s
experience cases of this type frequently suffer from degenera¬
tion of the lower neurones and exhibit optic atrophy and
tabetic symptoms. They are the probable juvenile homologues
of the “ ordinary chronic ” and “ tabetic ” types of dementia
paralytica.

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52 AMENTIA AND DEMENTIA, [Jan.,

In the view of the writer patients suffering from the imbecile
type of juvenile dementia paralytica would, if they had not
previously suffered from syphilis, have become ordinary examples
of the (stationary) premature dementia of marked degenerates.

In the high-grade ament form of juvenile dementia paralytica,
the patient has originally been of at least average intelligence,
and at times appears to have been distinctly well endowed
mentally. It is, however, common to find that such patients
become “ backward ” in their studies about the period of
puberty. Under what at times seems to be the “stress” of
normal environment, but is usually distinctly more severe, e.g.,
in some cases prolonged over-study, the patient, about the
period of puberty or adolescence, develops acute and progressive
dissolution of the higher cortical neurones, which, when the
morbid process has once got under way, often runs a rapid
course. The symptomatology presented by cases of this type is
at times identical with that given in ordinary text-book des¬
criptions of adult general paralysis. The writer has formed
the opinion, though he expresses it guardedly owing to the lack
of statistical evidence, that degeneration of the afferent systems
of neurones is less common in such cases than in the imbecile
type of juvenile dementia paralytica.

In the view of the writer, the subjects of the form of general
paralysis under consideration would, if they had not previously
suffered from syphilis, have become ordinary examples of
(stationary) premature dementia. In consequence, however, of
former infection with syphilis, these cases become the prema¬
ture homologues of the rapidly progressive adult variety of
dementia paralytica, in which, at the period of greatest mental
and physical activity, fulminating dissolution of the higher
cortical neurones is precipitated under the influence of excessive
mental and physical “ stress.”

Ordinary chronic dementia paralytica .—Whilst any of the well-
known types of symptomatology, including epilepsy, may occur
in the subjects of the chronic form of dementia paralytica, pro¬
gressive dementia is the prominent clinical feature, and the
course of the case is often so slow that, were it not for the
existence of the ordinary physical signs, the condition would
undoubtedly often be undiagnosed. Many such cases, in fact,
probably die unsuspected at home or in workhouses, for only
the cases which cause trouble are likely to be sent to asylums.

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BY JOSEPH SHAW BOLTON, M.D.

S 3

1908.]

Ideas of grandeur often exist, and the writer has seen several
cases which still exhibited this symptom after a residence in an
asylum of ten or twelve years. Such cases, as a rule, neither
exhibit the acute symptomatology nor provide the antecedent
history which occur in cases of the ordinary text-book descrip¬
tion, and they are often admitted to asylums when already in
an advanced stage of dementia. Two examples of this type
of dementia paralytica are described and figured on Plates
VII and VIII.

These cases are commonly, if not invariably, high-grade
aments, who often exhibit marked stigmata of degeneracy. It
is probable, therefore, that, especially in the examples who
do not suffer from convulsions, the often prolonged course
of the case is due to the same cause as has already been stated
with reference to the imbecile variety of juvenile dementia
paralytica, namely the readiness with which the cortical
neurones are affected by “ stress.” In such cases there is
consequently less immediate dissolution of the higher cortical
neurones than occurs in the more fulminating types whose
breaking-strain is not readily reached. Hence, when the slight
“ stress ” which has precipitated their breakdown is removed
by their being placed under asylum regime , the symptoms
largely subside, and, unless they should be discharged " re¬
covered ” and consequently relapse, these cases usually run a
prolonged course.

In the opinion of the writer, such cases would, had they not
previously suffered from syphilis, have become examples of the
ordinary chronic lunatic with moderate (stationary) dementia,
and a general symptomatology appropriate to their mental
constitution.

“ Tabetic general paralysis .”—In this form of dementia para¬
lytica dissolution of the higher cortical neurones is associated
with a more or less extensive degeneration of (usually afferent)
systems of lower neurones. Owing to the definite neurological
symptomatology in well-marked cases, it is desirable that these
examples should be considered a special type, as otherwise
dementia paralytica would require to be artificially sub-divided
into (a) dementia paralytica and ( b ) dementia paralytica with
involvement of lower neurones. This is, however, undesirable,
as many, if not the majority of, cases of dementia paralytica
exhibit some slight affection of these neurones when they are

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54 AMENTIA AND DEMENTIA, [Jan.,

submitted to systematic histological examination. As a rule,
however, when the affection of lower neurones is well marked,
the cases are either the rare examples of the imbecile variety of
juvenile dementia paralytica or are fairly high-grade degenerates
who, apart from involvement of the lower neurones, would fall
into the class of “ ordinary chronic dementia paralytica.”

The writer thinks it probable that, had they not previously
suffered from syphilis, certain of these cases would have become
examples of ordinary chronic insanity with moderate (stationary)
dementia, and the remainder would have suffered from a chronic
process of dissolution of certain systems of lower neurones, and
would have thereby come under the purview of the neurologist
rather than of the alienist.

Acute or subacute dementia paralytica in the highest grade
degenerates (general paralysis of the text-books).—It is unneces¬
sary to refer here to the classical symptomatology of this form
of dementia paralytica, and particularly so as it has already been
critically discussed under the subject of “Mental Confusion and
Dementia ” in an earlier section of this paper (Journal of Mental
Science , July, 1906, pp. 456-465).

It may, however, be pointed out that cases of this type are,
by cerebral development, frequently so little prone to suffer
from dementia, that only the severest forms of “stress ” (mental
and physical over-strain, business worries, alcoholic and other
excesses, etc.) are able to precipitate the onset of dissolution of
the higher neurones of the cortex. In such cases, where highly
evolved cortical neurones have long been strained to breaking-
point, fulminating dissolution occurs when this has been over¬
stepped, and a rapid case of dementia paralytica ensues.

In the view of the writer, if cases of this type had not pre¬
viously suffered from an attack of syphilis, they would either
have become temporarily insane, or would have developed a
more or less marked grade of non-progressive dementia.

General paralysis without mental symptoms may perhaps be con¬
sidered the very highest (and non-certifiable) grade of the form
of mental disease under consideration. Though well known to
neurologists, this condition does not fall into the sphere of
alienism, although certain rare cases of arrested or recovered
general paralysis might be included under the term. Such latter
cases are, however, more likely to be examples of what might be
called a premature onset of dementia paralytica, in which the

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1908.]

BY JOSEPH SHAW BOLTON, M.D.

“ stress” to which the cerebrum had been subjected had sufficed
for the production of symptoms, but had not been severe enough
to cause an appreciable degree of dissolution of the higher
cortical neurones. In these cases definite dementia paralytica
would be expected to ensue at some future time, provided that
the patient were again subjected to “ stress ” beyond the resis¬
tance of his cerebrum.

If, however, it be taken for granted that no mental symptoms,
rather than no certifiable mental symptoms, exist in such cases,
it is preferable to employ the term “ general paralysis in the
sane.”

The writer has necessarily excluded senile dementia paralytica
from his classification, as cases of this kind are usually compli¬
cated by the existence of senile or prematurely senile degenera¬
tion of the cerebral arteries of a grade which might in itself
result in the development of progressive senile dementia. Such
cases, in other words, as a rule, combine both the morbid
anatomy and the symptomatology of dementia paralytica and
of progressive senile dementia.

In these cases, in the experience of the writer, the attack
of syphilis has usually occurred at or after maturity, and its
influence has chiefly been in the direction of a gross exacerba¬
tion of normal senile vascular degeneration. This is shown by
the presence of well-marked dilatation and pearly fibrosis of
the aorta and of the larger and medium arteries, together with
extensive fibrosis of the smaller arteries (particularly in those
of the cerebrum), and a moderate amount of calcareous deposi¬
tion in the arteries generally.

The cerebral morbid anatomy of such cases, whilst suggesting
dementia paralytica, is frequently that of progressive senile
dementia, probably in consequence of a lesser capacity for
reparative reaction on the part of the non-neuronic elements of
the encephalon than exists in ordinary dementia paralytica.
The clinical symptoms presented by such cases agree with the
morbid anatomy in being chiefly those of progressive senile
dementia, although dementia paralytica is suggested both by
the physical signs which are present and by the type of mental
confiision which is exhibited.

Summary.

It is beyond the expectation of the writer that the evidence

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AMENTIA AND DEMENTIA.

[Jan.,

which he has collated should finally settle the vexed question
of the relationship of dementia paralytica to mental disease.
He, however, hopes that he has at any rate stated a case which
will justify the attitude he has adopted.

In brief, he considers that dementia paralytica is a branch of
mental disease, and that the subjects of this form of mental
disease would, if they had not been syphilised, have suffered
from one or other of the types of primarily neuronic dementia.
He is further of the opinion that former syphilis is a necessary
antecedent to dementia paralytica.

With regard to the first question, he has shown, by a study
of the death rates in mental disease at different ag£s, and by a
comparison of these death rates with the homologous death
rates in the corresponding general population, that the exclu¬
sion of the general paralytic population of an asylum leads to
the result that lunatics (particularly those of the male sex) have
an extraordinarily low death rate between the ages of thirty-five
and fifty-four. If, on the other hand, the general paralytic
population is included in the total lunatic population, this
result is not apparent.

He has also pointed out that the morbid anatomy and the
pathology of dementia paralytica do not differ in their essential
features from those of progressive senile dementia. He has
further shown, by a classification of the types of dementia para¬
lytica and a comparison of these with the varieties of primarily
neuronic dementia, that the two series are homologous.

On these various grounds he has based his contention that
dementia paralytica is a branch of mental disease. As confir¬
matory evidence he has pointed out the high percentage of
heredity of insanity and of parental and family degeneracy
which can be obtained in cases of dementia paralytica, and he
has shown that cerebral under-development occurs in certain
types of this form of mental disease.

With regard to the second question, he has indicated his
reasons for considering that former syphilis is a necessary ante¬
cedent to dementia paralytica. He is of the opinion that the
ordinary sane individual and the ordinary psychopath or
potential lunatic, if possessed of cortical neurones of average
durability, may suffer from syphilis with impunity as regards
the later onset of dementia paralytica, and he considers that
the same statement may be made with regard to the syphilised

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1908 .] OPSONIC INDEX TO VARIOUS ORGANISMS.

lunatics with little or no dementia, who are fairly common in
asylums. On the other hand, he holds that a psychopath who
possesses cortical neurones of subnormal durability, and who,
apart from an attack of syphilis, would develop a moderate
grade of dementia, would, after an attack of that disease, sooner
or later suffer from one or other of the types of dementia para¬
lytica.

He thinks that the important feature in which dementia
paralytica differs from progressive senile dementia consists in
the possession, by the subjects of former syphilis, of a perma¬
nently enhanced capacity of reparative reaction on the part of
the non-neuronic elements of the encephalon. In both cases
neuronic dissolution and non-neuronic reparative reaction occur
pari passu. In the case of dementia paralytica the latter is more
or less intense, and vascular degeneration is relatively slight;
in the case of progressive senile dementia the latter is relatively
feeble and vascular degeneration is relatively severe. He would
illustrate this point by a coarse analogy, comparing dementia
paralytica to certain types of progressive renal cirrhosis and
progressive senile dementia to senile renal cirrhosis.

On these grounds he includes dementia paralytica and pro¬
gressive senile dementia under the common group of “ Pro¬
gressive and Secondary Dementia.”

(To be continued.) \

Observations on the Opsonic Index to Various Organisms
in Control and Insane Cases. By C. J. Shaw, M.D.,
Senior Assistant Medical Officer, Montrose Royal Asylum,
formerly Assistant Medical Officer, Perth District Asylum,
Murthly.

In Wright’s earliest researches on the opsonic body in human
blood serum he used various strains of staphylococci. He found
in various forms of staphylococcal invasion, such as acne,
furunculosis, and sycosis, that the index of the patient so
infected was lower than that of an ordinary healthy individual
to the particular organism causing the disease. By his method
of inoculation of a vaccine made from the infecting organisms
LIV. 5

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5«

OPSONIC INDEX TO VARIOUS ORGANISMS, [Jan.,

he was able to greatly improve the condition and even cure
most intractable cases. Bullock has obtained like results, and
cases have been recorded where pneumococcal and other infec¬
tive diseases have been cured by similar treatment.

So far as is at present known the opsonic index of human
blood serum to the majority of organisms is very similar to the
tuberculo-opsonic index. For purposes of comparison as between
the healthy sane individual and the non-tubercular insane, I
examined the indices of five control cases and fifteen insane
patients to the Bacillus colt communis> Staphylococcus aureus ,
and Micrococcus rkeumaticus for five days before the injection
of Koch’s new tuberculin T.R. was given and for some days
thereafter.

Throughout the whole series of observations the temperature
and pulse-rate were recorded twice daily in both the control and
insane cases.

The quantitative and qualitative leucocytosis was observed
before and after injection in all the control cases and in nine¬
teen of those suffering from mental disease.

To observe the effect of the injection of tuberculin on the
insane the urine of ten patients who were confined to bed was
collected before and after injection, and the amount of urea and
chlorides excreted during each twenty-four hours recorded. At
the same time an accurate record of the albumen and chlorides
ingested daily was made, and the difference between ingestion
and excretion noted.

Daily notes were made of the mental symptoms, particularly
of the acute cases under observation.

The technique employed was the same as that already
described in the observations made with the tubercle bacillus,
but fresh organismal suspensions in a normal sodium chloride
solution were made every second day to prevent any error from
contamination with foreign organisms.

The films were stained with Jenner’s eosin and methylene
blue. The contents of fifty leucocytes were usually counted,
but on a few occasions only thirty were enumerated. The same
number of cells was always examined at the same observation
for any one organism.

Although there are no statistics to support the statement, I
have found during my residence in the Perth District Asylum
that the insane frequently suffer from acne, boils, and other low

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1908.]

BY C. J. SHAW, M.D.

forms of inflammation. From many such cases I have isolated
a Staphylococcus aureus. Clouston states that boils and skin
irritations are common in some forms of mental disease.

Cystitis occurs frequently in asylums, even in fairly healthy
patients. In many cases I have found the Bacillus coli communis ,
or an allied organism, present in the urine. Obscure intestinal
lesions are also common amongst the insane and may, in some
cases, be associated with this microbe. Johnstone and Goodall
found agglutinins to various strains of the Bacillus coli communis
in the blood of 60 per cent, of insane cases examined by them.
For my observations, therefore, I used Staphylococcus aureus and
Bacillus coli communis . The growth of the Bacillus coli used
was obtained from the faeces of a patient. The Staphylococcus
aureus was obtained from the bone-marrow of a case of acute
mania who died in a typhoid state. It was tested by Dr.
Dowson, of Messrs. Burroughs, Wellcome, & Co.’s Pathological
Laboratory, and was pronounced by him to be a pure culture
of this organism.

Dr. L. C. Bruce has isolated streptococci from the blood of
a case of acute mania, and also from a case of a form of
adolescent insanity—katatonia, and has found agglutinins to
these organisms in the blood of the majority of patients suffer¬
ing from the same diseases. Erysipelas is also relatively more
common amongst the insane than amongst the sane population.
In the district from which the Perth District Asylum draws its
patients, rheumatism, in its various forms, is perhaps the most
common ailment. Rheumatism, however, does not appear to
be more common in the asylum than in the country round.
Although rheumatism is not a common cause of insanity it is
so in some cases, and Clouston, in his book on mental diseases,
gives a most graphic description of a case of rheumatic
insanity. He also quotes statistics to show the important
relationship between rheumatic attacks and the periods of
puberty and adolescence. As almost 50 per cent, of all the
persons on whom observations were made were adolescents, or,
if insane, in whom the illness had begun in adolescence, I used
the Micrococcus rheumaticus as the type of streptococcus. I
found it much easier to work with than any other strain of
streptococcus obtainable, as it did not clump so readily in solu¬
tion, and was, therefore, more easily counted and gave more
accurate and reliable results.

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OPSONIC INDEX TO VARIOUS ORGANISMS, [Jan.,

Five control cases were examined to these three organisms
for five consecutive days.

To the Bacillus colt the average index was ro2, the varia¬
tion ranging between ’84 and 1*14. The variation in the
individual cases is greater than to tubercle, and is more easily
affected by outside influence. In one patient, who had attended
a public dinner the previous evening, the index to Bacillus coli
recorded at the usual hour next morning was 1*5, while there
was no marked difference in the indices obtained to the other
organisms employed at this observation. In these five control
cases the average tuberculo-opsonic index was ro8, which is
not much higher than that found to Bacillus coli.

The average index of the five control cases examined to
Staphylococcus aureus was ri, with a variation between *89 and
1*45. One case had invariably a very high index to this
organism, reaching on one occasion 1*63. The variation in
the other cases was not very great. The index to this
organism is rather higher than that to tubercle in the same
cases, being n as against 1*08.

In the case of the Micrococcus rheumaticus the same five
cases gave an index of 1*07. The variation ranged between
•89 and 1*22. The variation in the individual cases is also
wide. The average tuberculo-opsonic index in these cases was
ro8, the variations being between *97 and i # 32.

Table showing the Average Opsonic Indices of the Control Cases to
the Tubercle Bacillus , Bacillus coli, Staphylococcus aureus,
and Micrococcus rheumaticus.

T. b. B. c. S . a . M. r.

108 . 1*02 . ri . 107

There is, therefore, very little difference found in the average
index of sane healthy individuals tested to these four organisms.
That to Bacillus coli is lowest, and shows the least variation,
while that to Staphylococcus aureus is highest, and shows the
greatest amount of variation.

In twelve insane patients the average opsonic index to
Bacillus coli was 1*06, the variation being between *81 and
1*28. This result compares favourably with that found in the
control cases to this organism, although the variation is greater.
In the same cases the tuberculo-opsonic index was *97.

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1908.]

BY C. J. SHAW, M.D.

6 l

In fifteen cases tested to Staphylococcus aureus the index was
107, with a variation ranging between *91 and 1*38. This
differs very slightly from the results obtained in the control
cases. In the same cases the average index to tubercle was
only *9.

Eleven cases which were observed to the Micrococcus rheu -
maticus gave an average index of *94, the variation being
between 78 and V 2 \. This result is below the index of the
control cases and the variation observed is greater. The
average index to tubercle in the same series of cases was *91.
The amount of variation to the tubercle bacillus was the same
in each series of observations, viz.: *68 to 1*23. When the
cases are examined individually the range of variation is found
to be greater in the insane patients than in the control cases.

Table comparing the Tuberculo-opsonic Indices with the Indices
obtained to the Bacillus coli, Staphylococcus aureus, and
the Micrococcus rheumaticus in the Same Series of Patients .

Average opsonic index to B. c. 1*06; to t. b. *97
» >1 >» I 07 » M )) 9

>» m >* r. 94 > »> »» 9 1

The tuberculo-opsonic index is below the opsonic index of
these other organisms in the insane cases and the range of
variation greater.

Except in one case where a boil developed towards the end
of these observations none of the patients were known to suffer
from any infective condition, and all carious teeth or other
source of infection had been removed, as far as possible, before
the work was begun.

Table comparing the Average Opsonic Indices of the Control Cases
to the Tubercle Bacillus % Bacillus coli communis, Staphylo¬
coccus aureus and Micrococcus rheumaticus with those oj
the Insane Patients to the Same Organisms .

T.b. B.c. S.a. Af.r.

Control cases 1*08 . 1*02 . 1*1 . 1*07

Insane cases ’88 . 1*06 . 1*07 . *94

With the exception of Bacillus coli the average opsonic index
of the control cases was higher to all the organisms used in

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OPSONIC INDEX TO VARIOUS ORGANISMS, [Jan.,

these observations than in the insane patients. The amount
of difference between the two averages to Bacillus coli was
very small and much less than what was found in the case of
tubercle or Micrococcus rheumaticus.

It may therefore be concluded that the resistive power of
the insane to organismal invasion in less than that of the sane
healthy population.

The observations with Bacillus coli. Staphylococcus aureus, and
Micrococcus rheumaticus , were continued after the injection of
tuberculin. Each of the four of the control cases, who were
injected with 3-^ mgr. T.R., showed a negative phase to
Staphylococcus aureus. Three had a diminution of opsonic
power to Bacillus coli and two to the Micrococcus rheumaticus .

Of the two cases who showed no negative phase to tubercle
after injection, one had a fall in opsonic power to all the three
organisms tested, while the other gave a similar result with
Bacillus coli and Staphylococcus aureus.

Two cases developed a negative phase to the tubercle
bacillus after the injection of tuberculin ; one of these gave a
similar reaction with all three organisms, while the other only
did so to Staphylococcus aureus.

Table showing Number of Negative Phases in the Control Cases to
the Tubercle Bacillus , Bacillus coli, Staphylococcus aureus
and Micrococcus rheumaticus following the Injection of
T<ytf m S r ' T.R.

T. b.

B. c.

5. a.

M. r.

. N. .

N. .

, N.

. N. .

, N. ,

. O.

. O. .

, N. .

0 .

. N.

. N. ,

. N.

All the control cases, therefore, gave a negative phase to one
or other of these organisms, the Bacillus coli , Staphylococcus
aureus , and Micrococcus rheumaticus after injection with T.R.

Of the twelve series of observations made to other organisms
after the injection of tuberculin, in nine instances a negative
phase resulted, that is, in 7 5 per cent, of the total.

Only one control case injected with mgr. T.R. was
tested to the three other organisms employed. No negative
phase to tubercle was produced in this case, but there was a

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1908.] BY C. J. SHAW, M.D.

loss of opsonic power to the Micrococcus rheumaticus after
injection.

Nine insane patients injected with mgr. T.R. were tested
to Bacillus coli after injection, and in all a negative phase
resulted. All twelve insane cases who were injected with a
similar amount of T.R. were tested to Staphylococcus aureus ,
and in eight of these cases a negative phase followed, this is, in
66 per cent . Of eight cases in the same series examined to
Micrococcus rheumaticus five gave a negative phase, that is,
62 ‘S per cent.

Table showing Percentage of Negative Phases to all the Organisms
used in the Control Cases and Insane Patients after the Injection
°f Th m S r - T R •

T.b. B.c. S.a. M. r.

Control 50 . 75 . 100 . 50

Insane 91 . 100 . 66 . 62*5

On comparing the results obtained in the control cases with
those in the insane to each organism, it was seen that the
percentage of cases where a negative phase was observed
after injection was less in the control than in the insane
cases to tubercle, Bacillus coli , and Micrococcus rheumaticus , but
greater in the control cases than in the insane patients to
Staphylococcus aureus.

Only three cases injected with mgr. T.R. were tested to
the other organisms. One of these cases gave a negative phase
to tubercle only, but one of them showed this reaction to all
the other organisms, while the third had a fall in opsonic
power to Bacillus coli only.

Table showing Number of Negative Phases in the Insane Cases to the
Tubercle Bacillus , Bacillus coli, Staphylococcus aureus
and Micrococcus rheumaticus after the Injection of mgr.
T.R.

Case 17

T.b.

0 . .

B.c.

. N.

S.a.

. N. ,

M.r.

. N.

Case 20

N. .

. 0.

. O.

Case 29

. N.

. O.

. 0.

In some cases the fall in the opsonic curve to these
organisms was slight, and the continuation of the curve showed
little change from what it was before the injection of tuberculin,

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6 4

OPSONIC INDEX TO VARIOUS ORGANISMS, [Jan.,

but in many the curve closely resembled that of a typical
negative phase to tubercle.

After an injection of either sfo mgr. T.R., or rhs mgr. T.R.,
I find the number of cases in which a negative phase results is
greater in the insane than in the sane.

A series of sixteen observations was made on the control
cases after injection with mgr. T.R., with all four organisms
used, namely, tubercle bacillus, Bacillus colt, Staphylococcus
aureus , and Micrococcus rheumaticus. In all there were eleven
negative phases produced after injection, that is, in 68*7 percent.

A series of forty-one observations was made on the twelve
patients who were similarly injected. Of this total thirty-
three showed a negative phase, that is, 80*4 per cent.

With an injection of mgr. T.R. one control case showed
a negative phase in 25 per cent, of the observations made.

Twelve observations were made on the three insane patients
who were injected with the same dose. In these a negative
phase occurred in 41’6 per cent.

It is therefore reasonable to conclude that the general
resistive power of the insane to organismal infection is less
than that possessed by the sane.

A comparison of the results obtained in the different classes
of cases examined to the organisms used during these observa¬
tions, before and after the injection of tuberculin, would lead
one to suppose that there is a difference in the resistive power
to organismal invasion between these various classes.

In five control cases tested to all the organisms employed
before injection of the tuberculin the tuberculo-opsonic index
was ro8. Of the seven acute cases of mental disease examined
to two or more organisms, the tuberculo-opsonic index before
injection was ’87, as compared with *93 in eight chronic cases
tested to all the organisms.

The five control cases gave an average index of 1*02 to
Bacillus coli. In four acute cases the index to the same
organisms was *96, and in the eight chronic cases ro6.

To Staphylococcus aureus the index recorded in the control
cases was i*i. The index in the seven acute cases was roi,
while in the chronic cases the index was 112.

The index to the Micrococcus rheumaticus in the control
cases was 1*07. In three acute cases tested to this organism
the index was *9, and in the chronic cases ’96.

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1908.]

BY C. J. SHAW, M.D.

Table showing Average Indices of the Different Classes of Cases to
the Various Organisms before the Injection of Tuberculin.

T.b.

B.c.

5. a .

M. r.

Aggregate

average.

Control

ro8 .

1*02

I* I

1*07

. 1*06

Acute

•87 .

•96 .

roi

•9

• 93

Chronic

•93 •

ro6

ri2

. - 9 6

. roi

To each of the organisms tested the average index of the
acute cases was found to be below that of the control cases and
also of the more chronic patients. The average index of the
chronic cases is below that of the control cases to tubercle and
Micrococcus rheumaticus , but slightly above the control average
index to Bacillus coli and Staphylococcus aureus. As will be
seen from the foregoing table the aggregate average of the
control cases is ro6, while that of the chronic cases is roi.

As no acute case was injected with m g r - T.R., no com¬
parison can be made between the various classes of cases after
the injection of that dose.

In sixteen observations made on the four control cases
injected with 3-^ mgr. T.R. eleven negative phases followed,
that is 68*7 per cent.

Of the twelve patients who were injected with the same
dose, and examined to at least two of the organisms used
during these observations, seven are classified as suffering from
acute mental disease. A series of twenty-one observations was
made in these cases, and in seventeen a negative phase was
produced, that is, in 80*9 per cent.

Five cases similarly injected were classified as subacute or
chronic, and had been resident in the asylum from one to six
years. On these twenty observations were made, and a
negative phase resulted in sixteen, or a proportion of 80
per cent.

Table showing Proportion of Negative Phases in the Different
Classes of Cases after Injection with yj-g- mgr. T.R.

Controls. Acutes. Chronics.

687 . 80*9 . 80

The percentage of negative phases produced is highest in
the acute cases, and lowest in the control cases. This result
agrees with the conclusion arrived at from a consideration of
the preceding table.

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OPSONIC INDEX TO VARIOUS ORGANISMS, [Jan.,

The more chronic cases have, therefore, a greater resistive
power to organismal infection than the more acute and recent
cases, but they are more liable to infection than the sane healthy
population.

That the average index of the four control cases injected with
y$y mgr. T.R. is higher to all the organisms used in these
observations than in the corresponding twelve insane cases is
shown in the following table :

Table of Average Opsonic Indices to the various Organisms prior
to Injection with yj-^- mgr. T.R.

T. b.

B. c.

S. a.

M. r.

Control cases

I’o8 .

■99

• ns .

1*0 7

Insane „

•82 .

•98

. 1-04

*94

The difference in the percentage of negative phases following
injection of y£y mgr. T.R. in the control and in the insane
cases is similar to the difference between their average opsonic
indices before injection, the figures being 68*7 in the control
cases and 80*49 * n the insane cases. With the exception of
Staphylococcus aureus the percentage of negative phases to each
organism was less in the control than in the insane cases ; and
this was the only organism in which the amount of variation, in the
figures from which the average index was calculated, was greater
in the control cases than in the insane. The range of variation
was from *9 to 1*45 in the healthy, and from *91 to 1*23 in
the insane. This fact may help to explain the greater number
of negative phases obtained after injection.

To estimate the effect of two different doses of tuberculin
on the number of negative phases produced, the same type of
case must be examined in both instances. I have only examined
subacute and chronic cases after the injection of both yyy mgr.
T.R. and yyy mgr. T.R.

Twenty observations were made on the five cases injected
with yyy mgr. T.R., and in sixteen instances a negative phase
resulted, that is, in 80 per cent. Three cases were injected with
rhr mgr. T.R. Twelve series of observations were made in
these cases after injection and in five a negative phase was pro¬
duced, that is, in 41-6 per cent. The larger dose, therefore,
produces a higher percentage of negative phases after injection.

The fact here demonstrated that the injection of a large dose
of tuberculin lowers the resistive power of the human body to

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1908.]

BY C. J. SHAW, M.D.

6 7

invasion by organisms other than the tubercle bacillus, taken in
conjunction with the fact that the bacterial resistive power of
the cases of acute mental disease is lower than that possessed
by the more chronic cases, somewhat supports the view that
acute insanity is due to bacterial toxaemia.

Bulloch claims to have demonstrated that the opsonic body
in the blood serum is largely specific to its own special organ¬
isms. He based this claim on two experiments. He first
tested the serum against tubercle and Staphylococcus albus. The
serum was then mixed with one or other of these microbes, and,
after incubating and centrifuging the mixture, the supernatent
fluid was tested against both organisms. The fluid was found
to have largely lost its opsonin for the particular microbe with
which it had been in contact, while it largely retained its opsonin
for the microbe with which it had not been digested. In the
second case the serum of human beings was repeatedly tested
against both tubercle and staphylococcus. Injections of tuber¬
culin produced an increase in the tuberculous opsonin while
leaving the quantity of staphylococcus opsonin unaltered, and
vice-versa . He, however, does not state the dose given in his
experiment.

I have made no experiments of the nature of that first
described by Bulloch.

I have found that with a dose of mgr. T.R. in healthy
persons there is a fall in opsonic power produced to other
organisms. In the one control case injected with a dose of
7*77 mgr. T.R. no fall was recorded to tubercle ; but a negative
phase followed in the case of the Micrococcus rlieumaticus . There
was & rise recorded, however, at the first observation made
eighteen hours after injection, but this was succeeded by a fall
below any point previously recorded. In the three insane cases
wherey^ mgr. T.R. was given, four negative phases were recorded
after injection to the three organisms which were used.

The demonstration of the specificity of the opsonic body in
the blood serum is necessary to support the view that the
production of a negative phase, following the injection of a
minute dose of tuberculin, is diagnostic of infection by the
tubercle bacillus. My observations demonstrate that for such
diagnostic purposes a dose of mgr. T.R. is too large, and
that to give reliable results a much smaller dose is required in
the insane than in the sane individual.

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RECIDIVISM,

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A diminution of mgr. T.R. in the dose administered
caused a marked reduction in the proportion of negative
phases following injection in healthy cases. A smaller dose
than I have used has been found to produce a negative phase
in infected cases. It is therefore probable that further investi¬
gation along the line of my observations may lead to some
definite results as to the diagnostic value of the negative phase
after injection of a smaller dose of tuberculin.

Conclusions .

(1) The average opsonic index of healthy persons varies
little to different organisms, but in the insane the index, as a
rule, is lower than in sane individuals, and the amount of
variation greater, and therefore the insane as a class are more
liable to organismal infection than the sane healthy population.

(2) After the injection of a large dose of Koch’s new tuber¬
culin T.R, a negative phase may follow to other organisms
than the tubercle bacillus, but this result is more frequent in
the insane than in control cases.

(3) Persons suffering from acute mental disease are more
liable to organismal infection than more chronic cases, but the
latter have less resistive power than sane healthy individuals.

(4) The insane are more liable to tubercular infection than
to infection by other organisms.

Recidivism regarded from the Environmental and
Psycho-Pathological Standpoints . By J. F. Suther¬
land, M.D., F.R.S.E., Deputy Commissioner in Lunacy
for Scotland.

PART III.

The foregoing examples of degenerates, obsessionists, feeble¬
minded and mentally warped ( l ) could be multiplied indefinitely.
They present minor and less striking phases of the degeneracy
and mental disorders met with in asylums, and require, whether
at large or in confinement, some part of the care, supervision,

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1908.] BY J. F. SUTHERLAND, M.D. 69

and treatment which are accorded to the major degenerates
whom it has been found necessary to certify as fitted for
detention in asylums. In these institutions may be seen
paretic dements, paranoiacs, precocious dements (katatoniacs),
maniacs, imbeciles, terminal dements, etc., prone to, and who
may have committed, arson; folies circulaires, hysterics, maniacs,
moral imbeciles, and imbeciles prone to malicious mischief or
criminal prankishness; erotics, senile dements, paretic dements,
alcoholics, maniacs, epileptics, and imbeciles prone to indecent
propensities, rape, sexual perversion, and the entire gamut of
erotic besetments; general paralytics (first stage), imbeciles,
kleptomaniacs, climacterics, prone to, and who may have fallen
into the hands of the authorities for, theft; homicidal maniacs,
epileptics, katatoniacs, paranoiacs, puerperals, alcoholics, and
dipsomaniacs who may have committed crimes of blood,
cruelty and violence before certification, or who by mere
accident may not. These are the many points where criminality
and lunacy touch, and it seems at present either a question of
the degree of the mental warp or its non-detection which
decides whether the asylum or the gaol shall be the destiny
of such.

It is unfortunate that so eminent and widely read an alienist
as Professor E. Mendel, of Berlin O, should now apply the
term of “ recidivism ” to recurring insanities, seeing it had
come from long and general usage to apply to criminals and
offenders, and in this sense is accepted and understood by
every civilised country.

Criminal and Delinquent Physiognomy .

There is thus what one might designate a functional
physiognomy resulting from habits of crime, delinquency,
debauchery, vice and disease, malnutrition and poverty,
in short from an abnormal and unhygienic existence,
mentally and materially different from the physiognomy as
well as the stigmata and arrested development following ante¬
natal injury of the embryonic neuroblasts of the frontal cortex
area in congenital imbeciles and in the feeble-minded, typified
in some petty thieves, prostitutes, and vagrants. And further,
if the ante-natal causation be at work in the posterior associa¬
tion areas, various psychic defects are met with in sexual

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RECIDIVISM,

[Jan.,

perverts, habitual drunkards, and alcoholic criminals prone to
deeds of violence and cruelty.

In time the causes of this functional and passing physiognomy
will produce those permanent psychic changes brought about
by damage to the neurons in the posterior association areas of
the brain, and a fixed physiognomy. It is likely that the
functional and the pathological become blended in some of the
criminal and delinquent types. The furtive, restless eye, a look
of boldness, cunning, and determination, is specially charac¬
teristic of the “ professional ” criminal, who, although lost to all
sense of honour except that ascribed to them in works of fiction,
feels and resents loss of liberty. The stolid apathy of helpless¬
ness, the abject look of passivity is writ large on the countenances
of many petty delinquents, to whom frequent and brief losses
of liberty mean nothing, and for whom the police or prison-cell
has neither terror nor a sense of shame. The observer knows
right well that the striking physiognomy seen, and resulting
from years devoted either to crimes or petty offences, is, in a
very large number of instances, of a composite character, the
appearances directly traceable to the mode of life lived being
inwoven with evidences of mental defect, or mental warp of
the genetous or acquired type.

Criminal Anthropology .

Lombroso, of Turin, his henchman Ferri, Professor of Law,
at Rome, and the other disciples of the sub-Alpine school of
criminal anthropology, find ranged against them as uncom¬
promising opponents in regard to the criminel ne the leaders of
the Northern school in France, Germany, and Belgium—to
wit, Naecke (Leipsic), Dallemagne (Brussels), and Manouvrier
(Paris).

Ferri, although not postulating a type exclusively anatomical,
holds that the Vuomo delinquente, the criminal man, is a
detached and complete personality, at once biological, psycho¬
logical, and social, his criminality being the result of a triple
coalescence of factors which are most aptly described by the
French school as facteur anthropologique, facteur de milieu
physique , and facteur de milieu social . Every competent observer
recognises that a man may be born with all the stigmata
associated with crime and delinquency, and yet live—provided

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BY J. F. SUTHERLAND, M.D.

1908.]

he finds in his environment (son milieu) a sufficient resisting
force—without the commission of crimes or petty offences, and
conversely it is true, perhaps less frequently, he may find in his
hereditary antecedents the power to resist the evil influences of
his environment.

Dallemagne speaks of degeneracy as an abstract term com¬
prising diverse physiological processes, with this feature in
common, that they tend to the extinction of the individual and
the species. Viewed in this light it is a normal biological
process amounting almost to selection operating under the
influence of individual factors, especially the environmental
one. Dallemagne applies his principles to groups sufficiently
uniform to admit of individualising them. In imbeciles there
would be no criminality, degeneracy having ruined all capacity
of intention ; in some imbeciles and feeble-minded folk, de¬
generacy having damaged the intellect so far as to leave only
instinctive thoughts a delinquent predisposition has been
observed in the “ possessed ” and impulsive types. On the
other side it has to be stated that there have been many
instances in which there was no indication of degeneracy
independent of the criminal act itself.

Biometrics and National Eugenics .

National eugenics is a comparatively new science, and asso¬
ciated with it is the still newer science of biometrics with its
co-efficient of correlation, abscissa, etc., with which is identified
the name of Karl Pearson. In his hands biometrics applies
mathematical methods to various kinds of associations which
do not have the absolute dependence of free causation, and
hence he applies to heredity and biological data methods
similar to those employed by actuaries in calculating life tables.
If the same degree of certainty of results attaches to the former
as to the latter, then their general acceptance is assured.
Francis Galton defined eugenics as “ the study of agencies
under social control that may improve or impair the racial
qualities of future generations, either physically or mentally.*’

The doctrine of natural selection is based upon the hypothesis
that the healthier individual has a better chance of surviving in
the struggle with physical and organic environment, and in
consequence is better able to beget and rear an offspring inherit-

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RECIDIVISM,

[Jan.,

ing advantageous characteristics; a profitable variation is,
according to Karl Pearson, “ seized on by natural selection and
perpetuated by heredity,” the science of biometrics measuring
the degrees of variation met with, and indicating to what extent
variations are inherited, and the question of interest is whether
in families which present variation above or below the normal
that variation will be transmitted and in what degree ?

While Professor Karl Pearson’s statistics and investigations
go to show that degenerate stocks under existing social con¬
ditions—in other words, a humanitarian regime —are not short
lived, and have more than the average family, it would hardly
be safe to accept this beyond two generations; indeed, it would
not be a matter of much difficulty or doubt to predict what
would happen in the third and successive generations if unions
of the “ unfit ” continued. The stock would be wiped out;
and while it is exceedingly doubtful how far this doctrine of
degenerate stocks being neither short-lived nor failing to beget
the average size of family is true of one generation of the
vicious, habitual drunkards, and degenerate criminals, it is not
doubtful of succeeding generations of these. The experience of
the writer as to age and procreative capacity is in quite an
opposite direction, for reasons recorded in the development of
this monograph. Comte declared that sociology is impossible
without biology, and to this doctrine any disciple of race
efficiency may subscribe without reservation.

Degeneracy .

This is a comprehensive term physically as well as mentally,
which as yet has only a relative meaning and value, and it is
doubtful if it will ever be anything else. Dr. John Macpherson,
Commissioner on Lunacy for Scotland, who has studied the
question, has given me his views ( 8 ). “ For general purposes,”

he says, “ the word ‘ degenerate ’ is restricted to the feeble or
defective manifestation or development of qualities which are
common to a race or species. The definition is an arbitrary
one, for variation is continuous and gradual from the mean of
any quality to the most aberrant specimens whose places are at
the extreme end of the abscissa of the curve of which the mean
is the centre. All we can say is that a living being is degenerate
when to a certain degree, more or less indefinite, it falls short of

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1908.]

BY J. F. SUTHERLAND, M.D.

the type of the qualities of its race or species. Imbeciles are
degenerate, but they merge by continuous gradation into the
normal type of mind through every degree of increasing and
perfected intelligence. In the same way deformities are signs
of degeneration, but there are all degrees of deformity which
gradually become unrecognisable in the perfect animal form.”
The adverse circumstances which induce acquired degeneracy
as distinguished from genetic degeneration which depends
solely upon variations of the fertilised ovum are ante-natal
(intra-uterine), applied at an early stage of the ontogeny, and
before the development of the organism is completed, and post¬
natal, resulting from such environmental factors as diet and
toxines, such of the alcoholic and syphilitic types, the nature of
the occupation, insanitary dwellings, etc.

It is believed by biologists that within certain limits the
earlier the organism is subjected to inimical conditions the
greater will be the interference with its development, and the
more pronounced will be the degeneration. And if this position
be accepted as a feasible one is it to be wondered that among
criminals there are so many degenerates ? It is held by biolo¬
gists that the male embryo is much more liable to variation
and degeneration than the female. Does this in any way
explain the greater number of male criminal degenerates than
females ? Another proof of the degeneracy prevalent among
criminals is the relative sterility in evidence. The ranks are
mainly recruited in a way already explained. There is this
great difference between genetic and acquired variation, while
the former are hereditary the latter are not transmissible.
Genetic degeneration as things are, and, indeed, as they are
likely to be, is beyond control, there being no artificial selection;
acquired is clearly preventable.

The Causation of Recidivism.

As has been pointed out, the springs of criminality and
delinquency are (a) inherent (internal) and (6) external to the
criminal, and may be summarised as follows:

(a) Inherent .—Degeneracy of the genetic kind plus an un¬
favourable ante-natal environment, which makes those with this
hereditary mark unstable and incapable of appreciating and
following the standard of life and conduct—wide enough in all
LIV. 6

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RECIDIVISM,

[Jan.,

conscience—which society has laid down for the guidance of its
members. Much infringement of the moral law and its com¬
mands is tolerated before the criminal laws of a free country
interpose. As society is constituted selection is out of the
question, and there is thus no remedy for this as there is for
the unfavourable ante-natal environment produced by toxines
such as alcohol and syphilis. Owing to comparative sterility,
and utter indifference to every law, human and Divine, and a
high mortality among degenerates, their numbers do not
increase.

(b) External .—Embraces all the economic and social condi¬
tions favourable to its production and continuance. This is the
great post-natal environmental factor in its numerous and far-
reaching aspects, and so long as the conditions and environ¬
ment continue, so long will recidivists be reared. Some of
these may be mentioned: insanitary slum dwellings and one-
roomed houses, in which the decencies of life are not possible
(birth, death, wedlock, sleeping, feeding, ablutions), alcoholic
excess perhaps as often the sequence as the cause of human de¬
generation, idleness and debauchery, disregard of public opinion,
ignorance, a miasmatic atmosphere from the cradle to adoles¬
cence and onwards inimical to health and morals, the lack of
suitable employment adapted to the physical and mental
capacity of the individual, the absence of a living wage for
unremitting and, it may be, uncongenial toil. These sensibly
affect a majority of recidivists, and are clearly preventable by
a readjustment of the social condition, a better distribution of
the profits of labour, the sweeping away without compensa¬
tion of slumdom, and the substitution of healthy and cheap
dwellings possible by a change in the laws appertaining to land,
and the education of this class to live in human and decent
ways.

For the unemployed as well as unemployables there are, as a
rule, three portals open, first , the parasitic life of the slums,
second , the life of the tramp, and third , a life of open crime and
defiance of the law. It is not a necessity for the entrant to
either category to be of the “ unemployed.*’ There are those
who have no excuse of that kind who recruit the ranks of all
three. Among the unemployed one finds roughly three classes,
the genuine poor, who cannot get suitable work and who suffer
more than any other class; vagrants and paupers, who have

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1908.]

BY J. F. SUTHERLAND, M.D.

given up the struggle, or being constitutionally averse or incap¬
able abandon themselves to a life of dependence and parasitism;
and the criminal who has passed through the first class, avoids
the second, and enters upon a life of deliberate warfare against
property.

There is a kind of recidivism unfortunately too common that
is, so far as one can judge, without excuse, and that is the reci¬
divism of the professional criminals whose environment has been
correct, who have received a fair or good education, and who
have been trained to habits of honest industry as labourers or
skilled workmen, but have deliberately abandoned these and
embarked on the sea of fortune and reckless adventure. Some
of these, it is to be feared, society will always have in its midst
to control by present or improved penological methods.

Herbert Spencer, in his Prison Ethics , referring to the person
whose recidivism is deliberate, ventured the paradox “ that
mankind go right only when they have tried all possible ways of
going wrong.” The paradox falls short of the truth, and he
adds, “ Instances have shown me that when mankind have at
length stumbled into the right course they often deliberately
return to the wrong.” This is true of professional recidivism.

It has been stated and proved by Quarrier (Glasgow),
Bamardo (London), and other philanthropists, that if 1,000
children at a plastic age from the better classes were placed in
slums, and amid environments of a noxious kind they, whether
normal or degenerate, would, as a rule, become as the slum
children; and vict-vtrsa y if 1,000 slum children were removed to
healthy, moral, and physical environments they would, as a rule,
turn out well and become law-abiding and productive members
of the community, the physical and mental degenerates among
them receiving special care.

Sir John McDonell, Master of the Supreme Court, in his
introduction to the Judicial Statistics (Part II) of last year,
makes some valuable suggestions of a sociological order. He
indicates that while crimes against property are no doubt
affected by the conditions of employment and wages, the large
class of non-indictable offences are connected with the consump¬
tion of alcohol, and the consumption of alcohol follows the
movements of trade, increasing when it is prosperous and
declining when it is bad, the reverse being true of indictable and
non-indictable offences against property.

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76 recidivism, [Jan.,

He warns the public that the theory of a close connection
between crimes and drunkenness must be viewed with caution.

Pathetic, indeed, are his observations on the prison population:
" The prisons are peopled by the very poor, the very ignorant,
and the unskilled.”

It is felt by the votaries of natural selection that this law is
greatly interfered with by the humanitarianism of the age. Of
such critics and observers Bernard Shaw is the high priest, and
he puts the case forcibly, if laconically, thus: “ Being cowards we
defeat natural selection under the cover of philanthropy; being
sluggards we neglect artificial selection under cover of delicacy
and morality,” and the two remedies of sterilisation of the
“ unfit ” and “ State controlled marriage bureaus,” with its
staffs of medical and legal directors, are put forward to improve
the race and to prevent degeneracy. As to the first, if it means
isolation, good and well, if it spells mutilation it is not likely to
be entertained; as to the second, it is something in the nature
of a Utopian dream, because while it might prevent undesirable
unions that now take place, it would not prevent the production
of a degenerate offspring by couples who failed to get the
marriage bureau permit. It would be as reasonable, and no
less ridiculous, to give the marriage bureau power to compel
marriages of the certified fit, or alternately to tax fit spinsters
and bachelors who fail to contribute to race efficiency.

Discussing this question, Sir Arthur Mitchell, K.C.B.( 4 ), put
the case against the “ natural selection ” advocates with force
and lucidity. Writing from a wide knowledge and experience,
he points out that considerable “ variations ” of the degenerate
type are met with in animals even when artificial selection is
followed, instancing sheep, and the annual crop of “ sholts ” or
weaklings ; and in humans following what any “ marriage
bureau,” if it existed, would call healthy marriages. This, he
says, is the unexplained law of nature at present. It will be
admitted, of course, that the union of “ unfit,” and these are
very few when wedlocks, as a whole, are looked at, must
eventuate in a much larger production of variations of the sub¬
normal type, even if these in the aggregate, as is the case, are
few compared with the variations met with in the families
issuing from healthy wedlock. In this connection the writer
may refer to the views regarding imbeciles and feeble-minded
persons he submitted to the Royal Commission on the Care

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1908.] BV J. F. SUTHERLAND, M.D. 77

and Control of the Feeble-minded ( 5 ). After demonstrating by
numerous examples the close intimacy existing between, on the
one hand, imbecility and feeble-mindedness, and, on the other,
illegitimacy, and the presence of both in two or three genera¬
tions living under one roof, it was suggested by one of the Com¬
missioners that if such mothers—for the faux pas requires to be
made before public interference could well take place—were put
under control and supervision, the production of imbeciles
would to a large extent cease. So far as imbeciles are begot in
this way no doubt it would, but as imbecile “ variations”
appear not unfrequently among the offspring of, to all appear¬
ances, healthy marriages, and these are the vast majority of
marriages, and as illegitimacy is, in Scotland, only 67 per cent .
of the birth-rate, and the imbecile illegitimate only a fraction of
this, it follows that, as the law of nature or natural selection
stands, imbecile and weak-minded variations may, for some
unexplained reason, be expected. Male imbeciles are not, and
the feeble-minded males are only to a small extent, offenders in
this respect. As a rule the male weaklings are denied the pro¬
creation of their kind. But whatever the fecundity of female
“ unfits,” as a rule, the physically and mentally weak offspring
in urban areas die off in spite of humanitarianism.

The Criminal Law in Relation to Free Will , Responsibility , and

Punishment .

In the foregoing pages some idea was given of the hot
disputations that have gathered round the place of criminal
anthropology in relation to recidivism. And round the com¬
plex question of “ heredity ” and “ degeneracy ” there is even a
greater variety of opinion, just as there is over the attitude of
the criminal law to free will, responsibility, and punishment.
One is thankful in the contemplation of so much confusion and
contradiction in regard to these thorny points to be able to
record that, in regard to the overshadowing environmental
factor, the prophylactic measures required, and the need for
the further evolution of our penal system in the light of further
knowledge and experience, reformers are practically agreed.
For after all these latter are the factors that mainly work for
the good of society and of society’s enemies, enhanced, no
doubt, if sound and correct views could be stated with modera-

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78 ; recidivism, [Jan.,

tion and accepted in regard to the other debatable and difficult
questions.

It would serve no useful purpose to elaborate here the
attitude of the criminal law and its interpreters at different
periods towards crimes as a whole and specific crimes, and the
punishments meted out to deter law breakers. That is a
matter of history, ethics, and jurisprudence. A brief outline
will suffice.

In the usual conception of crime the intentional and voluntary
( i.e. f free will) transgression of the law is assumed in spite of
protests to the effect that such a conception fits no fact in
human experience. This was the dictum of Erskine, the
eminent jurist, and accepted by his contemporaries and
successors on the bench, and opposed by psychologists and
metaphysicians. It will be apparent that at once the question
of the absolute or relative action of free will is raised. Volition,
according to Huxley, is the impression which arises when the
idea of a bodily or mental action is accompanied by the desire
that the action should be done, and the question now before
us is whether this volition is free or determined. Such a con¬
ception should give pause to the advocates of the doctrine, and
the lengths it will carry them, that the will is free, seeing how
it is acted and reacted upon by such motive-forming causes on
mind as well as body as those of environment and natural laws.

And nowhere in this report is the attitude of the criminal
law ( 6 ) more mistaken than in relation to the vast proportion of
petty offences connected with drunkenness, and a small propor¬
tion of crimes, those of blood, violence, and cruelty indissolubly
associated with the same cause. It is a most anomalous
attitude if it be accepted that the state of intoxication is a brief
state of insanity, but the anomaly is heightened by contrast
with the attitude of the civil law, which to all intents and
purposes shields the drunkard from the evil and disastrous con¬
sequences of civil acts, testamentary dispositions and contracts,
etc., made in a state of intoxication. Manifestly volition is
seriously affected by a toxic agent from without, acting directly
on the brain, and remotely after it has induced permanent
pathological changes of the brain and other viscera.

A safe ethical and sociological maxim is that the idea of wrong
depends upon the moral, intellectual, and physical damage or
injury which volition and action brings to society. The idea of

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BY J. F. SUTHERLAND, M.D.

1908.]

freedom has been, as stated, the basis of criminal law, and where
believed in without qualification or reserve has set up the lex
talionis with its train of oppression, blood, and martyrdom.
The legal conception of free will is as ill-founded and as
reprehensible as the unqualified Calvinistic doctrine of pre¬
destination in which freedom of will has no part. Both are
extremes, and the middle course of relativity governed by
environmental and psycho-pathological conditions is one to meet
with acceptance. It is not to be inferred that an actual or
potential criminal is to be at large and society unprotected until
it was ascertained whether or in what degree he was innocent
or guilty from the standpoint of freedom of will. For such
contingencies society and its law makers has, to a very large
extent, made provision. Maudsley, whose views have always
commanded respect, writes “that every student of sociology
knows that just as there are manifold gradations of intelligence
from the highest intellect to the lowest idiocy, so also as natural
phenomena there are many degrees of moral power between the
energy of a well-fashioned and disciplined will and the complete
absence of moral sense.” The relativity of will power, of moral
sense, and the exercise of both thus set up inevitably leads
up to relative responsibility and relative guilt. A doctrine
such as this, made to fit into the criminal law and criminal
reform, would apply if the punishment fitted the criminal in
a major sense and the crime in a minor, or not at all, as is
now being strenuously urged. The knowledge of defective
organisation in the case of many criminals and offenders cannot
but tend to justice and more tolerant views of, and less hostile
feelings towards, so many of the doubtful cases inhabiting the
borderland between insanity and crime, and to bring about this
altered view the metaphysical notion of responsibility which
Maudsley aptly describes “as an abstract being endowed with
a certain fixed moral potentiality to do the right and to eschew
the wrong,” and “ that in regard to erring nature it must be
received as a scientific axiom that there is no study to which
the inductive method of research is not applicable.”

A caveat requires to be made to the effect that this doctrine
of relativity of freedom of will and of responsibility is not intended
to apply to the “ professional ” criminal, who is the greatest
menace to society, and who, to gratify indefensible acquisitive
propensities, will, to attain his object of plunder, stick at nothing,

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80 RECIDIVISM, [Jan.,

his watchword being in too many instances “ your money or
your life.”

Dr. C. Mercier 0 , whose writings and opinions have found
acceptance at home and abroad, both at the hands of jurists
and physicians, puts the matter thus: “ Desire is the motive
of all conduct/' and traces it “ to one primitive and funda¬
mental craving which lies at the root of all human as of all
animal dispositions." Further, “ Desire antecedes choice, and
a fortiori antecedes volition," and if there be no disorder of will
or intelligence, then I think responsibility attaches as soon as
desire obtains the sanction of will.

It will be felt from this line of argument that there can be no
breach of the criminal law if in the act the will of the agent
had no real part. For such a proposition there are three special
lines of defence—the physiological, the psychological, and the
metaphysical, the author’s extensive survey of the first revealing
among criminals and offenders abnormalities, somatic, cranial,
and facial; the second, moral insensibility, lack of ordinary
intelligence, perverted sentimentality, and extreme emotionalism
not met with to anything like the same extent in the general
population. To such a being tack on the effects of a vicious
environment—for environment moulds character—and is it
surprising that it should be held by so many competent
observers in regard to many criminals and offenders that there
is no such thing as absolute freedom of the will, but at the
most a relative sanction to the commission of misdeeds ?

But the trend of this discussion in regard to volition and
responsibility at once raises the question of punishment, which
must follow, because, call it by what name you may, the loss
of liberty incurred by feeble-minded and degenerate habituals,
including habitual drunkards, through detention in asylums,
labour colonies, etc., spells to these breakers of the law punish¬
ment, it may be more agreeable than the present, although
this will to some extent depend on the time limit, and many
of them, although mentally warped and defective, will not
appreciate society’s decision in regard to their good, and will
with the intelligence they possess clamour for liberty.

Punishment cannot be dispensed with even in asylums, in
which the proportion of the “ intellectually dead" is much
greater than would be the case in labour colonies, inebriate
retreats and reformatories. Insane persons, both with defective

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1908.] BY J. F. SUTHERLAND, M.D. 81

and disordered intellects are for misconduct deprived of parole ,
of privileges which they value and appreciate more or less,
such as tobacco, entertainments, dances, etc., and conform to
discipline. Indeed, the conduct of the insane of every degree
is influenced more or less by the ordinary motives of reward
and punishment which govern the conduct of the sane, and in
like manner the conduct of criminals and delinquents with or
without mental warp; and while that mental defect or warp,
evident to the trained observer, lasts and unfits them for
absolute freedom, their conduct as to petty larceny, drunken¬
ness, prostitution, vagrancy habitually indulged in, will, under
present conditions as to living and conduct, continue. With
that restricted freedom under supervision after adequate deten¬
tion in reformatories, etc., it would be reasonable to look for
considerable improvements.

There is a legal and judicial view of punishment which
requires to be stated, that is, the deterrent one—deterrent to
the guilty, and through them to others. Except in regard to
“ professional criminals ” (swindlers, resetters, housebreakers,
garotters), there could be no greater fallacy. From the mouths
of judges the deterrent view falls on the ears of habitual
drunkards, weakminded petty thieves, the authors of deeds of
violence and cruelty committed in a state of intoxication, in the
dock practically unheeded, and to those at large who may see
it in print or hear of it, it might as well not have been uttered.
Considering the object in view, this may be unfortunate, but it
is the case all the same. With the felon referred to it is
different. His conduct is deliberate, and the risks of return to
prison are coolly faced, escaping detection and justice as he
often does, which is an encouragement to wrong-doing.

Not once but often the writer has heard judges of the
supreme court, of sheriff courts, and of police courts solemnly
declare that in the interest of society and of public safety and
order, the sentences passed on the perpetrators of murder,
homicide, grave assaults, etc., and on “ drunks and disorderlies,”
would act as a deterrent to the culprits, and to others who
contemplated breaches of the law. And yet immediately follow¬
ing severe sentences for homicides, assaults, and cruelty to
children, the greater part of which were committed by reckless
persons in an intoxicated or semi-intoxicated state, and for
the offences of drunkenness and disorderly conduct, the record

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RECIDIVISM,

[Jan.,

of apprehensions for them all a day or two later touched a high
figure. Underlying the warning, excellent in its objects, uttered,
there is this fallacy in regard to the crimes and offences speci¬
fied, that the authors do not take drink, whatever may be the
cause for the habit—either a neurosis or social customs—in
order to commit these crimes and offences. These are incidents
of one or of many bouts producing a sodden state of mind and
body, and the marvel is that, when the week-end debauches and
their sordid results are unfolded ad nauseam on Monday morn¬
ing in police courts, not one but many homicides are the results.
It is not the fault of the assailants that these are not multiplied
a hundredfold.

What is the reasonable and rational conclusion to be deduced
for this line of argument ? Surely one that it is not safe to
dogmatise as to the responsibility of the largest section of petty
offenders and a small section of criminals, the “ inverts ” and
“ perverts,” the “ can’t workers,” and the “ born tireds,” if
with the average citizen reared and living under normal and
healthy conditions, absolutism as to free will, and anything like
perfection as to conduct is not looked for, but rather relativity.
There is much to be said for the relativity of the responsibility
of the derelicts of society with all the drawbacks and disad¬
vantages of environment, bad heredity, and a degeneracy
bequeathed or acquired.

Justice in the highest and best sense of the term renounces
the law of vengeance, and human laws are presumed to follow
closely after this ideal, and thus it should be that the main
purpose of punishment should be the protection of society and
of property by the reclamation by improved methods of habitual
criminals and offenders who are salvable, and by the sequestra¬
tion of those not so under safeguards. And when this is done
punishment will at least more aptly fit the criminal and offender
and lessen crimes and offences than it has hitherto done.

Crimes and Offences .

No attempt is made in this monograph to define a “crime” ( 8 ),
or an “ offence,” or what is meant respectively by a “ criminal,”
or a “ petty offender,” or “ delinquent.” For all practical pur¬
poses a “ criminal ” would mean in England and Wales a person
guilty of one of the eighty-three “ indictable ” offences tabulated

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908.]

BY J. F. SUTHERLAND, M.D.

in England, and in Scotland one of the fifty-four “crimes”
tabulated in Scottish Judicial Statistics. Correctly speaking, and
for statistical purposes, “offences” in any country should refer to
minor breaches of the law referred to in English statistics as
“non-indictable offences,” and in Scottish as “miscellaneous
offences.” There may be legal difficulties in altering terms,
but there can be none in asking for a better classification in
blue-books, such a classification, for instance, as would in
England remove “aggravated assault ” and “cruelty to child¬
ren ” from the “ non-indictable ” to the “ indictable ” list, and
on the other hand removing from the “ indictable ” to the “ non-
indictible,” “ indecent exposure,” “ habitual drunkenness,” and
‘‘suicide” (attempting to commit). Similarly in Scotland it
would be both proper and advantageous to remove from the
“crimes” to the “ offences” list “indecent exposure,” “drunken¬
ness under Inebriates Act,” and many cases of “ petty thefts,”
and of “ malicious mischief.” This latter term embraces trivial
as well as serious breaches of the law, and yet they all appear
as “crimes.” Not so in England, where a distinction is made,
some properly appearing as “ indictable,” some as “ non¬
indictable.” The truth is, certain breaches of the criminal law
should, depending on their nature, appear in both classes. It
is possible so far to form some idea of what is meant by a
“ crime ” and what by an “ offence ” by a regard to the Courts
in which these are unfolded. Thus in England “ indictable
offences ” (the Scottish equivalent being “ crimes ”), five out of
every six being cases of larceny, the perpetrators of which in 63
Per cent . were “repeaters,” refer to persons prosecuted on
indictment before assizes, quarter sessions, and summarily
under the Summary Jurisdiction Act of 1899, while “ non¬
indictable ” to persons prosecuted in courts of summary juris¬
diction, police, and justice of peace courts.

In Scotland “ crimes ” are unfolded in the High Court of
Justiciary in Edinburgh or on circuit, in sheriff courts after full
committal and summarily without full committal; “ offences ”
in sheriff courts without full committal, in police and justice of
peace courts.

Having regard to these points it should not be difficult to
differentiate between “crimes” and “offences,” “criminals”
and “ offenders,” nor to set up an improved nomenclature and
classification. It is as difficult for the statistician as for the

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8 4

RECIDIVISM,

[Jan.,

psychologist to understand why crimes against chastity governed
by the lust factor, and considered apart from the possibility of
mental flaw, are classed with crimes of violence and cruelty
with which they have no aetiological connection whatever. They
constitute, it may be small, a class by themselves.

Now if these be the two accepted types of recidivism which
the authorities have to contend with, it seems but proper to fix,
in a general sense, without the law laying down hard and fast
lines, the number of convictions which would constitute a
recidivist in each.

It will be apparent to anyone with knowledge of the subject
that “ professional,” as well as “habitual,” recidivists engaged
in serious crimes against the person and property, owing to
long periods of imprisonment will not have the same oppor¬
tunity of gratifying their acquisitive desires as habitual petty
offender recidivists, who, in consequence of brief losses of
liberty—quite long enough for them, as a rule, so long as the
punishment is roughly made to fit the injury done to Society—
run up in a short time a big score, as much as twenty con¬
victions in one year.

There would be nothing suggestive of harshness in fixing the
number of convictions to constitute a felon recidivist at two in
one year or four over any period, nor four in one year and seven
over any period in the case of a petty offender recidivist. So
that no injustice might be done either, the court investigating
such case would, before making its pronouncement, take into
its consideration the history, habits, occupation, associates, etc.,
of each; and in this way it would be possible to suspend a sentence
of lengthened social sequestration where it was ascertained that
although the specified number of convictions had been run up,
yet the accused, as a rule, was engaged in honest industry, and
contributed some share to the well-being of the community.

It should be kept in mind that the mental element enters
largely into “crimes,” specified as “attempting to commit
suicide,” “ habitual drunkenness,” “ indecent exposure,” many
of the sexual crimes, many of the petty larcenies, and the
numerous homicides and assaults associated with drunkenness;
and into “offences,” such as “drunkenness,” “prostitution,”
and “vagrancy.” And yet on the authority of Sir John Mac-
donell, in 4 his introduction to the Criminal Judicial Statistics for
England for 1902, “ there is comparatively rarely an inquiry

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1908.] BY J. F. SUTHERLAND, M.D. 85

into the mental condition of prisoners unless in the case of
grave offences such as murders.”

Crimes and Offences (An Addendum).

Among the authors of the various crimes and offences
specified, there are certain well-defined types met with. There
are first , the sexual perverts; second, the individuals low down
in the social scale, who, in the grip of one or numerous bouts of
ethylic or methylic alcohol, commit deeds of violence and
cruelty; third , thieves, embezzlers, resetters, housebreakers,
etc., professional criminals who live by plunder, whose intellec¬
tual and instinctive activities are normal, and whose conduct is
governed by avarice and acquisitiveness; fourth, the habitual
drunkard and prostitute, feeble-minded or neurosed from the
start, or becomes so by long indulgence to excess; and fifth, the
vagrants and unemployables, the “ born tireds ” of Pett Ridge,
who are decidedly below par mentally. These few classes have
been divided by observers into “perverts” and “inverts,” the
perverts or “wont workers” being as a rule active criminals, the
inverts or “ can’t workers ” passive delinquents. The skilled
house-breaker and burglar speaks with contempt of the inverts
as “mugs.” A true pervert also, although not an habitual, is
the forger, the fraudulent company promoter, and dishonest
financier with considerable intellectual gifts. In the main
this division into “perverts” and “inverts” may, with reserva¬
tions, be accepted as sound.

Whatever their intelligence and capacity, it will be shown
later by an anthopometric survey of these that their growth is
stunted and their stature much below the average ( 19 ). Some
psychologists maintain that society is permeated with potential
criminals, all that is lacking being opportunity or necessity,
which would mean acceptance of the French proverb, Voccasion
fait le voleur. There is less than the proverbial half truth in
this proverb, uttered without regard to the social environment
and the mental defects and disorders met with in criminals
and delinquents.

Statistics of Crimes and Petty Offences in Great Britain for 1903.

It is but to utter a truism to say that the face of society,
as a whole, and in all its ramifications in this or in any

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RECIDIVISM,

[Jan.,

country, is not stainless. Rather it is mottled all over by the
actions of its law breakers as well as by those who transgress
every article of the moral code when opportunity presents itself,
but skilfully avoid the meshes of statutes, and on this mottled
area there stands out in bold relief the dark and discreditable
blot of recidivism, perpetually hanging like a pall, which has
hitherto defied lifting in spite of many and costly attempts
made by the legislature. There is no single panacea for the
evil; there could not well be, seeing that underlying it are the

great social problems of our age, viz., intemperance, the housing
and land question in relation to slum and one-roomed dwell¬
ings, poverty, vice, illiteracy, lack of parental training, responsi¬
bility, and degeneracy both physical and mental. The bare
mention of these factors shows how complex the problem is
before the mentally defective and the incorrigibles, making up
the recidivist army of 37,700 of both types in Great Britain,
are reached and treated on rational lines. But at the same
time it can be said that the problem admits of some solution.

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190S.]

BY J. F. SUTHERLAND, M.D.

8 7

and of results infinitely more satisfactory than those resulting
from the unscientific and irrational prophylaxis and treatment
of crime and delinquency in the past. The optimism which
points a better way is ultimately bound to prevail over the
pessimism and the non-possumus attitude of the past. At present
the best legislative, administrative, legal, and medical minds
are turned to the problem, and remedies and suggestions put
forward as to the best means of coping with this festering
social sore.

Decent housing, education, a living wage, sobriety, employ¬
ment in harmony with varying physical and mental capacities
leave much to be desired. Some of these factors made the
dishonest and professional habitues who, in the beginning of
last century, were the terror of the hulks and gaols of England,
fairly respectable citizens of Australia, and by some said to be
fairly entitled to a share in the building up of that prosperous
colony, which is free from much that is regrettable in the social
fabric of older countries, such as poverty, intemperance, and
crimes and offences.

Apprehen¬
sion* and
citations.

Convictions.

Number of
imprison¬
ments.

Number of
individuals
imprisoned.

Recidivists.

England

810,950

660,300

223,910

« 49 . 3 °°

33 .°°°”

(a) 20,000
(*) 13,000

Scotland

166,180

124,220

60,080

40,000

4,700-

8 S

O tv

CO ~

—v/V
£2,

Total

977.130

784,520

283,990

189,300

37.000

(a) Criminal recidivists ; ( b ) petty offender recidivists.

By comparing the statistics of (i) apprehensions and cita¬
tions, (2) of convictions, (3) of the number of imprisonments,
(4) of the number of individuals represented by these imprison¬
ments, and (5) the number of recidivists engaged both in
“crimes” and “petty offences” for England and Scotland,
and illustrating them by concentric circles arithmetically con¬
structed, Great Britain’s criminality, delinquency, and recidi¬
vism not only may be seen at a glance, but also, what is of
value, their true purport. In this way the taxpayer and reformer
will be enabled to avoid taking too gloomy a view of the situa-

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Google

RECIDIVISM,

[Jan.,

tion, bad as it undoubtedly is in the most favourable light from
the ethical as well as from the financial standpoint.

Nearly a million apprehensions and citations by the police
in one year, or one to thirty-eight of the population, is a stagger¬
ing fact, whether considered ethically, statistically, or financially,
and provides food for serious reflection as to whether, after all,
things social, penal, legal, and administrative are for the best
in a country whose prosperity and Government as a whole are
both the envy and admiration of less favoured countries.
Evidently there is considerable room for improvement after
every possible explanation is made to minimise the magnitude
and significance of nearly a million apprehensions in one year
in Great Britain. After the lengthy trials of past methods and
ideas the times are surely ripe for a somewhat different and
more enlightened prophylaxis and treatment, involving changes
in our judicial, police, and penal systems, in the duties and
obligations of society, and in a better understanding of the
physical and psychical characteristics of chronic law breakers
themselves, necessary to meet the case. This, no doubt,
is a large order, but it has to be faced courageously and
tenaciously if a better way is to be found. The beginning of
the twentieth century saw things social, legal, and penal, vastly
different from what they were a century, or even half a century,
earlier, but a further evolution of the criminal and delinquent
problem on new lines is clamantly called for.

It will be observed that with convictions the approximate
million of apprehensions falls to little more than three quarters
of a million, or i to 47 of the population. With imprisonments
it shrinks to little more than a quarter of a million, or 1 to 131
of the population; and these latter in turn represent only
189,300 individuals, or 1 to 200 of the population engaged in
crimes and offences calling for imprisonment with or without
the option of fining. And among those in confinement and at
large there are approximately 37,700 recidivists, in round
numbers 1 to 1,000 of the population, imbecility and nsanity
being, according to last census, 4 # 2 per 1,000.

The 37,700, having regard to the nature of the criminal and
delinquent tendencies manifested, may be divided into two
sections, 14,700, or 1 to 2,540 of the population, representing
the genuine criminal recidivist of the professional type, and
23,000, or 1 to 1,620, the chronic drunken, disorderly, nomadic,

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BY J. F. SUTHERLAND, M.D.

1908.]

and petty larcenous delinquents. This division is a necessity
for statistical as well as reformatory purposes, although it is
often ignored by authorities, who speak and write as if they
were all of one type.

The figures for England have been slightly adjusted, not
only to admit of comparison with Scotland, but for the
valid reason that the somewhat arbitrary division of crimes
and offences of the former country into indictable and non¬
indictable in the police returns and in official compilations
leaves many crimes, such as aggravated assaults wholly,
cruelty to children mostly, malicious mischief and petty thefts,
partially in the category of “ non-indictable ” offences, whereas
in Scotland they all appear under “ crimes.” It would be better
if in both countries these were divided into two classes, those
considered serious and those not so, and these it would be pos¬
sible to allocate respectively to “ indictable ” and “ nonindict¬
able ” offences in England and to “crimes” and “miscellaneous
offences ” in Scotland their quota of each, so long as these are
the terms in use in official returns. The present arrangement
and classification is capable of improvement.

There are, it is evident, considerable differences in the statis¬
tical representations of criminal and delinquent manifestations
in England and Scotland. To begin with there is 1 apprehen¬
sion, etc., to 40 of the population; in Scotland 1 to27. Scotland’s
share in comparison with England is 5 to 1, whereas, according
to the respective populations, it should be much lower, viz., 7 to
1. It is not to be supposed that the Scottish character on its
erring side is 48 per cent . worse than the English, and to this
extent loaded with original and acquired guilt. Rather it is to
be attributed in part to the attitude of the police and magistracy
in Scotland towards the hordes of petty offenders that come
before them. In Scotland, it may be said, nearly every petty
offence is dealt with by the police, often unnecessarily vigilant
and hauling their captives, more especially “ drunks,” to police
cells, when, in many cases, it is safe to say it would be pos¬
sible and preferable by magisterial regulations with legislative
sanction, if necessary, to remove them to their homes at their
own or their relatives’ expense, met at the time or afterwards,
by giving time to the offender to recoup the public outlay incurred
in an evil hour on his behalf or to find security. The enormous
totals would melt away in an astonishing fashion if drunken-
LIV. 7

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RECIDIVISM,

[Jan.,

ness, petty thefts, prostitution, and disorderly conduct in
association with drunkenness in Great Britain were excluded.
Thus simple and minor larcenies amount to 57,735, or 61
per cent, of all indictable offences; drunkenness, disorderly con¬
duct, and prostitution to 403,260, or 45 per cent, of all non¬
indictable and miscellaneous offences; breaches of Vagrancy
Acts 65,018, or 7*4 per cent .; and offences against police regula¬
tions, road and highway, labour, factory, sanitary, poor,
education, game, etc., laws, 328,030, or 39 per cent.

This suggestion has chiefly reference to casual offenders and
“ pay day ” drunkards, who on occasion behave foolishly, and
not to the habituals, who neither toil nor spin and yet live, and,
like derelicts, drift in the tide currents, especially the sunken
ones of society, finding in the course of their movements the
prison-house something of the nature of a sanatorium in which
to spend each alternate week of their existence, which is thus
prolonged by a system which Bernard Shaw speaks of as ultra¬
humanitarian and calculated to defeat the law of natural
selection. Further, in Scotland as in England there is no such
thing as private prosecutions by aggrieved parties. This pro¬
cedure, peculiar to England, is to some extent, and to a much
less extent than the respective attitudes of the magistracy and
police to “ drunks,” explanatory of the more favourable position
of England statistically, for many defendants in consequence
escape the consequence of their misdoings, there being more
frequently than not no prosecution.

For a moment let the convictions and imprisonments be
examined. In England the former is 1 to 49 of the population,
in Scotland 1 to 37; the latter 1 to 146, and 1 to 76 respec¬
tively, Scotland in the matter of imprisonments being thus
double that of England. This excess for Scotland has already
in part been explained. The rest of the explanation has to be
sought for in the imposition of higher fines for drunkenness
and disorderly conduct, and in the prevalence of briefer and
more useless sentences in Scotland, and consequently more
frequent opportunities to repeat the offence. Perhaps the
national beverage of Scotland has got something to do with a
difference so adverse to the smaller country.

Felony and criminal recidivism is, on the other hand, in the
opinion of the writer, in proportion higher in England. This
is intelligible, having regard to its numerous dense urban

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BY J. F. SUTHERLAND, M.D.

1908.]

populations, with its inevitable slumdoms, as things are, shelter¬
ing and breeding a coarser and more daring type of felon.

No matter, however, which the type of recidivism, there need
be no doubt that many of the rank and file of both types are
physically weak and degenerate, feeble-minded, mentally per¬
verted and obsessed in various directions, and therefore cannot
conform to society’s conditions without the help of the moral
“go-cart,” implying the care and supervision of those more
happily circumstanced mentally, morally, and materially,
denied under present methods. How far the will is free in
regard to conduct will be discussed later.

Impressive and significant # were the words of the French
Minister of the Interior, who seventeen years ago visited the
haunts of the recidivist both in Liverpool and Glasgow and
saw for himself the degenerate race types : “ Surely these things
are not without a remedy in a land where blows the breeze of
freedom, and where the Christian faith soars high above the
coarse ties of flesh.” The fulfilment of this hope, shared by
everyone who knows the problem, is still awaited.

Recidivism in Relation to Lunacy .

The large circle (a) is designed to represent the population
of Great Britain, the smaller one the imbecile and insane
(b) as revealed by last census (153,000), and criminal recidivists
[d) (14,700), and petty offender recidivists (c) (23,000). Of
criminal recidivists it is not wide of the mark to say that one-
third or 5,000, are pathological specimens and suffering from
physical and mental degeneracy characterised by mental warp,
instability, and feeble-minded ness. These defects are to be
found chiefly among petty thieves, sexual perverts, and the
authors of crimes of blood, violence, and cruelty associated
with drunkenness. Of petty offender recidivists it is equally
safe to hold that two-thirds, or 15,300, are pathological in the
same sense. These include habitual drunkards, prostitutes,
and vagrants. England’s share of pathological specimens
requiring classification and differentiation of treatment, indeed
something different from the present cast-iron system, would
by this calculation be about 17,600, and Scotland’s 2,500, or
figures nearly equal to their respective present daily prison
populations. Under present methods, penal treatment has no

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9 2

RECIDIVISM,

[Jan.,

effect, certainly no reformatory effect, except to prolong their
lives by the sanatorium treatment, aptly referred to by the
Home Secretary (*).

The arrow-heads indicate the interchanges which take place,
some of the degenerate, feeble-minded, and morally insane
recidivists passing from ( c ) and (d) into (6), the insane zone,
from which a proportion emerge after a brief—by some con¬
sidered a too brief residence. Except in the case of many petty

thieves, prostitutes, and habitual drunkards of the female sex,
who pass freely from (c) to (d), there is little or no interchange.
As a matter of fact and experience all such are in reality petty
offender recidivists. It is difficult to see how the stay can be
prolonged in asylums under the present lunacy laws. For the
great majority it would perhaps be better to evolve a some¬
what different kind of institution from the asylum or prison,
such as has been foreshadowed in labour colonies, inebriate

Digitized by L^ooQle

1908.] BY J. F. SUTHERLAND, M.D. 93

retreats, and reformatories such as are to be found at Borstal
and Chatham.

The eminent Tuscan jurist Rosadi (*), in his recent work on
The Lost Ones of the Race , appears strongly in support of the
psychiater in connecting crimes with mental diseases, and the
“ diseased developments ” in the moral world of Carlyle are now
admitted by the law and practice of Italy. “ Inhibitory paresis,”
the bete noire of the juridical doctrinaire, he puts down as a
pathological condition capable of proof, and from his unrivalled
experience shows that crime may be coincident with morbid
deviations from physical health, that these deviations are both
inherited and acquired, and that, as a prophylactic on the
entrance of the child into school, something like a dossier should
be prepared by the school doctor, which would be available, if
need be, for reference at any period of his life. The views and
writings of this authority are calculated to give a strong impetus
to the solution of the problem.

The uniformity of the past in every detail of prison life,
suggestive of a mechanical, automatic existence, need only be
perpetuated in one, viz., compulsory detention for varying and
indeterminate periods. The various kinds of labour, and the
conditions under which these will be carried out, clothing, diet,
visits, letter-writing, rewards, room furniture, education, and
training naturally would cease, to a very large extent, to be
conventional, unnatural, and monotonous, and the faculty of
speech would no longer be repressed, but exercised under
safeguards.

( l ) Vide Article II, p. 568, July, 1907, of Journal of Mental Science. —(*)
Mendel, Berlin, Lietbaden der Psychiatric , 1907.—(*) Vide “ Morison Lectures,”
Royal College of Physicians, Edinburgh, 1906.—( 4 ) Science article in Scotsman ,
December, 1907.—( 4 ) Sitting in Edinburgh, June, 1906.—( 6 ) “ The Jurisprudence
of Intoxication,” by J. F. Sutherland, Edinburgh Judicial Review, July, 1898.—
(*) Criminal Responsibility , Clarendon Press.—( 8 ) The Right Hon. H. Gladstone,
M.P., Home Secretary, at City of London Magistrates’ Club, December, 1907.—
{*) Tra la Perduta Gente , by Signor Rosadi, 1907.

Errata. —Article .I, p. 346, total convictions, Class II, 103,933; grand total,
Classes I and II, 124,223; number of individuals, Class I, 7,400, Class II, 32,600,
and both, 40,000; p. 352, line twenty-second, the figures are 32,500, and line thirty-
ninth, apprehensions, etc., should be 810,950, or 1 to 40 of population, and con¬
victions 1 to 49, and number of individuals 149,300, or 1 to 220; p. 353, total for
breach of peace and drunkenness, 293,260, of vagrancy, 36,298, and of Class II,
711,020; grand total of apprehensions, I and II, 810,950, and of convictions,
660,300, and of number of individuals, 149,300; p. 354, first line, apprehended
number, 810,950, and ninth line, paltry offences, 711,020, or 87 per cent, of all, or
1 to 46 of population ; p. 355, line third, 304,790, line fourth, 1 to 107 and 36,300,
line fifth, 1 to 900, and line sixth, 369,935, or 52 per cent .

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STATUS EPILEPTICUS AND ITS TREATMENT, [Jan.,

Some Notes on Status Epilepticus and its Treatment.

By A. Banks Raffle, M.D.(Dunelm), Assistant Medical

Officer, Exeter City Asylum.

In all asylums and places where epileptics are taken care
of many cases of this condition must occur annually, and the
treatment of it must be of grave consideration in the care of
these cases. The figures of Dr. Lord ( 1 ) show us that in
ten years in the Hanwell London County Asylum 26 per
cent, of the deaths in epilepsy occurred in the “ status,” and
these figures are borne out by the returns of the Ewell Colony
for Epileptics. Much has been written on the subject, both by
British workers and by our Continental confreres, but it is
scattered through the literature in isolated monographs, and of
late years the interest in the subject seems to have lapsed.
The present paper is written with the purpose of inducing
someone, more competent than the author, to give us further
light on this very interesting condition.

Aetiology.

Age .—This seems to play a very small part in the production
of the condition. A reference to the tabulated series will show
how very wide is the range in the age-periods.

Sex .—In my cases there has been a remarkable preponder¬
ance of attacks in males over those in females—twenty-three
cases in males, four in females. As far as I can gather this
seems to be the experience of most workers amongst epileptics
in this country, but Continental observers, Lorenz ( 8 ), Bourn-
ville ( s ), and others, state that twice as many cases occur in
females as in males, while Clark ( 4 ) takes the middle view.

Causation .—The engorgement of the brain, oedema, flattening
of the convolutions, increase in the fluid in the ventricles,
perhaps punctate haemorrhages into the brain substance, are
amongst the more common findings post-mortem. Some work
has also been done on the changes in the nerve-cells found in
the condition, but these are apparently only an exaggeration of
the chromolytic changes met with in cases of epilepsy dying
from other causes.

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BY A. BANKS RAFFLE, M.D.

1908 .]

The fatty changes in the heart, liver, and renal epithelium
are interesting. In forty-nine cases of epilepsy examined
post-mortem these changes were only found in seven, and all
these cases terminated in the status. The remarkable likeness
between status epilepticus and eclampsia must strike one ; in
both we have muscular spasm, in both renal and liver changes,
in both cases constipation, and in both we have the same
tendency to death from cardiac collapse ; there is possibly a
close relationship between their respective causations. Death
in this condition, as has been just said, takes place from heart
failure ; this has been made a reason for discarding one treat¬
ment after another, the idea being that this or that drug
accelerated this termination. It would seem more likely that,
as it is apparently the normal ending of a case, drugs have no
great influence over it, or at least not so much as has been
attributed to them.

Another point of interest that has been raised is the influence
of the pyrexia upon the cells of the central nervous system.
It has been pointed out by Mott ( s ) that the changes found
could not be the result of the elevation of temperature since the
cells in the anterior cornua of the cord are not affected; perhaps
a more powerful argument is that these changes have been
observed in cases where the temperature never rose above
ioi° F. This is another of the conditions that we must assign
to the mysterious region of “ toxaemia.” The high temperature,
due in a great extent to the violent muscular exertions, the
albuminuria and kidney changes, the gradual culmination of
the symptoms until a point is reached at which the activity of
the cortical cells is dulled, the temperature falls sometimes to
subnormal, and the patient becomes comatose and dies from
heart failure, all seem to point to toxaemia. One thing must
be put down as certain, and that is that the cardiac degenera¬
tion could not be the result of the muscular exertion, since some
of the cases which have had fewest fits show marked change
post-mortem.

Another interesting point is Pierce Clark's ( 6 ) statement that
the sudden cessation of bromides causes the condition. Now
in asylums the cases seem to occur amongst the older epileptic
residents and not amongst the new arrivals, and this would at
first incline one to the view that—as these older patients are
usually untreated—this was a fallacy ; and yet on several

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STATUS EPILEPTICUS AND ITS TREATMENT, [Jan.,

occasions on which the relative efficiency of the different treat¬
ments have been tried, cessation of treatment has been followed
by a remarkable increase in the number of cases of “ status,”
seeming to lend support to Dr. Clark's statement.

Points of Clinical Interest .

Variation in intensity .—Striimpel drew attention to the
occurrence of mild and severe forms of status epilepticus,
many writers having confirmed this. These mild attacks
seem to occur in those cases which are specially prone to the
condition, a mild attack often being followed by one of greater
intensity : e.g. t A. B— had one slight attack in September, 1905,
followed by severe attacks in February, 1906, and June, 1906,
respectively.

In two of these slight cases occurring recently, the clinical
picture was that of " status,” but the duration—until recovery—
was less than fifteen minutes ; the coma was, as would be
expected, short. Both cases were untreated.

Albuminuria has been constant in all the cases I have had an
opportunity of examining ; its disappearance from the urine
coincides with the return of the temperature to normal. Hack
Tuke ( 7 ) records two fatal cases in which it did not occur, and
other observers have failed to find it in cases.

Reflexes .—Corneal reflex abolished, also the reflex to light.
The other reflexes are not constant, but in most cases—between
the seizures—the knee-jerks are exaggerated and Babinski's
phenomenon and ankle-clonus are present.

Temperature. —The temperature rises apparently in propor¬
tion to the number of fits and the duration of the seizure ;
this is clearly shown by the fact that in ail the cases cut short
by the hyoscine treatment the temperature never rose above
103° F. A very interesting point is also the unilateral variation
in temperature, which depends on the fact that one side of the
body is more convulsed than the other. The respiratory- and
pulse-rates coincide fairly regularly with the temperature, as
will be seen by the enclosed charts ; these show the tempera¬
ture, pulse, and respiratory rates in twenty cases of status
epilepticus. Another point worth noticing is the rise in tempera¬
ture which occurs on the day following the seizure, in those
cases which recover: the three charts appended show this rise.

Digitized by C^ooQle

1908 .] BY A. BANKS RAFFLE, M.D. 97

What the cause of it is is impossible to say ; possibly it is
reactionary.

Relation of number of fits to onset .—A marked feature in the
history of a case is the increase—from the normal number of
the patient—of the number of fits immediately preceding the
attack. In dealing with epileptics one is frequently able to
tell when an attack of this condition is pending. Usually there
is a number of fits immediately preceding the onset, and in
most cases the patient has been having more than his, or her,

Chart i.

<■

£ 102°

| 101°

too°

A M

P M-

A M

P M\

□

£.

—

r—

—

■

. i:

- £

—

L !

—

■R

Normal ]

■■

of Cv<*y J
Q ao

■i

97*

Day of Dis

Pulse

ftesp.

Pole

■t

■

”1

L^!

April'2!if

22nd

23C*

average number of fits for some days previously. Reference
to the tabulated cases will show how markedly this is the case
in these cases, and it holds good also in a large number of
other cases. A good illustration of this is :

J. H—, act. 56, had two severe attacks of status epilepticus,
from both of which he recovered under the influence of hyoscine
hydro-bromide. During a year's residence in the asylum he had
only twenty epileptic seizures, and five and six of these preceded
each attack of the condition respectively. He had been an
epileptic from childhood.

Recurrence .—The liability of the status epilepticus to recur

Digitized by L^ooQle

STATUS EPILEPTICUS AND ITS TREATMENT, [Jan.,

has been pointed out by many writers on the subject, and there
seems to be some ground for believing that each attack of the
condition leaves the patient more prone to another.

Six of the cases
attack.

in the tabulated

series

had more than

No. of case in series.

No. of attacks.

Result.

Recovered.

1 7

»>

»»

All these attacks were cut short with hyoscine hydro-bromide,
and therefore it is impossible to say what is the effect of the
recurrent attacks upon the severity of the condition, except to
repeat that in some cases the first attack is sometimes a mild
one and only the forerunner of a more severe one. The first
of these cases (No. 14) presented the following curious clinical
history.

F. D—, set. 72, had thirty-six distinct fits and then passed
into the “ status.” He was treated with hyoscine hydro-bromide
and recovered—duration five hours. This was followed by a
second attack twelve hours later; this was treated in the same
way and he recovered—duration two hours. This in its turn
was followed by a second attack twelve hours later, with the
same treatment and result—duration one hour. I have not
seen a similar case to this reported, nor has another case of the
same nature occurred in the series. Some of these cases are
always threatening to pass into the “ status,” and it is amongst
these that many of the slighter cases occur.

Diagnosis .—This paper deals solely with the status epilepti-
cus occurring in idiopathic epilepsy. The commonest condition
—in asylums—that must be distinguished from it is the pseudo¬
status of general paralysis of the insane.

The former history of the case, the physical signs, and the
milder form the attack takes should be sufficient to distinguish
this from idiopathic status. Most of these cases in general
paralysis seem to recover, although occasionally they terminate
fatally. Two other conditions must be distinguished : these
are the serial fits in Jacksonian epilepsy and the status
hystericus : in neither of these cases is the temperature raised

Digitized by L^ooQle

1908.]

BY A. BANKS RAFFLE, M.D.

nearly so high as in true status—in fact, in the latter of the
two it is not raised at all, nor is there such imminent danger
to life. Jacksonian pseudo-status and that of general paralysis
of the insane are probably very closely allied.

Prognosis .—The mild cases recover, nearly all the untreated
severe cases die. The mortality in my cases—under all forms

Chart 2.

tos°

m°

^ f03°

WJfS I

CT71

WiWzm

Edl

□

■1

■

■i

■

■1

■ .

■a

■

•

■

■1

■a

£ fQ2°

—

■

. S

100°

nnc

—

l5\

■■

■a

■■

H ;

■

fi\

■

□

t’j

■i

■

■■

■i

■

]

■

■I

■

l r i

■

Narmt>f\

■1

U-

97*

Day of D/s
Pulse

Resp.

Oafe

■

■I

■■

■i

■■

i /

i ^

wsmmz j

SOt/t!

The percentage of deaths

50 percent.

50 „

45 ..

• # 33 i „

Under treatment by hyoscine hydro-bromide out of seventeen
cases attacked there were fifteen recoveries and two deaths.

of treatment—was 44 per cent .
given by various authors is :
Burney Yeo ( 8 )

Nothnagel and Buisanger ( 9 )
Lorenz ( 10 ) (less than)

Clarke ( ll ) (out of 52 cases)

Digitized by C^ooQle

IOO

STATUS EPILEPTICUS AND ITS TREATMENT, [Jan.,

The earlier the case comes under treatment the more favour¬
able seems to be the chance of recovery.

Treatment .—With regard to the treatment of the condition
there is no greater evidence of the difficulty met with in deal-
with it than the number of remedies which have been
recommended for its cure. Chloral is the drug which seems to
have given the best all-round results, either with potassium
bromide or without it. On the other hand, chloral has failed
utterly in my cases, and this has also been the experience of
others, amongst whom may be mentioned Dr. Bevan Lewis ( 12 )
and Dr. White ( 13 ). Citrate of ergotin hypo¬

dermically ( 14 ), digitalis ( 16 ), amyl nitrite ( lfi ), and a host of
other drugs have all been useful in cases or groups of cases ;
all have been—with the exception of chloral—eventually dis¬
carded.

The most successful treatment in my cases has been that
with hyoscine hydro-bromide. With regard to the usefulness
and method of action of this drug there has been a great deal
of discussion. As to the points raised, most have been, and
will be, dealt with in other places, but an epitome of the action
of the drug itself must preface the remarks as to its use.

“ The dominant physiological action of hyoscine is upon the
cerebral cortex, producing sleep often accompanied by a low
delirium. It is also a centric depressant of respiration, and
depresses, though somewhat feebly, the whole motor cord. . .

Its influence upon the circulation is very slight and it appears
to exert no influence on the nerves or muscles ” ( 17 ).

Wood ( 18 ) also points out that the experiments made with
hyoscine must have been made with different alkaloids or com¬
binations of alkaloids. He insists most strongly on the point
that hyoscine has little effect upon the heart :

“ It has no sedative influence upon the heart; it may be used
when the feeble condition of that viscus forbids chloral,”
and points out that the only depressing effect is upon the
respiratory centre. In view of the fact that Mott has conclu¬
sively proved ( 19 ) that the tendency in status epilepticus is
death from cardiac failure and not from asphyxia, one of the
grave objections to the use of hyoscine—that it tends to
increase cardiac failure—is proved a fallacy. Moreover, there
are two other points with regard to this : First, our experience
with the drug has not shown any indication that it acts as has

Digitized by L^OOQle

1908 .]

BY A. BANKS RAFFLE, M.D.

IOI

been asserted. Second, I have used the drug in cases where
senile changes had already made the heart feeble.

Another point of great importance with regard to this treat¬
ment is the nature of the hyoscine used. We have already
pointed out Wood’s contention that the drug, as used, was not
always of the same composition, and this is borne out by the
following data : Firstly, after a succession of recoveries extend¬
ing over some years we had two fatal cases. Both these cases
were no more severe at the onset than the ones cured, both
were treated immediately on onset, and both were treated with
the same specimen of the drug , which was a new one . Secondly,
Amory Hare^) and others have drawn attention to the fact
that people greatly differ in reacting to the drug—is there
more idiosyncrasy or variation in efficiency in this phenomenon ?
Thirdly, hyoscine hydro-bromide in the form of pellets
standardised ready for use seems useless : of this I have satis¬
fied myself by investigation of cases in several asylums in
which it has been used extensively. The small dose neces¬
sary necessitates very careful preparation of our stock solutions.

The drug, as prepared by Merck, has been used in all our
cases, and we find now that the same variety of the drug was
used by Wood in his experiments.

Treatment by hyoscine hydro-bromide .—The routine treatment
is as follows: The solid hyoscine hydro-bromide is procured
from the source spoken of and a carefully prepared solution is
made (1 in 400, i.e . 9 gr. is contained in 4 minims) and a
small amount of a preservative is added. On the onset of the
“ status ” 4 minims are given by hypodermic injection ; half an
hour is allowed to elapse and if the symptoms show no signs of
amelioration another 2 or 4 minims are given ; the following
morning an enema is given. This treatment has been used
upon every occasion during the past six years and has seldom
failed.

The following case shows the effect of the treatment:

A. B—, aet. 25, an epileptic from birth. At 9 p.m. patient
had two sharp fits followed by a succession of smaller ones, and
then passed into the “ status.” When seen at 9.20 p.m. he
was having fits which followed each other at intervals of a few
seconds—there was no return to consciousness. The fits
started each time in the same sequence—lower lip, temporal
muscles, flexors of the forearm, sartorii, adductores longi—then

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102 STATUS EPILEPTICUS AND ITS TREATMENT, [Jan.,

becoming general. The tonic spasm was badly marked in all
cases ; the temperature was raised and the pulse forcible and
frequent. Four minims of the stock solution gr. of the
drug) of hyoscine was given hypodermically with almost imme¬
diate effect. Within three minutes the iris was widely dilated
and the fits became less frequent, the convulsive movements
of the leg being the first to cease. The fits ceased within
fifteen minutes, and, after recovering partial consciousness, the
patient fell asleep. Half an hour later he was sleeping

Chart 3.

soundly, the pulse was forcible and frequent (140), skin
moist and warm (io 2°F.), the respiration rather stertorous.
He made an excellent recovery.

With regard to failures with this drug there are two
apparent causes: (1) The drug, as has been pointed out, is
not always procured active ; (2) the doses used are too large.
The more quickly the drug is administered the smaller is the
dose necessary. Appended is a table showing the amount of
the drug used in fifteen recovered cases :

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BY A. BANKS RAFFLE, M.D.

103

No. of case in series.

No. 14, 1st attack
2nd „
3rd „

No. 16

Dose given.

6 r *

• • TXT >>

Charts showing Respiratory , Temperature , and Pulse Maximum in
Twenty Cases of Status Epilepticus .

Chart 4.

Chart 5.

The first ten cases (Chart 1) were treated in various ways,
the last ten (Chart 2) with hyoscine hydro-bromide.

No. 17, 1st attack .... „

2nd ,, .... loo yy

No. 18 ...... ,,

No. 19, 1st attack .... ,,

2nd ,, .... 0 y*

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104

STATUS EPILEPTICUS AND ITS TREATMENT. [Jan,

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TREATMENT OF ACUTE INSANITY.

105

No. of case in series.

No. 20
No. 21
No. 22
No. 23
No. 24
No. 25

Dose given.
1

tJtf »>

tJif >»

tV >>

In conclusion, given a pure and active drug, speedy appli¬
cation, and a careful regulation of the dose, there seems to be
no reason why we should not appreciably diminish the
mortality in this condition. Lastly, I must express my
indebtedness to Dr. Rutherford, Medical Superintendent of
the Exeter City Asylum, both for permission to report these
cases and also for much kindly advice and help given in its
preparation.

( l ) Archives of Neurology .—( 3 ) Recheras sur Vtpilepsie .—( 3 ) Inaugural address
at Kiel.—( 4 ) Spratling’s Epilepsy .—( 5 ) Archives of Neurology .—(*) Epilepsy,
Spratling.—( 7 ) Dictionary of Psychological Medicine .—( 8 ) Manual of Medical
Treatment and Therapeutics .—(*) Eulemberg’s Realencyclopddie .—( 10 ) Inaugural
address at Kiel.—( u ) Spratling’s Epilepsy .—( 1S ) Psychological Medicine, Lewis.—
( w ) Journal of Mental Science, White.—( l4 ) Ibid., White.—( 1& ) Ibid., Greeve.—
( w ) West Riding Asylum Reports, Browne.—( 17 ) Therapeutics : its Principles and
Practice, H. C. Wood (12th edition).—( 18 ) Therapeutic Gazette , Wood.—(*•)
Archives of Neurology, Mott.—(*) Text-book of Practical Therapeutics, Hare.

On the Treatment of Cases of Acute Insanity by Rest in
Bed in the Open Air . By J. Wiglesworth, M.D.,
F.R.C.P.

Having been engaged during the past three years in treat¬
ing cases of active insanity by rest in bed in the open air, I am
able to add my testimony to that of Dr. Easterbrook, as pub¬
lished in the last number of the Journal of Mental Science ,
as to the value of this method of treatment in suitable cases.

In the summer of 1904 I first tried the experiment of treat¬
ing cases of acute insanity in this way, and being satisfied with
the results obtained I extended the system, and during the past
two years all cases of recent insanity admitted into Rainhill
Asylum, which were in any way suitable, have been given a
trial of this method of treatment.

This institution being one of the older asylums is not
structurally as well adapted as could be desired for treating

LIV. 8

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106 TREATMENT OF ACUTE INSANITY. [Jan.,

patients on these lines, but wherever possible glass-roofed
verandahs have been erected for patients to lie out under, and
elsewhere canvas-covered tents with wooden frameworks have
been made to serve this purpose.

The patients are taken outside early in the morning, gene¬
rally about 8.30 a.m., and are kept out, lying down in the beds,
until about 6 p.m., having their meals outside. Unfortunately,
this treatment cannot be carried out in its entirety all the year
round in this climate, but has to be partially suspended during
the winter months. It is important that the patients be warmly
clad, and even then special care has to be taken in the case of
patients suffering from great physical prostration, who are best
kept indoors for a time unless the weather is quite warm.

I may say that I have never regarded with favour the treat¬
ment of recent insanity by prolonged rest in bed indoors, which
is such a feature of the German asylums ; at the same time, the
fact has more and more impressed itself on me that many of
these cases are capable of standing very little outdoor exercise
without undue fatigue. The truth seems to be that mental and
motor energy are inextricably mixed up in the brain, and
the latter cannot be discharged in excess, however slight,
without depressing the former. Lying down in the open air
provides the required rest, at the same time that the general
health is improved and natural sleep encouraged by that best
of all soporifics—fresh air; indeed, this treatment tends to
reduce to a minimum the use of hypnotics and sedatives, which
are so baneful to the nervous system.

The treatment is not applicable to all cases of insanity, but
the majority is capable of deriving some benefit from it. Cases
of active mania and melancholia and stuporose cases appear to
benefit most, but all cases showing signs of nerve exhaustion
(which is so frequent in our patients) should be given a trial of
it. It is not, of course, claimed for this method of treatment
that it is going to cure all cases of recent insanity, even if its
use were restricted to those cases which appear to be most
suitable for it; but my experience of the past three years leads
me to the conclusion that certain patients get well under this
treatment who would not otherwise have recovered, and that
the convalescence of many others is appreciably hastened. Even
if no more could be said than this, the treatment would more
than repay the little extra trouble involved in carrying it out.

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CLINICAL NOTES AND CASES.

107

Whilst on this subject, I may add that I have been in the
habit during the past five years of keeping all the patients
(except those who were too ill and those engaged in necessary
work) out in the open air all day, from 9 a.m. until 6 p.m.,
during the summer months, letting those patients who formerly
had their meals in the wards have them outside in the airing
courts. The improvement in the general health of the inmates
thereby effected has been quite noticeable, and a concomitant
appreciable reduction in the death-rate has been effected.

Clinical Notes and Cases.

A Case of Narcolepsy . By R. Dods Brown, M.D.,
M.R.C.P.Edin., D.P.H., Assistant Physician, Royal Asylum,
Edinburgh.

Narcolepsy is so rare that I deem the folfowing case
worthy of record. It is one occurring in a young man suffering
from hallucinatory and delusional insanity, who was admitted
into the Royal Edinburgh Asylum, in April, 1902, with the
following history.

A. B—, aet. 19, of a frank, cheerful disposition and well educated,
of good muscular development and athletic habits.

In April, 1900, he became affected by periods of “somnolence”
during the day, so marked as to give rise to much anxiety on the part of
his friends. He could be roused from the somnolent condition, but
was fretful when this was done. It occurred at any time of the day,
especially after a good meal At other times he would be listless and
lethargic without passing actually into sleep. He slept badly and had
very vivid distressing dreams, which troubled him greatly. He was
easily fatigued, and sometimes seemed unable to make much mental
effort. His digestive system was often disordered, but when this was
attended to the “ sleep attacks” were not so pronounced. Towards
the end of 1900 the attacks of narcolepsy became more marked, and
on one occasion while walking along a busy thoroughfare he passed into
a state of somnolence. He had a vacant expression, and when ques¬
tioned said he “ felt very sleepy, but would be all right shortly.” He
dropped a glove, and though conscious of the fact, he felt he could not
pick it up. This condition lasted about fifteen minutes.

There never seemed to be any sudden loss of consciousness. He
felt the “ sleep attack ” coming on gradually, could fight against it for a
while, but usually it was overpowering. The only suggestion of uncon-

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sciousness was once while cycling quietly along a road he, suddenly and
to his horror, found himself on the point of going over the edge of the
road into a loch. Again, while golfing, he would stop when about to hit
the bail and be quite unable to make his stroke. He was conscious of
the whole thing, but felt a muscular relaxation which he was unable to
fight against. This condition was sometimes brought on when he was
crossed or irritated. Frequently also he passed into a drowsy state
while speaking, and was unable to continue his conversation.

During the six months immediately previous to admission the attacks
of somnolence abated somewhat, though within the last two months
hallucinations had set in and became very pronounced.

State on admission .—He was a well-developed, strong, muscular
youth, 5 ft 9 in. in height, weighed 14 st 4 lb., and tended to be fat
The physical examination of all the systems revealed nothing abnormal,
except that the bowels tended to be constipated. The urine contained
no abnormal constituents. On examination, the eyes showed no patho¬
logical condition. Mentally he was somewhat slow and confused. He
was good-natured, but puzzled like a child at the strangeness of his
malady. His memory was quite good. He suffered from marked
hallucinations, and thought he heard his schoolfellows’ voices trans¬
mitted by telephones and wireless telegraphy.

At first during his residence in the asylum he suffered greatly from
hallucinations of sight and hearing, and narcolepsy was a very marked
feature of the case. He would fall into the narcoleptic condition at any
time of the day, even though placed in the most awkward and uncom¬
fortable position. If he happened to be walking in the grounds he
might begin to feel the attack coming on, and although he was only a
few yards from the door of the villa he would collapse on the ground,
completely overcome. It was quite common for him to go to sleep
while taking his food, and very often when playing billiards he would
suddenly stop, saying he “ felt very sleepy,” and leaning over the
billiard table he would immediately pass into the somnolent state. He
was unable to resist the attacks of drowsiness, although semi-conscious
throughout. Sometimes he could be easily roused only to relapse into
the same condition. There might be only one or two such attacks, or
as many as a hundred in one day.

As far as possible he had regular exercise in the grounds, and after
a few weeks there was distinct improvement both as regards the hallu¬
cinations and the narcolepsy. He conversed more intelligently and
freely.

In August, 1902, i.e., four months after admission, the hallucinations
became more vivid and he now began to labour under delusions. These
were so real to the patient that he began to act upon them. He thought
that the voices were those of the doctors, the staff, and patients, and as
a result he tended to become violent and homicidal towards these
persons.

This condition became so aggravated that it was decided in October,
1902, to operate in order to discover any source of irritation on the surface
of the brain.

A trephine opening was made over the word-hearing centre and
enlarged to i£ in. in diameter. The dura mater, which was found

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CLINICAL NOTES AND CASES.

109

markedly thickened and slightly adherent to the calvarium, was incised
carefully and the pia arachnoid exposed, but nothing abnormal was
found. The dura was stitched up and the scalp flap replaced.

The patient recovered from the operation, but the delusions and
hallucinations persisted, and he continued to exhibit great violence to
those near him.

In January, 1903, he had so far improved that he was placed in a
convalescent ward. The hallucinations and delusions were less marked
and the narcolepsy was not so pronounced. Unfortunately this con¬
dition of bettemess did not continue. He again became irritable,
delusional, and impulsive, while the narcolepsy was more marked.

During the year 1904 delusions of persecution were very marked, as
were also hallucinations, and he made several homicidal attacks on
attendants and others. The narcoleptic condition, however, was greatly
moderated. His memory still remained unimpaired, and when his
attention was not absorbed with hallucinations and delusions he con¬
versed readily and intelligently. At that time he began to complain of
vague pains in the head.

Since 1904 he has remained in much the same condition as regards
delusions and hallucinations. The narcolepsy still exists, but not to
anything like the same degree as formerly. Occasionally, throughout
the day he passes into a state of somnolence, from which he is easily
roused, and even when walking out in the grounds it may come on.
The patient begins to feel sleepy, and he at once leans against a paling
or wall for a minute or two until the “ sleep attack ” passes off. Some¬
times when he is engaged reading or writing he feels it coming, but is
unable to withstand it. He is aware of his surroundings all the time.

Treatment \—During his residence in the asylum he has had easily
digested food, exercise in the open air, and general tonic treatment.
Bromides had no effect, and intestinal antiseptics produced no appre¬
ciable benefit.

Whether the improvement can be assigned to the operation or not I
think it is impossible to say.

Literature.

In 1880 M. Gdlineau described the rare condition of narco¬
lepsy. He characterised it as an irresistible desire to sleep,
which was sudden in its onset, lasting for a short time, and
recurring at varying intervals. It may last only a few minutes
or it may go on for an hour. He limited the term to those
cases where there is only a partial disturbance of consciousness
usually of short duration. The patient feels he is virtually
asleep: he is but semi-conscious. There is an inhibition of
thought and volition sometimes, but not always of movement.
If the person is talking he may become incoherent and then
stop talking altogether. Again, for example, if he is writing or

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CLINICAL NOTES AND CASES.

[Jan.,

taking his food he drops the pen or spoon. He can see and
hear, but not distinctly. G6lineau thought the disorder de¬
pended on a special neurosis.

Later writers have not confined the term “ narcolepsy ” to
the condition originally described. Pathological somnolence
has also been included, but this is of comparatively common
occurrence in cases of obesity and diabetes. It also may occur
in severe anaemia, in heart and lung diseases, in organic brain
disease, in uraemia and cholaemia. Neurasthenia, hysteria, and
epilepsy also are important in giving rise to morbid sleep. The
person suffering from this condition is wakened with greater
difficulty than in narcolepsy and the sleep is of longer duration,
often, in some cases, lasting for a whole day.

Ribakoff distinguishes pseudo-narcoleptic crises from true
narcolepsy by the fact that the former come on suddenly and
are followed by a feeling of fatigue and by pains, a condition
identical with that seen after a true epileptic attack. He
differentiates between a hysterical sleep and narcolepsy by the
fact that in the former there are to be found other signs of
hysteria, e.g., anaesthesia and paraesthesia, and that there are to
be seen tremors and contractions of eyelids which are not to be
observed in narcolepsy.

Lamacq says that in epilepsy sleep not only may follow the
convulsion, but may also precede it and in rare cases take the
place of it. The patient in these cases is not wakened by the
strongest stimuli, and if the lids are opened the eyes show
irregular involuntary movements. When consciousness is
regained the patient has no recollection of what has happened,
and there is considerable confusion. He also states that in
hysterical pseudo-narcolepsy there may be incomplete closure
of the eyelids, which are more or less tremulous. Cataleptic
attitudes of limbs or body may be found, while anaesthesia or
paraesthesia may be elicited. He attributes the condition to a
functional derangement of some of the organs. Eickhorst
speaks of narcolepsy as an epileptic manifestation and
Oppenheim looks on it as a symptom of hysteria or epilepsy.

M’Carthy and Ribakoff both consider it a phenomenon of
degeneration, while M’Carthy has found nothing to suggest
that it is a distinct neurosis or disease.

There are many who declare that a toxine is the cause of the
affection, and in many cases there are gastric or intestinal

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I I I

1908 .]

disorders. Among the holders of this theory are Ballet,
Blodgett, Furet, and Caton.

Blodgett points out that in many cases of narcolepsy sugar
makes its appearance in the urine of the patient often long
after the disease is established, while Furet thinks that narco¬
lepsy and epilepsy are often associated symptoms of one
intoxication.

Stern has found from careful examination of patients that
the output of chlorides is excessive, and he says that there
exists in the blood a relatively low osmotic pressure. “ Because
of this there is diminished nutrition or stimulation of the nerve
substance, and therefore interference with its electrical con¬
ductivity. The sudden seizures of somnolence are explainable
by the lowered nerve impulses conducted through the cells of
the central system.” He asserts that “ sleep seizures seem to
be due to diminished ionization of the chlorides in the blood.”

It is found that many cases suffer from pain in the head or
in the eyes, or from a feeling of weight or compression, though
the general bodily and mental health remain usually good.

It has been pointed out that in many cases there is a distinct
heredity of nervous or mental trouble. Gastric and intestinal
disorders seem to occur in many of the patients. Lamacq
reports the case of a girl who had no symptoms of indigestion,
but who had a little abdominal distension, and when this was
removed by means of laxatives the narcolepsy disappeared.

Foot knew of a lady whose convalescence dated from an attack
of epistaxis, and because one of his patients complained of a
feeling of weight in the head, and because he had occasional
epistaxis, he applied leeches behind the ears. Distinct temporary
improvement followed this course of treatment.

The unique interest of this case lies in the fact that one can
find no record of narcolepsy and insanity occurring in the same
patient. It is easy to understand that the delusional and
impulsive conditions had their origin in hallucinations, but the
connection between the hallucinations and the narcolepsy
would be much more difficult to trace.

As we know nothing of the cause and pathology of this rare
disease, so the treatment is uncertain and unsatisfactory.
Sedatives give no benefit, and excitants produce only bad results.
Light diet and attention to the functions of the stomach and
bowels seem in many cases to alleviate the condition.

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CLINICAL NOTES AND CASES.

[Jan.,

Bibliography.

Gdlineau, Gaz. des Hopitaux y 1880, p. 628.

Foot, Trans . Acad. Med . Ireland , 1887, v, p. 1.

Caton, Afo/. Joum ., 1889, i, p. 358.

Ewen, Boston Med. and Surg.Journ. y 1893, p. 569.

L£vi, Arch . Gin. de Med ., 1896, p. 117.

Ribakoff, AVtf. 1897, xvii, p. 552.

Lamacq, ibid., 1897, xvii, p. 699.

MacCormac, Brain , 1899, xx ”» P- 4 ^ 9 *

McCarthy, Am. Journ. of Med. Sci. y 1900, p. 178.

Stem, New York Med. Journ., 1902, lvi, p. 47.

Blocq, Rev. de Neur., 1903.

Wilks, Lancet , 1905, p. 1614.

Friedmann, Journ. of Abnorm. Psych., 1907, ii, No. 3, p. 131.
Gowers, Rev. of Neur . and Psych. y 1907, v, 8, p. 615.

Three Cases of Juvenile General Paralysis . By Colin

F. F. McDowall, M.B., M.R.C.S., Assistant Medical
Officer, City Asylum, Newcastle-upon-Tyne.

In the following brief notes nothing is attempted beyond
placing on record three undoubted examples of this interesting
disease, and thus adding to an ever increasing list of cases.

Case i. —F. S—, aet. 20, general servant.

History .—Father and mother drunkards; in poor circumstances.
Patient fourth child of family of five; elder children reported healthy,
but younger sister mentally deficient. Patient was undoubtedly syphi¬
litic in early childhood ; had snuffles. Was always delicate ; of average
intelligence at school.

On admission, September 29th, 1905, she measured 4 ft. 9 in. Bridge
of nose slightly depressed ; marked cicatrices running at right angles to
circumference of mouth. Teeth irregular but not characteristically
syphilitic. Mammae rudimentary.

The mental condition on admission was one of slight melancholia
patient emotional, lachrymose; answers to questions irrelevant. Speech
distinctly affected ; some words stopped short and some run together ;
fibrillar twitching of facial muscles; tongue tremulous. Knee-jerks very
active; plantar reflexes normal and equal. Pupils equal and react
normally to light and accommodation.

Patient speedily recovered from depression and became irritable and
peevish; did ward work; clean and tidy in her habits. After six
months she became less observant, and was listless, apathetic, and idle.
Gait was now affected; patient walked in an ataxic, swaying manner;
legs dragged after her and fell with feet extended and wide apart.
Mental condition one of increasing dementia; ultimately unable to
answer the simplest questions, and during the last three months of life

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113

she was too demented and paralysed to speak at all. Fourteen days
before death, and seventeen months after admission, she became con¬
vulsed ; remained unconscious; had thirty-six seizures in all. Condition
after first convulsion : pupils dilated, equal, no reaction to light. Patellar
reflexes completely absent; well-marked bilateral Babinski sign. Shortly
before death the legs became cedematous, and there were indications of
gangrene of lungs.

Post-mortem examination. —Body emaciated. Hair poorly developed
over pubis and in axillae. Skull-cap adherent to dura mater, which is
dense and thickened; many Pacchionian bodies, especially along the
sides of the longitudinal fissure. Pia mater opaque; excess of sub¬
arachnoid fluid. On stripping off the pia the surface of the convolutions
appeared markedly eroded, especially over parietal and temporal lobes.
Lateral ventricles much dilated with clear fluid ; no granulation of lining
membrane, but abundant granulations in fourth ventricle. Convolutions
atrophied; the grey matter markedly diminished. Cerebral substance
generally soft. Basal arteries sclerosed. Liver fatty; capsule thickened ;
old cicatrix on under surface of left lobe. Deep notch in anterior border
of right lobe. Kidneys show cicatrices on surface. Heart normal.
Lungs contain scattered tubercular foci with large gangrenous abscess ;
cavity in right lower lobe. Uterus rudimentary. Encephalon = 1030
gnns. Right hemisphere (undissected) 400 grms.; left (dissected) 410
grins. Cerebellum = 110 grms. Pons = 15 grms.

Case 2. —E. M — , aet. 15, of no occupation ; admitted October 27th,
1899, from a home for waifs. Her mother reported to be a prostitute.
No further history obtainable.

On admission. —She has the appearance of a child of ten ; bridge of
nose depressed, nostrils wide, head large, forehead prominent. Typical
cicatrices at angles of mouth. Teeth irregular, not typically syphilitic.
Palate highly arched. Speech and gait normal. Patellar reflexes increased;
active plantar response. Pupils dilated, unequal; right larger than left;
reaction to light and accommodation normal. Mental state one of
extreme hilarity, mild excitement and restlessness with continuous
laughter and incoherent chattering. Ten days after admission she lost
power of legs; quite unable to walk; no seizure noticed. The reflexes
remain unaltered, but speech distinctly affected ; she cannot pronounce
“ artillery ” and similar test words ; distinct hesitancy and slurring.
Tongue tremulous, marked twitching in lips and facial muscles. After
a short stage of what resembled stupor, she again became happy and
intelligent; remained in that condition for the next five years. During
this period she once had retention of urine. In February, 1900, she
had an acute attack of broncho-pneumonia. Had an attack of interstitial
keratitis, which left permanent adhesions to lens in each eye. Men¬
struated regularly from admission till three months before death;
copious losses. Body-weight increased, but stature remained un¬
changed. During last two years of life she gradually became more and
more demented; not so hilarious, but quiet, reserved, demented, and
worked but little and in a listless manner. Three months before death
she again lost power in legs. Speech, which had gradually become

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[Jan.,

typical of ordinary general paralysis, now entirely lost, and patient quite
demented, understanding very little of what was said to her. Patellar
reflex increased. Marked bilateral Babinski phenomenon; Argyll-
Robertson pupils; no ankle clonus. Required catheterisation. Legs
became cedematous. Occasionally vomited bilious matter. Developed
a bulla over sacrum which disappeared before death.

Post-mortem examination .—Body well nourished. Hair abundant
over pubes, but scanty in axillae. Skull cap adherent to dura mater,
which is thickened and dense. Pia opaque. Marked excess of sub¬
arachnoid fluid, also of cerebro spinal fluid. Erosions of middle tem¬
poral and middle frontal convolutions on each side. Lateral ventricles
enormously dilated. Abundant fine granulations on floor of ventricles.
Cerebellum atrophied. Floor of fourth ventricle covered by coarse
granulations. Degenerated gummatous mass attached to pia in Sylvian
fissure. Arteries, especially basal, thickened. Liver shows cicatrix on
under surface of right lobe; capsule thickened throughout. Uterus
small, as are all the abdominal organs. Encephalon = 1075 grms. ;
right hemisphere = 430 grms.; left = 400 grms.; cerebellum = 56
grms.; pons =14 grms.

Case 3.—T. M—, aet. 14, of no occupation. Third child of parents
in good circumstances. Other members of family healthy. A reliable
history difficult to obtain. Patient stated to have been a bright, intelli¬
gent child until about twelve months before admission. She then became
irritable, peevish, erotic.

On admission , November 4th, 1905, she was passionate, declamatory;
habits faulty. Height 5 ft. 4 in. Weight 4 st. 11 lb. Bridge of nose
depressed. Teeth very irregular. Gait normal. Speech hesitating and
indistinct, complete words being occasionally dropped out. Plantar
and patellar reflexes normal. Pupil reflex not noted. Patient con¬
tinued noisy and irritable for two months when progressive dementia
developed. Bodily condition degenerated. Gait ataxic. Body bent
forward, head extended. Menstruation regular; the loss very small.
About middle of November (?) she began to have attacks of vomiting ;
bilious and liquid material ejected without effort. Makes inco-ordinated
attempts to scratch when interfered with. Cannot articulate at all;
points at articles and vainly attempts the pronunciation of their names.
October 29th, 1906. General condition very feeble; extremities cold,
livid. Pupils unequal; right dilated. Active patellar response.
Marked bilateral Babinski’s sign with flexion at knee-joint. Urine
retained. On November 3rd patient died after twenty-four hours of
unconsciousness, but no kind of “ seizure ” was observed.

Post-mortem examination, —Body well nourished. Legs cedematous.
Hair on pubis and in axillae poorly developed. Skull cap adherent to
dura. Pia thickened, opaque, and adherent to tips of convolutions
except throughout the posterior portion of occipital lobe on each side.
Lateral ventricles dilated. Small circular sclerotic patch in outer wall of
left ventricle. No granulations on lining membrane of lateral ventricles.
Grey matter diminished, soft and dark. White matter pultaceous.
Cerebellum normal. Floor of fourth ventricle covered by exuberant
granulations—a typical example of “ cat’s tongue.” Excess of cerebro-

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1908.] clinical notes and cases. I 15

spinal fluid. Encephalon = 970 grms.; right hemisphere = 395 grms.;
left = 370 grms. Cerebellum = 150 grms. Pons = 10 grms. Other
organs showed no pathological change.

Remarks .—When Clouston, Mott and others recorded their
cases of adolescent general paralysis, they drew attention to all
the points that receive attention from us as practical physicians.
Anyone acquainted with the literature of the subject must at
once perceive how the cases now detailed emphasise the
conclusions arrived at by former observers. In relation to the
age at which the disease usually appears, there is one point
which has attracted some attention, but about which nothing
definite has been decided; I refer to the age limit beyond which
inherited syphilis does not appear to be able to produce general
paralysis. Yet this is really an important question, which when
solved may account for those cases of the disease in which a
history of primary syphilitic infection cannot be obtained.

In two of the cases the stature was markedly under the
average; the patients appeared more like children, and this
juvenile appearance was retained to the end ; more especially
was this true as regards the facial expression. Though some
of the sexual characteristics were poorly developed, this was not
so in Case 2, who was a developed woman, though in miniature,
and in her the monthly periods were quite normal.

As already stated it is not my intention to use these three
cases as a text and to proceed to discourse on all the points of
interest arising from a consideration of general paralysis. Still
a word may be said as to the diagnosis of these cases. Until
Clouston recognised their true character they were considered
to be instances of dementia, but now asylum physicians have no
difficulty in diagnosing them. It is otherwise with the ordinary
practitioner. It is only rarely that he arrives at a correct dia¬
gnosis. Sometimes the mistakes are quite remarkable, but
only one need be referred to—that of a girl, aet. 18, in a refuge.
Although the history of the case was defective, it would surely
have been possible to avoid the error of considering her a deaf
and dumb idiot, when she really was a case of far advanced
general paralysis.

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CLINICAL NOTES AND CASES.

[Jan.,

116

Menstruation in the Insane . By T. C. Mackenzie, M.B.,

F.R.C.P.Ed., Senior Assistant Physician, Royal Asylum,
Aberdeen.

The following notes are the outcome of observations made
during a recent period of six months upon ninety-two patients
in the Royal Aberdeen Asylum.

Age.

15-20 21-25 25-30 31-35 36-40 41-45 4^-50 S l SS

years. years. years. years. years. years, years, years.

2 . 15 . 14 . 19 . 15 . l8 . 7 . 2

Disease on Admission .

Mania.49

Melancholia. 32

Secondary dementia.4

Dementia prsecox.3

Congenital imbecility.2

General paralysis . . . . 1

Nervous depression (voluntary) . . . 1

Total 92

Of the 49 cases of mania 20 showed no change during the
menstrual period, 22 showed increased excitement with impul¬
siveness and general exaggeration of their maniacal symptoms,
5 showed excitement during some periods and no change during
others, and 2 showed depression.

Of the 32 cases of melancholia 19 showed no change, 7
showed increased agitation or depression, and 6 showed depres¬
sion during some periods and no change during others.

In 2 cases of mania, 1 case of melancholia, and 1 case of
nervous depression it was noted that there was an increase of
excitement specially before the commencement of the mens¬
trual period.

In 3 cases there was a marked degree of sexual excitement
during the period.

Frequency of Menstruation and Duration of Menstrual Periods .

For 29 cases of mania admitted within the last two years, the
average number of menstrual periods to each patient during the

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1908 .] CLINICAL NOTES AND CASES. I 1 7

six months of observation was 3’g, and the average duration of
the periods was 5*5 days.

Similarly for 17 cases of melancholia the average number of
periods was 2*9, and their average duration 5*2 days.

Of 3 cases of dementia praecox, 2 were completely amenor-
rhoeic during the whole period of six months, and the third
case menstruated twice, each menstrual period lasting 5 days.

In 1 case of advanced general paralysis there was complete
amenorrhoea.

In 2 cases of congenital imbecility the average number of
menstrual periods was 6, and the average duration 5*4 days.

Relative Frequency of Menstruation in Recent and Chronic Cases .

For 21 patients between the ages of twenty-five and forty who
have been resident in the asylum for two years and less, the
average number of menstrual periods to each patient was 2*7,
and the average duration of the period was 4*3 days.

For 18 patients between the ages of twenty-five and forty, who
have been resident for five years and upwards, the average
number of periods was 43, and the average duration 5 days.

Complete Amenorrhoea occurred in n of the 92 cases, as Illustrated
in the following Table .

Disease on
admission.

Age.

Present state.

Remarks.

Mania

Acutely melancholic with halluci¬
nations

—

»*

Confused, with occasional acute
excitement

? Tubercular enteritis.

Secondary dementia

—

Discharged recovered after 5
months’ residence

Suffered from chorea when
admitted.

Discharged recovered after 9
months’ residence

.Subsequently died from
phthisis pulmonalis.

Discharged recovered after 8
months’ residence

Lactational insanity.

Melancholia

Suicidal and impulsive

Tubercular.

Depressed, irritable, suspicious

—

Dementia

Restless, confused, faulty in

—

praecox

habits

Dementia

Lucid remission after katatonic

Sister died from phthisis

praecox

resistiveness

pulmonalis.

General

paralysis

Died 11 months after admission

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I 18 CLINICAL NOTES AND CASES. [Jan.,

Acute Mania following General Ancesthesia. By Guy
Rowland East, M.B., Assistant Medical Officer, North¬
umberland County Asylum.

R. C—, aet. 21, was admitted to the Northumberland County Asylum
on August 28th, 1907, suffering from acute mania.

History .—Up till three days before his admission to this institution,
R. C— had never presented any indication of mental instability, either
in altered habits, change of personality, or sleeplessness. He had always
been a steady, hardworking man, a quarryman, clean living, and in no
way addicted to drink or other unhealthy appetites, nor had he shown
undue emotion in religious matters.

On August 24th, 1907, having arranged with a dentist for the extrac¬
tion of thirteen carious teeth, Dr. Gover, of Gosforth, administered a
general anaesthetic (ether). The patient took the anaesthetic well, but
the operation was somewhat protracted, the decayed stumps being
difficult of removal. He was under ether forty minutes. Immediately
on regaining consciousness, R. C— sat up and pointed across the room
saying that he saw God, dressed in a frock coat and top hat, standing
near the door.

He was afterwards taken home and put to bed, where he slept quietly
till midnight. On waking he at once got out of bed and began to dress
himself. His father, hearing the noise, came into the bedroom to find
R. C— with an open razor in his hand, which the father succeeded in
wresting from him after a struggle. Shortly after this incident R. C—
rushed from the house minus coat and stockings, nothing more being
seen of him till 5 o'clock in the morning of August 25th, 1907, when he
rang Dr. Gover's night bell and asked for an interview.

To quote Dr. Gover's own words :

“ At five o'clock in the morning patient came to my house without
his coat and stockings and said that his father was going to cut his
(R. C—'s) throat. He rambled continually about God and said that he
had become converted. He also asked me to pray for him. He after¬
wards flung himself on his knees and prayed in the street."

From this time onwards he became progressively more excited, being
altogether unmanageable, talking incoherent nonsense, extravagant in
his movements, flinging off his clothes, at times being violent and
dangerous or abusive and threatening in his language.

It was in this mental condition that he was admitted to this asylum.

Family history .—His maternal grandmother was subject to periodical
attacks of depression for many years, but was never certified as insane.
His mother died in an asylum.

August 29th, 1907.— Physical state: A fairly nourished man. Tem¬
perature 98° F., pulse 84, respirations 16. Gums swollen and bleeding.
Tongue furred. Breath foul. Appetite poor.

Mental state. —A nervous and fearful man who imagines he has daily
communion with God ; that God has ordered him to be discharged from
the asylum ; that the Devil poured noxious gases through a ventilator

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OCCASIONAL NOTES.

1908.]

119

and tried to stifle him, but by God’s intervention he stopped up the
inlet He is agitated, restless, gesticulates wildly, and has a frightened
expression in his eyes. He became violent last night and was removed
to a padded room. He refused his breakfast as he said it was
poisoned.

For the following three days he continued in this excited mental state,
and as he persistently refused to take any nourishment he was forcibly
fed during this period, being confined to bed in a single room day and
night, but was not secluded.

Temperature 99*2° F., pulse 84, respirations 16.

September 4th, 1907.—To-day he is quieter and rests contentedly in
bed after a somewhat restless night. Later in the day he was severely
purged and towards night his temperature rose to 102° F., respirations
20, pulse 96. He was put on milk diet and given astringent mixtures.
Slept moderately at night.

The diarrhoea ceased during the next three days, in which time the
patient became rational. He had no recollection of anything that had
happened since his visit to the dentist on August 24th, 1907.

His ultimate recovery was uninterrupted and uneventful.

The interest in this case lies in the fact that a young man,
act. 21, previously exhibiting no signs of mental instability, but
with hereditary taint, undergoes a somewhat trivial operation,
under ether, which results in an attack of acute mania. His
recovery was preceded by a febrile attack, associated with severe
diarrhoea.

Occasional Notes.

The Treatment of Incipient Insanity .

Dr. Clouston is indefatigable. He once more appeals to the
charitable public in the columns of the Scotsman , for the
establishment of wards in the Edinburgh Royal Infirmary for
the treatment of incipient insanity. The editor of the Scotsman
lends his powerful aid to the proposal, and various letters have
followed on this inception. Six years ago the scheme was care¬
fully considered and definite proposals were made, but financial
difficulties compelled postponement. The unanimity of the
medical profession and the apparent assent of the philanthropic
public augured favourably for success; and it is hoped that the
public interest is again awakened by the representations which

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120

OCCASIONAL NOTES.

[Jan.,

have been made more recently. It would appear that the
success of the special department of the Albany Hospital in the
State of New York and the special wards established in Glasgow
has been undoubted. The former is in contact with a general
hospital and has all the advantages of such a connection, but
the latter is specialised and separated from the general hospitals
of the west. A suggestion has been made that Saughton Hall
might be used for the purpose indicated, but we would strongly
deprecate any arrangement of that kind. The whole intention
is to avoid segregation and the very appearance of an asylum,
to bring the early treatment of mental disorders into living
contact with the medical work of a great hospital. It is not
proposed to create an asylum within the Edinburgh Royal
Infirmary, but to provide open wards for the early treatment of
the insane, under the care of a skilled physician who will enjoy
the active co-operation of the medical and surgical staff as may
be found necessary in the circumstances of each particular
case.

We trust that this appeal will meet with a generous support
and that Edinburgh will lead the way. We believe that
success will follow upon a concerted and active enterprise
carried out on the lines which Dr. Clouston and his colleagues
have indicated.

The Ministry of National Health .

Health is the most important asset of a nation or an indi¬
vidual, without which all other possessions are comparatively
valueless, and it is astonishing that this fundamental truism
has not been recognised by a people priding itself on its
common sense and practicality.

The absence of any important department of government,
dealing with this vital national asset, is sufficient refutation of
any claim to the possession of such qualities by the British.

The need for a Health Department has been demonstrated in
the fullest possible manner by the Reports of Royal Com¬
missions in the last few years. These, however, have only
emphasised the urgency of the want that had long been recog¬
nised by the medical profession and a considerable proportion
of that very small section—the thinking public.

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1908.]

OCCASIONAL NOTES.

I 2 I

The demand for the formation of a Health Department of
the Government, with a responsible minister to represent it, is
growing both in force and urgency, and has been eloquently
voiced at many recent medical meetings of importance, as well
as in the discussion opened by Dr. Clouston before the Medico-
Psychological Association.

The jumble of conflicting authorities dealing with health
matters generally, chaotic as it seems, is orderly when com¬
pared with that which obtains in regard to lunacy. The discus¬
sion alluded to brought out the fact that no fewer than seven
different authorities have a share in the mismanagement of
matters concerning mental diseases, the crowning absurdity
of the muddle being the investment of paramount power in the
treatment of the insane, not in a medical, but in a legal
authority, the Lord Chancellor.

This legal luminary, for whom in his legal sphere every
Englishman entertains a very proper respect, in the aspect of
physician in chief to one hundred and twenty thousand mentally
sick persons, can only be regarded with derision. This poten¬
tate exercises other functions, equally unconnected with the
law. The sense of the ludicrous excited by this combination of
functions is forcibly reminiscent of a role in comic opera.

The British Pooh-Bah, however, cannot be suspected of
pocketing “ insults ” like his prototype, but the prerogative of
making lucrative appointments for persons possessing no qualifi¬
cations for the duties cannot be altogether without “ consola¬
tion.”

This comical travesty of rational government has, however,
its serious, nay, even its tragical side.

The Lunacy Law and its administration, originated by succes¬
sive Lord Chancellors, has constituted a tragedy, the enactment
of which has occupied scores of years, has cost numerous lives,
unmeasurable suffering and immense expenditure. Nor can
this country expect to see at any early date the closing
scenes of this perennial play.

SucLa description of lunacy law, past and present, may sound
exaggerated to those unversed in lunacy matters, but it is a
simple statement of the case to those acquainted therewith.

The pages of this Journal for the last forty years are a lasting
memorial of the evils resulting from this predominance of law
in lunacy, from the testimony of numerous men, whose know-

Liv. 9

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OCCASIONAL NOTES.

122

[Jan.,

ledge of the facts cannot be contested, and whose experience
is beyond all question.

The marvel consists in the absence until the present moment
of any serious effort to obtain reform.

The effort to obtain a ministry of health has commended
itself to our Council, which has authorised the Parlia¬
mentary Committee to act for the Association in this
matter. It is not probable that this Committee will give any
support to the suggestion that national health should be placed
under the care of the Local Government Board. Such a result
would constitute a serious disaster in regard to the public
health, but more especially as affecting the welfare of the
insane. It would indeed be a substitution of King Stork
for King Log, and should be opposed to the utmost extent of
the power of the Medico-Psychological Association.

Clinical Work in Asylums.

The desirability of increasing the output of clinical work in
British asylums has been frequently dwelt on in the pages of
this Journal, but no apology is needed for again recurring to
the subject, since there still remains very considerable need of
further progress in this direction.

Clinical work is at once the foundation and the evidence of
interest in medical work, and is so obviously the true founda¬
tion of legitimate professional success that self-interest alone
would seem to supply a sufficient motive. That it does not do
so in a large number of instances proves that other influences
must exist to inhibit this.

A thorough inquiry by the senior members of the specialty
in regard to these inhibiting causes and the means of removing
them is most desirable.

The first inquiry should be in regard to the encouragement
and assistance given by the seniors to the juniors. Asylum
superintendents, with scarcely an exception, encourage their
juniors to undertake clinical work, but do they sufficiently
earnestly impress on these latter the importance of it, or
demand it of them as a duty, or aid them sufficiently in their
earlier attempts ? Do the superintendents take sufficient trouble
to ascertain and overcome, if possible, the indolence, indiffer-

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REVIEWS.

1908.]

123

ence, bashfulness, or other causes that keep the younger men
from producing such work ?

The professional qualifications of the juniors are usually of a
very high order, and would forbid the idea that they were not
trained to record clinical observations, and hence some of
the reasons suggested, or others not alluded to, must come
into play in preventing the present output of work, large as it
is, from becoming larger and more valuable.

Whatever the causes, it is most important that they should
be investigated; that measures should be taken to remove
them and to substitute inducements and encouragements of
every possible kind with the end of raising to a still higher
level the reputation of the specialty for scientific interest in
morbid psychology.

Part II.—Reviews.

The Sixty-First Report of the Commissioners in Lunacy for England.

The report deals with the year ending December 31st, 1906. It
begins with the good news that the increase in the number of certified
insane is below the average. The total number of insane under certi¬
ficate in England and YVales on January 1st, 1907, was 123 988, an
increase for the year of 2009, and thus below the average increase for
the last quinquennium (2655) and the last decennium (2462). Pauper
patients constitute 91*2 per cent, of the total number certified. Atten¬
tion is again drawn to the increase of patients classified as “ private ” in
county and borough asylums; this, it is explained, is largely due to the
fact that a patient, whose friends pay the full maintenance rate, is not
technically a “ pauper,” but since county authorities are not bound to
provide accommodation for private patients it is customary to make a
higher charge for such patients for the capital expended on, and upkeep
of, the building. The position is an anomalous one, as many counties
have not room for their pauper patients, but have to find room for
patients whose friends can pay the full maintenance, and, perhaps,
something more. In a word, this increase of “ private ” patients in
county asylums emphasises the necessity of the establishment of asylums
where patients can be maintained at a figure slightly higher than the
ordinary pauper rate.

The Commissioners have not yet been able to answer the much
asked question of “ whether insanity is on the increase.” The number
of the insane to the general population is 1 to 282, ten years ago it was
1 to 314. An instructive table (on page 8) shows the number (per
10,000 population) of the admissions and first attacks since 1876. The
conclusion drawn from this table is that the' number of “ first attacks ”

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124 REVIEWS. [Jan.,

is on the increase, and therefore, presumably, the “incidence” of
insanity; but the Commission very properly hesitate to accept this as a
fact, because the figures deal only with the certified insane, and it is
well known that many cases now come under certificate who used not
to do so.

The fluctuations in an asylum population are worth study, they show
that of the admissions in any one year about 46*8 per cent remain
longer than one year, 35 *6 per cent. than two years, 14*4 per cent . than
twelve years, and only 6 per cent, after twenty years. Of those patients
that recover 88*8 per cent., and of those that die 48*5 per cent., do so
within a period of two years from their admission.

As regards statistics of special medical interest are, the recovery-rate
for the year, 37*32 per cent., a fraction below the average, and the
death-rate, 9*85 per cent., also a fraction below the average. As regards
sex, the ratio in the admissions 49 to 51 is much the same as in the
general population ; but among the resident insane is as 46 men to 53 9
women, owing to the higher death-rate among the male insane. Mania
appears to be diminishing and melancholia increasing, but mania is
more liable to relapse ; not much reliance can be placed on this state¬
ment as it is largely one of nomenclature. It is to be hoped that in
future, owing to the efforts of the Statistical Committee of the Medico-
Psychological Society, more uniformity in nomenclature will be brought
about. It would appear that senile dements have not usually been
insane before. The age period for general paralysis of the insane is
35—44. The incidence of epilepsy is chiefly among male paupers.

Though so many asylums have been built of recent years, the
Commissioners still find it necessary to comment on the neglect of
local authorities to provide accommodation, thus necessitating the
patients being housed elsewhere at an increased cost to the ratepayer.

Considerable space is given in the report to the conditions of service
of those attending on the insane. It is fully recognised that the hours
of duty ar£ very long, but also it is admitted that shortening the day
for nurses and attendants is not within the range of practical politics.
They suggest that compulsory pensions, good pay, liberal allowances of
occasional leave are due to those who spend their lives in a very
harassing employment An effort has been made to discover whether
insanity is more common among asylum employes than the general
population, and the conclusion is that it is so, taking into consideration
the standard of mental and physical fitness required before such
employment can be undertaken.

The cost of maintenance per head per week of the pauper lunatic
has dropped twopence, and has not been so low since 1902.

The returns of dysentery and diarrhoea in asylums indicate that the
latter is associated with the former, and there is evidently a growing
belief that the condition is contagious.

Much has been written lately about the system of boarding out
lunatics, and there is every reason to suppose that it might be adopted
in England with advantage, were there more facilities for doing so.

Among the prosecutions is the case of embezzlement by a clerk and
steward. In these days it is very necessary that every conceivable
check on the stores and books of a large institution should be kept

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1908.]

125

Another case of importance is that in which a workman, employed by a
contractor, misconducted himself with a female patient. The learned
judge held that, not being “a manager, officer, nurse, or attendant,” he
did not come within the meaning of the Lunacy Act, 1890, §324.

In conclusion, the Commissioners draw attention to the total in¬
adequacy of their number to cope with the work allotted to them.
Their report is, under such circumstances, sufficient evidence of how
thoroughly they do their work, and of the high standard they set them¬
selves.

The Forty ninth Annual Report of the General Board of Commissioners
in Lunacy for Scotland , 1907.

The Report gives in the first place the usual statistical information in
regard to lunacy in Scotland for the year 1906. On January 1st, 1907,
there were in Scotland, exclusive of insane persons maintained at home
by their natural guardians, 17,593 insane persons known officially to
the Board. Of these, 17,121 were registered insane, comprising 14,214
persons in Royal, district, parochial, and private asylums and in lunatic
wards of poorhouses, and 2,907 persons under care in private dwellings.
The non-registered insane were 51 persons in the Criminal Lunatic
Department of the General Prison at Perth, and 421 in training schools
for imbeciles. Of the registered insane 2,375 were maintained from
private sources, and 14,746 by parochial rates; and the figures show
that during the year 1906 there was an increase of private patients by
9, and of pauper patients by 166. Among the non-registered insane
the number in the Lunatic Department of Perth Prison (and maintained
by the State) was the same as in the previous year, while in training
schools for imbeciles there was a diminution of 32.

Amount of insanity in proportion to population .—The statistics show
that in eighteen counties there was a decrease (amounting to 96) in the
number of pauper lunatics, and that this decrease occurred not only in
counties in which the population is stationary or falling, but also in
counties having large industrial growing centres of population, such as
Aberdeenshire, Forfarshire, and Fife. This was more than counter¬
balanced by an increase of 262 in the remaining fifteen counties, but of
this increase 201, or 77 per cent is contributed by the four counties of
Edinburgh, Lanark, Renfrew, and Stirling, in which the general population
is growing rapidly, and in which, therefore, an increase in the number of
the insane might naturally be expected. Taking private and pauper
patients together, the proportion of registered lunatics fell from 363
(per 100,000 of estimated population) on January 1st, 1906, to 362 on
January 1st, 1907. This is the first year in which a decrease has
occurred since the beginning of the statistics in 1858 ; and viewing it
along with the stationary figures of the previous two years the Report
expresses the hope that the burden which lunacy entails upon the
country is probably reaching its limit. The tables showing the number
placed on the register annually, and the number of persons registered
for the first time in each year, are continued, and point towards the
same conclusion. The largest number placed on the register in one
year occurred in 1902, when it was 3,660. It fell to 3,616 in 1903,

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126

REVIEWS.

[Jan.,

rose to 3,658 in 1904, and has since fallen to 3,449 in 1905, and 3,370
in 1906. Taking the numbers registered for the first time, the table
shows that in the case of private patients the proportion to population
has fluctuated within narrow limits during the thirty-three years
included in the figures, and is for the year 1906 lower than it was in
1874. For pauper patients the proportion rose more or less steadily
until the year 1902, when it reached the maximum of 52*6 (per 100,000
of population). It has since fallen, the proportions for the past three
years being respectively 50 5, 47*9, and 45*1. Combining the figures
for private and pauper patients, the largest fall has occurred in the year
which has just closed.

Admissions , discharges , and deaths. —Excluding transfers from one
establishment to another, the number of private patients admitted to
asylums during 1906 was 536, being 9 less than in the preceding year,
and 33 less than the average for the quinquenniad, 1900-04; and the
number of pauper patients admitted was 2,856, being 64 less than the
number in the preceding year, and 152 less than the average for the
quinquenniad, 1900-04. The number discharged recovered was equal
to a percentage on the admissions (excluding transfers) of 41*2 in the
case of private patients, and of 39*4 in the case of pauper patients, both
these figures being somewhat below the average of recent years. Calcu¬
lated on the average number of patients resident, the percentage of cases
discharged unrecovered (again excluding transfers) was 5*2 for private
patients, and 3*8 for pauper patients. Of the pauper cases discharged
unrecovered, 216, or 48 per cent ., continued afterwards to be provided
for as pauper lunatics in private dwellings, while 235, or 52 per cent. y were
removed from the poor roll and ceased to be under the board’s
cognisance. The proportion of patients who died in asylums during
1906 (9*4 per cent, of the average number resident) was considerably
higher than the average of the preceding five or six years, both for the
private and for the pauper class. There has in fact been a pretty steady
increase in the death-rate since 1890; and it is pointed out that the
occurrence of this higher death-rate in spite of improved sanitary
arrangements, of lessened overcrowding, and of more efficient means of
treating special diseases, such as pulmonary consumption, lends support
to the view that patients physically broken down are being received into
asylums in increasing numbers, a condition which also has an effect in
lowering the recovery rate.

Attendants and servants. —The number of changes among the
attendants and servants engaged in asylum work is relatively large ; and
it is again urged that an inducement to more steady service would be
held out if the district asylums in Scotland were put in possession of
the same rights in regard to pensions as the county and borough
asylums of England. In connection with this point it may be mentioned
that the Scottish Division of the Medico-Psychological Association is at
present taking steps to have the matter of pensions brought again under
the notice of the Government.

Lunatics in private dwellings .—The number of pauper patients pro¬
vided for in private dwellings on January 1st, 1907, was 2,774. This is
the highest total ever reached, and represents 18*8 per cent, of the total
number on the lunatic pauper roll; and it shows that the system of

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1908.]

REVIEWS.

127

private care continues to play a very important part in the Scottish
arrangements for providing for the insane. The reports of the Deputy
Commissioners emphasise its efficiency and suitability for certain classes
of lunatic patients, and indicate that with more energy and more hearty
co-operation on the part of asylum superintendents and inspectors of poor
it would be possible to extend it considerably further, some parishes
having as many as 28 per cent . of their lunatic poor provided for in this
way. In this connection the following sentences taken from a report by
Commissioner Dr. John Macpherson deal with a point of prime im¬
portance : “ It is not infrequently urged against the Scottish family care
of the insane that there is not the same constant supervision of the
duties of the guardians which exists in some continental lunatic colonies.
While there can be no doubt as to the truth of this statement, it may be
contended, on the other hand, that inspection may be carried so far as
to weaken the sense of responsibility of the guardians. My experience
is that no supervision, however frequent, is a sufficient protection
against certain defects which are occasionally found in the care of
patients. I have also learnt, after some familiarity with the system of
boarding-out, that it is generally possible to decide in the course of a
short visit whether the duties of guardianship are properly performed,
and that it is almost always possible to discover whether the patients
are admitted within the family circle or are treated as outsiders. Upon
this question of admission to the family life hinges the whole success of
the Scottish system ; where it is neglected, however perfect in other
respects the guardianship may be, the results are disappointing; where
it is conscientiously adhered to official visitation tends to become less
inquisitorial and more a means of strengthening a relationship which is
in itself the surest prevention of abuses.”

Several other points of interest are dealt with in the report. The
want of accommodation for the poorer class of private patients is
again pointed out, and the opinion is expressed that permissive power
should be given by statute to the District Lunacy Boards to provide
accommodation for these cases. Several pages are devoted to the
question of restraint and seclusion in asylums, and a table is given to
show how far these have been used during the last five years. It is
recognised that these measures may occasionally be justifiable under
exceptional circumstances; but it is noted with approval that there has
been a very marked diminution in the extent to which they are now
resorted to, and it is pointed out that this reduction has been not only
unattended by any known disadvantage, but has also been of material
benefit both to the patients and to those in charge of them. Reasons
are given for adopting in future a different method of classifying the
causes of death among the insane, with the object of securing more
trustworthy results in the deductions drawn from them. From informa¬
tion collected for the use of the Royal Commission on the Care and
Control of the Feeble-minded, it appears that in every 100 patients
admitted to establishments for the insane (including training schools for
imbecile children, but excluding transfers) 7*3 are the subjects of con¬
genital or infantile imbecility, and 92*7 of acquired insanity. Much
detailed information is given in regard to the cost of providing asylum
accommodation and the cost of the yearly maintenance of patients.

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128 REVIEWS. [Jan.,

The former varies very greatly in different instances, according to the
special circumstances of each case, while the maintenance expenses
fluctuate within much narrower limits. A table drawn up from the
expenditure in sixteen district asylums shows that for the year 1906 the
average cost per patient was jQi*j 12 s. 2 d. for providing accommodation
and ^25 10s. lod. for maintenance expenses, giving a total cost of
Z s ' Per patient.

The present blue-book is, as in former years, very informative ana
suggestive, and well deserving of study by those concerned in admini¬
stering lunacy relief.

Fifty-sixth Report of the Inspectors of Lunatics on the District\
Criminal , and Private Asylums in Ireland for the year ending
December 31 st, 1906.

In their special report on the alleged increase of insanity, published
last year, the inspectors, in alluding to the reduction in the number of
first admissions, which in recent years has shown “ a progressive and
substantial falling off,” express the hope that “ we are reaching, if we
have not already reached, the highest curve of the line indicating the
annual rate of insanity in this country ”—a welcome piece of informa¬
tion. The statistics for the year 1906, when taken in connection with
those of the previous few years, go far to support this view, as the
figures show a general reduction all round in total admissions, first
admissions, and in the increase of patients under care.

Taking the last first, the total increase of patients under care on
January 1st, 1907, was only 189 over the number at the beginning of

1906, as compared with an increase of 369 in the previous year, that of
1906 being the lowest recorded for the past twenty-one years, with the
exception of 1893, when it amounted to 152, and being 311 less than
the average for the preceding ten years, which was 500. In the ten
years ending 1905, the average increase was 405 ; the highest average,
however, was in the decade 1894-1903, when it attained its maximum
of 551. The aggregate number of insane under care on January 1st,

1907, was 23,554 ? of whom 19,306 were in district asylums. The
numbers in these institutions increased by 249, as compared with 442
in 1905; those in private asylums by 27, the increase in 1905 having
been 23 ; those in Dundrum Asylum by 2, while the number in work-
houses decreased by 87, there being now only 13 per cent . of insane
under care in those institutions, whereas twenty years ago they formed
25 per cent . of the total, or all but double the present proportion. This
depletion of the insane in workhouses is bound to continue until these
institutions are completely relieved of such a charge, for which they are
not in any way adapted, unless some of the workhouses themselves are
transformed into properly equipped auxiliary asylums, which is not
beyond the limits of possibility.

The number of total admissions into district asylums for the year was
3,524, a fall of 248 from that of the previous year, when they were
3,772, the number of first admissions having also fallen from 2,966 to
2,763, a reduction of 203. There has been a progressive diminution in

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129

the number of first admissions for the past four years, the decrease
being for each year 48, 22, 137, and 203 respectively.

It may be objected that this absolute decrease in the number of
admissions must be largely discounted in the face of a decreasing
population, which is still unfortunately a feature in Irish statistics; but
if we calculate the ratio per 100,000 of estimated population of first
admissions, we find that there has been a very decided decrease during
the past five years, as shown by the following short table:

Year.

Estimated

population.

First admis¬
sions to

district asylums.

Propor¬
tion per
100,000.

Percentage

decrease.

1902

4 , 43 2 > 2 74

3,173

7 X '5

1903

4,413,658

3» I2 5

70*8 !

0-97

1904

4,402,182

3 ,io 3

70-4

0-56

1905

4 i 39 i. 5 6 5

2,966

65*2

738

1906

4,387,887

2 > 7 6 3

62*9

3 ' 5 2

The facts disclosed by the above table suggest that the practical
usefulness of the table on p. 15 of the inspectors* report would be
greatly enchanced if after each column of first admissions, re-admissions,
and total admissions respectively, another column giving the proportion
per 100,000 of population of the figures under each heading were added.
Once the calculations for the series of years included in this table were
made out and recorded, the additional labour of computing the ratios
for each successive year would not be of any magnitude, and such a
table would be of material assistance to the inspectors themselves or
their successors when compiling their statistics of lunacy for their
annual reports, and still more so whenever they might be called on for
a special report, as after each census, when they would be simply
invaluable. The Lunacy Office has generously responded—so we are
fain to think—to suggestions made in these columns from time to time
as regards the furnishing of additional tables, for which we are exceed¬
ingly grateful, and we should feel under fresh obligations to the
inspectors if they could see their way to adopt the one now offered. *It
would merely mean the extension to the table of admissions of the
principle adopted in the table on p. 13, where the proportion of insane
to population is given for a series of years. Such a return would, in fact,
be of more value than any other with respect to the question of the
increase of insanity, as the ratio of first admissions to population is
admittedly the only just criterion of that increase, and a table of this
kind would show at a glance the one fact which both the profession and
the public, and we might perhaps add, the Government, are mainly
solicitous to know.

It would seem, then, that we are almost within sight of a cessation to
the “ increase of insanity ” in Ireland, in the only legitimate sense of the
word, although the number of insane under care may go on increasing
for some time to come, owing to the persistence of its one chief cause,

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[Jan.,

accumulation. But as an increase in the death-rate, owing to the
greater number of senile cases sent to asylums than heretofore, is not
unlikely to occur, the accumulation may proportionally decrease and
perhaps cease to occur. However, even four years is not a sufficiently
long period on which to build prognostications with any certainty. We
must still bide our time, and seek to possess our souls in patience.

The decrease in admissions was not universally distributed over the
various districts, being in fact limited to sixteen of them, while there
was an increase in eight. Over 66 per cent . of patients were admitted
on warrant as dangerous lunatics, a proportion probably wholly unjusti¬
fied by facts, but we have commented ad nauseam on this objectionable
mode of procedure which exists in Ireland alone of all civilised
countries, and with respect to which our legal authorities seem unde-
sirous of making the slightest move towards its abolition.

The recovery rate was 37 per cent '. on admissions, being fractionally
higher than that of the previous year, Downpatrick showing the very
high ratio of 597 per cent., while Sligo only discharged 24*1 percent .
of its patients recovered. It is difficult to account for such extreme
differences, but, as a matter of fact, there is no asylum in Ireland where
more scrupulous care and attention are given to the interests of the
patients, whether from a hygienic, medical, or social point of view, than
in Downpatrick, and the high recovery-rate may at least in part be
fairly attributed to the very able management of that institution and
the individual concern of which each case is made the subject.

The death-rate was 7*6 per cent, on the daily average, or just the
average for ten years past, there being hardly any fluctuation in this
proportion for a long series of years. The highest death-rate was 11 *4
per cent, in Maryborough, and the lowest 4*3 per cent, in Limerick
Asylum. Pulmonary phthisis accounted for 25 per cent, of the total
deaths, which is below the average of previous years. If we take the
three last quinquennia we find that the death-rate from phthisis was
258 per cent., 28*4 percent., and 27 per cent, respectively of the total
mortality. It is a high ratio, but it is so far satisfactory that it does not
appear to be on the increase. The relative mortality from this disease
in English asylums is 15 per cent '., but as there is a far higher mortality
in Ireland from this cause than in England amongst the general popula¬
tion it is not to be expected that asylums would escape. The recent
movement in Ireland to endeavour to limit the ravages of this dreadful
scourge will, it is hoped, have some beneficial effect, but it will probably
take more than one generation to convince “ the people ” of the para¬
mount necessity of cleanliness and ventilation which are too often con¬
spicuous by their absence in the homes of the Irish peasantry. A
vigorous crusade for the propagation of this gospel is urgently needed.

The inspectors comment on the fact that phthisis is most prevalent
in those districts where we might expect it to be less, and vice versa .
The climate of the north is on the whole a much more severe one than
that of the south, yet the relative mortality from phthisis in Belfast
asylum was only 6 per cent., whereas in Dublin it was 27 per cent., in
Ballinasloe 33 per cent., in Limerick 36 per cent., and 41 per cent . in
Cork. Mildness of climate, therefore, does not of itself seem to have
any protective influence, but probably in the southern parts of Ireland

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131

there is not so much attention paid to cleanliness as in the north; and
dirt is one potent factor in the dissemination of tuberculosis.

The relative mortality from general paralysis for the last three
quinquennia was 2*96 per cent., 3 92 per cent., and 3*69 per cent, respec¬
tively. There are, therefore, no grounds for supposing that there is any
progressive increase in the death-rate from this disease. Forty-nine
cases in all were admitted, of which 10 were females, out of a total of
3,524, giving the very low percentage of 1*3. In English asylums the
ratio is 6*2 per cent., or nearly five times as large. The incidence on
the two sexes differs very widely in the two countries, the proportion of
males to females being thirteen to one in England, and four to one in
Ireland, a fact it would be difficult to explain.

In the table on p. 19 giving the number of deaths due to consump¬
tion, general paralysis, and epilepsy, for a series of years, an additional
column giving the relative mortality from each of these causes as a per¬
centage of the total mortality would be of distinct advantage. Absolute
numbers, no doubt, give a certain amount of useful information, but
percentages are the only reliable statistical data on which to found con¬
clusions as to the influence or prevalence of any cause or factor in either
the production or fatality of insanity. The more tables of this kind
we have the better, and in this respect the Irish still lags far behind the
English blue-book.

Two suicidal attempts with fatal result are recorded, and five deaths
occurred from misadventure, only one of which calls for comment,
where the patient drank a quantity of Jeyes’ “disinfecting fluid, and
died within an hour from asphyxiation, caused by the swelling and
resulting closure of his gullet, all attempts to pass a stomach-tube
having failed.” It is not clear how closure of the gullet with failure to
pass a stomach-tube could of itself cause “asphyxiation” proving fatal
within an hour. Some further light is thrown on the matter by the
statement lower down that, “as regards the patient's treatment it
appeared that the only chance of prolonging his life lay in the imme¬
diate opening of the windpipe.” But for the reference to the stomach-
tube one might have surmised that “ gullet ” was a misprint for “ larynx,”
but the description is rather mixed. Jeyes’ fluid claims to be non-
poisonous, but this case shows that it cannot be taken internally with
impunity.

The number of patients in private asylums has been steadily increasing
for the past twenty years. If we divide the twenty years 1887-1906 into
four five-year periods, we find that the average admissions into private
asylums were 1624, 170*8, 205*6, and 240*8 respectively for the four
quinquennia, the rise in the second being 5*1 per cent., in the third 20*3
per cent., and in the last 17*1 per cent, over the previous period. And
if we calculate similarly as regards the numbers resident, the quin¬
quennial averages work out at 622, 654, 709, and 795 respectively,
the percentage increments in the last three periods being 5*1, 8*4, and
12*1 respectively. The number resident in 1906 (845) compared with
that in 1887 (625) shows an increase of over 35 per cent.

This increase, however, does not necessarily denote a proportional
increase in the amount of insanity occurring in patients of the better
class, and is, probably, rather an indication of a growing confidence in

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132 REVIEWS. [Jan.,

the management of Irish private asylums, owing to which no doubt
patients are sent to them now who would have been sent to English or
Scottish asylums were it not for the greatly improved conditions which
obtain in Irish institutions of this class compared with those which existed
a quarter of a century ago. At that time many of them were characterised
by a depressing dinginess and dreariness, undermanned as regards the
staff of attendants, for the most part without a resident physician, and
deficient in any means for the recreation or entertainment of the patients.
This has all been changed, and Irish private asylums are now comfort¬
able homes where the sick in mind are well cared for, and where every
means is taken to promote their recovery. They have consequently
risen proportionally in the estimation of the public, who are glad to
avail themselves of the advantages they offer, without the necessity of
sending patients across the Channel, far from their friends, and, as a rule,
at considerably higher charges for maintenance. The present lunacy
inspectors have never ceased their efforts in this direction, and deserve
to be accorded a full recognition of their valuable endeavours to raise
the status of private asylums, and acknowledgment is also due to the
proprietors of these establishments for the readiness with which in the
large majority of instances they have responded to the demands made
on them.

The inspectors comment favourably on the condition of Youghai
Auxiliary Asylum, much improvement being noticeable in the care and
treatment of the inmates. The patients are far better off than in the
“ idiot wards ” of workhouses, and the cost of their maintenance is 35
per cent, under that of the district asylums. The death-rate was heavy,
15*2 per cent, on the daily average. This was to be expected, having
regard to the class of patients admitted—old, decrepit, and worn out.
But what we should not expect is the high relative death-rate from con¬
sumption, 38 per cent, of the total mortality. This is certainly unusual
in patients long past the meridian of life, as most of these presumably
are. It is not without significance that the capitation cost for the
important necessaries of life, provisions, clothing, bedding, and fuel, and
light is 38 per cent, under that of the district asylum average, the relative
decrements under these several headings as compared with district
asylums being 31-5, 58 4, 83 2, and 36 6 respectively. These seem
large differences, and it is to be hoped they do not represent a too
niggardly mtnage. The inspectors, however, appear to be satisfied
with the arrangements, and it is not impossible that some adequate
explanation is forthcoming.

Reports on the condition of the lunatic wards of eleven workhouses
are appended. Most of them are sombre in character, mournful reading
for anyone who has any claim to possess feelings of ordinary humanity.
Limerick, Armagh, and the South Dublin Union are honourable
exceptions. Sligo is one of the worst, and deserves to be pilloried. No
proper provision for the care of such cases, no fixed bath or hot water
supply, no trained attendants, no one responsible for supervision, many
of the inmates in a very neglected condition, their bed-clothes filthy
and infested with vermin—a sickening description, which ought to
appeal to even the slumbering conscience of the Sligo Poor Law
Guardians. But bowels of compassion are not to be looked for with

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133

any degree of confidence in the anatomical organisation of the so-called
“guardian of the poor.”

The changes in the personnel of the asylum medical service have not
been numerous during the past year. Dr. Taylor, of Monaghan
Asylum, retired “ after thirty-one years’ faithful service.” Dr. James J.
Fitzgerald, Medical Superintendent of Carlow Asylum, was appointed to
the more important and responsible position of Superintendent of Cork
Asylum. Dr. Fitzgerald was only appointed to Carlow in 1903, but had
proved himself a capable and efficient officer. We congratulate him on
his early promotion.

The inspectors regretfully record the death of Dr. G. W. Hatcheil,
Medical Superintendent of Castlebar Asylum. He was the son of the
late Dr. George Hatcheil, who with the late Sir John Nugent were the
predecessors in office of the present Inspectors in Lunacy.

One other fatality in the ranks of the medical staff merits more than
a passing notice. By the death of Dr. R. A. Graham, Junior Assistant
Medical Officer of the Belfast Asylum, the asylum service has sustained
a severe, almost an irreparable loss, for such men are not easily replaced.
Dr. Graham’s industry and enthusiasm in scientific study were well
known to his asylum colleagues throughout Ireland. Rarely has any
assistant physician done so much good work during such a brief career,
showing clearly what can be achieved by the younger members in the
speciality if only they are in earnest in taking advantage of their oppor¬
tunities, which in so many cases are quite overlooked, mere routine
supervision being too often regarded as the sum total of asylum work,
and comparatively little interest evinced in those questions of sur¬
passing interest which can be studied within the walls of an asylum by
any trained mind gifted with even a moderate desire for knowledge.
The life of many assistants, which is often regarded as attended with
more or less monotony and ennui, might be ttansformed into one of
intense interest and pleasure could they once be induced to apply their
energies and use their opportunities in the cause of scientific investiga¬
tion. It is to be feared, however, that the man of scientific instincts,
like the poet, nascitur non fit, and where this zeal for knowledge does
not, at any rate to some extent, already naturally exist, it is a question
whether it can be artificially developed. The inspectors pay the follow¬
ing warm tribute to the work and character of Dr. Graham :

“The loss of this most promising officer, whose gentle manner
endeared him to all with whom he came in contact, is one which is
greatly to be deplored, on scientific as well as on personal grounds, as
his great skill and untiring zeal in the pursuit of pathological research,
which we have frequently commended in our reports on the asylum,
gave promise of results which might have proved far-reaching in their
effect.”

These words will find an echo in the hearts of all those who had the
privilege of knowing Dr. Graham.

As has been more than once remarked in these pages, the Lunacy
blue-books in latter years have been greatly enhanced by the supple¬
mentary tables in the body of the inspectors’ reports, the most valuable
of all being those which give percentages extending over a series of
years. Only thus can statistical figures be made really useful, and solid

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134 reviews. [Jan.,

and well-grounded conclusions arrived at. We hope that this practice
will be continued in all future reports, and that, even though the Office
is handicapped by a numerically inadequate staff, we may look for still
further useful additions of this kind in the coming years. We have
arrived at an exceptionally interesting stage in the annals of insanity,
and we may perhaps venture to hope that before long we may be in a
position to make more cheerful forecasts than hitherto regarding the
future prevalence of insanity as the fruit of each year’s statistical
harvest.

Insanity and Allied Neuroses: a Practical and Clinical Manual . By
George H. Savage, M.D., etc., with the assistance of Edwin
Goodall, M.D., etc. New and enlarged edition. Cassell & Co.,
1907. Pp. 624.

We are glad to welcome a new edition, which is not merely a reprint,
of this excellent handbook. Savage’s Manual has been a household
word with the English student and practitioner for the last twenty-three
years, and although it is not to be expected, considering the pace we live
at nowadays, that it will not need revision within some years, we confi¬
dently expect that in the improved form in which it comes before us it
will hold its pride of place for several generations of students.

Three chapters in the earlier part of the book are devoted to aetiology.
No portion of the author’s work shows better his characteristic width of
view and balance of judgment. The mixed causation of most cases of
insanity is evidently ever present in his mind. The curious purblind
tendency of many moderns, which they deem a “ scientific ” attitude,
leading them to deny the existence of any coefficients and to reject
every cause except a narrow “ physical ” one, is quite opposed to the
broad, free outlook of our author, who will not shut his eyes to facts
merely because they cannot be made to conform to preconceived
theories or to the deductions of other branches of science. Even in
cases where there is a very well-marked and distinct cause of the toxic
order there may be a contributing cause, and the latter may either be
what is commonly called “physical” or “psychical.” Thus it is
shrewdly pointed out that delirium tremens is often known to follow in
a toper upon a physical shock or injury. Every experienced physician
or surgeon has seen such cases well recognised by the older writers
under the designation of delirium traumaticum . Dr. Savage points out
that under similar conditions a similar state (insanity closely resembling
or identical with delirium tremens) may be produced by a severe
mental shock. Similarly, he insists in a later chapter on the importance
of worry as a factor in the production of general paralysis. “ My chief
objection to any tabulated returns of the causation of insanity as seen
in asylum patients is that it is extremely uncommon to find a simple,
straightforward case in which there has been but one predisposing and
one exciting cause ” (Chapter III). Of course, the statistical tables of
our large asylums are only of value as indicating the comparative fre¬
quency with which certain causes are attributed to mental illness.
Circumstances of various kinds render it impossible in most cases to

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1908.]

obtain a life history of each patient that is of any value. The ignorance of
patients* relatives, the stupidity of patients themselves, the numerical
insufficiency of the medical staff in all our large asylums, and, above all,
that neglect of the methods of clinical research which is so carefully
cultivated in this country, combine to render our statistics a very hap¬
hazard affair. The conditions at Bethlem Hospital, where Dr. Savage
so long worked and taught, are, of course, very different, and this fact,
together with his singular sagacity and clearness of judgment, give all his
opinions a power and weight rarely to be found in the utterances of any
specialist. He is one of those few writers who “ see life steadily and see
it whole.” As Emerson said of Shakespeare, “ he is no cow painter nor
remarkably eminent at drawing grass ” He sees the world as it is and
draws it as he sees it, often, indeed, in a large sketchy outline, but always
truly. The numerous cases and illustrative histories scattered up and
down through this book may be frequently brief, but are ever unlaboured;
they are photograph snapshots—exactly to nature and absolutely un¬
adorned with midnight oil or chamber perfumes. They have an air of
vigour and veracity which is all their own, and they recall instantly, to
those who have had the pleasure of hearing him vivd voce , the bed¬
side discourses of this great clinical teacher.

In his new edition our author has not thought it necessary to displace
the old terms because they are not satisfactory and substitute others
quite as vague and eclectic. Thus he has not replaced “ mania ” and
“melancholia” by “manic-depressive” insanity. To “ primary dementia”
he gives a wider significance than is usually applied to this term, making it
cover most cases of an acute or subacute character which do not begin
as the distinctly maniacal or melancholic symptoms. Dementia praecox
is briefly described under its three main varieties, “ but,” it is said, “ it
is not yet definitely proved that all such cases end inevitably in dementia,
and that such a termination may, in a very early stage of the disease, be
prognosticated by certain specific symptoms. The clinical evidence for
the recognition of dementia praecox as a definite disease is insufficient.”
It is a remarkable thing that neither of the eminent teachers who have
been the leaders of clinical psychiatry, respectively in the modern
Athens and the modem Babylon, have been able to recognise this
dementia praecox as a distinct disease, though they were among the
earliest, if, indeed, they were not the very earliest, to describe the
remarkable peculiarities often exhibited by the adolescent insane.

The clinical description of general paralysis is of great excellence.
The author, however, has probably not reviewed his earlier opinion,
with regard to the relation of syphilis to this affection. At any rate in
the work before us he attributes far less importance to old-standing
syphilitic infection than most writers of to-day. As above mentioned,
he lays some weight upon worry and anxiety as causes of this disease.
Of course, this is in no way inconsistent with the now common view of
the importance of syphilis as a cause, at least, of the predisposing order.
The famous saying, “ Syphilisation and civilisation,” means syphilis plus
the wearing conditions of modem life, which may, perhaps, be briefly
termed “worry.”

The recent very remarkable work of Dr. Ford Robertson with regard
to the diphtheroid bacilli which that able pathologist has believed to be

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REVIEWS.

[Jan.,

the essential cause of this disease is mentioned, with the cautious note
that Dr. Robertson’s “ observations have not, so far, been accepted by
English pathologists.”

In connection with moral insanity, the sexual perversions are briefly
but efficiently dealt with.

A short chapter is given to volitional insanity—obsessions, impulse,
doubt—of which we have to say that it is to be regretted that Dr.
Savage, from his vast experience, has not given a more detailed account
of these interesting border-land conditions, the study of which is so
fascinating. By the way, the position of this chapter between “ Insanity
due to Toxic Influences ” and “ Idiocy and Imbecility ” is a somewhat
jolting arrangement. The occasional appearance of what the geologists
would call intrusive formations is probably inevitable when a standard
work has to be re-written.

The chapters on insanity associated with visceral disease and insanity
due to toxic influences are well up to date and not in advance of the
times as a good deal of modern writing is. It is wiser to reserve judg¬
ment than to assume the truth of a number of hypotheses as yet un¬
proved, and which, perhaps, never will be proved.

The book concludes with chapters on the responsibility of lunatics and
the legal relationship of the insane, both useful, the former penned in
the usual philosophic spirit of Dr. Savage’s writings.

We may fairly infer that the parts of the present work which deal
with the morbid anatomy of insanity are chiefly due to Dr. Goodall,
and they are well calculated to enhance the reputation of that excellent
pathologist. Nothing could be better for the purposes of a student’s
manual. The descriptions are brief, clear, well balanced, and thoroughly
abreast of what is essential in modem work.

On the whole, the new Savage, or, as we should say, the new Savage
and Goodall, is to be classed as a text-book of the first rank.

Alcoholism: a Chapter in Social Pathology . By W. C. Sullivan, M.D.

London : James Nisbet and Co., 1906. 8vo. Price 3 s. 6 d. net.

Dr. Sullivan’s work throws a new light upon alcoholism. It is
marked by a breadth of view and a freedom from all intolerance which
carry the reader through an intelligent and intelligible discussion of
this difficult subject with never a wish to skip a page or to elude the
issues so clearly set forth. The book is more particularly designed to
elucidate the connection of alcoholism with industrial conditions, which
hitherto have been inadequately recognised. We thus escape the
dreary details which writers on this subject have repeated so uniformly,
and at such intolerable length. We are brought to a consideration of
a social problem by an array of facts which show how widely Dr.
Sullivan has cast his net, and by an orderly process of argument which
reveals his well-balanced mind. He introduces the subject with a brief
historical sketch which indicates the beginnings of the modern industrial
system and the change in the legal attitude towards intemperance, by
the Licensing Law of 1551. His new view of the question leads him

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to remark on the enormous increase of alcoholism by the national
policy in favour of free distillation in the end of the seventeenth century,
and to indicate the effects of the development of the factory system
in bringing about a rapid extension of industrial drinking.

In order to make his standpoint clear, Dr. Sullivan then enters on a
consideration of the physiological action of alcohol, especially discussing
the conclusions of l6-aepelin and his school. The dulling of sensation
and the stimulation of motor activity giving rise to a sense of well-being,
the notable gain in working capacity before the phase of depression sets
in, and the modification of coarse food by the addition or substitution
of alcohol are mentioned with many other facts in this excellent rksumk
of recent observations and researches. He concludes that the labourer
finds, in these and similar effects, an aid to enable him to perform his
daily tasks, however detrimental the effects in the end.

Dr. Sullivan then considers drunkenness as a state of acute intoxica¬
tion before passing to the discussion of chronic alcoholism, and the
prevalence of acts of suicide, violence, and lust in that condition. He
makes short work of the crude opinion that inebriety is a symptom of
disease and the fantastic theory of the “ drink-crave,” and sharply con¬
trasts convivial drinking with industrial drinking. We regretfully omit
any attempt to condense Dr. Sullivan’s study of the social causes of
intemperance; but we may mention his finding that the low rate of
alcoholic mortality and of suicidal attempts in the great mining counties
despite their high rate of drunkenness, corresponds with the relative
immunity of coal-miners from alcoholic disease. He proves that
drunkenness and alcoholism are so far independent phenomena that
the maximum of drunkenness may coincide with the minimum of
alcoholism, and that the tendency to chronic alcoholism is mainly con¬
nected with the mode of industry.

The sixth chapter is a most important contribution to the proper
understanding of alcoholism in England and Wales. It is the result of
laborious and thoughtful industry, and deals with the habits of water¬
side labour, unskilled transport labour, building trades, carriage building,
gas-stoking, glass-blowing, metal trades, textile industries, boot and shoe
making, printing, coal-mining, etc. His remarks on the industries
employing women are of special importance, showing that it is the rule
that women working at or in connection with a trade where the alcoholic
tradition amongst the male workers is strong, will in a large measure
adopt that tradition, quite irrespective of whether the character of their
own labour does or does not involve any intrinsic tendency to industrial
drinking. In addition, Dr. Sullivan remarks on the disorganisation of
their domestic duties, which interferes with the acquisition of house¬
wifely knowledge during girlhood. So have we heard a distinguished
German discourse on the failure of our women of the industrial class
as mothers and housewives, and regard it as the main cause of our
appalling drunkenness. Thus alcoholism is increased not only in itself
but in its evil influence on the health of the stock.

In discussing the factors of industrial drinking it is acutely stated
that the higher consumption of liquor in “good times” is not a true
indication of an increase in alcoholism, and Dr. Sullivan concludes that
the present evolution of our industrial conditions is tending towards a

LIV. I o

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138 reviews. [Jan.,

decided decrease in the prevalence of alcoholism, most pronounced in
the skilled industries, but also evident in the lower sorts of labour.

We regret to be unable to refer in detail to the chapters on alcoholism
and suicide, crime and insanity, but must note in passing the interesting
nature of the argument, specially the conclusion that alcoholism is the
cause of a large proportion of homicidal offences, but is a relatively
insignificant influence in crimes of acquisitiveness. Comparing the
counties high in the scale of alcoholism with the mining counties where
drunkenness is most rife, they are both shown to have very low rates
of insanity.

Finally, we would note that Dr. Sullivan does not believe that the
degenerative effects of parental alcoholism are in the category of trans¬
mitted acquirements, but are the results of a deleterious influence
exerted on the germ-cells, which constitutes a most serious and evil
consequence of intemperance.

Dr. Sullivan insists that nearly all the graver effects of intemperance
are due to chronic intoxication and hardly any to simple drunkenness—
that is to say, due to industrial as opposed to convivial drinking. Thus,
the drink question is practically reducible to the effect of this industrial
drinking, which is connected with the use of alcohol as a stimulant for
muscular work. It is this alcoholism which becomes recognisable in
social history on the introduction of the modem industrial system, and
which is now to be found in its inception in the centres of that system
lately introduced into Spain and Italy. The factory creates the drink
question in Dr. Sullivan’s opinion, and we refer our readers to the book
in question for the process by which he reaches that conclusion and the
remedies by which he would mitigate present troubles.

Lucretius , Epicurean and Poet . By John Masson, M.A., LL.D.

London : Murray. Demy 8vo, pp. 453.

Lucretius was a contemporary of Julius Caesar, as Epicurus was a
contemporary of Alexander. Dr. Masson has read all about Lucretius
and everyone else who lived in those stirring times. In going through
such critical disquisitions it is difficult to avoid the attraction or the
recoil from a host of commentators. In this respect it is to be wished
that Dr. Masson had less modesty or more self-reliance. In quoting
the “ opinions of the highest living authorities ” on Cicero and Caesar,
he in many places gives us a set of stepping-stones instead of a bridge.
While we wish to get into the times of Lucretius, the notes entering into
small controversies continually drag us down to the mediocrities of the
present age. We know not whether Dr. Masson’s wide reading, wan¬
dering from Plato to Shelley and Victor Hugo, will add interest to the
book with the readers of the twentieth century. We hope, however,
that in another edition Dr. Masson may have the courage to sweep
away most of his footnotes, as a carpenter, having finished his work,
sweeps away his shavings. At the same time it would be unfair to
deny that this excursive part of the work is often well written. At any
rate our review will be confined to Lucretius and his philosophy. Of
the poet himself we know scarcely anything save a few traditions loosely

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139

gathered by Eusebius. He was said to have become insane by a
philtre given by his wife or mistress, and to have written his wonderful
poem at sane intervals, and to have died by his own hand at the age of
forty-four. His poem De Rerutn Natura is dedicated to Memmius, who
gained the rank of tribune and praetor, and took side against Caesar in
the civil war.

Apparently Lucretius carried out the precepts of Epicurus by shun¬
ning public employments and devoting himself to philosophy. There
are no clear allusions to his life in the poem. In discussing the
question or nature of his insanity Dr. Masson lays much stress upon a
monograph by Ettore Stampini. This scholar believes that Lucretius
M suffered from intermittent insanity (pazzia alternantc) in the same
way as did Tasso, who was subject from time to time to violent accesses
of mental disorder, but that in the intervals he was able to write both
poetry and philosophy.” He considers it to be “ a kind of epilepsy, in
which maniacal acts, mental exaltation, and painful hallucinations
alternated with periods of extraordinarily active power of thought.”
There is no evidence that Lucretius ever suffered from epilepsy, and
the statement that Napoleon was an epileptic, even if it were correct,
bears little upon the question. Tasso was no doubt insane; but his
writings, after he became deranged, showed a marked falling off The
case of Auguste Comte would be a better illustration. Philtres were
much in vogue in those times, furnished by a disreputable class, who
seemed to have used large doses of powerful drugs, such as henbane or
stramonium, which disordered the intellect. Although the use of a
philtre to make a person fall in love with a given individual is a super¬
stition, it might reduce the subject to a condition in which the will
power was deficient and the sensual desires were excited. It does not
seem clear that because Lucretius mentions dreadful dreams and
illusions that he had them himself, any more than Dr. Masson’s
surmise that he had been wounded in battle because he describes the
feelings of a fallen combatant.

Scanning the poem with a careful eye Dr. Masson seeks to show the
influence of the times upon the poet in his hostility to the religion of
Rome. This has been generally thought by modern historians to be a
thing of rites and public ceremonies, carried on by men who had
already become sceptics. Dr. Masson, however, believes that the old
religious belief still kept a strong hold on the great majority of the
Romans, and that in his childhood Lucretius must have experienced
the terrors of Tartarus and the superstitious fears of the interference of
the gods in the ordinary course of nature, and public and private
events. It was a time full of cruel wars, frightful massacres, and ruthless
extortion and pillage from conquered nations; but these had no con¬
nection with religion.

As Bacon remarked, Lucretius when he beheld Agamemnon en¬
during the sacrifice of his own daughter, exclaimed “ Tautum religio
potuit suadere malorum.” What would he have said if he had known
of the massacre in France or the powder treason in England? He
would have been seven times more Epicure and atheist than he was.

The Epicureans were never persecuted. They would never have
refused, as the Christians did, to burn a little incense at the shrines of

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REVIEWS.

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the gods. It is generally thought that Epicurus, in admitting the
existence of the gods, while he allowed them no part in the creation
and upholding of the world, merely did so to disarm hostility; but
Masson holds that both Epicurus and Lucretius really believed in the
existence of these idle gods, apparently on the ground that they found
religious rites in all countries.

Dr. Masson covers the whole ground of Epicurean philosophy. The
creation of the world by the fortuitous concourse of atoms, the nature
of the soul, the origin of society, and the explanation of natural
phenomena. His chapter on the life and writings of Epicurus, drawn
from new sources, such as the inscriptions in the ancient town of
Oinoanda in Asia Minor and the deciphered rolls of Herculaneum,
does much to raise our estimate of the character of Epicurus.

Perhaps it is a natural enthusiasm for his subject which makes our
author assign such a high place to the Epicureans as the scientific men
of those times. It is evident, however, that Lucretius was an attentive
observer of natural phenomena, but in geometry and astronomy the
Epicureans were below the philosophers of other schools.

The notion of atoms, which Epicurus took from Democritus, appears
in our text-books of chemistry, but it is the fact of definite com¬
bining proportions experimentally worked out by Dalton and Berzelius
which makes modern chemistry hold together as a science. The
existence of atoms is an assumption which some eminent chemists
have doubted.

It is somewhat startling to learn that, while he believed the soul to
be material, Lucretius admits the freedom of the will fatis avolsa
i>otestas. Materialistic philosophies have been, in all times and in all
countries, sometimes entertained in secrecy, sometimes openly avowed.
Such views are rife in our own day, as Masson shows. There is a class
of mind prone to accept such negations. Epicurus died 171 years
before Lucretius w»as born in a different medium, and the great
astronomer poet of Persia, Omar Khayyam, lived in the time of the
first Crusades. Like Epicurus, he derided the idea of an after life, and
thought the world a self-acting machine.

With the aids of the scientific writers of the day Masson goes over
the whole scope of JDe Rerum Natura. He finds in it the outlines of
Darwin's views on the struggle for existence and the survival of the
fittest. He observes that Lucretius grasps the principle of inductive
reasoning and the unchangeableness of the course of nature. Some of
his absurdities, such as his doctrine of floating images, need no refuta¬
tion ; but the Epicureans correctly showed that illusions are founded
upon a wrong interpretation of sensory images. Masson considers that
Lucretius's attacks upon the religion, or the superstitions of the times,
served to prepare the way for a purer Theism. He exposes the weak¬
ness of the Epicurean ethics, and shows that tranquillity alone will not
satisfy the human heart.

Masson justly observes that De Rerum Natura is the only book in
which the subject matter is science, but which still remains a poem.
There is now no chance of another of the kind being written. Modern
science and modern philosophy are of too close a texture to allow any¬
thing of the kind. What poetic fire and skill of expression could

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141

put in poetry the Scholia and Corollaries of Spinoza or the Categories
of Kant ?

But while the philosophy came from the Greek the poetry came
from the Roman. The amazing skill with which Lucretius uses the
resources of the Latin tongue to express his arguments in difficult
controversies, the felicity of the illustrations which he draws from
nature and human life, the beauty of his verse music, the sublime
passages in which he soars to contemplate the frame and fate of the
world and the sadness of human destiny, with the intense fervour
pervading the whole, render this unfinished poem one of the most
wonderful productions of human genius. We know of no other
didactic poem which can be put near it save the Georgies of Virgil.
Dr. Masson shows that Lucretius had a powerful influence upon the
great poet who followed him.

The author in his analysis and critical remarks upon the De Rerum
Natura shows a ripe scholarship and a refined poetic taste. We cannot
give Dr. Masson higher praise than to say that his work is worthy of
the subject.

William W. Ireland.

William Blake. By Arthur Symons. London : Constable, 1907.

Pp. 433, 8vo. Price 10s. 6 d.

William Blake will always be an interesting figure to the psychologist
and alienist because he represents the essential qualities of genius carried
to that extreme point at which the question of its sanity became a delicate
and difficult problem to consider. The material for reaching a solution
of this problem has never been so clearly and fully presented as in the
attractive and important volume which Mr. Arthur Symons has lately
devoted to Blake. Mr. Symons has adopted an admirable method. In
the first half of the book he presents his own finely interpreted version
of Blake’s life and Blake’s work ; in the second half he brings together
without comment, and for the first time in a fairly complete shape, all
the first-hand biographical material on which every estimate of Blake
must be founded. We are thus enabled to form an independent
opinion.

An aboriginally independent person who lives in a world of his own,
who creates his own ideas for himself, who comes to regard the facts ot
the external world as mere symbols of the inner realities with which he
is chiefly concerned, is a person who undoubtedly has much in common
with the ordinary inmates of asylums, and by the ignorant and unthinking
is apt to be confused with them. For the journalist of his time Blake
was “an unfortunate lunatic,” and even Charles Lamb—a man of
genius, who had once been insane, and thus well entitled to speak with
authority—uses the word “ madhouse ” in connection with Blake. The
“visions,” also, which played so large a part in Blake’s life, introduce an
element which is legitimately regarded as suspect. But so far as can be
ascertained these visions were not only not of a hallucinatory character,
but they were in no way connected with any delusional ideas. Blake
was much of a child, and his visions seem fairly comparable to those

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142 REVIEWS. [Jan.,

hypnogogic visions, more or less under control, which nearly all normal
children can see on the curtain of the closed eyelids. Like a child,
also, Blake would look for pictures in the fire, and sketch them, and this
alone suffices to reveal the real character of his visions. “ I can look
at a knot in a piece of wood till I am frightened at it,” he once said.
But Blake was by no means really terrified at his visions; on
the contrary, he carefully cultivated them for artistic purposes.
In this he was following excellent examples and high authority.
Piero di Cosimo, we are told, would gaze for hours at discoloured mud-
bespattered walls in order to gain ideas for pictures, and Leonardo
da Vinci expressly recommends the artist to adopt precisely this device
as a source of valuable suggestions for work. It is true that Blake,
being a mystic as well as an artist, treated these “ visions ” with much
reverence, but he never confused them with the phenomena which the
ordinary man regards as alone real. When the sun rose Blake might
see the heavenly hosts arrayed in the skies, but he was perfectly well
aware that you and I would only see a round yellow object rise above
the horizon.

It may be added that in the ordinary conduct of life, notwithstanding
his extravagance in the spiritual world, Blake showed no signs of
insanity, and though sensitive, intolerant, and exclusive, as men of
genius sometimes are, he was yet normal beyond most poets and artists.
He was exemplary in his domestic life, an unceasing worker, a hard-
headed man of business, and he left no debts at his death.

Dr. Maudsley wrote many years ago that if we may accept as true the
story of Blake sitting naked with his wife in their arbour, reading
Paradise Lost , he was certainly insane. Blake’s friend Linnell dis¬
credited this story, and Mr. Symons thinks Blake had too much sense
of humour for such an episode. Its possibility scarcely seems, however,
entirely excluded. Blake had strong views on the propriety of repre¬
senting the body in art as tanned by sun and air. Nowadays the sun¬
bath system is becoming established in all lands, and a born pioneer
might well have been ahead of his time in this matter without
losing his reputation for sanity or even for humour. Blake’s contem¬
porary, Benjamin Franklin, a republican like himself, practised naked¬
ness on hygienic grounds, once, it is said, shocking a servant girl by
absent-mindedly opening the door in this state, but no one has ques¬
tioned his prosaic sanity. Shelley’s friends, the Gisbomes, carried the
same ideas into practice. Dr. Ungewitter, in a recent book devoted to
the hygienic virtues of nakedness, goes so far as to present a portrait of
the author at his desk clothed only in sandals, without, apparently,
arousing suspicions as to his mental condition. The Blake incident is
told as taking place in private, and if accepted would still show nothing
in common with the random impulse of the insane to throw off their
clothing.

It would be out of place to speak here of the literary qualities of
Mr. Symons’ work. The estimate of Blake’s genius, especially in
poetry, continues to rise, and that it has never stood so high as at
present is clearly witnessed by this brilliant and beautiful book.

Havelock Ellis.

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143

Die Erkennung und Behandlung der Melancholic in der Praxis . Von
Dr. Th. Ziehen. Halle, 1907. 8vo, pp. 67.

This monograph gives us a glimpse of the German psychiatry of the
day, from which some useful knowledge may be gleaned.

Dr. Ziehen defines melancholia as a primary sadness or depression
continued without any motive, or, at least, without any adequate motive.
It is often accompanied by a retardation of mental processes. He dis¬
tinguishes primary melancholia from the distress which sometimes follows
the delusions of persecution. Primary melancholia may also be followed
by delusions and hallucinations. Pure melancholia is commoner with
women (16*4 per cent.) than with men (5*3 per cent.). It occurs at all
ages, and especially between twenty and fifty. The most frequent of
the predisposing causes of melancholia is heredity, sometimes by the
father's, sometimes by the mother's side. After this come nervous
affections in youth, as chorea, neurasthenia, and migraine. He allows
little to alcohol as an exciting cause, more to exhaustion from lactation,
or loss of blood. Generally there appears more than one cause ; often
the triad, hereditary disposition, over-exertion, and powerful emotion.

After explaining in a skilful manner the course of melancholia, its
complications and its diagnosis, the professor devotes sixteen pages to
the treatment. He has three main methods—rest in bed, opium and
hydrotherapy. For the way his systematic treatment is carried out we
must refer the reader to the pamphlet itself.

William W. Ireland.

Part III—Epitome of Current Literature.

1. Neurology.

The Cortex Cerebri , its Volume and Nerve-fibres \Die Grosshirnrinde
in ihren Masse und in ihrem Fasergehalt]. (Jena , 1907 ; reported
in Neurol. Cbl ., Nr. 15, 1907.) Kaes, T.

Dr. Kaes has studied the growth of the anatomical elements of the
cortex from infancy to old age, and has illustrated his expositions by
graphic curves and tables. He has found that the inner layer of the
cortex increases and produces new fibres till it reaches a certain size.
At the same time the outer mantle becomes thinner. The cortex
which is most developed and richest in nerve-fibres is also the
smallest.

Kaes has examined thirty-nine brains at twelve areas of the pallium,
and his diagrams especially show the changes which the fibres undergo
in the course of years. His illustrations also demonstrate that in the
first months of mental development the tangential fibres keep up the
paths of intra-cortical association while the outer mantle appears to be
still without fibres. At the eighth month the outer layer of Baillarger,
and then by degrees the whole outer mantle, becomes fully developed.
The growth of the inner layer and of its nerve-fibres is completed by

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EPITOME.

[Jan.,

the nineteenth year, but the fibres of the outer layer keep on increasing
until the forty-fifth year, and perhaps longer. Kaes is of opinion that
the higher mental development of man cannot be realised without the
co-operation of the paths in the outer layers of the pallium, while for
the simpler class of conceptions the association paths of the inner layers
are sufficient.

Kaes examined the brains of two microcephalic idiots and also that
of a female dwarf, which weighed 1,373 grms. and had a corresponding
convoluted surface. In spite of the great difference of weight and super¬
ficies, the arrangement and thickness of the big brain presented in the
proportion of the fibres great analogies with the poorly developed
cortices of the microcephales.

Kaes also examined five brains ot delinquents, three of whom were
habitual criminals who had been beheaded. Deviations from the
normal structure were observed in them all, either an abortive
development or a premature degeneration of the nerve-fibres.

William W. Ireland.

On the Longitudinal Inferior Bundle and the Central Optic Bundle .
( Nouv . Icon . de la Salpt ., and Neurol\ CbL , Nr. 13, 1907.) La¬
Salle-A rchambault .

The author finds that the tapetum contains no association fibres; its
fibres go with those of the corpus callosum. In the human brain there
is no occipito-frontal association bundle. All the fibres which come
from the posterior and under parts of the hemispheres to the pedun-
culus arise from the temporal lobe, especially from the second and third
temporal gyri. These fibres go to join the fasciculus of Turck in the
spinal cord. William W. Ireland.

The Double Motor Apparatus in the Brain [Der Doppel-motor itn
Gehirn\ {Neurol. CbL , Nr. 15, 1907.) Adamkiewicz.

Dr. Adamkiewicz begins by observing that the discoveries of Fritsch
and Hitzig in 1870, while they showed that the muscles of the body
could be set in motion by an electric stimulus applied to particular
points in the brain, introduced an unfortunate error into science. The
generally-received opinion that motor centres exist in the anterior
portion of the brain cortex, while sensory areas occupy the posterior
brain, he regards as erroneous. He finds that the frontal portions of
the brain are concerned, not only with motor functions, but with all
those mental operations which arouse or guide such motions, and that
the occipital portions of the brain are not only concerned with vision
but with all the motor functions therewith connected.

Adamkiewicz holds that the cortex cerebri is not separable into motor
and sensory spheres, but has areas in which complex organic functions
are represented. Within these areas conceptions take form, leading to
revolutions and motions. He roundly states that the cerebral cortex is
not motor. One can remove the whole cerebrum in an animal, the
rabbit for example, without doing the least injury to muscular capacity.
The attitude and movements of the body remain unimpaired after the
removal of the hemispheres. The animal thus treated sits stiff and
still, because his intelligence and will are lost, and therefore he is not in

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NEUROLOGY.

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1908.]

a position to originate. The fact that muscles may be set in motion by
electric currents applied to the cortex does not prove that these areas
are motor, but that they stand in a certain relation to the motions of
the body, because the electric stream has the power of replacing the
mental stimulus, especially that of the will.

He finds the true motor of muscular action in the cerebellum, upon
which the impulses of the cortex operate like a pianist on the keys of
the piano.

Adamkiewicz claims to have given sufficient evidence of the correct¬
ness of his views in some books, 1 which we have not had an opportunity
of reading.

The cortex is exclusively the organ of the higher mental functions.
In its passive state it produces dreamy images ; in its active state and
in full consciousness of the environment it evolves conceptions and
resolutions leading to action. The will is thus, along with the intelli¬
gence, the product of the whole hemispheres, which discharge their
functions through different portions having similar physiological capa¬
cities. Thus, though the grey matter of the brain is the seat of images,
thoughts, and will impulses, it never sets agoing motions. For this
purpose the mental impulses must be communicated to the cerebellum
through the fibres of the corona radiata, and probably the crura
cerebri. From the cerebellum they are sent into the grey anterior
columns of the spinal cord. Anyone who has inquired into the func¬
tions of the cerebellum must have perceived that it is an organ of
highly complex action, and that it is extremely difficult to define its
functions from the results of experiments or the study of diseases.
There is, as Adamkiewicz observes, another way by which the impulses
of the will are transmitted to the spinal cord, that is through the corona
radiata to the inner capsule, and the crux cerebri to the pyramids of the
coid and the multipolar cells of the anterior columns. Adamkiewicz
has no doubt that the will uses both ways at once, and that the two
waves of innervation meet in the multipolar ganglion cells of the
anterior horns to send their united strength to the last station of the
motor mechanism; at the same time he allows for the cerebellum a
legulating influence (tonisierenden Einfluss) upon the voluntary muscles.

Dr. Adamkiewicz found that after the insertion of laminaria within
the cranium of rabbits* the pressure causes paralysis of the opposite
side. In further experiments he made punctures designed to reach the
deeper portions of the hemispheres, avoiding as far as possible injury to
the cortex. The professor acknowledges that the results of these
experiments were not so prompt and exact as he hoped. He believes
that he has demonstrated that in the subcortical ganglia there are
separate centres for the anterior and posterior centres of the opposite
sides of the body. He finds the centre for the movement of the fore
paw in the anterior portion of the optic thalamus, between it and the
corpus striatum, and the centre for the hind paws in the posterior
portion of the thalamus, between it and the corpus quadrigeminum.
Injury to the corpus striatum itself does not cause any paralysis in the

1 Die Wahren Centren der Bewegung und der Akt des Willens (Vienna, 1905).
Die Functions storungen des Grosshirns (Berlin, 1898), besides papers in divers
periodicals.

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EPITOME.

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rabbit. In conclusion he claims to have proved that the so-called
Jacksonian epilepsy, consisting of convulsions of one side of the body,
without loss of consciousness, has nothing to do with genuine epilepsy,
being dependent on mechanical irritation of the motor centres within
the substance of the cerebral hemispheres.

Compression of the cerebellum may be followed by half-sided
paralysis, never by convulsions, which gives us an important aid in the
differential diagnosis of intercranial tumours.

William W. Ireland.

On the Entrance of the Optic Tract into the Human Cortex [ Uber den
Eintritt der Sehbahti in die Himrinde des Menschen ]. ( Neurol .

Cbl. y Nr. 17, 1907.) Mayendorf E. N

In the course of a discussion upon the distribution of the optic tract
to the hemispheres, which can scarcely be reproduced without a literal
translation of great part of his article, Mayendorf observes that clinical
facts tell both against the view which would place the central projection
of retinal impressions in the cortex of the occipital convexity, and
against the view which would place therein a gathering point for visual
memory through which the identity of seen images are realised. From
the examination of a brain in which the corpus callosum had been
destroyed, and another in which it had never appeared, Mayendorf
came to the conclusion that the bundles of fibres which enter the two
upper occipital convolutions are connecting fibres of the two hemi¬
spheres and not projection fibres. In fact there are few projection
fibres in these occipital gyri. William W. Ireland.

The Loss of Function following on Lesions of the Central Nervous System
\Ueber die Ausfallerscheinungen nach Lasionen des Central Nerven-
systerns], {Neurol. Cbl. f Nr. 13, 1907.) Rothmann, Max.

Rothmann points out how important it is to surgeons that the
localisation of lesions in the brain and spinal cord should be made with
the utmost accuracy. In many cases diseases do not strike suddenly
upon a nervous system previously intact. Often the circulation has
been previously deranged by arterial sclerosis, which prepares the way
for transitory hemiplegia or aphasia. Sometimes there is loss of func¬
tion after central lesions, which disappears in longer or shorter time.
Goltz and his followers have treated many effects following the extirpa¬
tion of the whole or part of the cerebrum as due to what they call
inhibition (Hemmung). Thus the functions of the spinal cord are
much impaired after removal of the cerebral ganglia, or the lower
portion of the cord loses its reflex function after section higher up, but
after a while it again resumes its action.

The nervous system in the living being cannot be divided into so
many organs acting independently of one another; the injury to one
part reacts upon another, after a fashion which often renders efforts to
arrive at a knowledge of functions by extirpation or local stimuli very
difficult to interpret.

Munk has shown that after section of the upper spinal cord the reflex
irritability of the lumbar portion almost ceases, to return from six to
eight months after the operation and in greater measure than ever. To

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NEUROLOGY.

147

1908.]

this abnormally heightened reflex activity he gives the name of altera¬
tion of isolation. The same phenomena in the functions of the cord,
though in a lesser degree, follow injuries to the subcortical ganglia.

To explain such phenomena Monakow has proposed a theory to
which he has given the name of “diaschisis.” This he defines as a
transitory division, or impairment (Spaltung) of a nervous function which
follows injuries to a guiding or transmitting nervous tract or to a group
of nerves, and which passes away, leaving behind some residuary loss of
function. This theory seems difficult to apply, and further elucidation
of it would demand the translation of several pages of Rothmann’s
article. The facts requiring explanation are of the following kind.
After the removal of the lesser brain in a dog, the animal can move
about when the first prostration has passed away. In the monkey,
after the extirpation of one arm region, movements common to both
arms begin the next day. After extirpation of the motor regions of
all the extremities, the movements of the limbs return some days after,
while in the human subject several weeks elapse before active move¬
ments return after lesions to the cortex. Recovery of motor power
takes place earlier with young animals.

Rothmann has applied the researches of Monakow on the phylogeny
of the nervous system to explain these late-coming restitutions. He
divides the encephalon into direct and indirect regions, and other parts
not therewith connected, which correspond to recent middle-aged and
old areas. In the process of evolution the old organs are stunted in
their growth, while the younger parts fall more under the control of the
cerebral hemispheres, and suffer in their function when these latter are
injured. But after the removal of the motor areas of the cortex they
begin to resume their ancient independence. In animals of a less
complex organisation the lower ganglia have never abandoned their
functions to the hemispheres, and so the removal of the hemispheres is
not followed by a marked loss of motor power. In the higher mammalia,
the dog for example, the subcortical motor ganglia work under the
influence of the cortical centres, but they retain so much of their old
phylogenetic independence that they can exercise a motor function even
after losing in great part the impulse of the cerebrum, and, indeed,
according to Goltz, after the complete loss of it. In the monkey the
rule of the cerebrum has become stronger, so that loss of the whole areas
for the limbs causes more impairment to the functions of the ganglia.
In man the cortex has gained full supremacy ; all motor impulses come
from it, so that after removal of the motor area there is complete para¬
lysis, or at least any slight return of function requires several months
for the lower ganglia to assume a feeble capacity. The same rising
subordination to the higher functions of the cerebrum is shown in the
reflexes. The patellar reflexes, which are weakened in the dog and ape
after extended injury to the brain, generally disappear in man after
apoplexy, to assume their functions with greater intensity under the action
of deeper brain centres. But after injury to the middle brain, transitory
cortex lesions become permanent.

Hitzig has observed that under favourable conditions the removal of
a portion of the visual area of the cortex causes an inhibition of the
activity of the lateral geniculate ganglia, and that after a lesion of the

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148 epitome. [Jan.,

sigmoid gyrus, the region of the limbs in the dog, there is inhibition to
the subcortical optic centres without any direct lesion to the optic
centres themselves. Rothmann’s experiments do not confirm this
observation, but favour those of Munk. He observes, as in dogs, the
experiments of Manque, Exner, and Paneth show that the cutting off
of the sigmoid region the sensory area of the cortex destroying the
association fibres has the same effect as extirpation of the area. It
ought, however, to be noted that Exner and Paneth failed to keep the
projection fibres uninjured.

The classical case of apraxy furnished by Liepmann has shown that
extensive destruction of the association fibres of the motor region of the
arm does not cause suspension of the function of the limb, the projection
fibres of the said region remaining uninjured. It was shown by the
dissection that through a subcortical abscess in the left frontal region the
connections of the median convolutions were interrupted, while by
another abscess under the cortex of the parietal lobe and by the com¬
plete disappearance of the corpus callosum the connections between
the occipital and temporal lobes, as well as the connection with the
whole right hemisphere, was broken off. The anterior median gyrus
was found quite intact, the posterior one smaller, with diminution in the
number of fibres, but no traces of inflammation. The projection fibres
of the median convolutions were intact, save that they had been injured
by a slight lesion in the posterior part about six months before death.

In this case, although there was a nearly complete interruption of the
association fibres of the left extremity, there was not suspension of the
motor capacity of the right arm, but an apraxy or awkwardness of action
which has been thoroughly analysed by Liepmann.

In reference to the localisation of the speech centres which have
attracted so much attention through the recent criticisms of Dr. Marie,
Rothmann suggests that out of the numerous persons who are right-
handed there may be a few people bom left-handed who have been
drilled into the use of the right hand for external actions, but in whom
the centre for speech still holds to the right hemisphere, and also that
in some persons the speech function may be more equally divided
between both sides of the brain. This would explain the negative
results which have been produced from occasional post-mortem examina¬
tion to throw doubt upon the localisation of aphasia in the region of
the left third frontal.

In this controversy, which so much engages the attention of neuro¬
logists, it appears to me the work of Sir Frederick Bateman on aphasia
has been forgotten. The result of his study of the question, founded
upon accurate observations, was that the localisation of a speech centre
on the left frontal was “ not proven.” William W. Ireland.

On the Localisation of Mental Blindness [ Uber die anatomisch-histolo-
gische Grutidlage der sogen . Rindenblindheit und uber die Lokalisa -
tion der kortikalen Sehsphdre , der Macula lutea und der Projektion
der Retina auf die Rinde des Occipitallappens\ (Graefes Archiv f
Ophthalmologic , Ixii; reported in Neurol . Cbl., Nr. 15, 1907.)
Wehrli.

Wehrli has made a careful study of a brain of a subject who had

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1908.]

NEUROLOGY.

149

double hemianopsia. The clinical symptoms have been already
described in the second edition of Monakow’s Gehirnpathologie. The
patient had total blindness, following an apoplectic attack, which
remained constant on the left side, although on the right vision was so
far restored that he could distinguish light from darkness. Central
vision remained lost till death, which took place three months after the
attack. There was found softening of the cortex in the neighbourhood
of both calcarine fissures. Both occipital arteries were blocked after
the origin of the temporal vessels. Microscopic examination revealed
involvement of the medullary matter, so as to destroy the connection of
the calcarine gyri (the cuneate and lingual ?) with the convexity of the
cortex. Wehrli considers that the optic radiation must also be injured,
as it has the same vascular supply as the calcarine gyri. From a study
of the whole literature of the subject, Wehrli believes that no pure
cortical lesion in connection with hemianopsia has yet been observed.
He considers that this case, as well as others which he cites, support
the views of Monakow, who holds that the visual field, and especially
that of the macula, is represented by the whole occipital lobe, including
the posterior part of the gyrus angularis.

In reporting this case Liepmann remarks that it is now universally
acknowledged that the fasciculus longitudinalis inferior contains many
projection fibres, but it appears from Wehrli’s description and plates
that a considerable portion of this layer, as well as the frontal part
of the inner sagittal layer, is intact, so that the optic paths to the
gyrus angularies, as well as the first and second occipital gyrus is not
interrupted. Why then, he asks, did central vision not return during
the three months if the macula be represented on the convexity of the
occipital cortex. William W. Ireland.

A Case of Left-sided Aphasia and Apraxia [Ein Fall von Linksseitiger

Apraxie und Agraphie]. (Neurol. Cbl. f Nr. 17, 1907). Maas , O.

Dr. Maas discusses a difficult diagnosis in a patient who suffered
from paralysis of the right side, especially of the leg, with unconscious¬
ness which lasted for two days, after which the faculty of speech was
found to be injured and the intelligence much diminished. The
paralysis passed away in two months, when he was found unable either
to write spontaneously or to write to dictation with the left hand,
although he could copy writing. The power of expression through
signs was also impaired on the same side. The patient had always
been right-handed. He could write well enough with the right hand,
and speech was free, although the intelligence was considerably
diminished. Thus what remained of the paralysis was entirely on the
left side of the body. As there was paralysis of the right side in the
beginning. Dr. Maas supposes that the lesion was in the left hemi¬
sphere. The difficulty is, assuming that there was one central lesion,
to indicate a spot from which the affection both of the right and left
side could result. He places the lesion about the anterior horn of the
left lateral ventricle near to the nucleus caudatus, where the commissural
fibres gather to enter the corpus callosum, thus injuring them in their
passage to the right hemisphere and also injuring the projection fibres
going to the right side of the body. As these latter recovered their

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EPITOME.

ISO

[Jan.,

function the lesion was supposed not to be extensive. This diagnosis
does not explain the decided and lasting impairment of the intelligence.

William W. Ireland.

Organic Hemiplegia ~without the Babinski Symptom [ Ueber organische

Hemiplegieen Olive Babinski]. (Amsterdam Congress .) By chow ski.

In a paper read to the International Congress for Psychiatry at
Amsterdam, Dr. Bychowski has shown that although the value of the
Babinski symptom is now universally recognised, exceptions are met
with which seem to lessen its pathognomonic importance. These
exceptions, however, fall into a special group. In the cases of cerebral
hemiplegia in which the phenomenon was wanting, we have to deal
with affections implicating the cortex cerebri or its neighbourhood, as
has been proved by trephining or subsequent post mortem examination.
In some cases of traumatic or spontaneous haemorrhage into the brain
substance where the Babinski sign was absent it was found that the
bleeding and subsequent softening had affected the cortex. On the
other hand, hemiplegias following upon tumour of the middle or inner
brain were found to be constantly accompanied by the Babinski
phenomenon.

Bychowski has observed that in cases in which the reaction had not
been observed the reaction appeared shortly after operations in the
cerebrum, because in the removal of the tumour or in plugging of the
wound the adjacent white substance on the motor paths had been
injured. On the other hand, after haemorrhages implicating the inner
capsule the Babinski phenomenon appears in a few hours. We may
thus regard this symptom as a fine test for a lesion of the pyramidal
tracts, and its absence in a hemiplegia not a proof of a simply functional
affection, but an indication of a superficial lesion of the cortex and of
the intactness of the pyramidal paths.

Bychowski also observes that in hemiplegia the abdominal reflex is
absent in the same side as the paralysis, and here also the reflex is
retained when the cortex is affected. Thus the absence of the Babinski
sign and the presence of the abdominal reflex are of value in the
differential diagnosis between functional and organic hemiplegias.

William W. Ireland.

2. Physiological Psychology.

Psychology and Sexual Symbolism in Folk-lore [.Psychologic und Sexual -
symbolik der Mdrchen]. (Psychiat. Neurolog . IVochensch., Nos . 22—
24, 1907.) Kiklin.

In this series of articles Dr. Riklin presents a summary of a forth¬
coming book in which he proposes to apply certain of Freuds ideas to
the explanation of folk-lore and fairy tales. Freud believes that a large
proportion of our dreams represents in a symbolic form the gratifica¬
tion of wishes, often of a more or less sexual nature, experienced during
waking life. This theory, at all events in the extension given to it by
Freud, is disputed by many. Riklin, however, believes that it corresponds

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1908.] CLINICAL NEUROLOGY AND PSYCHIATRY. 151

to a general tendency of thought when left to itself. In poetic produc¬
tion, he argues, we may see the impulse to realise those things which
actual life denies us. In psychoses such as general paralysis we observe
the same thing. The compositions of spiritualistic mediums are of
similar character. Legends correspond to our dream-life, as thus con¬
ceived, and to the conceptions of insanity. In illustration Riklin traces
the history of the snake as it occurs in folk-lore as the sexual rival of
the hero or heroine ; he regards the snake as a sexual symbol alike in
the dreams of healthy persons and the ideas of the insane. He then
proceeds to discuss similarly some other groups of legends. The
existence of sexual symbolism in folk-lore is indisputable, but it can
scarcely be said that Riklin’s development of his thesis is at the present
stage very convincing. Havelock Ellis.

3. Clinical Neurology and Psychiatry.

Eany Diagnosis of Multiple Sclerosis . {Med. Klinik , No. 36, 1906.)

Kurschman .

He notes that Babinski’s sign is an early symptom along with increase
of tendon reflexes. The abdominal reflexes are often absent.

William W. Ireland.

Late Epilepsy \de VApilepsie Tardive ]. ( Gaz . des^ Hop., September 12th f

1907.) Marchand, Z., et Monet, H,

Although there is considerable diversity of opinion concerning late
epilepsy, the majority of writers are agreed that: (1) Epilepsy may be
described as late when it manifests itself after thirty years of age ; (2) it
has the same symptomatology as idiopathic epilepsy; (3) it is generally
in relation with cardio-vascular degeneration, arterio-sclerosis, cerebral
lesions, alcoholism, phenomena of auto intoxication.

The authors contend that epilepsy should always be regarded as
symptomatic, and that in every case the lesions of chronic meningitis
and superficial cerebral sclerosis are to be found. As regards this point
no distinction is to be made between late and idiopathic epilepsy. The
late variety owes its rarity to the fact that lesions in the adult brain
seldom cause convulsive phenomena, whereas it is well known that the
child’s brain is peculiarly susceptible in this respect. Late epilepsy is
rarely to be attributed to atheroma of the cerebral arteries; in cases
where this condition is present, a careful histological examination will
almost always demonstrate the co-existence of the lesions mentioned
above. Bernard Hart.

Dementia [Daffaiblissement Intellectuel dans la Dimence Pricoce, la
Demence Sinile , et la Paralysie Glnlrale\ (DAnnie Psychologique ,
1907.) Masse Ion, R.

A comparative study of the three most important varieties of dementia.
The conclusions reached may be resumed as follows :

Dementia prcecox is essentially characterised by a primary lesion of
the affective faculties, by indifference, apathy, and aboulia. Volitional

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EPITOME.

152

[Jan.,

activity is not only enfeebled but may be perverted ; hence the develop¬
ment of negativism and various automatic phenomena, e.g., impulses,
motiveless fugues, and stereotypies. The relating function of the mind
is disturbed and incoherence is thereby established, but the mental
elements are preserved comparatively intact, and do not disappear until
the dementia is very profound. The patient’s mental facts seem dis¬
located, affected in their order of appearance, but new mental facts
can be acquired, and old ones can be recalled.

Senile dementia .—Here the disease affects primarily the mental
elements, while the relating activity is comparatively normal. Memory
is markedly affected and the number of available mental images is much
diminished, but association proceeds along normal lines. The patient
has preserved the framework in which the thoughts develop, but he has
lost the faculty of acquiring new images, and that of recalling the images
and notions which experience has accumulated in him. Hence in this
case we have cohesion but diminution of material, whereas in dementia
praecox we have relative conservation of material but disordered cohesion.
The senile dement is morbidly emotional, and the prevailing affective
tone is one of depression.

General paralysis is variable in its mental manifestations, and cannot
be efficiently described in general terms. As a rule, however, it is
characterised by a diminution in the memory power with a progressive
failure of the associative function. But while the cohesion is less than
in senile dementia the conservation of material is less than in dementia
praecox. Brusque clmnges of affective tone occur, varying from depres¬
sion to expansion, but some degree of euphoria is certainly the most
common. Bernard Hart.

Arson in Hysterical Somnambulism [ Une Hysterique Incendiaire pendeni
retat Somnambulique.\ (Arch.de Neurol., August, 1907.) Cullerre .

The rarity in medico-legal literature of references to pyromaniac
impulse in hysterical somnambulism has led Dr. Cullerre to record this
interesting case. The patient was a married woman of neuropathic
stock, whose health had deteriorated under the influence of excessive
child-bearing and uterine disease aggravated by morphinism. When
set. 28 she developed hystero-epilepsy with moral perversion, and was
certified insane. She remained under treatment for two years, during
which period she presented, in addition to a multiplicity of neurasthenic
and hysterical symptoms, various somnambulistic phenomena. These
latter took the form sometimes of attacks of maniacal excitement, some¬
times of hallucinatory phases with suicidal and other impulses, some¬
times, again, of prolonged periods of altered personality. A peculiarity
of these somnambulistic phases was that they allowed the emergence of
fixed ideas which were latent in the intervening periods of relative
health. This was shown strikingly in the patient’s correspondence;
letters begun in the normal condition and written in calm and coherent
language, if continued in the dream-state were filled with threats of
suicide and of vengeance to be wreaked on the patient’s relatives by
poisoning them, or more insistently by burning their property. The
patient’s mental health eventually improved enough to allow her to be
sent home, where she remained apparently well for seven years. She

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I908.] CLINICAL NEUROLOGY AND PSYCHIATRY. 1 53

then went back to the morphia habit, and had a recurrence of the same
hysterical and somnambulistic symptoms as in the previous attack.
During one of these phases of dream consciousness she set fire to the
farm of her father-in-law, who had been the special object of her
antipathy during her delirious attacks.

Commenting on the case, Dr. Cullerre draws attention to the
remarkably long interval—nearly ten years—intervening between the
appearance of the pyromaniac obsession and its realisation in the
criminal act. W. C. Sullivan.

Tumour of the Pituitary Body with Rontgen Photograph [Fall von
Hypophysis Tumor mit Ron tgen-Photogram m ]. {Neurol. CbL, Nr.
18, 1907.) Schuster.

It is a signal triumph that through the discoveries of physical science
we can obtain a visible representation of what is going on at the base of
the brain. Dr. Schuster first saw the patient whom he describes on
March 25th, 1907. He was a man, aet. 33, who had suffered from
diminution of vision for three years and from headache for about two
years and a half. The sight of both eyes was now entirely lost. There
had been hemianopsia. The patient remarked that during the last year
his gloves had become tight, and his rings did not fit. There had been
frequent vomiting during the preceding months.

On examination the skin appeared pale and dry as in myxoedema;
hair in axilla and pubis scanty. Nose somewhat enlarged. There was
divergence of the left eye, and the light reaction was diminished, but
more so on the right. There was atrophy of both optic nerves. Men¬
tally the patient was in a state of indifference, and easily wearied. The
diagnosis of tumour of the pituitary body with symptoms of acromegaly
was confirmed by the Rontgen rays. This is illustrated by two engrav¬
ings, one giving the normal appearance of the sella turcica, the other of
the case in question showing the sella enlarged to three times the usual
size and the hollow altered in form. Dr. Schuster explains that the
engraving is but a faint reproduction of the Rontgen photograph, which
may well be.

In the same number of the Centralblatt Dr. Ludwig Lowe, of Berlin,
discusses the methods of removing tumours of the pituitary body, which
he holds may best be done through the nasal passages.

William W. Ireland.

Maniacal Chorea. (.Dublin Journ . of Med. Sci ., May, 1907.) Finney,

f. Magee.

The patient whose case is here described as suffering from this rare
disease, chorea insaniens, was an unmarried girl, aet. 17, whose occupa¬
tion is not stated. She suffered from rheumatic pains in her legs for a
fortnight, upon which chorea supervened. A mitral systolic murmur
audible on admission and of varying loudness was present until her
death, which occurred nine days afterwards. The pulse was quiet and
regular until the last three days, and her temperature normal or sub¬
normal until the day before her death, when it rose to 103*4° F.

The choreic movements were slight for about forty-eight hours, after
which they became extremely violent. The psychical phenomena were

LIV. 11

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154 epitome. [Jan.,

prominent, out of all proportion, and at first quite overshadowed the
motorial. They differed, however, by the absence of incoherent speech,
and wild garrulity, from the forms one is accustomed to associate with
the acute delirium of fever or acute mania. Up till three days before
her death she would occasionally grow calmer for a little time, under¬
stand what was said to her, and answer “ yes ” or “ no ” intelligently.
Drugs had no effect on the course of her disease, but chloral proved
the most useful in securing a few hours' sleep and muscular rest.

The autopsy revealed a small quantity of mixed clot in the longi¬
tudinal sinus, engorgement of the vessels of the cortex, a very small
amount of fluid in the lateral ventricles, thrombosis of some of the
small vessels of the cortex in the Rolandic area ; while in others, cells
with oval nuclei lay heaped up in the perivascular lymphatic spaces,
which also contained clumps of broken-up nuclear material.

The spinal cord and the other organs of the body were normal, except
the heart, which was very atrophic, and some calcified tubercular glands
in the mesentery and root of lung. Careful bacteriological examina¬
tion of the cerebro-spinal fluid yielded negative results, and no micro¬
organisms were found in the meninges on section. The author regrets
that so many standard works of reference on medicine and on insanity
do not mention maniacal chorea at all, or else give a very short descrip¬
tion of it.

He thinks that the embolic theory as causative of any form of chorea
is no longer tenable, but that all choreic manifestations must be recog¬
nised as due to the presence of a toxine.

He quotes the conclusions arrived at by Poynton and Holmes that,
in the first place, chorea is a manifestation of acute rheumatism, and
secondly, that the Diplococcus rheumaticus is the infective agent in acute
rheumatism.

He admits that his own case does not exactly add support to these
views (which he apparently shares), as no micro-organisms were found
on bacteriological examination of the brain and spinal cord.

A. W. Wilcox.

Visual Hallucinations on the Blind Side in Hemianopsia . (Medicine,
July , 1906.) Burr , Charles W.

After referring to those cases exhibiting the above condition already
recorded, the author proceeds to describe the case of a white man, aet.
20, admitted to his wards in the Philadelphia Hospital in March, 1906,
complaining of severe headache and blindness on the right side and of
seeing devils, angels, and bright lights in the blind field. He knew
that the objects seen were unreal. They were not persistent, but came
and went. Sometimes they appeared for only a minute or two, some¬
times remained for hours. They were never visible on the left side.
They were small, sometimes movable, sometimes stationary. They
first appeared several months after an attack of unconsciousness
occurring in July, 1905, which attack was preceded by sudden illness
and vomiting. He was unconscious for a short time only and then
became delirious, and on the following day stuporose, in which con¬
dition he was admitted to the Episcopal Hospital. He could be
roused, and when roused became confused. Light disturbed him.

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1908.]

SOCIOLOGY.

I 5 S

There was no paralysis of the arms, legs, face, or ocular muscles. His
pupils were unequal at times, the right being the larger ; both reacted to
light. His reflexes were normal, and his control of sphincters unim¬
paired. Kernig’s sign was present for a short time, about a week after
admission. On ophthalmoscopic examination hyperaemia of the retina
was found, more marked in the left eye. Five days later neuro-retinitis
was present, and there was general hyperaemia around the disc in both
eyes. The left eye in addition showed a retinal haemorrhage in the
periphery in the lower temporal region. Six days after this examination
his mind was clear and he talked better. A further examination
seven weeks later showed the typical appearance following a marked
neuro-retinitis, and he was discharged next day as much improved.

He had a right homonymous hemianopsia, but the date when this
fact was discovered is not stated in the notes. When examined by
Burr this was the one prominent symptom. Slight slowness of thought
was the only mental symptom shown by patient. The author believes
that there was probably a gumma or specific arteritis (the man had a
clear history of infection and bore treatment well) somewhere in the
occipital lobe, the presence of optic neuritis pointing rather to its being
a massive gumma. He thinks that the higher visual centre, on the
convex surface of the occipital lobe, was either itself, or the white matter
underlying it, slightly diseased or else merely pressed upon.

A. W. Wilcox.

4. Sociology.

The Question of Responsibility. (Rev. NeurolAugust, 1907.) Ballet, etc .

At the recent Congress of French Alienists and Neurologists held at
Geneva and Lausanne, the much-debated question of the proper
attitude of medical science towards the metaphysico-legal idea of
“responsibility” received full and interesting discussion. Professor G.
Ballet had been appointed to prepare a report on “ The Question of
Responsibility.” In accordance with the opinions which he has always
consistently maintained, Ballet concluded that the question is outside
the medical domain. A number of speakers, notably Joffroy, supported
Ballet. Grasset, of Montpellier, disagreed, but he admitted his dislike
of the use of the word “responsibility.” By a large majority the
Congress affirmed its agreement with Ballets proposition that, since
questions of responsibility are of a metaphysical and juridical order and
outside the physician’s competence, a judge is not entitled to demand
the physician’s opinion concerning them. This decision marks a real
progress of opinion, and seems to indicate that the clear-headed genius
of France is taking the lead in putting an end to that illegitimate
subserviency of medicine to antiquated legal metaphysics, which has
often proved so disastrous in weakening the authority of medical
science. Havelock Ellis.

Sexual Hygiene in France \L\Abstinence Sexuelle\ (Prog. Med., August-
September\ 1907.) Leal, Foveau de Courmelles, etc.

The various problems connected with sexual hygiene in relation to

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EPITOME.

[Jan.,

156

mental and general health have recently begun to be agitated in France,
though their discussion has so far revealed wide discrepancies of opinion
as well as a considerable amount of prejudice against any discussion at
all. This has been well brought out lately in various communications
to the Progrte Medical . Guy L£al, a pronounced advocate of the
necessity of the sexual education of youth, introduces the question
afresh by giving a summary of a recent collection of opinions from
prominent German physicians regarding the results of sexual abstinence.
He recalls that though Pfliiger refused to reply because youth is not
amenable to arguments in favour of complete sexual abstinence, a large
number emphasised the harmlessness of abstinence. Many counselled
a wise limitation of sexual commerce, and Strumpell advised early
marriage, and in its absence regarded masturbation as a less harmful
alternative than prostitution. In this connection L£al mentions that
recently when the question arose of a course of lectures on sexual hygiene
to the students of the Paris University, the medical professor (“well
known for his plain speech ”) who was asked to deliver the course told
the Rector that he should call a spade a spade, and would advise his
young hearers rather to resort to masturbation than to run the risk of
contracting syphilis or even gonorrhoea. The Rector was shocked and
the proposal fell to the ground. L£al himself, though not out of
sympathy with the plain-spoken professor, considers that the physician
is going outside his social rdle in preaching either sexual intercourse or
sexual abstinence. “ What he has to do in this matter, and it is sufficient,
is to teach sexual hygiene and the sexual education of youth with
perseverance and without ambiguity.”

In a subsequent number Foveau de Courmelles is aroused to a
vigorous assault on the evils of masturbation. He thinks that Tissot's
famous book on onanism is far from exaggerated (which suggests doubts
as to his acquaintance with that manifestation of exuberant rhetoric),
and he declares that he “does not fear to affirm that onanism is worse
than gonorrhoea or even syphilis.” He is entirely at one with L£al as
to the necessity of teaching sexual hygiene, and mentions that he was
one of the authors of papers on this question prepared for the recent
Congress of Educational Hygiene in London, where English “pudi-
bonderie” was careful to place the question in the background.
“Sexual education is, however, necessary in all countries, but one
must know how to carry it out.”

The difficulties and prejudice on the part of the lay mind which such
education still meets with in France are well illustrated in the same
number of the Progrh Midical , in an article discussing the enlightened
recommendations of the Commission Extraparlementaire du Regime
des Moeurs in favour of giving instruction in sexual hygiene by medical
lecturers to the higher classes in all lyceds, colleges, and popular
universities under Government control. Various examples are brought
forward of the reception given by the French middle-class authorities
to the unofficial attempts at present made to impart instruction in sexual
hygiene by the Soci£t£ Fran£aise de Prophylaxie Sanitaire et Morale
(with the support of leading medical authorities), and of the lofty moral
indignation with which even the mayors of large Paris arrondissemcnts
sometimes receive a request to lend a municipal building for a lecture

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ASYLUM REPORTS.

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on the perils of prostitution and of venereal disease. The veteran
Fournier is devoting his immense energies in old age to popular propa¬
ganda in this direction, and the distinguished medical dramatist,
Brieux, has written a famous play, Les Avariis , which is as remarkable
for its salutary lessons as for its poignant dramatic art. But it is
evident that, on the whole, France, though ahead of England on this
question, is still far behind Germany, where the principle of instruction
in sexual hygiene is not only widely accepted, but is now beginning
to be carried out systematically in many great urban and educational
centres. Havelock Ellis.

Asylum Reports issued in 1907.

Some English County and Borough Asylums.

Carmarthen .—We read with considerable surprise some very trenchant
remarks made by the visiting Commissioners in their report. They
regret to find that many matters requiring attention have remained
neglected for years because of the dispute that rages between the
authorities contributing to the asylum. Among these is mentioned the
absence of any proper system of drainage. The Commissioners record
their opinion that by this neglect of the above and other things the
interests of the asylum and the patients suffer to a considerable extent,
and that the condition of things is not creditable to those responsible.
But far more serious, in our opinion, is the record, “ It does not appear
from the entries of visits that two or more members of the committee
have visited the institution on any one occasion during this year.”
Some of us think that the best chance of solving lunacy difficulties lies
in relaxing some of the cast-iron precision of the lunacy law in
favour of increased liberty of experiment and exploitation on local
initiative. How this can be conceded when the Commissioners have to
whip up committees to carry out the very first essential of their being it
is impossible to see. The actual facts, however, suggest that the
cast-iron precision of the lunacy law, inconvenient in many important
matters, is not of much value where it is particularly wanted. We note
that considerable use has been made of electric baths, but no report of
the results is given.

Cumberland and Westmorland. —We entirely endorse the following
remarks of Dr. Farquharson :

In the case of patients who have been known at one time to be suicidal, it is
always a grave responsibility to decide when to withdraw the special supervision,
but the decision has to be made for two reasons ; the number of suicidal cases is
constantly being added to by fresh admissions, and if this class is allowed to
increase in number indefinitely, the special precautions for suicidal cases lose their
value; on the other hand, infinite harm may be done to curable cases, and their
chances of recovery lessened if the idea that they are the object of constant dis¬
trust is kept too prominently before them, and if their personal liberty is too much
restricted when improvement has set in. Risks have to be run sooner or later, and
our immunity from accidents of this kind for several years is proof that they are
not run unduly. Better many recoveries with an occasional accident than few
recoveries with even then the possibility of accident.

Derby Borough .—Dr. Macphail finds that out of 660 cases discharged

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EPITOME.

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recovered, 20 per cent . were relapses. The average period of relief in
the cases readmitted during the year after discharge on recovery was
six years and two months. We again express our opinion that it is a
pity that this latter average is not more constantly worked out.
Obviously in dealing on broad lines with the probable requirements of
a district, it must be of value to know that the incidence of a given
quantity of fresh insanity probably entails a reappearance after discharge
of a proportion at any estimated time. From the scientific point of
view, too, some forecast as to the probable amount of respite is
necessary. It is a point that might well have received treatment from
the Statistical Committee.

Dorset .—The incidence of insanity in this county appears to be at a
standstill for the time. The fresh admissions were less in number
than in the preceding year. The number of private patients increases,
the rate of payment being between 10 s. 6 d. and £$ per week.

Glamorgan .—The sad death of Dr. Stewart naturally supplies the first
subject of remarks in the reports of both the visiting committee and
Dr. Finlay, the latter especially bearing testimony to his deceased
friend in well chosen terms. It is fortunate that the Committee could
call on yet another officer of over twenty years* tried service to take up
the command. We wish Dr. Finlay all success in his heavy responsi¬
bility. Here, too, the rate of increase in population seems to be lessened,
while the admissions are but three more than in 1905. Glamorgan as a
county has 1 insane patient in each 415 of the population, against 1 in
283 for the kingdom. A decrease in alcholic causation is noted. The
following figures afford food for reflection :

Males. Females. Total.

General paralytics admitted 38 4 42

Venereal disease predisposing 1 3 4

„ „ exciting . . — 2 2

Hereford .—It was found by Dr. Morison that among the male admis¬
sions 29 per cent.) and among the females 40 per cent ., exhibited cardio¬
vascular disorder, accompanied in the latter sex by a large proportion
of glycosuria or goitre. The latter existed in a third part. The ques¬
tion of aetiology is put aptly:

Our strenuous endeavour to obtain on admission as complete a history as
possible can only be forwarded by the intelligent co-operation of those whose duty
it is to obtain facts correctly at the time and place the patient is seen, and where
his antecedents are well known. Guardians, relatives, and relieving officers have
in this matter a real responsibility to discharge towards the patient sent to the
asylum. The complete family and personal history is a sine qud non to the
proper treatment of “ insanity.” Insanity is not a definite disease, it is a mere
term ; it does not describe the conditions or factors causing the disorder.

In connection with this we note that the Committee refer approvingly
to the new registers of the Commissioners and to the Association Tables.
Referring to the evidence of Mr. Davy before the Commission on
the Feeble-minded Dr. Morison argues, correctly we think, that if
unification between asylum and workhouse care of the insane is to lead
to one body having the supreme charge, that body should not be the
Local Government Board as desired by Mr. Davy, for the reason that
the Poor Law entirely lacks the elasticity and enterprise which charac¬
terises the evolution of the asylum.

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Kesteven .—We note with satisfaction that the committee arrange
that in addition to the ordinary meetings two visitors shall attend, not
only to inspect patients, but to discharge those who have recovered.
It always has seemed to us absurd, if not indeed harsh, that a patient,
if he misses the one monthly chance of discharge, should have to wait
till another comes round. Why the discretion of discharge that is given
to the medical superintendent of every other form of institution should
be withheld from the heads of public asylums is not evident. In this
direction, as well as in the power of sending patients on trial, even with
the power of granting the allowance so often given now, much more
elasticity is required.

Lancashire , Prestwick .—Dr. Percival speaks caustically, but not a
whit too caustically, about the prevention of insanity by regulating
Nature.

In this, our own county of Lancashire, such attention has been recently strongly
in evidence. So much so, indeed, that some members of the special committee
appointed to consider the question were prepared to adopt the very strongest
measures, such as castrating the males and spaying the females. After a con¬
siderable amount of deliberation and discussion by this committee and the medical
experts from their various asylums, the difficulties only seemed to get greater,
and some members were undoubtedly disappointed that a workable scheme could
not be.produced forthwith.

Most people, I take it, would be thoroughly in sympathy with any measure or
measures that showed a reasonable prospect of success. But this prospect must
be definite. There must be no mistake about it. Not before can we expect the
people to sanction laws that would place such extraordinary powers in the hands
of those deputed to administer them. For instance, the regulation of marriage,
that is, the restriction of unions between the unfit. Who shall determine the unfit P
Children by unsound parents, whether mentally or physically so, do not always
inherit their parents’ defects, or suffer from allied diseases. On the other hand,
children of sound parents may become afflicted. I am not at all sure that man
has been particularly successful where he has taken selection into his own hands.
Look at horses, cows, dogs, pigeons, etc. A sound horse seems a difficult thing to
obtain, most of the cows are tuberculous, and the dogs, pigeons, etc., seem to have
few added merits outside the artificial standard of the show.

He seems to think that Nature is not going to be baulked. She will
see to plentiful reproduction, leaving it to elimination of the unfit to put
matters right. We in our turn do our best to defeat elimination by
succour and protection. We have always thought that one danger of
regulating production by selection is that if any bar is put on the
legitimate satisfaction of lawful desires among the great mass of the
people, then these desires will be satisfied without authority, this
occurring the more readily amongst those who come under the ban of
unfitness. The offspring of such alliances will have superadded to
heredity many of the worst risks of environment.

Leicester and Rutland. —Dr. Stewart anticipates the new statistical
scheme in giving the causes of the insanity in those who have recovered.
It is remarkable that while in the admissions six males and one female
are attributed to alcohol, only one male appears in the recovery. Of
course, it does not follow that the seven admissions will have this poor
chance of recovery, but it would seem that drink in Leicester does not
supply the evanescent attacks of insanity with which it is commonly
credited. Writing of the unnecessary sending of senile patients to an
asylum, Dr. Stewart instances a case, aet. 80, which was brought because

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160

[Jan.,

she bit the nurses in the workhouse. On examination it was found
that she had not a tooth in her head.

We have received an elaborate description of the new asylum at
Narborough. This is being taken into occupation now. The plans
show much evidence of careful thought, and we can see that in many
respects the best points in successful asylums have been worked in
here. We imagine that, in spite of the outcry in favour of economy,
the day of the barrack asylum has gone. Plenty of room and a sunny
aspect for all wards are good investments. These are to be found at
Narborough, and we congratulate Dr. Stewart on having a first-class
institution. The system of heating is by low-pressure steam. For
ventilation, the patients* blocks are furnished with the Nuvacuumette
system, the radiators being entirely inside the wall with access doors.
There are thus no pipes, etc., in the rooms. In the hall the system is
the Plenum.

London City. —Dr. Steen expresses his satisfaction with the assump¬
tion, for all but statutory purposes, of the title of “mental hospital.” We
agree with him. The private element is becoming of increased
importance, this class of patient nearly equalling the rate-paid. We
note that the payment is the same for all —£i is. per week. The
receipts from the relatives are nearly double those received from the
rates. As the weekly maintenance rate is about 12 j., the excess of 9 s.
would appear to be a very moderate sum to meet extra treatment and
rent. Of course, the large number of such patients would enable
things to be done with relative economy, but after making all allowances
of the kind it would appear that all that a county can be called upon to
do for its insane of the lower middle classes can be reasonably well
done for one guinea.

London County.

For the first time in their existence the Committee are enabled
to report an actual decrease in the number of patients under
asylum treatment, there being thirty seven less on April 1st than on
January 1st of 1907. No great weight is attached to this, as it has
been found before that a preternaturally large increase has occasionally
followed a sensible decrease. The committee think and hope that, as
the density of population and the area of the county have their limits,
the time is coming when the high-water mark of resident population
must be reached, and this must have some effect on the bulk of lunacy
to be dealt with. In relation to the alleged increase in occurring
insanity, the well-known conclusions to which Mr. Noel Humphreys
has come in regard to all England have been applied to the county,
where ample means of investigation are available. The results are in
favour of the idea that actual increase of the disease as occurring cannot
be substantiated, the increase in actual numbers being due to accumula¬
tion, a shifting of patients, who would have formerly been at home or
elsewhere, into the asylum, and, finally, to an extension of the qualifica¬
tions for admission thereto. As to the accumulation the evidence seems
to be quite conclusive. The first three years and the last three years of
the County Council's assumption of responsibility for the asylums were
taken, and it was found that if the average rate of increase for the former

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1908.]

had been preserved in the latter 2,083 fewer beds would now be required.
This state of matters was not confined to the county’s asylums, but was
found, though to rather less extent, in the patients taken to the Metro¬
politan Asylums Board institutions. The accumulation, of course,
depends on the recovery and death-rates falling behind the admissions.
Another fact in aid is that the mean age of patients at the end of the
years for 1891-1894 was 45*8 years, while for 1903-1906 it was 47
years. Yet again it was found that of each 1,000 patients there were
found on the average during the same period 271 over 55 years of
age in the former and 307 in the latter. From the copious tables
furnished it would appear that the opening of Long Grove Asylum
would afford almost sufficient room for all the patients for whom the
committee is responsible. Accordingly the committee propose to hold
its hand in the matter of providing its eleventh asylum.

In view of the probable reporting of the Commission on the Feeble¬
minded, no further steps have been taken about the proposal to institute
receiving houses.

Having found considerable difference between their asylums in
amount and details of expenditure, the committee has instituted the
plan of preparing each quarter graphic tables showing the variations,
which are to be circulated among the medical superintendents. The
latter are to take whatever steps may be necessary in regard to differ¬
ences. This appears to be a most practical idea, which has the merit of
defining the powers of those on whom the responsibility is fixed.

The scale of pay for attendants and others has been revised. The
new scheme involves the abolition of the £2 good-conduct money. As
a similar amount has been added to the wages there is not much to say,
but we think that the committee are hardly justified in stating that the
whole object of the grant was to provide means for dealing with minor
offences. Our impression is that, in most places at least, the idea was
to provide means for rewarding continuance of good behaviour solely.
It is rather repugnant to the general idea of an attendant’s worth that it
should be assumed that he would go wrong in small matters.

Before going into details of the various asylums and departments we
wish to renew our appreciation of the immense care and earnestness on
the part of the committee and its superior officers that is evidenced by
this huge report. Perhaps it would not be inappropriate to say that we
noted with the greatest satisfaction that during all the recrimination
accompanying the last County Council election not a word was uttered,
as far as we know, in disparagement of the committee’s work, and this
notwithstanding the great demands made by the asylum on the ratepayer’s
pocket.

At Bexley the male acute hospital has been finished and brought into
operation. One feature is the provision of a large solarium. There are
no fences, the only boundary being a planted mound. As usual Dr.
Stansfield furnishes an extensive sheet showing the correlation of causes
in the admissions, to which we shall make reference again. He treats
the principal and associated causes of death much in the same way. It
is somewhat astonishing to read that among the male admissions syphilis
was a principal factor in 37 per cent., while in the females'it appeared in
11 per cent. The general paralytics formed 13*6 per cent, of the male

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EPITOME.

[Jan.,

and 2‘i percent . of the female admissions. Evidence of syphilis was
afforded in 91*8 per cent . of the males and 66 6 per cent, of the females
admitted.

Claybury .—Dr. Robert Jones reports that a female patient, described
on admission to be suicidal and under electrical delusions, was ordered
by the Commissioners to be discharged after eighteen days of detention,
the certificate not being considered to contain facts indicating insanity
warranting detention. No more was heard of her. He points out that
in his admissions the male clerks and persons of no occupation formed
a disproportionately large part. On reference we find that this is the
case in most of the other London asylums. In both the county
average is much in excess of the ratios last published by the com¬
missioners for the whole kingdom. The assignment of heredity was
found to be justified in a high ratio, while alcohol appears in 29 per cent.
of the histories.

Colney Hatch .—Dr. Seward mentions a heavy epidemic of colitis,
sixty-eight patients being attacked, with a mortality of 27 per cent . He
adverts to a veritable plague of flies which arrived and was prevalent
during the two months of the greatest severity of the dysentery. There
was a large collection of town refuse not far from the asylum grounds,
and as the flies suddenly disappeared when the cold weather came on,
the colitis subsiding at the same time, and as the disease was spread
very widely over the wards he had a suspicion that the flies helped to
disseminate the disease.

Hanwell. —Nearly 20 per cent, of the admissions were admittedly
heavy drinkers. We assume that this way of putting the matter, which
is practical, excludes the cases where drinking was an accidental or a
symptomatic occurrence. If all returns of alcoholic causation were
differentiated on this basis they would assume real value. There was a
family history of drink in about 16 per cent. Syphilis was found in 44
per cent, of the male general paralytics, and in four out of the five
female patients suffering from the same disease.

Horton. —After an interval of four months, during which Dr. Stans-
field took charge temporarily, Dr. Lord entered into supreme command
of this asylum, and we wish him all success. We recognise in his
report yet another useful channel for the dissemination of valuable
observations on the scientific facts which must pass before the eyes of
the superintendent of a large institution. He maintains that the
married people among the patients have much the best of matters.
Fewer, in comparison with the population, stated according to the civil
state, were admitted, while of those admitted the married were discharged
recovered in the ratio of 22 per cent, as against 12 of the single. The
similar proportion for all the London asylums was 34 and 27 respectively.
We incline to think that Dr. Lord is right in the way he views the
questions raised by increasing brain degeneracy:

I cannot range myself with those who take up an extreme alarmist's view
regarding the stated increase in lunacy; yet statistics show the situation to be one
which calls for serious consideration. It should be remembered that insanity is
not the only waste product of the social machine ; there are others which com¬
plicate the problem, such as criminality, chronic alcoholism, epilepsy, vagrancy,
etc. These have not given rise to such drastic proposals as in the case of the
insane. As regards the latter, various remedies have been advocated to prevent

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163

contamination of future generations; some crude, and morally bad, such as the
lethal chamber ; others more humane, like sterilisation, and segregation in colonies.
All states of degeneracy are so much allied that a remedy which deals with one
and not with all is of only partial benefit. The proliferation of degeneracy in its
widest sense calls for some preventative measures. But it is practicable; and, if
successfully undertaken, would the problem be solved ? Iam not too sanguine,
though I should be sorry to discourage efforts in this direction. The real fault lies
with the social machine generally, and, although by-products are always to be
expected, yet much could be done by hygienic and educational reform.

We note that he, in common with Dr. Stans field, regards general
paralysis as an aetiological factor of insanity, and each returns a pro¬
portion of cases as having this relation. From time to time we have
dissented strongly from this position, and we see no reason why we
should alter our opinion on the point. There is this difference between
them. Dr. Stansfield states the /actor as general paralysis of the
insane, while Dr. Lord uses the definition of “ the lesion of general
paralysis.” We cannot see how a paulo post futurum symptom can
under any name become a cause. If, on the other hand, general
paralysis is regarded for this purpose as a symptom-entity, the cause
and the disease caused are one and the same thing. If, once again,
Dr. Lord’s rendering is intended by both, why should we not talk of
the cause of mania being the lesion of mania ? We know no more of
the exact lesion setiologically of mania than we do of that of general
paralysis. In any case the assignment of a lesion as a cause must
commit one both scientifically and practically to an attempt to assign
the cause of the lesion itself. We think that perhaps it might be
defensible to assign the actual existence of paralysis as an associated
factor if we could define and name a disease, having a morbid psychology
of its own, which could be demonstrated to occur with or without
paralysis. But then this, if it were possible, would be doing away with
the one entity that promises some day to be capable of a reasonable
pathology, and which might possibly in its evolution give the line to a
reasonable pathology of other forms of insanity.

Epileptic Colony .—Dr. Bond makes his last report before taking his
departure to Long Grove. We beg to heartily congratulate him on
his preferment.

The following weighty words support the remarks of Dr. Lord already
quoted:

Among the epileptic cases admitted, a family history of insanity was ascertained
in 21 per cent, of epilepsy and alcoholism each in 26 per cent., and a history of
personal alcoholic excess in 16 per cent. But every occasion which affords an
opportunity of obtaining a family history of any given case with any satisfactory
degree of completeness impresses me the more with the pre-eminent importance
of a faulty heredity. The truth of this is being more and more recognised, and in
its light, with the laudable aim of prophylaxis, the desirability of legislative measures
is from time to time urged. While to some extent in sympathy with them, a
warning seems to me necessary that the advocates of such measures, should they
succeed in obtaining them, may then find their cherished panacea much less
effective than anticipated. Our clinical records, for instance, show either that a
considerable proportion of the cases, both of insanity and epilepsy, rightly judged
to be the offspring of a faulty stock, were born before the appearance of the
diseases in the relative, or that an intervening generation of immunity had
occurred and rendered the known warning note too faint to be practically effective,
even upon the ear of a public educated upon these matters. Moreover, I believe
that the r 6 le of heredity in filling our asylums is not limited only to the neuroses

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EPITOME.

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but that, for instance, it largely accounts for 4 the arterio-sclerosis occurring in
early life, to the importance of which, as an associated bodily condition in some
cases of insanity, I have alluded in previous reports.

Speaking of the question of recovery, Dr, Bond shows that out of
the ten cases thus discharged four were well mentally, the fits con¬
tinuing ; in one the existence at any time of epilepsy was doubtful, in
three the epilepsy and insanity depended on alcohol, and the reality of
their recovery will depend on their abstinence. In the other two the
epilepsy recurred at long intervals, bringing the insanity with it. There¬
fore relapse is to be looked for. He cannot, therefore, speak with
optimism on the curative rdle played by the colony, though he insists
on the large amount of alleviation worked by its ministrations.

Pathological Laboratory. —Dr. Mott deals at some length with both
the dysentery and the tuberculosis questions. With regard to the latter,
he is still of the opinion that in only relatively few cases is the disease
acquired in the asylum. A large amount of obsolescent disease was
found, in fact the average yearly percentage of cases showing obsolescent
without active tubercle was 36*3 in the males and 31*2 in the females.
These were found among all classes of insanity, but while in general
paralytics and most chronic forms the mischief was limited, in dementia
praecox, imbecility, epileptic imbecility, the tuberculous lesions were
generalised and extensive. In about 13 per cent, of the cases a tuber¬
cular heredity of some sort was established. Post-mortem examinations
were held in 1,415 cases in the county asylums during the year, and in
175 cases thus examined tuberculosis had been diagnosed ante mortem.
The diagnosis was confirmed in 149, and the other 26 cases showed
only obsolescent or no tubercular lesion. On the other hand, in 39
cases unsuspected and active tubercle came to light.

With regard to dysentery, Dr. Mott reports a marked increase over
preceding years. The same applied to diarrhoea, and Dr. Mott insists
from his observations that the only hope of eradicating the former disease
is to treat and isolate the latter with the same rigour as dysentery
receives. The contention of Ford Robertson and Macrae that the
Bacillus paralyticans exists is not supported by the work done at
Claybury Laboratory.

The Metropolitan Asylums Board Asylums. —The portion of the
Board’s report which deals with imbecility contains as usual much that
is of interest. We learn from the Committee’s report that success has
attended the experiment of allowing female members of the staff to
sleep away from the asylum. It has benefited the officers themselves,
in that it enables them to get quite away from their depressing environ¬
ment, and it has saved the provision of extra staff room. The Com¬
mittee refer with deep regret to the death of Dr. J. R. Hill, one of our own
members, who for many years had rendered it invaluable aid in asylum
matters. A very useful department of the Report is that which deals
with Defective Children (Appendix V). Miss Turner, the Medical Officer
who visits and reports on the many homes for such children scattered in
or near London, evidently takes much pains to forward amelioration by
the now recognised methods of discipline and training. She, like others,
has difficulties to overcome in carrying out wholesome treatment to a
sufficiently prolonged extent.

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The second boy could not be sent, as his parents wished his return, and he was
therefore discharged to them. This, I think, is a matter for much regret, for
although the boy was so much improved that I thought it highly undesirable that
he should remain longer with children who are deficient, yet, on the other hand, I
equally did not desire that he should return to his home, where he is sure to find
those influences still at work which had helped to cause his defect. A course of
strict discipline was, in my opinion, necessary in order that he should remain per¬
manently at the level of mental improvement at which I found him in June; still
more necessary was it if he was to attain the fullest mental development of which
he was capable.

A typical family history. —It will be interesting to follow his case in the future,
and see whether his mental condition improves or deteriorates. Personally, I am
strongly of opinion that deterioration will take place, his being a typical case of
bad family history. The family history is as follows; Father had phthisis and was
insane; paternal grandfather died of phthisis; paternal grandmother is in an
asylum with mania and religious fancies; mother was laid up for four months
before the boy’s birth with spasmodic paralysis, and afterwards lost the use of her
legs for some months; maternal grandmother died of consumption ; ten brothers
and sisters (nine living) have all, with one exception, suffered from some nervous
trouble. To give particulars of the last in order of age : No. 1 (brother) is strong.
No. 2 (sister) had meningitis, and for the last few years has had fits, evidently of
an epileptic character. She also suffers from frequent swellings of the knee-joint,
which are probably tubercular in origin. No. 3 (brother) suffered as a child from
severe headaches. No. 4 (brother) had a severe nervous illness, nature unknown.
No. 5 (brother) had meningitis, and is paralysed. He is mentally dull, and at
seventeen years of age could not spell “ cat.” No. 6 (the boy whose history is in
question) has had chorea. No. 7 (sister) has had meningitis, is very irritable, and
Object to headaches. No. 8 (sister) had paralysis, and was for two months in a
hospital for nervous diseases. No. 10 (brother, who died) was paralysed in the
legs.

This is one of those cases which suggest most forcibly the advisability of having
the control of children of this mental condition for a fairly long period.

In a sense the department supervised by Miss Turner is unique. It
is only a huge area like the one now under report that can arrange to
deal with a whole class of children who are between the normal and the
imbecile, or, in other words, between their own homes and Tooting-
Bec or Darenth. Every district has such children, but few have them
in numbers sufficient to justify systematic handling. The work that
has been carried on so far in London justified the opening in 1906 of
a Colony at Witham for feeble-minded boys. Miss Turner speaks
cautiously of the good that it has already done. It is evident, she says,
that very considerable classification will be required. Mentally, trade
instruction is found to be efficacious, but needs careful organisation. She
places much value on proper physical exercise, drills, etc. “ It is very im¬
portant for a variety of reasons that these boys should be worked as
hard as possible. ,, They seem to be very apt in drill. Musical instruc¬
tion, leading to the provision of a band, is much desired since it tends
to brighten the home side of life. On the moral aspect Miss Turner is
somewhat unhappy, and this cannot be a source of wonder. She,
knowing the tendencies, thinks that they are best kept in check by the
good influence exerted by women in small homes. If the boys are to
be taken from such homes into the larger institution it is absolutely
imperative that the staff should be ample enough to keep up the closest
supervision. At Brentwood there is a similar colony for girls. This
seems to be of a more satisfactory type, consisting as it does of a group
of small cottages, thus enabling the pupils to have the benefit of more

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166 EPITOME. [Jan.,

intimate personal control combined with the advantages of aggregation
for teaching, recreation, etc. In both sexes Miss Turner finds a necessity
for a well-regulated form of instruction in ordinary scholastic subjects,
this, of course, being such as tends to exercise the brain rather than to
impart special knowledge.

In his report of Tooting Bee, Dr. Beresford gives a useful table
showing various heredities in his admissions to the children's part. Ol
156 cases 62 had no such history, 41 had no known history, while 32,
14, o and 7 had heredities of insanity, phthisis, syphilis and alcohol
respectively. In 7 cases the labour at their birth was returned as
abnormal.

At Leavesden the efforts to seclude and neutralise the dangers of
tubercular infection, to which we drew attention some years back, have
been attended with considerable success. The death-rate calcu¬
lated on average residence has dropped from 5’46 per cent, in 1902 to
2*24 per cent, in 1906.

At Caterham Dr. Campbell utters a strong protest against the want
of facilities for proper nursing and care of the increasingly unsatisfactory
admissions. This seems to arise from the wards, which were originally
designed for one class of quiet imbeciles, having been gradually taken
over for quite another class.

At Darenth Dr. Rotherham makes the same complaint as Miss
Turner does about the removal of unfit patients. He says with regret
that seventeen patients between the ages of five and twenty-three were
discharged to the care of their friends by the order of the guardians,
and in no instance was the patient fit in his opinion to be discharged
from the asylum. Training in trades is made a great interest here,
with good mental and financial results.

The statistics of all the asylums singly and summarised are worked
out in a thoroughly conscientious manner, of course on the old system
of the Association. It is to be hoped that similar treatment will be
accorded to the new tables. One cannot help feeling that with all the
immense care and labour, both in principle and detail, bestowed by
the two bodies principally entrusted with the mass of London’s insanity
and mental want, great results would follow a cordial collaboration in
exploiting in combination the immense masses of information tabulated.
Separately the figures of neither class of institution represent the whole
field of mental disease; together they supply materials for scientific
inquiry which can hardly be equalled anywhere in the world. We
might go further and say that the labour, of the Metropolitan Asylums
Board in connection with the broad zone that lies between the normal
and the abnormal have materially extended the scope of inquiry. The
will to do the best work is evident; cannot the way to correlation be
found ?

Monmouth .—The figures about general paralysis at this asylum are
very striking. It is not so long ago that this disease was comparatively
rare in that part of the world. Now we find that of 336 admissions
(less 164 transfers to the asylum) there were fifteen cases. Of these
seven were females. This is all the more remarkable as it occurs after
the withdrawal of the large urban population of Newport. Alcohol
and syphilis were assigned as causes in very few instances.

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ASYLUM REPORTS.

167

Salop .—This report adverts to a matter in which the law might be
well altered with good effect. The authority wished to combine with
several others to lease Sandwell Hal )for the purpose of an asylum for
idiot and imbecile children. The Commissioners were compelled to
say that this was ultra vires . It is said sometimes that the propinquity
of an asylum has an injurious effect on the price of land. From the
report it appears that the Committee had to give almost ;£i8o per acre
for an estate of 104 acres, with house, etc. This is pretty well for land
two miles and more from a town that is not the largest in the country.
The price for the land only without the house and appurtenances would
have been double.

Somerset , Cotford .—To Dr. Aveline belongs the distinction of
being the very first of county asylum superintendents to publish his
annual statistics in the new form adopted by the Association. The
scheme has come in for much criticism during the pre-experimental
stage. No doubt further criticism will be bestowed on its appearance
in concrete form, and we feel that it would be too early to attempt to
review the results thoroughly from only one example. But a few ideas
strike one. Accustomed as we are to looking over for the purposes of
review many reports each year, we must say that the tables are somewhat
bewildering at first. The amount of information is immense, and the
re-arrangement in different form makes it difficult to find the usual
particulars. But a little patience gets over such troubles, and then
a certain amount of purpose is found to be behind the change.
Just the same feelings existed in the 80% we remember, when the
last set was devised, though, of course, the bulk was then much less.
They have been lived down, and we suppose that the same happy end
will come again. The mere expense of putting all the matter into
print must be considerable, but we do not think that it would in any
case be found really an appreciable addition to the ordinary disburse¬
ments. Leaving general principles for the present and turning to the
individual tables, the first one that calls for special notice is the one deal¬
ing with occupations in direct admissions, giving the ages at the com¬
mencement of the disease in the first-attack cases. We see that out of
6 domestic female servants 5 fell ill between thirty-five and forty-five. If
such a fact as that should prove to be according to general experience,
something fresh will be gained for the study of social conditions. The
etiological table (on admission) is certainly an improvement, as it
allows minor influences to be stated with something like a valuation of
circumstances attaching to the onset of an attack. But its principal
use from the asylum point of view will be in relation to the table in
which the admission aetiology is applied to the recoveries. In relation
to alcohol the experience at Cotford is very different to that at Leicester
as mentioned above. The recoveries are 14 as against 16 admissions.
It was assigned far more frequently as a contributory than as a prin¬
cipal cause. The influence of heredity is especially notable. Of the 115
direct admissions 49 had this assigned against them as principals (con¬
genital 2, first attack 30, and not first attacks 17). Of the 62 recoveries
of all kinds 35 had the taint. Here again will be found information of
the first value—information that took Thurnam many weary years to
collect. The 49 cases having heredity are analysed as follows: Having

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168 EPITOME. [Jan.,

paternal taint without maternal 22, maternal without paternal 16. In
both classes some, but not universal, fraternal taint was found. In the
remaining 11 cases fraternal taint without discovered parental taint was
found. The death tables allow of contributory circumstances being
enumerated for the first time.

We commend to all asylum officials a study of Dr. Aveline’s figures,
feeling sure that this will reconcile those who may be alarmed by the
apparent magnitude of the task involved in using the new scheme. Dr.
Aveline himself does not make any remark as to the increase of labour
in compiling his figures.

East Sussex .—Dr. Taylor reports that he found heredity to be by far
the most common element in the aetiology of the admissions, no less
than 47 per cent, of the males and 52 percent '. of the females having the
taint. This large proportion is probably as much due to diligence in
search as to actual excess over other districts. History could only be
obtained in 4 out of 11 male general paralytics, but in each of these
there was evidence of pre-existent syphilis. A death occurred from
typhoid, the occurrence of which was quite inexplicable. The patient
had seen no friends for a long time, had had no parcels, the milk and
water were found to be perfect, and there was no other case before or
after. Such events bring much worry to those who don’t deserve it.

Wiltshire .—Dr. Bowes, in expressing a hope that the view that
insanity is a disease requiring special treatment will grow stronger on
the public mind, writes:

An adequate and efficient staff has led to more personal care and supervision,
with the result that restraint and seclusion, which were necessarily freely resorted
to in former years, have of late almost been abolished.

The following figures show the difference in the mode of treatment, with the
results accruing from the change.

Year*.

Average
No. of
patients.

Proportion of
attendants
to patients.

Restrained. Secluded.

Escapes.

Inquests.

1881 to 1886

6204

i to 13

, 258

1901 to 1906

9637

i to 9 4

We think that he might have fairly fortified this evidence by a
refererence to the medical results of treatment. For the same periods,
as we find on reference to Table III, the recovery rates were 317 and
34*5 respectively, the percentages of death on average residence being
10*8 and 8.

This county appears to have been more than usually successful in
persuading boards of guardians to take back to the workhouse patients
who are considered fit for residence there. Twenty-two were thus dis¬
charged, relieving the overfull asylum.

Yorkshire , West Riding , Wakefield \—The aperient treatment of
patients in anticipation of colitis seems to be highly successful in keep¬
ing this scourge at bay, the incidence being shown by a table to have
decreased in a remarkable manner. Dr. Bevan Lewis gives a table
showing the results of work in the Electro-therapeutic Department.

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ASYLUM REPORTS.

169

Form of insanity. Number of

J cases.

Recovered.

Relieved.

No effect.

Sinusoidal baths .

Acute mania

Dementia prsecox

Systematised delusional

insanity .

—

. 2

Exhaustion psychosis

—

. —

Acute melancholia

Chronic melancholia .

—

Stupor

Static baths .

Exhaustion psychosis

—

. —

Acute melancholia

. —

—

Dementia praecox

—

Stupor ....

. 2

—

The results, as far as regards stupor, are most satisfactory. We
presume that by the term is meant the heavier form allied to the so-
called acute dementia. In comparing this table with the section of
Table XI which deals with the form of insanity in those who recovered,
we are much struck by the large number of recoveries that have taken
place in forms that usually yield but poor returns. We imagine that
Dr. Lewis does not read into the titles of the term “ dementia ” that
amount of hopeless degradation that occurs to many in connection with
it. We have always felt that sufficient provision in classification has
not been made for the state not infrequently seen in which the intellect
becomes clouded either as a passing episode in an attack of insanity,
or as an independent manifestation of temporary loss of function—a
state that might not unfairly be termed “ benign dementia.” Dr. Bevan
Lewis speaks in high terms of the beneficial work done at Stanley Hall
in training weak-minded and imbecile boys. Steps have been taken to
found a similar institution for girls.

Some English Registered Hospitals .

Barnwood .—Here the admissions as between the sexes have differed
immensely in number. The males have numbered 14 only, while the
females were 30. In addition, too, the prognosis varied much. In the
former only one, an alcoholic, presented any probability of recovery,
while at least half of the other sex have either recovered or have a good
chance of recovery. Dr. Soutar makes the following remarks on these
facts:

It is generally recognised that women recover in larger proportion than men
do from mental disorders. This report is not the place to discuss the explana¬
tions given for that fact, but it may be mentioned that we have found in recent
years that insanity amongst the male patients from forty years of age upwards
has, in an increasing number of cases, been associated with ascertainable arterial
degeneration. These early “ senile changes ” are still comparatively rare amongst
the women. In the case of most of the men alcohol or syphilis may be excluded
as a condition precedent to the arterial changes, but we find them amongst those
who have struggled and striven, often successfully and with little relaxation, in
arduous mental work. In other cases it would seem as if excessive devotion to
athletic exercises, carried on beyond the elastic years of youth, led, in those pre¬
disposed, to old age arteries in middle-aged men.

uv. 13

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170

EPITOME.

[Jan.,

Oxford\ The Wameford .—Here, too, there is a notable falling off in
the male admissions, while the female side has been overflowing. Dr.
Neil makes the subjoined remarks about the dealing with “incurable”
cases in registered hospitals. This is an old and burning question.
No doubt, if it can be proved that the original intention of the founders
of an institution was that it should be used more for the cure than the
care of insane people, it is right that the incurable should be turned out
to take their chance of admission elsewhere. It has to be remembered
that such cases, if troublesome, always have an extra difficulty in find¬
ing a new home, while none need more the protection of an institution
than they do. We think, too, that even in the absence of any proof
of original design a committee may well consider that it has a large
duty towards the curable, and seek to make room for them as far as
possible. But, if such a principle must be pushed to the prejudice of
some who might profitably remain, then logic would suggest that it
should be applied indifferently to all after a given period of treatment,
as is the case at Bethlehem. We know that some selection must be
made in relation to payments, so that the less affluent should derive
benefit from the surplus paid by the better-off. Beyond that, selection
should in our opinion not favour the amenable at the expense of the
troublesome, who, as said above, have as much if not more claim on
benevolence.

A number of transfers from other care have always appeared in our yearly
admission lists, although for 1906 they are fewer than usual. The reasons for the
transfers are generally of a pecuniary nature, and few of the patients have much
prospect of recovery. One of our transferred patients during the past year was a
lady whose friends, to their great distress, had received an unexpected notice from
the registered hospital where she was being treated that she must be removed as
“ incurable.” They applied at another hospital, and on stating that the case was a
troublesome and unfavourable one were told that her admission was “ impossible.**
They then made application here, and the patient was admitted at a lower charge
than they had been previously paying. The case proved to be an exceptionally
difficult and trying one, and for a time taxed our nursing resources to the utmost.
Some improvement has lately appeared, and the treatment is now easier, but the
lady will probably not recover completely. I quote this case as an example of the
advantages offered by this hospital to patients of the educated classes whose means
are limited.

Exeter , Wonford .—This institution is full to overflowing. This may
be partly accounted for by the remarkable fact that with an average
residence of 131 there was only one death. This speaks well for the
equable moral atmosphere pervading the hospital. Nevertheless, there
were 26 admissions, of whom only 8 could be regarded as probably
curable. Dr. Deas thinks that, speaking broadly, his belief is that
physical causes exceed to a considerable extent the mental, and that in
many cases the modus operandi is of a toxic nature. We are glad to
note that financially the last year was unprecedentedly successful. A
year or two like this are wanted to confirm the financial ease for which
the Committee and Dr. Deas have strenuously fought for years past.

York , Ihe Retreat. — Dr. Pierce has shown the way among the
hospitals in first producing his statistics in the new shape, and we think
that he and Dr. Mackenzie are to be therefore congratulated. The
numbers are small, but the work must have been large. We do not
propose to do more than make a casual remark or two on them. We

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ASYLUM REPORTS.

171

note that all the alcohol cases are entered under the “ principal factor ”
column. It is a great gain that such cases can be argued about with
certainty. We note that here all the heredity is treated as “contribu¬
tory,” whereas at Cotford it is treated in the contrary way. The rights
of the matter would form a fine subject for debate.

The same remark applies to the causation by mental stress. Here
perhaps the difference in social position may account to some extent for
the variation in views. We do not find any return of the original causa¬
tion in the twenty recoveries. This will always be of cardinal importance.
We note in the very useful table giving the forms of insanity in the
residue, that in the total of 169 residents on December 31st there are
no less than twenty-eight cases of primary dementia. Under that fact
must lie some principle of definition that is not usual. We remember
that when the new nomenclature was published, some felt doubts as to
the precise meaning to be attached to the term.

Dr. Pierce makes the bold, though not unwarranted, suggestion that the
principle of detaining recent and curable cases under modified certifica¬
tion in private houses should be extended to treatment of them in
institutions. Thus the stigma of definite certification and declaration
would be held over for the time until failure of cure had been demon¬
strated. He had a case in which certification served ipso facto to lose
the patient his business position. We very much doubt whether any
such proposition would receive consideration, although Dr. Pierce con¬
templates magisterial inspection of each case.

Some Scottish District Asylums .

Aberdeen ,, Kingscat. —This being the only asylum report at present
dealing with an absolutely discrete system of accommodation, the record
of a second year’s progress must be of much interest. That record is
certainly satisfactory. The ratio of recoveries is high, well above average
indeed ; the death-rate is normal; there has been the average amount
of accidents. The patients are reported by the Commissioners on each
occasion to be comfortable and free from excitement, and the weekly
maintenance rate is quite reasonable. These are the points by which
the scheme and management must be judged. No doubt there must be
much advantage in breaking up population into items that can be treated
with varying liberality. We note that 80 men and 79 women, a total
of 159 out of 412 patients, are on parole. This large ratio no doubt
is to some extent rendered possible by the segregation of the asylum
itself. Some plates supplied in the report suggest miles of open country
round the institution.

Glasgow , Gartloch. —Dr. Parker deplores the character of the majority
of his admissions; 66 per cent . of these were ill over a year, were
congenital imbeciles, or had been previously ill. Of course this high
proportion would be expected after Dr. Carswell had paid his attentions
to the bulk of fresh insanity in the district. As Dr. Parker points out,
these attentions must have some effect on the number of patients
admitted into asylums and thereby vitiate the calculations of the Com¬
missioners when they seek to estimate by admissions the yearly incidence
of the disease. It is claimed and admitted that several short cases that

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172

EPITOME.

[Jan.,

would formerly have come under the notice of the Commissioners are
not now returned to them. A table put forward by Dr. Parker shows
how the proportions respectively of young, middle-aged, and senile cases
have gradually shifted since 1898. The first named are now 32 percent .
of the admissions, tending on the whole, though not markedly towards
increase. The centre group, thirty to fifty years of age, however, have
decreased by regular stages almost from 60 to 36 per cent., while those
over fifty have increased from 14 to 31 per cent . He suggests that
boarding out might be increased in efficiency if those subjected to it
could be grouped, so as to be within easy supervision of some individual
inspector—a medical man for choice. The influence of parental inebriety
on the production of insanity in offspring is becoming an accepted fact
in spite of some disinclination to accept any evidence as conclusive on
any point connected with aetiology. The figures given by Dr. Parker
again this year are striking enough to be reproduced here. In 112 cases
with a definite history, parental alcoholism was established in 70 and
excluded in 42. Of the same 112 cases 49 commenced before the age
of twenty-six, and in these there was parental alcoholism in 41, or 83 per
cent., while in the other 63 the percentage was 46 only.

Govern , Hawkhead .—Govan has followed the lead of Glasgow in
establishing observation wards apart from the asylum itself. Therefore
not only are the admissions into Hawkhead reduced by straining off
several mild and evanescent cases which get well inside of six weeks,
but the ratio of recoveries is naturally reduced. In spite of that the
latter is quite respectable. The chief item of interest must be Dr.
Watson’s new system of aetiological record, to which we adverted last year.
In spite of his further remarks in this year’s report, we still think that
we are correct in holding that the public has a right to expect an expres¬
sion of opinion on the causation of insanity from those to whom it gives
the best chance of forming that opinion. Dr. Watson says that aetiology
ought to be regarded as in the collecting stage. So it may be, but
how long is collection to go on? For ever? If not for ever why
should not a man with the experience of many years digest and
use his own collection of facts. If, on the contrary, this process
is to be perennial —medicus expectat dum fluviet arnnis —surely time
and opportunity are being wasted. Particularly in regard to the effects
of alcohol on the human race Dr. Watson is very averse to anyone
giving an opinion. Of course some men may be of a slovenly way of
thinking, but there are others whose logic is unassailable, and some of
these may claim to found a logical opinion on long and trained
observation of facts. He himself has made use of experience in classi¬
fying three males and two females under the head of alcoholic. We
presume that a careful weighing up of known facts has enabled him to
state positively that these cases have fallen victims to the toxine. Why
may not others be equally positive? The same arguments may be
applied to the use by him of the term “ puerperal insanity.” If no
attempt is to be made as yet to assign definite causes, classification
needs revision. But whatever argument or difference of opinion may
arise over these questions we shall always think that Dr. Watson has
done a great thing in producing his valuable collection of facts, in the
form devised by himself.

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ASYLUM REPORTS.

173

Inverness. —Dr. Campbell shows that the average number of admis¬
sions for the last ten years exceeds the number actually admitted in the
year under record. He thinks, therefore, that there has been no increase
of insanity of late years in the district. It is curious to read as a pos¬
sible explanation that the public is more tolerant of insanity than
formerly, the obverse being one of the stock allegations made in the
south for the purpose of discounting a very obvious increase in totals.
Yet it may be true in a neighbourhood like that of this asylum, where
boarding out is practised to a large extent.

In dealing with the high ratio (34 per cent.) of readmissions, Dr.
Campbell points out that this depends in great measure on the strong
efforts that have been made to relieve the asylum of cases entitled to
have a trial of outside life. Some of these must inevitably be failures
in course of time, but in respect not only of them, bqt also of those
who still remain boarded out, credit has to be taken for the relief pro¬
duced by their absence. He also points out that such a high rate is
the best proof of determined attempts to weed out cases not requiring
asylum control. In considering the influence of alcohol in particular
cases, he frequently finds that when an abstemious man becomes
mentally indisposed he takes a little alcohol under the belief that it
will help him to do his work, and then of course the progress of events
is hurried on. It is proposed to remodel a house on the asylum estate,
on which being done forty-eight beds will be added at the rate of
^40 each. We note that a second assistant medical officer has been
appointed—not before time, seeing that there are nearly 700 patients.

Roxburgh District .—Now that the accommodation has been so much
increased arrangements have been made for taking private cases at £40
from the district and £45 from outside. Dr. Johnstone makes an
energetic protest against the asylum being made use of by the law.

A woman, charged with the wilful murder of her two infant children by drowning
them in the Tweed, was sent to the Asylum under the 15th Section of the Act 25 and
26 Viet., cap. 51. Twelve days later she was removed to Edinburgh Prison by
order of the Sheriff. At her trial she pleaded guilty to culpable homicide, and was
sentenced to six months’ imprisonment. No opinion is expressed here as to the
regularity of the legal procedure followed in this case ; but a protest must be raised
against what appears to be a growing tendency to make use of asylums as con¬
venient houses of detention for dangerous criminals. The modern asylum is
essentially a hospital; its arrangements are not designed to meet the requirements
of a gaol, and, in so far as its conditions are made to resemble those of a prison, its
efficiency as a hospital must suffer. It is most unfair that respectable members of
the community sent to the institution for medical treatment should be forced into
association with malefactors and murderers, and the presence of such persons in
the wards is keenly resented by the patients.

A comment we may add is that sentence of six months* imprisonment
for two murders seems to be so inappropriate that some idea of
irresponsibility on the part of the offender must have been in the mind
of the judge. The peculiar grievance that is felt by district asylums in
regard to the absence of any power for the granting of pensions is
discussed at some length, and we consider that Dr. Johnson has put the
arguments for such power being given in a particularly clear and con¬
vincing manner. Perhaps if the Scottish officials keep on pressing the
matter on their members, they may in the end get a compulsory instead
of a permissive scheme such as England has to put up with.

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EPITOME.

[Jan.,

Lanark District '.—After seven years of constant moaning and lamen¬
tation, kept up to the annoyance of all around, a female patient
suddenly got quite well, and has kept so. She is so grateful for her
treatment that she wishes to devote the remainder of her life to nursing
mental patients. If we remember right it was in regard to the statistics
of this asylum that several years ago, in the time of Dr. Campbell
Clarke, we first raised objection to general paralysis being assigned as
a cause of insanity. We should not wish to add anything to what we
have said on this matter on a former page had not we seen another
table supplied by Dr. Kerr. This shows the bodily condition on
admission of the patients admitted. Under the head of the nervous
system there are two patients returned suffering from this disease. We
find, however, that in the cause and the form of mental disease
tables, five cases are entered. This increases the difficulty we find in
ascertaining the principles on which general practice is departed from.

Stirling District .—Dr. Robertson points out that his admission ratio
for last year is exactly the average for the last eight years. As the total
population of the district supplying the asylum has probably increased
by 40,000, his belief that the volume of occurring insanity is gradually
decreasing receives support. He thinks that this might be expected.
Insanity is a symptom of physical disease, and he is of the opinion that
with the increase in physical improvement insanity must be expected to
lessen. He considers, too, that the amount of so-called alcoholic insanity
in a district can be taken not so much as a measure of alcoholic excess
as a test of the amount of degeneracy. In mentioning the rapid
decrease in the tuberculosis ratio, he states that systematic spraying
with formalin solution of the whole interior surface of the asylum is prac¬
tised. Dr. Robertson sets great store by having in charge of all the
departments, male and female, an educated and trained assistant matron.
The staff on the male side is composed of eleven nurses and twenty-five
attendants, lliis replacement of men by women is worth a trial, no
doubt, and it will probably succeed under the energetic care of
Dr. Robertson. But it will have to go very well indeed to go at all.
As soon as the least laxity or laziness creeps in there will be serious risk
of abuse and failure. The criticism that is bestowed by Dr. Robertson
on Lord Rosebery’s Bangour speech is very much to the point. Touching
the comparison of the patient’s comfortable surroundings with the
opposite conditions found in their relatives’ homes, Dr. Robertson
suggests that the latter should be asked which they would wish to have
—the comfort for themselves and the discomfort for their insane friends,
or the reverse. He says that whenever he has asked this question the
answer is at once for the patient. The one consolation that friends
have in giving up their mentally sick is that nowadays the State, when
it takes the charge, does so in no niggardly manner. This is most true,
and the feeling is at the root of that change in public opinion which has
pressed and will continue to press for the best treatment, in spite of all
cry for economy.

The table of the restraint and seclusion used in Scottish asylums
for five years is reproduced in this report, having been taken from the
Commissioners’ Report of the preceding year. We are enabled to
congratulate Dr. Robertson on his exceeding good luck in not having

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1908.]

ASYLUM REPORTS.

I 7 S

had during this space of years to deal with a case calling for either mode
of treatment. We are not quite sure that any very good reason can be
shown for the appearance of this table here, except as a peg on which
to hang thankfulness. As to its publication by the Commissioners we
are also more than a little sceptical. Looking to the character of the men
in charge of Scottish asylums, and to the extremely moderate use made
of the tabulated items, the only lesson to be learned is that in spite of
aversion to either restraint or seclusion there are from time to time a
few patients who must be treated by such means. This we all, or most
of us, know, but the public does not know. It occurs to us that such
a table might easily be misread; its purpose might appear to even
the instructed public pour encourager les autres , like the lists of names
sometimes placarded in railway stations. If such an idea got about
immense mischief would be done. In a case in which restraint might
seem to be almost imperative, a superintendent might well be excused
for reflecting that if it was applied then his asylum might be at the head
of the published restraint averages, and for deciding the matter in
favour of his own reputation, but not necessarily in favour of the patient,
other patients, or the staff.

Some Scottish Royal Asylums .

Dumfries , The Crichton .—Dr. Rutherford having retired, the present
report is the last that will be signed by him. This is not, of course,
the place to attempt to deal with the services to the cause that have
been rendered by him, but we feel that we shall be losing an old friend
whose progressive liberality of view generally provided something in his
report to think over and annotate. The near completion of the whole¬
sale re organisation of the rate-paid accommodation must be a satisfac¬
tion to him. The very last items are a reception house, an infirmary,
and two closed villas. The number selected for the first, that is to say
twelve beds, seems to be rather on the small side. It may be enough
for those who will actually get well, but for the considerable fringe of
doubtfully curable cases the opportunity of the treatment that will best
solve the doubt would seem to be too small. One objection sometimes
taken to these truly mental hospitals is the effect on patients of removal
from them to those other premises where hope is admittedly less. Such
an objection, if true, would have greater effect where the margin of room
is so small. The closed villas will be for thirty patients each. We
quite recognise that the provision for places where the violent, noisy,
and dangerous must be gathered together is an essential element of the
segregation method. But it is undoubtedly a very weak point in all
these schemes. In discussing the differences between rate-paid and
private discharges without recovery, Dr. Rutherford writes:

When the cost of maintenance is defrayed from private sources, and when the
family of the patient is in straitened circumstances, a powerful inducement is held
out to them to remove the patient as soon as the malady has assumed a manage¬
able form. On the other hand, when the cost of maintenance is defrayed by the
parish, the pecuniary motive for removal ceases to operate, and as the family of
the patient is relieved of all trouble and responsibility, a great inducement is held
out to leave him where he is. A very large number of pauper patients are thus
unnecessarily detained in asylums. In the two houses of Brownhall and Maiden-

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EPITOME.

176

[Jan.,

bower there are twenty-eight female patients, nearly all of whom could be boarded
out, and the same might be said of many of the men in the farm annexe.

Lord Rosebery’s speech at the opening of Bangour attracted Dr.
Rutherford’s attention as being unnecessarily alarming. He himself
thinks that there is no increase of insanity among the class that pay
over of board. The same he holds of the well-to-do, artizan
classes, while from a most interesting table it appears that the actual
number of the insane at the present day in the purely rural parts of the
whole of the district served by the asylum is less than it was in 1831,
which was the year of inception of the asylum. In this district, as is
the case everywhere, according to Dr. Rutherford, the increase in the
number suffering nowadays comes from the very lowest classes to be
found chiefly in the large towns.

Edinburgh, Momingside .—Dr. Clouston, in discussing the prevalence
of general paralysis (35 males and 20 females admitted) naturally adverts
to the work of Drs. Ford Robertson and MacRae. He confirms the
claim of these physicians that improvement has followed treatment on
their lines in early cases. But, as he points out, the first thing is to
improve diagnosis, so that the cases can be caught when in their earliest
stages, before the brain is seriously damaged.

I have for many years believed, and have written, that the disease has really
begun in most cases long before it is even suspected or its known symptoms have
become recognisable. There are certain changes in conduct and in the higher
faculties of mind, such as the will, which may occur several years before the speech
becomes affected, that being the common diagnostic sign that enables us to say
that the disease is there.

On May 27th, 1907, Morningside completed its hundred years of
usefulness. A short history of those years is supplied by Dr. Clouston.
The institution appears to have had but three physicians—Dr. Mac-
kinnon to 1846, Dr. Skae from that time to 1873, and Dr. Clouston
from then onward. The present sketch, beyond being short, deals
with a considerable variety of matters, as was bound to be the case
seeing that it is intended for the many classes into whose hands the
report annually falls. The subject is worth treatment from the purely
medical side, and we would suggest that Dr. Clouston could not find a
better subject for a contribution to the journal of which he was so long
editor than the scientific good that Morningside has done. It would
appeal to the very large proportion of our members who have in one
way or another an intimate knowledge of Morningside and its ways.
We are glad to note that the removal of the rate-paid patients to
Bangour enables the institution to receive all cases that can afford to
pay ^32 10s. It will thus be able to resume the benevolent work for
which it was thought out and established. #

Glasgow , GartnaveL —We take the following extract from the speech
of the Lord Provost of Glasgow, who was in the chair of the Governors’
meeting at this asylum. It is encouraging to find from a layman such
an extensive appreciation of the truth that underlies every particle of
care and treatment of the insane. We think that perhaps the second
sentence somewhat strains the logical application of the first, but if pro¬
minent citizens like his lordship are imbued with the idea, much
assistance can be looked for in quarters where too often the medical
has to yield place to the financial interest.

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ASYLUM REPORTS.

177

1908.]

It is a hopeful feature about the mental illnesses of recent times, the growing
belief—a belief justified by experience—that the symptoms in connection with
such cases arise from physical causes—from some disorder of the organs; and that
goes to show plainly that the mind is affected by the condition of the body, and
that, if such physical symptoms were taken in their earlier stages, the mental
symptoms might be prevented altogether. It also fosters the belief that such cases
could very well be dealt with, in their first stages at any rate, in the general hos¬
pitals of the country rather than in the special hospitals for mental diseases, and
the friends of patients in the earlier stages of the disease would have far less
objection to have them removed to a general hospital than to such an institution
as that in whose interest we have met to-day.

The finances of the institution are such that it was possible to admit
twelve acute cases for 2 5 each per annum. In none of these cases
could the regular minimum of be paid.

Perthy The Murray .—Dr. Urquhart, in his report, quotes some par¬
ticulars that he worked up for the Morison Lectures for this year. As
he says, we have to do with a disease profoundly affecting bodily nutri¬
tion and secretion, mainly originating in hereditary defect, and issuing
in a liability to repetition of attacks. Thus insanity is brought into
line with other diseased bodily conditions, and the mystery of madness
is left on a par with the mystery of rheumatism, which also is of a cyclic
character quite different from those maladies which, like smallpox,
appear to confer immunity upon the individual. Of 809 persons
admitted, 1880-1904, 45 per cent had the heredity of insanity, and
72 per cent . that of neuropathy.

An examination of the families of insane parents, however, showed that 47 per
cent, of the children of insane fathers were alive and sane, while 29 per cent, were
insane; 4a per cent, of the children of insane mothers were alive and sane, while
39 per cent, were insane; 33 per cent, of the children of insane fathers and mothers
(both parents) were alive and sane, while 44 were insane. Mr. David Heron
calculated that this morbid heredity falls heaviest on the eldest child, and rapidly
diminishes with the number of children. There is, even in the most disastrous
class, an effort towards regeneration, and a curability which does not greatly differ
from that of insanity, which is not hereditary in the first instance, although
hereditary defect is apparent in depressing the final recovery rate and raising tne
death-rate.

Some Irish District Asylums .

Clare, Ennis .—We have made the following extracts from the
reports of the Commissioners in 1905 and 1906. They tell, indeed, a
remarkable tale. It is refreshing to find, however, whether in the
Committee’s reports or in those of the Commissioners, or in the
figures bearing on restraint, accidents, and so forth, ample recognition
of the method in which Dr. O’Mara manages the institution in the face
of appalling difficulties. It would appear, too, that the blame for what
is happening cannot be attributed with justice to the Committee, as
plans for remedying much of the mischief had been passed by them.

1905.—The Commissioners write:

The Committee have recognised the necessity of providing further accommoda¬
tion, and have had plans for the work prepared. These plans received the statutory
approval of the Lord Lieutenant, under the 9th Section of the Local Government
(Ireland) Act, 1898, in November, 1904, but, when the action of the Committee
came before the County Council for confirmation, that body postponed the con¬
sideration of the matter, pending the issue of the report of the Commission which
is at present inquiring into the working of the Poor Laws.

LIV. 1 3

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178 EPITOME. [Jan.,

This, having regard to the great overcrowding of the asylum, was a very serious
step, and I cannot help thinking that the Council can scarcely have considered the
matter in all its bearings before arriving at their decision.

Having regard to the constitution of the Poor Law Reform Commission, I feel
sure that its recommendations will be both important and valuable; but I may
point out that it does not come within the scope of its functions to deal with the
wants of the large body of acute cases of insanity for whose treatment provision is
required in County Clare.

There is, as has been frequently stated, scarcely any proper day-room accommo¬
dation in the asylum, so that the present surroundings of the recoverable cases
tend to aggravate and perpetuate their mental derangement rather than afford
them the means of treatment towards recovery which the law and humanity alike
demand.

It would be little exaggeration to say that the old and barbarous method of
smothering maniacs between feather beds was, in a sense, more humane than
placing them in conditions which tend to intensify the mental agony from which
so many of them suffer.

Enteric fever was very prevalent, and no wonder, for, as the Com¬
missioners report, the drain was built of rubble masonry with little
fall, and is now riddled by rats, and ventilating into the wards :

1906.—From the Commissioners’ report:

In order to meet the daily increasing demand for additional accommodation
temporary sleeping rooms have been provided in the airing courts by converting
the old sheds into dormitories. By this means sleeping room has been obtained
for twenty patients of each sex. This has, in some degree, lessened the crowding
at night, but it is inadequate to meet the exigencies of the case, either as regards
the want of dayroom space, or room for fresh admissions. Nor, indeed, did it
afford sufficient room for the patients at night, as at the present time six men
have to sleep on the floor through want of room for their bedsteads.

Owing to the want of suitable accommodation, the acutely insane, the suicidal,
the sick, and the epileptic have to be treated in the same ward. It is needless to
point out out how disastrous it is to the hopes of recovery in the newly admitted
cases that they should have to pass their days with those whose malady must be a
source of terror and repugnance.

The overcrowding in the dining-hall renders the service of the meals a matter
of very great difficulty and of some danger, but, nevertheless, on both sides the
quiet and regularity which prevailed was certainly astonishing.

Having regard to the great difficulties which must daily arise in the administra¬
tion of this asylum, owing to the excessive overcrowding and the inadequacy of the
various departments, every credit is due to Dr. O’Mara for his careful management
of the establishment, under circumstances which are not encouraging.

Down. t Downpatrick .—This report is garnished with some excellent
photographs of the wards and rooms in the asylum. From these it is
apparent that in the matter of furniture and general cheerfulness the
asylum is in no way behind the best examples in other parts of the
kingdom. Dr. Nolan states that, while the average incidence of
insanity for all Ireland is 1 in 178, in his district it is no more than
1 in 216. This he attributes to freedom from dire poverty and the
state of unrest that accompanies failing prosperity, and from the wear¬
ing strain of agrarian agitation, all combined with a sense of a fairly
prosperous state of things. He is very anxious that the Association’s
new tables should be made statutory in Ireland. “It would be a
genuine pleasure to record well-considered facts; to be compelled to
dump down a yearly quota of unsifted generalities is an uncongenial
task.” We think that the following extract from the evidence that he
gave to a special committee is quite as appropriate to other parts of the
kingdom as it is to Ireland :

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NOTES AND NEWS.

179

1908.]

In a poor country, such as Ireland is, it would appear to me that the most expen¬
sive wav of dealing with the insane would be to set up several classes of asylums
adapted to treat the supposed stereotyped clinical forms of insanity, as differentiated
by a Parliamentary draughtsman, when one knows and considers that the clinical
features of such cases are so very variable. On the other hand, an auxiliary
asylum, which would be a department of an existing district asylum, offers all
obvious advantages to economy and efficiency.

Limerick .—The Commissioners, if they can speak with vigour as at
Ennis, can also utter some nice words, as here:

During the inspection of the wards the patients were wonderfully quiet and well
behaved. The Limerick Asylum is an object lesson in this respect, as showing
the effects of modern and humane treatment in restraining the violence and excite¬
ment which, in old days, characterised insanity. Forty years ago it was reported
that in no district in Ireland were the insane so noisy and extravagant in demeanour
as those belonging to Limerick, and thirty years ago, in going through the wards,
one could recall the pictures of Hogarth—the patients rolling on the ground in
rags, shouting, fighting, and attacking all who came near them. Now in no institu¬
tion could one see better conducted and more orderly people.

When dealing with alcohol Dr. O’Neill strongly advocates teaching in
schools the perils and dangers of intemperance. We are with him in
this entirely. Reformed drinkers are satisfactory when found, but
prevented drinkers are the hope of the future. The establishment of
temperance societies for the young has done more good than all the
regulations affecting the conduct of drinking places, even throwing in
the Habitual Drunkards Act.

Part IV.—Notes and News,

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

An Ordinary Quarterly Meeting of the Medico-Psychological Association
was held at n, Chandos Street, Cavendish Square, London, W., on Tuesday,
November 19th, 1907, under the presidency of Dr. P. W. MacDonald.

Present:—Drs. T. S. Adams, A. J. Alliott, H. T. S. Aveline, W. H. Bailey,

C. H. Bond, D. Bower, A. N. Boycott, J. F. Briscoe, C. Caldecott, J. Carswell, J.
Chambers, C. Clapham, A. Corner, M. Craig, J. F. Dixon, A. C. Dove, P. L.
Down, W. Ewan, H. E. Haynes, J. H. Higginson, G. H. Johnston, W. S. Kay,

D. Ker, P. W. MacDonald, T. W. McDowall, W. J. Mackeown, M. E. Martin,
W. F. Menzies, C. Mereier, A. Miller, C. S. Morrison, W. F. Nelis, Hayes
Newington, A. Nobbs, F. W. Nutt, M. E. Paul, J. P. Race, H. Rayner, G. H.
Savage, J. Scott, G. E. Shuttleworth, P. C. Smith, R. P. Smith, J. G. Soutar,
T. E. K. Stansfield, R. H. Steen, R. J. Stilwell, W. C. Sullivan, F. R. P. Taylor,
D. G. Thomson, T. S. Tuke, J. M. Turner, F. Watson, E. W. White, T. O. Wood,
and Albert Wilson.

Visitors:—Drs. W. J. Attwater, E. C. Bunch, H. C. Burt, D. G. G. de Cllrambault,
H. Fagan, Eliot Howard, A. P. John, A. Lamont; Sir Ralph Littler; Dr. Jay
Smith; Rev. J. G. Stevenson; Commissioner R. J. Sturgess; Miss G. Toynbee,
Drs. A. Wallace, A. White, and R. Wiglesworth.

Apologies for absence were received from Drs. J. L. Baskin, T. S. Clouston,
C. H. Fennell, Robert Jones, H. Wolseley Lewis, Bedford Pierce, J. Stewart, and
A. R. Turnbull.

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180 NOTES AND NEWS. [Jan.,

The minutes of the last quarterly meeting having been previously printed in the
Journal, were taken as read, agreed to, and signed.

The following new members were unanimously elected:

Harold Reginald Burpitt, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Metropolitan Asylum, Darenth, Dartford, Kent. Proposed by
A. Rotherham, R. H. Steen, and H. Hallett.

John Stothart Farries, L.R.C.P., L.R.C.S.Edin., Assistant Medical Officer,
Royal Albert Asylum, Lancaster. Proposed by Archibald R. Douglas, D. M.
Cassidy, and H. Hayes Newington.

Mules, Bertha Mary, M.B., B.S.Durh., Court Hall, Kenton, South Devon. Pro¬
posed by P. Maury Deas, H. Hayes Newington, and C. Hubert Bond.

James Parker, L.R.C.S.&P. and L.M.Irel., Assistant Medical Officer, West
Riding Asylum, Wakefield. Proposed by W. Bevan-Lewis, H. Hayes Newington,
and C. Hubert Bond.

Helen C. Stewart, M.B., Ch.B.Birm., Edae, Chigwell, Essex. Proposed by
Frederick W. Mott, A. I. de Steiger, and W. Stanley Hughes.

The President said that before he called on Dr. Albert Wilson, he wished to
make one or two brief observations. He was sure it was the desire of the meeting,
and of the whole Association, that there should be officially communicated to Mrs.
Urmson an expression of their sincere sympathy in the loss of Mr. G. H. Urmson,
who had been for many years a Commissioner in Lunacy. It would be agreed by
every one who knew him that Mr. Urmson was one of the truest English gentlemen
they could wish to meet. He also thought that reference should be made, at that
the first meeting after the event, to the signal and great honour which had been
conferred on an honorary member of the Association, Sir Thomas Clifford Allbutt,
K.C.B., and to him they offered hearty congratulations. He next mentioned, with
regret, the long and serious illness of a former President of the Association, Mr.
G. W. Mould, late of the Cheadle Asylum, who was now lying seriously ill in
Wales. He was sure it would be the wish of members to convey their sympathy
to him in his illness.

Dr. G. H. Savage said that it was perhaps scarcely necessary to put in the form
of a vote the expression of the feeling of members concerning the death of the
late Commissioner in Lunacy, Mr. Urmson. Some of them knew him not only
officially, but personally, and in whatever capacity they knew him they always
respected him, and looked upon him as being as fine a type of English gentleman,
English lawyer, and Commissioner as could be found anywhere. Therefore he
was sure all would agree that a message of condolence and sympathy should be
sent to Mrs. Urmson and family.

The resolution was agreed to in silence.

The President called upon Dr. Albert Wilson to supplement his previous paper
by a few short observations, and expressed the pleasure he felt at seeing so many
visitors present.

Several visitors and members took part in the discussion which ensued and Dr.
Wilson replied.

Dr. Robert Jones was to have communicated an account of the International
Congress on School Hygiene (at which he was the Association’s delegate) but was
unavoidably prevented from being present at the meeting.

In view of the lateness of the hour the description of the Amsterdam Interna¬
tional Congress on Psychiatry, etc. (held last September), which Dr. F. W. Mott,
F.R.S., had similarly kindly promised to give, was taken as read.

The members afterwards dined together at the Cate Monico.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division was held by the courtesy
of Dr. R. J. Stilwell at Moorcroft, Hillingdon, on October 8th, 1907.

Among those present were Drs. David Bower, W. H. Bailey, H. Baird, A.
Bowles, R. H. Cole, James Chambers, F. G. Crookshank, Augustus C. Dove,
R. Langdon-Down, F. Edridge-Green, J. Francis Dixon, David Hunter, J. Higgin-
son, H. E. Haynes, T. B. Hyslop, G. H. Johnston, P. G. Kennedy, J. Gordon
Munn, E. D. Macnarmara, J. J. Murphy, H. J. Macevoy, Mary E. Martin, E. S.

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1908.]

NOTES AND NEWS.

I8l

Pasmore, J. P. Race, W. Rawes, H. J. Stilwell, G. E. Shuttleworth, G. H. Savage,
J. Stewart, A. H. B. Stoddart, E. F. Sail, G. N. 0 . Slater, T. Outterson Wood,
F. Watson, and R. H. Steen (Hon. Sec.).

The visitors included Drs. Parry, C. R. Wood, R. Brown, and Mr. J. Stilwell.

Apologies were received from the President and Drs. J. Bayley, Fletcher Beach,
Bond, Boycott, Edwards, Elkins, Haslett, R. Jones, A. S. Newington, H. H.
Newington, P. C. Smith, Percy Smith, A. De Steiger, Seward, Taylor, and
Thomson.

The house, adjoining villas, and Hayes Park were inspected, and subsequently
Dr. R. J. Stilwell entertained the members to luncheon. At the termination of
the lunch Dr. T. Outterson Wood proposed a vote of thanks to Dr. R. J. Stilwell
for so hospitably receiving the Division.

A meeting of the Divisional Committee was held at 2.15, Drs. Crookshank,
Dixon, Langdon-Down, Slater, Stoddart, and Steen being present.

The general meeting was held at 3 p.m., Dr. T. Outterson Wood in the chair.
The minutes of the last meeting having appeared in the Journal were taken as
read and confirmed.

The invitation of Dr. Seward to hold the spring meeting of the Division at
Cobey Hatch Asylum on April 28th, 1908, was unanimously accepted, with much
pleasure.

Dr. Charles A. Mercier having, with regret, resigned his seat on the Council as
Representative Member for the Division in that as President elect he is a member
of the Council, Dr. H. Wolseley Lewis was unanimously elected Representative
Member for the Division.

Contributions.

“A Short Account of Moorcroft, Past and Present,” by R. H. Cole, M.D.

In response to the invitation of our Divisional Secretary to contribute to the
meeting to-day, it was thought possible that a few remarks dealing with the
development of this institution, which for nearly a century has been an asylum for
patients of the upper classes, might not be without interest. It would seem also
to be an opportunity for reviewing our work, and for observing what advances
have been made in the treatment of patients of this class.

The conditions of our practice here are somewhat different from # those of most
asylums, inasmuch as our patients are by no means under one roof! Indeed, our
work resembles a system of colonies, the component units of which extend into our
two neighbouring parishes; thus our male patients, with occasional exceptions,
live here in Hillingdon, whilst our female patients, for the most part, reside in
Hayes. It is hardly possible for one medical officer to make an efficient and com¬
plete round in the course of the morning, as this may entail a visit to nine or ten
houses and villas, some of which are situated about a mile apart from one another.

Moorcroft, the parent institution, was officially opened as a house for the recep¬
tion of the insane on July 1st, 1816. The great-grandfather of our colleague, Dr.
Reginald Stilwell, lived here at that date. Tradition states that his family offered
a homely shelter to occasional cases even earlier still. Most of these cases appear
to have been derived from the immediately surrounding district, but its easy access
from town soon commended it to some London physicians as a convenient home
for treating their patients in these pre-asylum days, and no doubt stimulated
the growth of the institution.

We have some early pictures of Moorcroft, which may be of interest to you in
illustrating what the place was like in these olden times, and we will point out
where the extensions were made. We are informed that the customary dress of
the patients at this period consisted of nankeen breeches, a buff waistcoat, with a
stock and a blue frock coat with brass buttons, and no one appeared in the garden
without a silk hat.

On examining the files containing the old admission papers, which may interest
you, we find the document for the reception of a patient was indeed simple in these
days, and we hand round specimens for your inspection. You will observe that
merely a written note from the medical attendant requesting the admission of a
patient was all that was required. The earliest that we can find are dated 1816.

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182

NOTES AND NEWS.

[Jan.,

During the ensuing four years the same procedure seems to have been followed.
These letters were probably only looked upon as safeguards for those receiving
the patients, and might be of use in the event of subsequent proceedings for sup¬
posed illegal detention, and were no doubt usual at this period.

In 1820 we notice the first printed form. This was called a medical certificate,
but no facts indicating insanity were stated therein. It served the purpose, how¬
ever, of showing that the patient had been personally examined by a medical man
whose opinion was that suitable confinement in a licensed house was necessary and
proper.

Nine years later, namely in 1829, new forms came into use, whereby two separate
medical examinations were necessary, but even then the certificates were of a
similar simple character. These were accompanied by an order of the patient’s
relative or guardian, together with a statement of particulars which was in dupli¬
cate, and involved the responsibility of the certifying medical men as well as that
of the person who signed the order. Perhaps the object of this was to corroborate
the identity of the patient.

This method continued for the next sixteen years, which brings us to the year
1845, when the basis of our present certificates was formulated. Facts indicating
insanity were then for the first time insisted upon, and, indeed, the certificates were
in substance much as they are now, but they appeared on the same sheet of paper.
This, as you are aware, was altered in 1890, when the order of a magistrate, on the
petition of a relative, was introduced.

The first report by officials that we can find here is dated in 1828, so that it is
improbable that the house was ever visited before that time by the commissioners
appointed by the College of Physicians. The house being embraced within the
sphere of the Metropolitan Commissioners, who were appointed by the Home
Secretary in that year, was subject to regular visitation by them four times annu¬
ally until the present Board was constituted in 1845, since which time the visits
have been increased to the present number.

The gradual development of Moorcroft and its annexes has been the natural
Outcome of the increasing number who have applied for treatment. It has been
the ambition of the proprietors to make such improvements as are possible with
old buildings to give adequate accommodation to the class of patients that is
received, and to keep abreast of all modern tendencies in the care and treatment
of the insane.

The oldest part of Moorcroft House dates back to Tudor times and forms
the central part of the present structure. With greater foresight than was shown
in many contemporary houses the original designers fortunately planned the
building in such a manner that the principal living rooms face south. At this
period it was a farmhouse and the front door was where the garden entrance to
the smoking room now is. The age of this room is established by what remains
of the original fireplace and its supporting oak beam. The characteristic bricks
and their arrangement in herring-bone pattern deserve notice. There is also a
portion of the old masonry to which additions have been made in recent times.
The window frames in this room, the adjoining dining-room and in the bedrooms
above on the first floor, indicate the extent of the first house. The electricians
found considerable difficulty in wiring this portion of the building for lighting
purposes owing to the thickness of the floors.

There are small cellars below this part, and it is recorded that ten priests were
once concealed there for four days, having sought a hiding place in the days of
their persecution; a priest-hole perhaps secure, if not comfortable, since it is men¬
tioned at that time the floor was covered some inches in water. Reference is made
to this in a book entitled Secret Hiding Places in England , by Mr. Fae.

The kitchen and offices for the steward, etc., are at the back of the central part
of the house and they have been modernised from time to time.

Both sexes were at first tended in Moorcroft House itself, and the numbers
increased year by year so that there were 18 in 1837, 25 in 1840, 30 in 1843. Ex¬
tensions became necessary, another storey was superimposed, and the structure was
augmented in both easterly and westerly directions. In 1848 Woodend House
was acquired and the ladies were transferred to that establishment in order to give
more accommodation to the gentlemen. The west wing which contains the large
general sitting-room, attendant’s quarters, and dispensary was built in 1876, and is

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NOTES AND NEWS.

183

1908.]

that part of the present building which is used by our less tractable patients. The
east wing was added in 1891 and has served largely as a family residence of our
colleague’s parents, Mr. and Mrs. John Stilwell, who undertake the lay manage¬
ment of the institution.

The license for Moorcroft is granted for 48 patients, including 8 ladies, who are
accommodated at Laurel Lodge and the cottage.

The Lawn—the house in the front garden, formerly occupied by Dr. Henry
Stilwell, who retired last year after forty-six years’ service, is now used as a recep¬
tion house for borderland cases or for a single certified patient. There is also
a separate villa at the farm, which has been used as occasion arises, and we fre¬
quently have single cases in houses in the district further afield.

The extent of the gardens, orchard, and pasture lands comprises nearly sixty
acres of ground surrounding Moorcroft. The cricket ground is largely patro¬
nised, and there are ample walks for those patients who are unable to take their
exercise beyond the grounds. The flower garden is used for convalescent and
quiet patients, and here the usual tennis courts, croquet lawns, golf and bowling
greens are provided. The billiard room is built away from the house, which in
our opinion has some advantages.

Church services are held morning and evening every Sunday in the large general
sitting room in the west wing, where also our entertainments usually take place.
The fire arrangements consists of hydrants and hose, both inside and outside the
house, connected with a water supply of considerable pressure. We also have
Minimax extinguishers to be used in case of need. Periodical fire-drills are prac¬
tised by the attendants under the superintendence of one of the medical officers.

Woodend House and Hayes Park, where most of our ladies reside, are licensed
for 19 each, and were opened in 1848 and 1849 respectively. The former is an old-
fashioned building with a delightful old garden, and is very comfortable. It is said
to be on the site of a former house which served as a hunting-box for Henry VIII.
Hayes Park, which was annexed five years ago, is a more modern mansion stand¬
ing in sixty acres of ground. It has some separate villas, in one of which our
colleague, Dr. Higginson, the special medical officer resides.

Our registers show that over 1300 cases (700 males and 600 females) have been
under treatment since the three licensed houses were opened. The average
numbers in residence during the past five years are 39 gentlemen and 39 ladies,
excluding a few single cases and voluntary boarders, whilst the admission rates on
the licenses during this period consists of 11 gentlemen and 18 ladies, 29 in all per
annum. These numbers vary considerably in individual years and depend to some
extent on the vacancies which arise, and we usually have more changes on the
female than on the male side. Our recovery rate, according to our books of the
last quinquennium, excluding the transfers on admission, works out at 39*5 per
cent . for our gentlemen, and 447 per cent, for our ladies. The death-rate in the
same period has been 5*3 per cent. t or 87 per cent, for the gentlemen, and 2 per
cent, for the ladies. These figures are of little value with our small numbers, but
apparently we have progressed during the past half-century, for, on taking the five
years, 1839 to 1843, the statistics of which are available, in the Commissioners’
reports we notice that the recovery rate for both sexes in this asylum was 19 per
cent, and the death-rate was 10*2 per cent.

With regard to our patients we regret that we are unable to give you any
demonstration of them as can be done with pauper patients, especially as we have
some of great interest. We do not appear to receive so many cases of acute mania
as in former years. Delusional melancholiacs with refusal of food and suicidal ten¬
dencies, paranoiacs, and cases of dementia praecox are very prevalent amongst our
recent admissions. General paralysis we receive practically on the male side only,
and we have as many as five in the house at the present time, all of whom have a
reliable history of specific infection. During the past five years they form 7 per
cent, of the total admissions—in one of these years we received as many as seven,
whilst in the previous year not one was admitted. During the past sixteen years
we have had 30 cases, including one juvenile general paralytic. Their average
age has been forty-four, the youngest being 27, the oldest 62. Two have lasted
over six years, but their average duration has been two and a half years. Latterly
we have found the operation of lumbar puncture to be helpful in establishing the
diagnosis in doubtful cases.

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I 84 NOTES AND NEWS. [Jan,

We endeavour to trace family histories with special regard to hereditary taint,
but it is difficult to obtain accurate information inasmuch as the relatives of private
patients wilfully mislead us in the matter. We do not propose to discuss etiologi¬
cal factors, but we would like to mention that alcohol, in our opinion, plays but a
small part as a causative agent in our cases. This we believe to be in accord with
the experience of most private asylum medical officers.

As to treatment our aim has been to guide our patients through their attacks
with the feeling of as little restraint as possible. This has entailed no little anxiety
at times, although our staff of nurses and attendants is adequate. The con¬
valescing patients are encouraged to feel the freedom of an ordinary eountry house,
and are duly classified and separated from those of a more disturbing nature. We
try to individualise our treatment as much as possible, and we believe greatly in
the beneficial effect of the sane on the insane mind. Besides the gentlemen com¬
panions that are engaged as occasion arises the medical officers devote a large pro¬
portion of their time to the patients, for it has not seemed right to leave sensitive
and convalescing patients of the upper classes too much to the care of attendants.
It has always been difficult to induce our patients to take up manual work; we
endeavour, however, to promote this object by encouraging them to assist in some
of the lighter occupations connected with the farm and garden. To amusements
rather than work we are bound to have recourse to find employment for them.
Bicycling, motoring, and horse exercise are encouraged, as well as the usual
pastimes and recreations.

With regard to medicinal treatment, on examining some of the old case books,
one notices with surprise the large amount of opium that was administered in
former years to allay excitement. Tartarated antimony seems to have been a
favourite remedy for acute cases. The blue pill and black draught were freely
given for the benefit supposed to be derived from a reducing effect. Our ideas
have changed since then, for now we feed up our patients who are in a state of
excitement, and our melancholics are washed out in accordance with modern
toxaemic theories. We share the views held by the Association generally as
regards the sparing use of hypnotics and sedatives. These, however, we have to
give in obstinate cases of insomnia or where restlessness persists, and the new
drugs are given a fair trial directly their virtues are extolled. It has been
customary to rely a great deal on bromides judiciously administered sometimes in
large doses, believing as we do that the bromides are less harmful than the more
complex and modern drugs, especially to highly organised brains. Great things
were hoped for when thyroid was first introduced as a therapeutic agent in mental
diseases, and, although we have observed excitement supervene in cases of stupor
from the administration of this drug, we cannot claim a recovery from its use.

Through the kindness of Dr. Ford Robertson and Dr. McRae, of Edinburgh, we
have lately been enabled to treat two cases of general paralysis with their anti¬
diphtheroid serum. Both have shown marked improvement, whether propter hoc or
post hoc we are not prepared to say. The one aged twenty-seven was first injected
last Christmas after six months acute and violent excitement. To the other, aged
forty-one, of a melancholic type, the serum was first administered in March shortly
after admission. Twenty c.c. of the injections were given subcutaneously once a
week, but latterly the serum has been poured through the nose or taken through
the mouth. On every occasion there has been a slight feverish reaction, which
we are informed does not take place in non-general paralytics. The first patient
has so far recovered as to return to his wife, and continues to have the serum
under our supervision in town. The other patient is still here, and shows certain
improvement. Both still exhibit motor signs of the disease, but it is possible that
a remission of mental symptoms at any rate may have been assisted by the use of
this serum.

Treatment by baths plays a small part here, and, as in other institutions, we use
the bath to subdue cases of excitement. The electric bath is also used from time
to time for some of our neurasthenic cases. We do not treat our acute cases in
bed so much as is customary in public asylums, but cases of acute delirious mania,
cases of exhaustion, and melancholics with determined suicidal tendencies are
kept in bed. We prefer still to let our acute manias expend their excitement as
much as possible in the open air. We feel, in spite of what has been said against
it, that it is better to have a healthy outlet for the morbid energising of the brain.

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185

rather than to subject a restless or violent patient to the restraining influence of
enforced rest in bed during the daytime.

Open-air treatment for the insane is under discussion at the present time. Last
year we treated a case of melancholic stupor in an open-air tent in the garden
during the summer months with some improvement in the patient's general
condition, although mentally there was practically no change.

Hanwell being in such close proximity to us, the dominant influence of Conolly
made itself felt here from the commencement of his movement against the use of
mechanical restraint. It appears from the past records that but little restraint was
ever used at Moorcroft, and we have not been able to find any implements such as
are exhibited in some of our old asylums. We still believe that a strait waistcoat
has its proper place as a remedial agent to prevent injury to self or others in some
cases where struggling with attendants would otherwise ensue. So also seclusion
is, on rare occasions, practised here, and we find the benefit of a padded room. In
cases of refusal of food our custom, as a rule, is to use the nasal tube with a
funnel, our experience being that this is the best form of forcible feeding when
this is impossible by means of a spoon. There are some antiquated stomach
pumps here, but they are never used now, although sometimes the large oeso¬
phageal tube is passed in order to administer food of a thicker consistence or
where the nasal tube is difficult to pass.

Suicidal attempts have occurred here as at most asylums. As each patient
sleeps in a separate bedroom we have no system of partial supervision at night
such as we can exercise in the day time. As a patient improves there comes a
time when the presence of the attendant can be dispensed with to test the patient
and to promote recovery, and we have to rely on our judgment in this matter.
Casualties from actual violence affecting the medical officers and others have been
rare, although not unknown, but we are glad to say nothing serious has ever
happened. Occasional escapes have been made, but on the whole the system of
parole given to patients has not been abused. Very rarely has any trouble arisen
from patients when out for recreation, but we could mention instances of chronic
patients, usually quiet and manageable, breaking out suddenly into excitement, so
that one feels an insane person can never be implicitly trusted.

Our attendants’ staff at Moorcroft consists of a head attendant and sixteen
others, and a night attendant who makes hourly rounds. Extra attendants are
engaged for suicidal cases. At our ladies’ establishments we have twenty-one
nurses who are supervised by six lady companions. The attendants for the
most part live in cottages in the district, and are not prohibited from marrying.
They therefore remain long in our service. A father and son in more than one
instance have been employed at the same time. Our senior attendant, who can
count upwards of forty-five years’ service, and has been awarded the gold medal
of the Asylum Workers' Association, has during the past year been placed on the
pension list by reason of ill-health. We make it a rule now to insist on all new
comers to our attendants’ staff being total abstainers, and we have no difficulty in
finding men willing to be teetotalers. A course of lectures is given each year for
the instruction of nurses and attendants, many of whom possess the nursing
certificate of the Medico-Psychological Association. They are encouraged to
join the A.W.A., and to take a general interest in their calling. We prefer to
e °gage as attendants for the most part men retired from the services, especially
those who have been accustomed to valet and wait upon gentlemen.

Moorcroft being originally a family residence, its influence as such has been
maintained to the present day. The two lady companions on the male side we
find of the greatest assistance in promoting the patients welfare. No harm has
ever come to them from their freely mixing with the quiet and orderly patients,
and their presence has a distinctly humanising tendency. It must be remem¬
bered that more than half our patients are chronically insane, and therefore the
general arrangements have to be adapted for their comfort and happiness, and it
has been our object to make them feel their position as little as possible. Our
dependencies being separate afford opportunities for frequent parties and enter¬
tainments, where those of both sexes who are well enough assemble together, and
this association has a social and beneficial effect.

Moorcroft, like most other private asylums in the country, seems to have
fulfilled its purpose to the satisfaction of the public and profession alike judging

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186

NOTES AND NEWS.

[Jan.,

from its steady development in the past. As to the future we cannot increase our
numbers as public asylums do, for, as you are aware, no extension of a license is
permissible; we therefore try to improve our accommodation year by year for
those included in the licenses, and take a few extra patients when their mental
state permits in villas outside. We are in accord with the proposed clause in
future lunacy legislation as to the notification of incipient cases of insanity. In
the present state of public feeling this will be a great relief to those who have the
horror of certification at the outset of an attack of insanity. Looking ahead at
the probable future expansion of London it is not unlikely that the work here may
some day have to be moved further afield. However, for the present we are in
rural surroundings in a reposeful atmosphere, and our patients can still take their
walks in country lanes.

Having made an inspection of our establishments this short account is merely
meant to Serve as a supplement, and may possibly provide material upon which
some members of the division may feel inclined to raise a discussion as to the
management of private patients. We shall therefore be glad of any criticisms
and suggestions that may help us to further improve the condition which we have
at present reached in our work at Moorcroft and its dependencies.

In the discussion which followed, the Chairman expressed the gratitude of the
Division for the very interesting paper contributed by Dr. Cole, and in comment¬
ing upon the admirable nursing arrangements at Moorcroft he hoped that the
word attendant would soon be banished, and that the word nurse would take its
place for all those of both sexes who tend the insane.

Dr. Bower stated that his own figures with regard to alcohol corresponded with
those of Dr. Cole, and pointed out how they differed from those in the Blue
Books. He believed that in many cases the alcoholic intemperance was more the
result of the insanity than the cause of it. The supervision of the suicidal
patients was an important question, and he often found difficulty in deciding as to
when total supervision could best in the interest of a particular patient be with¬
drawn.

Dr. Stewart followed, and stated that in his opinion in 70 per cent, of the
inebriates the inebriety was not the result of alcohol, but that the taking of alcohol
to excess was the result of the inebriates being neurotics.

The Medico-Psychological Association should let the public know that it is not
satisfied that alcohol is the cause of insanity to the extent it is supposed to be.

Dr. Savage, in thanking Dr. Cole for his paper, pointed out the many advan¬
tages to be found in private as compared with public asylums. Among these he
would specially mention the great individual care which was possible, in a well-
managed private institution.

Dr. Cole replied.

“ Babinski’s Conception of Hysteria.” By W. H. B. Stoddart, M.D.

I am only too well aware that there may be several members of my audience to
whom Babinski’s views as to the nature of hysteria are familiar, and who may have
come here under the misapprehension that I am about to offer a criticism of those
views. To such I offer my apologies, for, at the outset, I wish to say that I am in
entire agreement with Babinski in this matter, and I propose merely to give an
exposition of his views, believing that they are not as well known in this country
as they deserve to be.

The very name of the disease already predisposes to a misconception as to its
nature, being derived from a Greek word varepa, meaning the uterus; it being
supposed in former times that hysteria was the result of some functional disturb¬
ance of the generative organs, perhaps sexual excess or sexual deprivation. With
subsequent experience, however, we have come to learn that hysteria has nothing
to do with the uterus, since it occurs almost as frequently in men as in women,
and it occurs in children before the onset of puberty, and in old people after the
sexual functions have become extinct.

Now Pye-Smith used to submit that the essential features of a good name for a
disease were that it should be short, classical, meaningless, and capable of forming
an adjective. The word hysteria possesses all these characteristics, if you will
allow it to become meaningless. Just as you allow the word artery (a structure
containing air) to be meaningless, so far as its derivation is concerned; there will

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NOTES AND NEWS.

1908.]

187

then be no reason why we should not retain the name " hysteria ” for the disorder
we are about to discuss.

It is necessary, however, that the disorder known as hysteria should be defined.
If you will take the trouble to look up the definition as given by various authors,
you will find that there is no unanimity of opinion; and some authors, especially
Las^gue, go so far as to say that the definition of hysteria has never been given
and never will be.

This is a deplorable state of affairs. To say that words, which we intend to
retain, cannot be defined is as much as to suggest that words precede ideas. What
would you think of a naturalist who said that it was impossible to define some
zoological species, whose existence he admitted ?

We must admit either that hysteria is a nosological entity with definite character¬
istics, and therefore capable of being defined, or that we are confusing it with other
neuroses, to which the various cases, hitherto called hysterical, will have to be
relegated. Such are the alternatives to which we are inevitably led, and I believe
that no neurologist would hesitate to accept the former. The majority of medical
men who have written on hysteria have not contested the possibility of a definition,
but they have not felt equal to enunciating one, which even they themselves could
regard as satisfactory.

Hysteria, according to the commonly accepted view, is characterised by a certain
grouping of symptoms, and it is only possible to define it by describing these sym¬
ptoms succinctly and showing how they are related to one another.

It is generally said that hysteria is manifested by two different kinds of disorder,
the first being permanent—the stigmata of hysteria—and the second being transi¬
tory. The stigmata, to which great importance is attached, have the characteristic
that, besides their fixity, they develop unknown to the patient. They are
anaesthesia of the back of the throat, hemianaesthesia consisting, when well
developed, of abolition of cutaneous sensation in its various forms, unilateral
diminution of the acuity of the special senses, especially of vision, with concentric
retraction of the visual fields, monocular diplopia or polypia, and a dyschroma-
topsia which, unlike that of tabes and alcoholism, affects blue and violet, while
perception of red remains normal. The characteristic headache known as clavus
hystericus, ovarian hyperesthesia and submammary tenderness are also reckoned
among the stigmata. Among the transitory phenomena are included such sym¬
ptoms as hysterical convulsions, paralyses, contractures, aphonia and mutism.
These usually appear quite suddenly, perhaps under the influence of some emotion,
they last some time and then disappear just as suddenly, perhaps to give place to
some other transitory phenomenon.

Such is the classical conception of hysteria. It follows that when one is con¬
fronted with a patient presentingany of the transitory hysterical manifestations, one
proceeds to look for the stigmata ; if they are present there is no longer any hesita¬
tion as to the diagnosis of hysteria. Many are not even as exacting as this ; when
any given symptom appears to them difficult of interpretation and cannot, in their
opinion, be ascribed to any other neurosis, they feel justified in calling the symptom
hysterical, provided they can discover any of the hysterical stigmata in the
patient.

By such a method of procedure, the most varied symptoms are at times classed
as hysterical. You will gain some idea of the extent to which this principle may
be carried, if I enumerate some of the disorders which have been ascribed to
hysteria.

Without referring to the convulsions and anaesthesias already referred to, we
have paralyses of all kinds, hemiplegias, monoplegias, paraplegias, as well as
paralyses limited to the distribution of one or more peripheral nerves, such as
musculospiral paralysis, and paralyses of the third or sixth pair of cranial nerves.
Hysterical neuralgias are also described, especially hysterical sciatica.

Divers forms of mental disorder are also at times attributed to hysteria.

The visual apparatus is held responsible for a wealthy array of hysterical mani¬
festations; besides the diminution of visual acuity, retraction of the visual fields
and ocular paralyses, already mentioned, hysteria is held responsible for pupillary
immobility during the convulsions, and even between the convulsions, as well as
for inequality of the pupils and abolition of the light reflex.

Cutaneous and vasomotor troubles are also from time to time ascribed to hys-

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188 NOTES AND NEWS. [Jan.,

teria:—Erythemata, haemorrhages, petechiae, bullae, ulcers, and even gangrene.
Numerous observations of hysterical oedema, especially oedema with cyanosis,
have also been published.

Among hysterical disorders of the respiratory system, we hear of aphonia,
mutism, spasm of the glottis, oedema of the glottis, pulmonary congestion and
haemoptysis.

Tachycardia, bradycardia, and angina pectoris are also sometimes described ais
hysterical. Gastralgia, vomiting, haematemesis, polyuria, anuria, haematuria,
albuminuria, incontinence and retention of urine have all been described as mani¬
festations of this neurosis.

Lastly, hysterical fever has frequently been described, and recently cases have
been put on record, which have been considered indisputable. This is an incom¬
plete list; but it will give you some idea of the various ways in which it is
supposed that hysteria may manifest itself. Charcot used to say that hysteria was
the great simulator; a more recent way of expressing the same opinion is, “ Hys¬
teria can do anything.” There are plenty of medical men who are quite ready to
accept such a view, since it conforms quite readily to their nebular conception of
hysteria; but I think most of you will already have come to the conclusion that
such a conception of hysteria is too wide.

I will now subject this conception to criticism, using, as far as possible,
Babinski’s own words, but, of course, substituting English for French.

First, let us consider the stigmata which, according to the classical doctrine, are
of fundamental importance. Fixity or permanence is regarded as one of their
essential features. We believe, however, that we are justified in contradicting this
assertion, since for many years we have found that, whenever we are confronted
with a patient presenting hemianaesthesia or contraction of the visual fields, we
endeavour to cause these disorders to disappear, and, except in the case of those
patients with whom hysteria is their profession and a source of income, we have
succeeded in every case. When I have before me a patient presenting hysterical
hemianaesthesia or general anaesthesia, however complete it may at first sight
appear to be, transfixion of the integuments with a needle evoking no evidence of
painful perception, I proceed as follows:—I apply to the pulp of the fingers two
electrodes (one being a stiff wire brush) connected with a faradic battery giving a
maximum current. Nineteen times out of twenty the patient withdraws his hand
and makes a grimace denoting painful perception. Some of these patients will
not allow the electrodes to be applied again, they prefer to go to some other
doctor, whose electrical apparatus may be undergoing repair; others, who, I am
glad to say, are in the majority, recognise that they nave experienced the sensa¬
tion, and wish to continue treatment. I then repeat the application with the
assurance that it is an infallible cure for anaesthesia; and—as I have said—one
meets invariably with success, the cure sometimes being effected at a single sitting.
By analogous proceedings we can easily cure contraction of the visual fields,
dyschromatopsia, and anaesthesia of the throat which, by the way, is incorrectly
called " loss of the pharyngeal reflex,” for reflex excitability is never abolished in
these cases.

The second cardinal feature of the stigmata is that they develop unknown to
the patient. Now, we are of the opinion that these phenomena are the result of
autosuggestion, or rather of unconscious suggestion on the part of the medical
man, a view which has previously been advanced by Bernheim, of Nancy. The
usual mode of examination of a hysterical patient is of such a nature as to suggest
to his mind the idea of hemianaesthesia or of some visual disorder; it is,therefore,
of the utmost importance to take every precaution to avoid this fallacy.

It is inadvisable to examine these patients before others, or to talk to one’s
students before the patient about symptoms which may be observed in hysteria.
The same circumspection should be observed when the patient is in a convulsion
and apparently unconscious, seeing that we have to deal rather with a case of sub-
consciousness, in which every remark made in the patient’s presence will be
remembered. Before examining sensation it should be explained to the patient
that he will feel light touches, pinpricks, pinches, sensations of warmth and cold,
and that he will be required to say what he feels on each occasion. The various
stimuli should then be applied, and interspersed with passive movements of the
limbs. If there is no response, say “ What do you feel, what did I do to you P ”

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1908.]

NOTES AND NEWS.

189

Bat never say ,f Did you feel that ? ” or •' Do you feel as well on one side as on the
other ? ” because such a way of putting the question suggests anaesthesia to the
patient. By adopting this method for many years Babinski has not found a
single case of hemianaesthesia among patients, who had not previously been
submitted to a neurological examination. Babinski’s experience extends to more
than one hundred such patients who were undoubtedly hysterical.

Similarly, contraction of the visual fields does not develop spontaneously without
the influence of suggestion. You are all well aware of the usual method of investi¬
gating this symptom. The patient is placed in position before a perimeter, and
he is asked to say, as the carrier is moved forward, when he sees the piece of
paper which is placed in it; or, as the carrier is moved backward, when the paper
disappears. This mode of procedure is insufficient and fallacious. Vision is
normally indistinct at the periphery of the field, and a hysterical patient is liable
to wait until his perception of the paper is perfectly clear, thus leading the
observer into error, and serving as a point d'appui for subsequent suggestion and
autosuggestion. It ought first to be explained to the patient that he is to make
some sign as soon as he is able to say that there is anything there, and that he is
not to wait until he has a clear perception of the paper. The carrier should
occasionally be advanced without any paper in it, so as to ascertain that the
patient is not making random shots, and it should be alternately advanced and
retired so as to get the maximum visual field. Examined in this way none of
Babinski’s patients exhibited contraction of the visual field, provided they had not
previously been subjected to similar ophthalmic examinations. Similarly,
Babinski has never met with monocular diplopia or polyopia or so-called dys-
chromatopsia, t. e. among new patients. And similarly with the other stigmata,
such as ovarian hyperesthesia, they are all the result of suggestion.

Thus, gentlemen, you see that the symptoms called stigmata are not permanent
phenomena, and that they do not develop unknown to the patient; they are
found to be wanting, at least in the majority of cases, when the examination is
carried out in the manner which I have indicated. They are not of that funda¬
mental importance which the classical conception of hysteria attributes to them ;
and definitions of hysteria founded on their existence must find themselves shaken
to their foundation.

Passing to the transitory manifestations of hysteria I will endeavour to show
that, of all the characteristics above enumerated as contributing towards a defini¬
tion of hysteria, there is not one which ought to be retained. That emotion
plays an important rdle in the genesis of hysterical troubles is incontestable ; but
it may also be responsible for attacks of asthma, gout, circulatory troubles in
patients suffering from certain vascular lesions, and even for the onset of diabetes ;
this feature is therefore not characteristic of hysteria, and can take no place in the
definition. Nor can rapidity of disappearance be regarded as a special feature of
hysterical phenomena ; the pain of a renal colic or of a tabetic gastric crisis may
disappear quite as suddenly. And as regards one manifestation clearing up and
giving place to another, the same thing occurs in gout. Finally, hysteria is not
the only malady which, as a rule, causes no disturbance of the general health;
psychasthenics (patients who suffer from obsessions, morbid impulses, and morbid
fears) enjoy good general health.

You see therefore, gentlemen, that the classical definition of hysteria cannot
stand the test of criticism, either when examined as a whole or in respect of any
of its details.

In order to frame a definition of hysteria it is necessary to determine and to
enunciate the features which are peculiar to it. To do this we must analyse such
nervous manifestations as hysterical fits, certain contractures, hemianaesthesia,
monoplegia, and other paralyses and manifestations, all of which medical men
are unanimous in regarding as hysterical; and we must compare them with those
nervous troubles which, in the opinion of everybody, are certainly not hysterical.
We shall then be able to judge of the distinctive characters of hysteria.

Having cleared the ground in this way Babinski is led to the conclusion that
hysterical manifestations possess two attributes, viz.:

(1) The possibility of being reproduced by suggestion, with rigorous exacti¬
tude, in certain subjects, and

(2) The capability of disappearing under the exclusive influence of persuasion.

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NOTES AND NEWS.

[Jan.,

Babinski draws an important distinction between suggestion and persuasion.
Suggestion signifies the action by which we endeavour to make someone accept or
realise an idea which is manifestly illogical. To tell someone whose muscles are
functioning normally that he is hemiplegic or paraplegic is to suggest , but to
declare to a patient with functional paralysis that he will get well, either by a
simple effort of will, or by the aid of electrotherapy or other treatment, is to per¬
suade, for the idea is reasonable or at least it is not an offence against reason.

To continue our argument. The symptoms undoubtedly hysterical, which I
have already mentioned—fits, hemianaesthesia, and so on, can in certain subjects
be reproduced by suggestion so faithfully that it is impossible to distinguish the
copy from the model; I need not insist on this point, for I would certainly find no
one to contradict it. On the other hand, any of the classical affections now
regarded as non-hysterical can not be exactly reproduced by suggestion. One may,
perhaps, obtain a very imperfect imitation, which it would be quite easy to distin¬
guish from the original; but I defy anybody to reproduce by suggestion to any
individual, however suggestible or hypnotisable he may be, the characters of a
peripheral facial palsy, musculo-spiral palsy, paralysis of the oculo-motor nerves,
organic hemiplegia or organic paraplegia. It would even be impossible to obtain
a faithful reproduction of other neuroses. Assuredly, one might produce by sug¬
gestion a morbid fear, an obsession or a pain in the head, and one might thus
create states of mind which might be mistaken for psychasthenia or neurasthenia
by a superficial observer, but a medical man, familiar with these affections, would
not allow himself to be so easily deceived, he would interrogate such subjects
attentively and, if necessary, would follows the case for some time to avoid
confusion.

Just as all the major hysterical manifestations may be reproduced by suggestion,
they are susceptible of being dispelled under the exclusive influence of persuasion,
and there is not one of these manifestations, which one has not at some time or
other seen dispelled a few moments after adopting the proper means of inspiring
the patient’s confidence in a successful termination. This occurs in no other
affection, and, if one has had no experience in this method of treatment, one is
surprised at the setbacks one receives when one attempts to cure by persuasion
certain patients, with whom one would, h priori , expect this method of cure to be
efficacious. Take the case of a patient suffering from obsessions, probably an
intelligent man, having no delusion and fully realising the absurdity of his thoughts,
knowing that there is no ground for his fears, and animated with an ardent desire
to get rid of a trouble which renders his life intolerable; let us suppose, further,
that this patient is readily hypnotisable. Such a case appears to offer the most
favourable conditions for cure by persuasion. But experience gives the lie direct
to such preconceived notions; persuasion may procure for the patient a certain
degree of calm which is useful to him ; but it is incapable of curing him. Again,
let us suppose that we have to deal with a neurasthenic who is in constant fear of
mental enfeeblement, and is tormented by hypochondriacal ideas that he cannot
chase away; he beholds himself threatened with insanity, and this obsession,
which is a real mental process, aggravates his neurasthenic symptoms. If one
can manage to persuade the patient that his fears are ill-founded, and that therefore
he ought to get well, one procures that mental rest which is indispensable for him,
and which accelerates his return to normal health. The psychotherapy has done
good, it has accelerated the amelioration of the patient’s disorder, but it has not
been the sole means of cure: in such cases, we have recourse to other means,
especially mental and physical rest more or less prolonged.

I have so far referred only to the primary manifestations of hysteria, such as
anaesthesias, paralyses, contractures, crises, mutism, etc., which may appear with¬
out having been preceded by other hysterical manifestations. I take it, however,
that it is legitimate also to call those symptoms hysterical which, without present¬
ing the characters of primary symptoms, arise as a direct result of these, and are
dependent upon them. To such symptoms, Babinski applies the epithet secon¬
dary. Muscular atrophy in hysteria is of this kind; it never appears primarily;
it cannot be induced by suggestion ; it is entirely dependent on and subordinate
to some hysterical paralysis or contracture. It is an atrophy from disuse—a
secondary manifestation.

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You will say that I have only defined hysterical symptoms, and you would ask
me to define hysteria.

I might reply that hysteria is a psychical condition rendering an individual,
suffering from it, susceptible of suggestion and liable to autosuggestion ; we have
seen, in fact, that certain symptoms, such as hemianaesthesia and contraction of
the visual fields are the result of medical suggestion and, in the cases in which the
suggestion is not apparent, it is justifiable to conclude that we have been unable to
trace it or that autosuggestion has been at play. But you may object that certain
disorders, absolutely foreign to hysteria, are also the result of autosuggestion; is
it not by some sort of autosuggestion that the hypochondriac comes to the con¬
clusion that he is suffering from an incurable disease, or the paranoiac imagines
that a conspiracy is at work against him ? As a matter of fact, the mental process
is quite different, for this reason :—The autosuggestions of the hysterical patient
are susceptible, as I have just shown of being reproduced by suggestion and dis¬
pelled by persuasion ; this is not the case with the delusions of the hypochondriac
or the paranoiac.

It is, of course, impossible to separate hysteria from its manifestations ; to do so
would be to materialise an abstraction; and if we wish to remain within the realm
of fact, on clinical terra firma, so to speak, it is the hysterical manifestations
which we should seek to define. From such consderations, I now make a slight
modification in the text of the definition which I have already given and, by way
of r£sunU t I submit to you the following definition (Babinski’s):

Hv steria is a peculiar psychical state which is capable of giving rise to certain
conditions which have features of their own.

It manifests itself in primary and in secondary symptoms.

The former can be exactly reproduced by suggestion in certain subjects, and can
be made to disappear under the sole influence of persuasion.

The secondary symptoms are in direct relationship and subordination to the
primary ones.

In the discussion which followed the Chairman, Drs. Savage, McNamara,
Dixon, and Crookshank took part.

Dr. Stoddart having replied the meeting then terminated.

The members to the number of fourteen dined together afterwards at the Cafe
Monico.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of this Division was held on October 25th, 1907, at
Fisherton House, Salisbury, by invitation of Dr. Baskin, who kindly entertained
the members to luncheon.

The following members were present: The President, Drs. Baskin, Ireland
Bowes, Glendinning, Mackeown, Morton, Nelis, Eden Paul, Pope, Prentice, (the
Hon. Div. Secretary), and one visitor.

The Chair was taken by the President.

William Edward Ruttledge, L.R.C.P.Lond., M.R.C.S.Eng., Assistant Medical
Officer, Somerset and Bath Asylum, Wells, was, on the recommendation of Drs.
Pope, Shera and Aveline, elected a member of the Association.

Dr. Pope showed plans and gave a short description of the York City Asylum,
and Dr. Baskin read a paper on “ Insane Movements,” illustrated by a case.

The proceedings terminated in a vote of thanks to Dr. P. W. Macdonald for
presiding, and to Dr. Baskin for his hospitality.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held, by the
invitation of Dr. Middlemass, at the Sunderland Borough Asylum, Ryhope, on
Thursday, October 17th, 1907, at 2.30 p.m. Dr. Middlemass presided.

The following members were present:—Drs. Archdale, Eades, Fraser, Geddes,
Harris-Liston, Hopkins, Kershaw, C. MacDowall, T. W. MacDowall, Mackenzie,
Merson, Miller, B. Pierce and Dr. Middlemass.

The following visitors were also present :—Dr. C. A. Drew, of the Massachusetts

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Asylum for Insane Criminals; Drs. Morgan and Hubbersty, of Sunderland; Rev.
Dr. T. Randall.

The minutes of last meeting were read and confirmed.

A letter was read from Dr. Ewan, suggesting that the North and Midland
Divisions should divide owing to the large area the joint district includes. The
President, Drs. MacDowall and Miller doubted the wisdom of making any change,
but on the motion of the President, seconded by Dr. Hopkins, it was resolved to
refer the letter to the Divisional Committee for further consideration.

Dr. Merson moved and Dr. Arch dale seconded that Drs. T. W. MacDowall,
Hitchcock, and Macphail be reappointed to form the Divisional Committee.

As previously arranged it was announced that the next meeting would be held
at Storthes Hall Asylum, near Huddersfield, on April 30th, 1908, at the kind
invitation of Dr. Adair.

On a ballot being taken, Annie Davidson Urquhart, M.B., Assistant Medical
Officer, Northumberland County Asylum, was unanimously elected an ordinary
member.

Dr. Middlemass showed a patient with marked inco-ordination of the muscles of
leg, arm, and those concerned with speech, accompanied by a spastic condition
with some mental enfeeblement. The patient’s elder brother, admitted at the
same time with very similar symptoms, had died, and at the autopsy there was no
evidence of insular sclerosis. In discussing the cases Dr. Middlemass suggested
that they appeared to resemble what had been described by Westphal as “ pseudo-
sclerosis.”

Dr. Colin MacDowall read a Report on Three cases of Juvenile General
Paralysis occurring in Female Patients (see page 112). In the discussion which
followed, Drs. Middlemass, Morgan, B. Pierce, and Drew took part.

A member introduced an informal discussion on some of the lessons of experi¬
ence, contrasting the present with the past, and dealing with many of the improve¬
ments that have occurred within his recollection. An interesting discussion
followed. Dr. Drew, speaking for American asylums, said the assistant medical
officers often had not sufficient inducement to stay and undertake scientific research.
He discussed many recent methods of treatment, alluding to systematic washing
out, to hydrotherapy, etc. Drs. T. W. MacDowall, Miller, and B. Pierce also
joined in the discussion.

A vote of thanks to Dr. Middlemass for his hospitality concluded the business.

SCOTTISH DIVISION.

The Half-Yearly Ordinary Meeting of the Scottish Division of the Medico-
Psychological Association was held in the Hall of the Royal College of Physi¬
cians, Queen Street, Edinburgh, on Friday, 22nd November, 1907.

Present.—Drs. Bruce, Carlyle-Johnstone, Clouston, Gostwyck, Havelock,
Hotchkiss, Ireland, K. D. C. McRae, Marshall, Mitchell, Oswald, Robertson,
Turnbull, Urquhart, Yellowlees, and Marr (Divisional Secretary). Dr. Yellowlees
in the Chair.

The Chairman, before proceeding to the ordinary business of the meeting,
made appropriate reference to the resignation of Dr. Rutherford, one of the
oldest members of the Association, from the post of Medical Superintendent of
the Crichton Royal Institution, Dumfries. Such an event, he thought, could
not pass without the Association recognising the great services rendered by Dr.
Rutherford in the interests of lunacy, and moved that it be recorded in the
minutes ** that the members learned with heartfelt regret that illness was the
cause of Dr. Rutherford’s resignation, but hoped his retirement from active
asylum service would be the means of restoring him to good health.”

Dr. Carlyle Johnstone, in seconding the motion which was carried unani¬
mously, also referred to the good work done by Dr. Rutherford concerning the
welfare and treatment of the insane.

Apologies for absence were submitted from Dr. P. W. MacDonald, President of
the Association; Drs. Campbell, Carswell, Easterbrook, and Keay.

The minutes of the half-yearly meeting of the Division held at Glengall Asylum,
Ayr, on Friday, 22nd March, 1907, were read and approved, and the Chairman
was authorised to sign them.

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The following gentlemen were admitted members of the Association, viz.:

John A. McLeod, M.B., Ch.B., Junior Assistant Medical Officer, Inverness
District Asylum. (Proposed by Drs. R. B. Campbell, Keay, and Bruce.)

Alfred M. Gloag, M.B., Ch.B., Senior Assistant Physician, Inverness District
Asylum. (Proposed by Drs. R. B. Campbell, Keay, and Bruce.)

Andrew Alexander Robertson Meek, M.B., Ch.B., Second Assistant Medical
Officer, Gartloch Asylum, Gartcosh. (Proposed by Drs. Parker, Baugh, and
Marr.)

Peter Horne Macdonald, M.B., Ch.B., Pathologist, Gartloch Asylum, Gartcosh.
(Proposed by Drs. Parker, Baugh, and Marr.)

Charles G. A. Chislett, M.B., Ch.B., Second Assistant Medical Officer,
Woodilee Asylum, Lenzie. (Proposed by Drs. Marr, Watson, and Carre.)

J. J. Harrower Ferguson, M.B., Ch.B., Senior Assistant Medical Officer, Fife
and Kinross Asylum, Cupar-Fife. (Proposed by Drs. Turnbull, Clouston, and
Marr.)

Arthur M. Dryden, M.B., Ch.B., Third Assistant Medical Officer, Woodilee
Asylum, Lenzie. (Proposed by Drs. Marr, Watson, and Carre.)

Robert Durward Clarkson, M.D., B.Sc., M.R.C.P.(Edin.), Medical Officer,
Scottish National Institution for Education of Imbecile Children at Larbert.
(Proposed by Drs. Marr, Parker, and Watson.)

The motion by Dr. Urquhart, “ That the Division proceed to elect a Business
Committee for the Division; that it consist of three members who are at the
same time ordinary members of the Council and of the Association ” was laid
before the meeting, and the matter having been fully discussed, it was agreed, on
the motion of Dr. Carlyle Johnstone, seconded by Dr. Robertson, that the
Committee be formed, consisting of the three official members of the Council,
with two other members, to be elected. Drs. Carlyle Johnstone and Sturrock
were thereupon elected.

It was remitted to the Business Committee to consider the most appropriate
means of celebrating the jubilee of the present legislative system of lunacy in
Scotland and to report to next meeting.

On the suggestion of Dr. Carlyle Johnstone, the question of retiring allow¬
ances for officials in Scottish asylums then received the particular attention of the
meeting, and it was resolved that a committee be formed, consisting of Drs.
Carlyle Johnstone, Urquhart, and the Divisional Secretary, to further the scheme.

Dr. Urquhart’s proposal “ That the dates of the meetings of the Division be fixed
now'* was the next item to receive consideration, and it was agreed that the half-
yearly meetings be held on the third Fridays of March and November, the
Secretary being instructed to report the decision in time for the May meeting of
the Association. As regards the arrangements for fixing the dates of the clinical
meetings, these were left in the hands of the Business Committee.

Dr. Marshall then read a paper on •• Mental Symptoms with Brain Tumour,”
which was much appreciated.

Dr. Ireland gave a short account of the International Congress of Neurology
held last September in Amsterdam, and to which he was a delegate of the
Association. He spoke in warm terms regarding the manner in which the
members of the Association were received by the Dutch. The only objection he
had to the work of the Congress was that it was conducted in three divisions, viz.
those of psychology, psychiatry, and the care and nursing of the insane. As the
business of each of the three divisions frequently took place at the same time, and
was of great practical interest, it was impossible that one could attend to all the
several sections. He also intimated that the International Congress of 1908
would be held at Vienna.

This concluded the business of the meeting, and the chairman was thanked for
presiding.

LIV.

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IRISH DIVISION.

The Summer Meeting of the Division was held at the Down District Asylum,
Downpatrick, by the kind invitation of Dr. Nolan, on Thursday, July 4th, 1907.

The morning having been spent in a visit to various places of antiquarian
interest in the neighbourhood, the members were shown over the asylum by Dr.
Nolan, who subsequently entertained them at luncheon.

At the meeting afterwards Dr. C. E. Hetherington was voted to the chair, and
there were also present Drs. M. J. Nolan, T. Drapes, F. E. Rainsford, C. Norman.
R. R. Leeper, J. J. Fitzgerald, J. Cotter, and W. R. Dawson (Hon. Sec.). Dr. R.
L. Donaldson, who had attended the preliminary proceedings, was obliged to leave
at the commencement of the meeting. Letters regretting inability to attend were
received from Drs. W. Graham, G. R. Lawless, and a number of other members.

Before reading the minutes, a unanimous resolution was passed, congratulating
Dr. Conolly Norman on the honorary degree recently conferred upon him by
Dublin University, and his election as Vice-President of the Royal College of
Physicians of Ireland. Dr. Norman replied in suitable terms.

The minutes of last meeting were signed, and the Hon. Secretary reported with
reference to matters contained therein.

A letter was read from Rev. T. S. Graham, on the death of Dr. R. A. L. Graham,
thanking the members for a resolution of condolence passed at the last meeting of
the Division.

The following were duly elected Ordinary Members of the Association, viz.:

Henry Richard Charles Rutherford, L.R.C.P.I., L.M., L.R.C.S.I., Assistant
Medical Officer, St. Patrick’s Hospital, James’s Street, Dublin.

Thomas Aloysius Flynn, L.R.C.P.I., L.M., L.R.C.S.I., Assistant Medical
Officer, Portrane Asylum, Donabate.

It was decided to hold the Autumn Meeting of the Division at the Royal College
of Physicians, Dublin.

Dr. Norman having brought under the notice of the meeting the International
Congress of Psychiatry, Neurology, Psychology, and the Nursing of the Insane, to
take place at Amsterdam September 2nd—7th, 1907, the Hon. Secretary was
directed to send postcards to all the members of the Division calling attention to
same.

Dr. F. E. Rainsford read a paper entitled “ A Case of Medico-legal Interest.”

Dr. Conolly Norman made a communication entitled ‘‘Witchcraft and De¬
moniacal Possession.”

Dr. M. J. Nolan reported four cases of a condition probably akin to Amaurotic
Family Idiocy.

A unanimous vote of thanks to Dr. Nolan for his kind hospitality having been
passed, he replied, and the meeting terminated.

The Autumn Meeting of the Division was held at the Royal College of
Physicians, Dublin, by the kind permission of the President and Fellows of the
College, on Tuesday, November 5th, 1907. Dr. Conolly Norman occupied the
chair, and there were also present Drs. J. Mills, T. Drapes, R. R. Leeper, E. D.
O’Neill, J. Lentaigne, M. J. Nolan, J. O’C. Donelan, M. J. Forde, and W. R.
Dawson (Hon. Sec.). A letter was read from the President of the Association,
regretting inability to be present. Letters to similar effect had been received from
Drs. J. J. Fitzgerald, R. L. Donaldson, J. A. Oakshott and B. C. Harvey.

The minutes of the previous meeting were read, confirmed, and signed.

The Hon. Secretary reported shortly on a matter arising out of the minutes.

The following was unanimously elected an Ordinary Member of the Association,
viz.:—

Patrick J. Dwyer, M.B., B.Ch., R.U.I., Clinical Assistant, Richmond District
Asylum, Dublin.

The kind invitation of Dr. Leeper to hold the Spring Meeting of the Division
at St. Edmundsbury, Lucan, was unanimously accepted with thanks.

A discussion then took place with reference to the best methods of securing
assured superannuation for all Irish Public Asylums Officials. Finally, the

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following resolution was unanimously agreed to, on the proposal of Dr. Nolan,
seconded by Dr. O’Neill, viz.:

“That the members of the Irish Division of the Medico-Psychological Associa¬
tion of Great Britain and Ireland hereby approve of the action taken by the Irish
Asylum Officials Superannuation Committee, and beg to recommend the proposals
made to the kind consideration of the Chief Secretary.”

A resolution of thanks to Mr. John Redmond, M.P., for the kind support given
by him to the representatives of the above-mentioned Committee was proposed
by Dr. Drapes, seconded by Dr. O’Neill, and also passed unanimously.

A discussion on the best method of increasing interest in the work of the
Association amongst the Assistant Medical Officers of Irish Asylums was opened
by Dr. Leeper, and joined in by most of the members present. Several sugges¬
tions having been made, it was proposed by Dr. Leeper, seconded by Dr. Dawson,
and resolved.—“ That a Committee be formed consisting of Drs. Leeper, Norman,
Nolan, Mills and Donelan, to consider the best method of promoting increased
interest in the work of the Association amongst the Assistant Medical Officers:
and that the Secretary to the Division be an ex-ojfficio member of the Committee
and the convener thereof.” The last clause was added at the suggestion of the
Chairman.

Dr. Norman brought forward a letter which he had received from Dr. Pilcz
with reference to a Congress on the Nursing of the Insane to be held in Vienna,
October 7th—nth, 1908, with a request that he would form a Committee, and
stated that he was prepared to receive names of those desirous of attending.

Dr. Drapes then read a paper entitled “The Unity of Insanity, and its bearing
on Classification.”

The meeting concluded with a vote of thanks to the President and Fellows of
the Royal College of Physicians for the use of the College Hall.

In the evening the members dined together at the Shelbourne Hotel.

THE AMSTERDAM INTERNATIONAL CONGRESS.

Reported by W. W. Ireland, M.D.

The International Congress for Psychiatry, Neurology, and Psychology was
held at Amsterdam from the 2nd to the 7th of September. The opening meeting
in the Municipal Concert Hall was honoured with the presence of Queen
Wilhelmina and her husband Prince Henry, with a staff of officers and many
distinguished citizens. Addresses were delivered by Dr. van Raalte, Minister of
Justice, and Professor Jelgersma, of Leyden. Some national songs and hymns by
Verhulst and Handel were beautifully sung by a choir of 200 ladies.

Next morning the proceedings of the Congress commenced in the rooms of the
University. In the programme it was announced that there were delegates from
sixteen countries of Europe and North and South America, besides Japan.
Britain, Austria, and Portugal had none. There were also delegates to represent
forty-two learned societies. The official languages were French, English, and
German. Seven hundred and fifty members were enrolled.

The subjects were discussed in three separate rooms. There were two sittings
each day, and nearly a hundred communications were announced in the pro¬
gramme.

Section 1 was devoted to Psychiatry and Neurology. Dr. L. J. J. Muskens, of
Amsterdam, gave a demonstration, with lantern slides, of his researches about
cerebellar connections, principally carried on with vivisections on the rabbit and
the cat. He indicated that after entire removal of the flocculus cerebelli and
staining by Marchi’s method, no degeneration is found in the corpora restiformia
or the spinal cord; but there is coarse degeneration of the middle third of the
superior crus cerebelli. The ventral cerebello-thalamic bundle of Probst, or the
bundle of descending collaterals of the superior crus after Pelizzi and Cajal, is in
all cases degenerated on the other side.

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From observations in the cat’s brain Muskens is led to believe that most ot
the fibres of the ventral cerebello-thalamic bundle may be considered as a part
of the decussation of the superior crus ; the only difference being that they cross
the raph£ more deeply in the pons.

As far as the discussion on the functions of the cerebellum went, it is apparent
that we have not reached a clear idea of the functions of that perplexing organ.

Dr. Jklgersma, with lantern views, gave a demonstration of numerous sections
of the whole brain and cerebellum.

Ramon Y. Cajal gave illustrations of the degeneration of the axis-cylinders of
the cerebrum and cerebellum after traumatic injuries.

Dr. F. W. Mott, commencing with a description of the lemur’s brain traced
the evolution in the sensory areas through the primates to the human races.

Dr. W. H. Gaskell, of the University of Cambridge, gave a demonstration of
the evolution of the vertebral central nervous system, from which it was made to
appear that vertebrate animals were descended from the arthropoda. Though
researches in genealogy sometimes help psychology, it must be owned that this is
going pretty far back.

There was animated debating amongst the French and Germans about the
pathology of hysteria. The old difficulty is to find for it an organic basis. Dr.
Pierre Janet insisted that it was a mental disease to be studied after the methods
used in psychology.

Dr. Ernest Jones, of London, read a paper on “ The Clinical Significance of
Allochiria.”

Dr. David Orr, of Manchester, and Dr. R. G. Rows, of the Lancaster Asylum,
gave a lantern demonstration of lesions of spinal and cranial nerves experiment¬
ally produced by toxins.

Dr. M. Chartier, of Paris, detailed some experiments on dogs and rabbits to
show that cultures of virulent microbes injected into the carotids may become the
cause of inflammations identical with acute haemorrhagic encephalitis.

Drs. J. Moreira and A. Peixoto gave an elaborate communication on the
Mental Diseases in Brazil. In this vast territory there is a great variety of
climates: a tropical and a sub-tropical zone, with a range of mean temperature
varying from 15 0 to 25 0 C. There are also towns situated at high elevations.
Brazil is inhabited by a great variety of races, and Europeans have better health
than in any other country so near the equator. Notwithstanding these diverse
conditions, the learned professors assure us that they failed to find any variation
or particular character in mental pathology. They have not even observed in the
tropical climates any great frequency of insanities connected with malarial fevers.

Their leading idea is that there is everywhere an increase of insanity following
the progress of civilisation, and the unrest and excesses which accompany it.
Neurasthenia is rare in Brazil; hysteria frequent. The percentage of cases of
insanity set down as due to abuse of alcoholic liquors has, for the last ten years,
kept about 28 in the number admitted to treatment. General paralysis is not so
common in Brazil as in Europe; but is increasing year by year In the National
Hospital for the Insane at Rio there were 9609 patients from 1889; amongst these
there were 266 general paralytics, of whom only 12 were women, that is 276 per
cent, of the number received.

Section II was devoted to psychology under the presidency of Dr. G. Heymans,
Professor of Philosophy at the University of Groningen. Among the subjects con¬
sidered were the difference between perception and idea, the illusions of simul¬
taneity for disparate impressions, the oscillations of the attention, and negative
hallucinations.

The President gave a lecture on the biographical methods of studying
psychology.

Miss Louise Robinovitch gave the results of her studies on the genesis of
great men. Out of seventy-four biographies she found only ten first-born
children, Gibbon, Milton, Arago, Addison, John Adams, Brahms, and Rubinstein
were named; one might add Robert Burns, Sir Henry Vane, and Sir John Moore.

Dr. Paul Sollier made an attack upon the view of the emotions upheld by Pro¬
fessors W. James and Lange. These philosophers consider that after an affecting
conception a wave of excitement passes through the whole nervous system to the
arteries and viscera according to the nature and intensity of the impression, and

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there is then a returning sensation of the changes thus induced in the body; all
these processes are conjoined to make up an emotion. Dr. Sollier argued that it
is the sentiment of the discharge of cerebral energy along with the intense activity
of the brain which constitutes the emotion.

Dr. RdifBR, Sanitary Engineer to the Royal Marine of the Netherlands, has made
a study of sexual periodicity in man. His observations on the rise and fall of the
" geschlechtstriebe ” are illustrated by four tables of curves, showing maxima
every four days. They become highest about the full moon. Dr. Rdmer is
inclined to think that owing to the angle in which the sun's rays are reflected by
the moon a species of polarisation takes place, which may explain the effects.

Section Ill, which was given to the consideration of the care and nursing of the
insane, was held in a room the walls of which were covered with portraits of former
professors.

Dr. van Deventer read a paper on the 11 Education, Rights, and Duties of
Attendants on the Insane.” He would have those desirous of such employment to
go through a course of training commencing with some knowledge of nature and
of a trade which might be useful, and, with the female nurses, acquaintance with
domestic economy and cooking. They should then have to go through a special
education with yearly examinations, to end with a certificate or diploma. Dr.
Deventer proposes liberal salaries for the attendants, and that they should be
assured against accidents, sickness, and retirement from age, and pensions given
to their widows and orphans.

It may be safely said, that unless the emoluments of the attendants on the insane
be largely increased, there is no chance of candidates presenting themselves to go
through such studies and examinations; but with the material we have for
attendants and nurses we may console ourselves with Deventer’s remark that the
la veritable education du garde-malade reside en bonne partie dans Vexperience.

In a pamphlet of thirty pages lying for distribution, Dr. Deventer gives some
account of his experience of twenty-five years in charge of the Hospital Wilhelmina,
at Amsterdam, and the Asylum of Merenberg. During the last half century the
number of the insane has increased much beyond the accommodation provided for
them. Dr. Deventer looks back upon the time when, during the Easter Fair, the
public were admitted, on payment, to see the mad people, and the keepers were
accustomed to provoke them to fury in order to increase the interest of the
spectacle. He is able to report great improvements, some of them introduced by
himself, in the treatment of the insane in Holland. He argues at length in favour
of the employment of female nurses in the male wards.

He tells us that for some years back a great number of lunatics have been
admitted into the receiving houses ( asiles urbains) situated in or near the town.
These establishments have a special organisation, or, as at the Wilhelmina
Hospital, occupy a particular section of the buildings. It has been found that
from 30 to 75 per cent, of the patients admitted quit the urban hospitals recovered
after from some weeks to six months medical treatment, and are thus saved from
being consigned to the asylum. These good results are obtained especially when
the patients are admitted without delay and on the first appearance of the mental
derangements.

Dr. Deventer was followed by Dr. Shuttleworth, who detailed what was
being done in England to raise the education and position of the attendants
on the insane. It formed a striking antithesis when Dr. Alt, of Uchtspringe in
Saxony, and Dr. Pesters, of Gheel, dilated at length on the merits of the family
treatment of the insane. No question here of special studies or examinations for
the attendants. The willingness to receive a lunatic into a cottage at a small
board seems of itself to confer the ability to treat the patients in a way superior in
every respect to that bestowed in the hospitals and asylums. Dr. Peeters main¬
tained that even cases of acute insanity were better treated when boarded in
families in Gheel. He further observed that from the absence of amusement and
healthy occupation in the closed asylums ( asiles femUs) there was a superadded
tendency for the patients to sink into dementia.

These views were repeated in a special conference, and seemed to have passed
without public criticism, although every one was not convinced. Indeed, during
the whole Congress there was a dearth of discussion ; but with so many papers it
was difficult to get through them all.

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198

[Jan.,

Dr. Marie, of Villejuif, considered that all cases of acute insanity should go as
early as possible to the hospitals. To make room for fresh arrivals convalescent
and chronic patients should be transferred to colonies thrown around the asylums
where country work would be provided for them. Harmless lunatics, epileptics,
and grown-up imbeciles might be boarded in more distant places.

Dr. van Renterghem, in a paper on “ Psychotherapy,” defended the employ¬
ment of hypnotic suggestion against the strictures of D6j£rine and Dubois, in
which he was supported by Dr. Lloyd Tuckey.

Dr. W. W. Ireland read a paper on “ The Increase of Nervous Diseases and of
Insanity”; after which Dr. J. H. Macdonald read Dr. Easterbrook’s paper on
“The Treatment of Active Insanity by Rest in Bed in the Open Air.” The rest
treatment was introduced by Dr. Paetz, of Alt-Scherhitz, in 1881, and the open-
air treatment has been used for several years on an extensive scale in the State
Hospital in Ward’s Island, New York, as recorded in a communication to the
Congress by Dr. William Mabon. It has also been used for several years by Dr.
H. Marr, of the Woodilee Asylum. Dr. Easterbrook has, at the Ayr Asylum,
combined these two methods. He has found that, in his patients lying in bed all
day in the verandahs, the open-air has a calmative effect, promoting sleep and
increasing the appetite. The improvement commences with the mental symptoms,
whereas, when the patients were walked about by attendants the mental improve¬
ment was subsequent to that of the general health.

There was an interesting exhibition in the City Museum illustrating the History
of Medicine and Pharmacology. The members were supplied with a catalogue of
104 pages, in Dutch, French, English, and German, with ten plates designed to
portray the dismal apparatus of confinement and restraint used in the old asylums.
A collection of these were exhibited in one room, and in another the complex in¬
struments of physiological research, amongst which the instruments for registering
muscular and other motions designed by Dr. Wertheim Salomonson, were especially
noteworthy. Old strait waistcoats, muffs, and manacles form not unusual exhibits
for visitors to medical associations, though it may be questioned whether it is
wise for those who have in their hands the treatment of tne insane to be so ready
to recall neglect and mismanagement, which have passed away never to return.
Practitioners in ordinary medicine and surgery take no delight in reminiscences of
the old blunders of Dr. Sangrado and Diaforius, bleeding in fevers, leeching in
consumption, mercurial salivations by the quart, and other horrors of the past.
It is assumed, somewhat too lightly, that the present generation of medical men are
quite exempt from carrying to excess treatment based upon theories not completely
proved.

The members had reason to be grateful to the Secretaries, Drs. Deventer,
Wayenburg, and Londen, for securing them accommodation, and rendering their
stay in Amsterdam agreeable. The usefulness of these International Congresses
consists, not so much in announcing or discussing new scientific discoveries, as in
diffusing amongst medical men and jurists a knowledge of the most advanced
ideas on the care and treatment of the insane.

The entertainments so kindly provided were certainly as much attended as the
formal meetings. They comprised a reception by Dr. and Mrs. Deventer, another
by the Students’ Club, and a third by the Burgomaster of Amsterdam, and a
choice Choral Entertainment in the Leidische Plain Theatre.

There was an excursion to Zaandam to see the hut where the Tzar Peter lived
when he came to Holland to learn shipbuilding. From the deck of the steamboat we
looked down upon the flat fields, gardens, and moist meadows divided into squares
by ditches and canals. We had the pleasure of exchanging greetings with our
American colleagues, most of them already known to us by reputation. Amongst
others we met with Dr. Alder Blumer, Dr. Brush, Dr. C. H. Hughes, Dr. Hurd,
and Dr. Carlos MacDonald. There were forty American members at the
Congress.

On Saturday there was an excursion to Leyden and the Hague. We were
shown through the asylum at Endegeest, where there are about 400 patients. The
Congress terminated with a public dinner in the Kursal of Scheveningen, a fashion¬
able watering-place, and a concert. It may be here mentioned that preparations
have been already begun for holding the next International Congress at Vienna in
the autumn of 1908.

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NOTES AND NEWS.

199

1908.]

At the International Congress held at Milan in 1906 a Committee was elected to
consider the causes of mental diseases and their prophylaxis. The members met
at Amsterdam in the University. It was announced that the King of Italy had
promised his patronage, and the Italian Minister for Foreign Affairs had engaged
to bring this business before the governments of different countries and to ask
them to send delegates. In a communication drawn up by Dr. van Deventer, of
Amsterdam, and Dr. J. W. Deknatel, of Breda, it was recommended that an
International Committee should be formed for the study of mental diseases, which
should collect all documents and information relating to the prevention of such
derangements and to the degeneration of the human race, with a view to enlighten
governments and peoples about the general measures to prevent such degenerations,
especially insanity. Each country might send several delegates, but should only
have one vote. It was suggested that the sum of from 10,000 to 30,000 francs
should be granted for the expenses of a central bureau, and that the money should
be raised by contributions of so much for each million of the population (a shrewd
proposal, coming from a small State). The International Committee should meet
once a year, and should hold an International Congress every three years, and
publish noteworthy contributions to the knowledge 01 the subject.

“The Commission will prepare the organisation of the international statistics of
lunacy,” assuredly a most desirable object.

The meetings of the Committee at Amsterdam were occupied with some brisk
debates about laying down rules of procedures and lines of inquiry. Members of dif¬
ferent countries had a difficulty in understanding one another. How many questions
connected with insanity require to be settled before we can set out on the collective
investigation of its etiology! e.g. What amount is to be allowed to drunkenness as
an efficient cause ? Is insanity increasing ? Is cerebral apoplexy a nerve-substance
or arterial disease ? Then we must agree to have a common classification of
insanity. British alienists will be urged to receive paranoia, and Germans to give
up katatonia.

Drs. Marik and Ladamk proposed that an international commission should be
constituted to consider the conditions under which foreigners who fall insane
should receive assistance or be sent back to their own countries.

REPORT ON THE MENTAL HOSPITALS OF THE COLONY OF
NEW ZEALAND FOR 1906.

This report has been prepared by Dr. Frank Hay, who has succeeded to the post
of Inspector-General on the death of Dr. Macgregor, who had served the Depart¬
ment of Asylums and Hospitals for twenty years, during which time the number of
patients on the registers increased from 1613 to 3206, while the number of officials
increased from 213 to 464. The cost per patient in 1886 was ^30 ns. 8|d., net
jf27 os. 9 d .; while the cost in 1906 was £35 2 s. iod., net ^26 10 s. 6 \d. It is
interesting, to note that ordinary attendants are now paid as against j£8o
maximum, nurses ^55 as against ^45 maximum in 1886. Dr. Hay relates that
the Departments of Asylums and Hospitals were administered by no ordinary
man; Dr. Macgregor had a mind as massive as his frame, his nobility of thought,
his geniality, his forcefulness in action, made up a personality which left its mark
on the civil service of the Colony. He bequeathed to the Department a tradition
of justice, of courage to do what is right without thought of applause or blame,
and of a righteous regard for the public purse. Those who had the advantage of
knowing something of Dr. Macgregor and his work will re-echo Dr. Hay’s testi¬
mony.

The official records of the mental hospitals, now departmentally disjoined from the
general hospitals of the Colony, form interesting reading. As we have indicated, the
total number of patients has greatly increased and they are now accommodated in
seven public and one private asylum. The numbers in the former vary from 714
ia the Dunedin Asylum to 145 in Nelson Asylum. The accommodation for men is
sufficient for present requirements, but an excess of 35 women is spread over the
mental hospitals. The proportion of the total insane to the total population is 3*49

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200

NOTES AND NEWS.

[Jan.,

per iooo exclusive of Maories, and 3*35 inclusive of Maories. It is an unfortunate
fact that while the native-born inhabitants of New Zealand contribute considerably
more than two-thirds of the population, they contribute less than one-third to the
number of the insane. It would appear that the colony is thus burdened with the
support of the majority of the insane, who were born outside its borders. One in
a thousand of all immigrants, tourists, etc., became insane within the year in which
they arrived (1905), and contributed 4*7 per cent, of the admissions (659) for that
year. Dr. Hay finds that there is a remarkably low incidence of insanity among
the New Zealand born, and suggests that the conditions of colonial life awaken the
prepotencies of the race and assist the environment to triumph over evil
heredity.

The percentage of recoveries on the admissions was—males 3975; females
47731 total 42*94 for the year 1906. The percentage of deaths on the average
number resident was—males 8*i ; females 671 ; total 7*48. Only 13 deaths were
due to tubercular disease, and there were no dysenteric disorders.

Dr. Hay refers to the training and registration of mental nurses, and hopes to
have the support of the department for general hospitals in their receiving mental
nurses for further training and special certification, without loss of seniority in
their own sphere.

In conclusion, he expresses general satisfaction with the year’s work, and closes
a most interesting report which is indicative of real progress.

AUSTRALASIAN MEDICAL CONGRESS, MELBOURNE, 1908.

We are glad to observe that our colleagues in Australasia have arranged for an
Inter-State Medical Congress to be held this year in Melbourne, from October
19th till the 24th. The Section of Neurology and Psychiatry will be served as
Secretary by Dr. Beattie Smith, 4, Collins Street, Melbourne. Dr. Truby King,
of Seaclill, New Zealand, has been elected President. In addition to the usual
dfscussions there will be a Museum of Pathological Work, and the Section will
visit the new Receiving House and the Acute Mental Hospital. Contributions to
the Congress will be welcomed by Dr. Beattie Smith, and we hope this new venture
will be a great success.

NOTICES OF MEETINGS.

Quarterly Meeting .—The next meeting will be held, by the courtesy of
Dr. Miller, at Hatton Asylum, Warwick, on Thursday, February 20th, 1908.

South-Eastern Division .—The Spring Meeting will be held, by the courtesy of
Dr. Seward, at Colney Hatch Asylum, on April 28th, 1908.

South-Western Division .—The Spring Meeting will be held, by the courtesy of
Dr. Soutar, at Barnwood House, Gloucester, on April 24th, 1908.

Northern and Midland Division .—The Spring Meeting will be held, by the
courtesy of Dr. Adair, at Storthes Hall Asylum, near Huddersfield, on April 30th,
1908.

Irish Division .—The Spring Meeting will be held, by the courtesy of Dr. Leeper,
at St. Edroundsbury, Lucan, on April 30th, 1908.

Scottish Division .—The Spring Meeting will be held on March 20th, 1908.

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> 908 .]

NOTES AND NEWS.

201

APPOINTMENTS.

Butcher, Miss Flora, M.D., Assistant Medical Officer to the Fife and Kinross
District Lunatic Asylum.

Donald, Robert, M.B., Ch.B.Glasg., Assistant Resident Medical Officer of
Riccartsbar Asylum.

Easterbrook, Charles Cromhall, M.D., F.R.C.P., has been appointed Physician-
Superintendent to the Crichton Royal Institution, Dumfries.

Leggett, William, M.B., Ch.B., and B.A.O.Dublin, Senior Assistant Physician
at Montrose Royal Asylum.

McEwan, Thos. Duncan, M.B., Ch.B.Glasg., Junior Assistant Physician to the
Glasgow Royal Asylum.

McRae, Douglas, M.D., and F.R.C.P.E., Assistant Physician, West House,
Royal Edinburgh Asylum, has been appointed Medical Superintendent of the Ayr
District Asylum, Glengall, Ayr.

Miller, John, M.B., Ch.B.Glasg., Assistant Medical Officer. Roxburgh District
Asylum, Melrose.

Rice, David, M.R.C.S., L.R.C.P.Lond., Medical Superintendent, Norwich City
Asylum.

Roy, I. Allan Chisholm, M.B., Ch.B.Vict., Assistant Medical Officer, Cheadle
Royal Hospital.

Sail, Ernest F., M.R.C.S., L.R.C.P.Lond., Medical Superintendent of the
Canterbury Borough Asylum.

Shaw, Charles John, M.D.Edin., Senior Assistant Physician to the Glasgow
Royal Asylum.

LIV,

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For Borderland Patients. PHILIP H. HARMER.

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JOURNAL OF MENTAL SCIENCE, APRIL, 1908.

THE

JOURNAL OF MENTAL SCIENCE

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

No. 225 [^no 8 ^ 8 ] APRIL, 1908. Vol. LIV.

Part I.—Original Articles.

Dr . Conolly Norman .

Conolly Norman is dead; and henceforward, to those who
knew and loved him, the world is no longer the same. It is
hard to realise that that burly form, that strong, kind,
humorous face will no more be seen at our meetings. The
staunch friend, the wise counsellor, the delightful companion,
the witty talker, the upright, just, sympathetic, capable man, is
tom from amongst us, and the wound will remain fresh and
raw until we also are called to join the great majority. To
those who knew him best, his loss cuts one of the ties to life,
and renders the prospect of their own departure less formidable.

Conolly Norman was born in 1852, of a north of Ireland
family, and spent practically the whole of his professional life
in the psychiatric specialty. After serving a few years as assis¬
tant medical officer in England, he returned to Ireland, and at
a very early age his great ability secured recognition in the
appointment of Medical Superintendent of the Monaghan
Asylum. From hence, after a few years, he was transferred to
Castlebar, whence, after six years* service, he was appointed to
the premier position in lunacy in Ireland—the command of the
Richmond Asylum in Dublin. He found the asylum sunk in
almost mediaeval inefficiency, and engaged at once in a
campaign against dirt, restraint, overcrowding, bad food,

LIV. 16

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204

DR. C0N0LLY NORMAN.

[April,

inefficient attendance, and all the deficiencies of the old
regime ; and in a comparatively short time he raised the institu¬
tion to the very first rank, not in Ireland merely, but in the
world. A few years after he had assumed control of the asylum,
and while still actively engaged in innumerable reforms, he
found himself confronted with a very serious outbreak of a
disease then almost unknown, and at all times most difficult to
recognise—beri-beri. His anxieties were redoubled by the

insufficient accommodation at his disposal, by the obstruction
to his efforts opposed by superior authority, and by persistent
attempts to cast upon him responsibility for the origin, spread,
and persistence of the disease. It was at this time that these
accumulated anxieties, added to the burden of over-work, and
possibly to some infection with the disease itself, culminated in
his first serious breakdown in health, and a weakness of the
heart from which he never recovered, and which has now
brought him to the grave. Under the advice of Sir Douglas
Powell he went to San Remo, and for several weeks his con¬
dition showed no improvement. In the meantime, however, a
friend had been working on his behalf, and a complete state¬
ment of the whole of his struggle, authenticated by official
documents, was published week by week with inexorable per¬
sistence, in the columns of Truth . Attention being thus called
to the matter, questions were asked in Parliament; official
investigation was made. A great meeting was held in Dublin,
at which the Lord Lieutenant explicitly laid the blame for
whatever laches had been committed, not upon Dr. Conolly
Norman, but upon the very persons who had been endeavouring
to fix upon him the responsibility. It was upon receipt of a
telegram at San Remo, apprising him of the appearance of the
first article in Truth , that Norman began to improve, and ulti¬
mately, though his heart never regained its .normal strength,
yet he was able to work strenuously for many years.

Dr. Norman had always been a very active member of this
Association; for many years he was Irish Secretary, and in 1894
he was elected President. It was he who first initiated the
practice of extending the Annual Meeting over more than one
day, and the meeting at Dublin over which he presided, and
which lasted the best part of a week, was in some respects the

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1908 .]

DR. CONOLLY NORMAN.

205

most memorable the Association has ever experienced. The
members from England and Scotland, as well as several
distinguished Continental alienists, then discovered for the first
time the full meaning and extent of Irish hospitality. Every
day of the meeting they were entertained both at lunch and
dinner, every day there was a garden party in the afternoon,
and a reception, a conversazione, or a dance in the evening,
and on some of the days they were even invited out to break¬
fast. The effect of these hospitalities was apparent at the
service at St. Patrick’s Cathedral, which formed a ceremonious
and appropriate conclusion to the meeting. The long succession
of busy days and short nights; the result of almost continuous
conviviality ; the atmosphere of the crowded cathedral on a
hot June day ; the lulling effect of the music as “ through the
long-drawn aisle and fretted vault the pealing anthem swelled
the note of praise,” combined to produce a somnolence so over¬
powering, that not only was the sermon preached to deaf ears,
but several members of the Association, headed by the President,
were seen to be fast asleep as they stood during the anthem.
It was rumoured afterwards that the precentor, observing the
state of affairs, had at first chosen for the anthem “ He maketh
peace,” but at the last moment substituted for it " Sleepers
wake! ” Among other things for which the Dublin meeting
is memorable, is that it was the last meeting of the Association
attended by Dr. Hack Tuke, who, in spite of failing health and
increasing feebleness, insisted on attending every function. He
was one of the large house-party entertained by Dr. and Mrs.
Norman on the occasion, every one of whom carried away a
life-long memory of the unbounded hospitality, the goodness of
heart, the consideration, kindness, and untiring attention of
their host and hostess.

Dr. Conolly Norman was happy in being a man of many
interests and many activities. A good linguist, he was fond of
foreign travel, and eagerly welcomed at the meetings of learned
bodies abroad. At the recent Congress at Amsterdam he was
elected to the chair of one of the sections. He was a man of
extensive reading, with a wide acquaintance with out-of-the-
way literature. It was difficult to find any literary subject on
which he could not converse with first-hand knowledge. He

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206

DR. CONOLLY NORMAN.

[April,

had a fine taste in art, and thought a good book should have a
worthy binding. He was a competent archaeologist, and had
a good knowledge of architecture and of music.

It was in his own branch of his own profession that he
shone. Not all the demands upon his energy, that were made
by the administration of a great institution, could prevent him
from contributing to that realm of observation that he thought
least cultivated and most deserving of cultivation in our
specialty—the realm of clinical observation. His contributions
to this branch of science are well known to our readers, but in
addition to these he wrote numerous reviews, which, whether
signed or unsigned, were always recognisable by their keen
insight, their racy style, and the humour and wit that illumi¬
nated them. But it was as a letter writer that he was most
delightful. He cultivated the fine, but well-nigh lost, art of
what our grandfathers called “ epistolary correspondence,” and
the writer of this memoir has a heap of his letters, the product
of many years of familiar intercourse, all dashed off at high
pressure, in the intervals of important business, and all
exhibiting such real literary merit as well as human interest,
that they are the subject of frequent reference and frequent
re-perusal. In his very last letter, dated but a few weeks ago,
he asks, apropos of the arrogant attitude of a person then
attracting attention, “ What has God Almighty done that He
should be taken under the patronage of-? ”

For Conolly Norman has unfolded that portal everlasting
that gapes for us all. When we in our turn pass through it,
may we leave behind us such a record as he has left of duty
manfully done; of a clean, pure, upright life; of fights in which
he never hit below the belt, or showed or left a trace of
ill-feeling; of services rendered without solicitation and with¬
out reward; of affection inspired in high and low, in near and
far; of the highest standard of honour adhered to without
deviation; of a life which reaped its fit reward in “ honour,
love, obedience, troops of friends.” He who can leave behind
him such a record, such an example, has not lived in vain.

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1908.] the symptoms and etiology of mania. 207

The Symptoms and Etiology of Mania : The Morison
Lectures , 1908. By Lewis C. Bruce, M.D.

Lecture I.

The physician, in his dealings with disease, has always the
consolation of knowing that he has Nature on his side. One
of the most wonderful forces of Nature is antagonism to disease,
and when disease has gained sway her efforts to promote
recovery are untiring. I have seen it stated that Nature kills
or attempts to kill unsuitable stock. Such a statement is
opposed to the little that we do know of Nature’s methods.
The weaker the stock the more carefully does Nature lay her
plans for its perpetuation. Why are the families of tubercular
parents large ? Because Nature is preparing for a heavy death-
rate.

In a certain American state efforts have been made to
legalise the elimination of persons suffering from incurable
disease and of those physically unfit. Should such a measure
ever become law it would, I believe, defeat its own aims,
because it is opposed to this great law of Nature. All the
advances in medicine and surgery have been made along the
lines of Nature’s methods of promoting recovery from disease or
injury, and the retrogressions have been due to ignorance of, or
the ignoring of, Nature’s methods.

When we come to study mental diseases we find that this
same law holds good, and although the work of the psychiatrist
is often discouraging, his course is plain : he must study Nature’s
methods of treating these diseases and base his treatment upon
that study.

No department of medicine is more confusing or more
difficult to understand than that known as psychiatry, or the
study of mental diseases, because the earlier workers in the
speciality have been constantly attracted along the path of
morbid psychology when they should have been devoting their
attentions entirely to physical symptoms. Many of our best
and most original workers have drifted down this psychological
path, which terminates in a maze of words from which there
is no escape and no possibility of advance. How many of the

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208 the symptoms and etiology of mania, [April,

present day psychiatrists affirm that the mind influences the
body ? which statement, followed to its logical conclusion, means
that the mind is something apart and distinct from the body.
If this were true, then mental disease must indeed be a thing
apart from general medicine, for it would not be concerned
with bodily functions. Such a conclusion is manifestly absurd.
All forms of energy of which we are cognisant can be
demonstrated to be forms of molecular vibration, and, arguing
from analogy, it is most probable that all forms of nervous
energy are also merely molecular vibration. Man, by means
of his special senses, is constantly receiving energy from with¬
out, in the form of molecular vibration, and this energy, in
some way which at present we do not understand, is received,
stored, and altered in the central nervous tissues, and, as
education advances, we see that it is capable of being repro¬
duced as mental energy. The proof that this must be so lies
in the fact that if man were born without any special senses
he would have no such thing as mind. In this and the
following lectures I place mind on this simple basis : that it is
a product of molecular vibration in the protoplasm of the
central nervous system, and that any disorder of the mechanism
or function of this nervous protoplasm may, given certain con¬
ditions, produce symptoms which we call mental disease.

I am firmly convinced that if we are to advance our
knowledge of the intricate mass of symptoms called, at the
present day, mental diseases, we must attack the problem from
the physical side. The mental symptoms must be to us mere
incidents, nothing more, often assisting us in arriving at a
diagnosis,but subsidiary and secondary to the physical symptoms
which they so frequently mask, and which can only be demon¬
strated by direct and special investigation—investigations in
which we can hope for no assistance from the patient, who, not
unfrequently, is not in a state to' render intelligent assistance.
Speaking, however, from an experience of fifteen years* work, I
have no hesitation in saying that, taking the so-called insane
patients as a class, I have found them more easy to deal with
than patients in general practice or in general hospitals, and
that when they were in such a condition as to be able to have
their condition explained to them, they most readily assisted in
any means which were adopted for their treatment. As the
result of work done on these lines I propose in this and the

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1908.]

BY LEWIS C. BRUCE, M.D.

209

succeeding lectures to lay before you the physical symptoms
which are to be observed in that class of mental disease at present
designated as conditions of mania. Wherever it is possible to
do so I will compare the symptoms in these diseases with
similar symptoms, which I have from time to time been able to

Chart i.

Table comparing the age of onset in mania and acute rheumatism.

observe myself or collect from others, as well as in diseases
which are allied to insanity, but are rarely complicated by
mental symptoms. I refer particularly to rheumatism, which,
in the various forms in which it manifests itself, is closely allied
to the insanities known as mania.

Mania, or states of mental excitement or exaltation, con¬
stitutes between 50 and 60 per cent . of all the admissions into
asylums. Mania may occur at any period of life, but in the
vast majority of cases it is a disease of adolescence or early

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210

THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

adult life, and in this it closely resembles rheumatism
(Chart i).

The disease conditions commonly spoken of as mania may
be divided into two great classes, which may be readily dis¬
tinguished from one another by the mental symptoms alone,
They are firstly, mania, with confusion—a state of delirious
excitement in which the patient is wholly or partially uncon¬
scious of the environment, and in every case of which confusion
is a marked symptom. Secondly, mania without confusion, or
the excitement of folie circulaire y more directly designated on
the continent “ manic-depressive insanity,” from the fact that
patients who suffer from this form of excitement are also liable
to have attacks of depression. The excitement of manic-depres¬
sive insanity is characterised by elevation of mind, with little or
no confusion. The patient keeps in touch with the environ¬
ment, the special senses are hyperacute, and the chief mental
characteristic of the disease is a rapid, ill-regulated, and easily
disconnected train of thought. Confusional or delirious mania is
a condition which, if not recovered from, is liable to pass into a
chronic state of excitement, which may closely simulate the
excitement of manic-depressive insanity, and still later tends
to pass into a delusional condition, associated with restless
excitement, destructiveness, and noise, and still later terminates
in dementia, more or less complete. A most interesting and
instructive fact about this type of the disease is, that the state
of early delirious excitement may never manifest itself, the
onset of the disease in some cases being so gradual and
insidious that the mental symptoms only become evident when
the patient passes into the delusional state, with complete
change of character, and then it is only by physical examina¬
tion that the true nature of the condition can be demonstrated ;
but whatever its method of onset or terminations may be,
mania of the confusional type is never complicated by attacks
of depression, which are extremely common in the allied disease,
manic-depressive insanity, so common, in fact, as to have led
to the term “ depressive ” being added to the nomenclature.

The causes of the onset of all insanities are physical, and
this is particularly the case in the victims of mania. I know
that you will not believe me when I say that insanity is never
the result of love affairs or religious excitement, because such a
statement traverses one of the most dearly-cherished delusions

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1908.]

BY LEWIS C. BRUCE, M.D.

2 I I

of the laity and many professional men. Emotionalism is a
symptom of an unstable brain, and after insanity evidences
itself it is a symptom of the insanity, just as alcoholism is far
more frequently a symptom than a cause. This latter state¬
ment I can demonstrate to you by several most striking cases
—cases in which I rely upon physical and not psychological
evidence to support my statements. Further, states of mania
never arise de novo as the result of brain disease pure and
simple. However defective any organ of the human body may
be that organ never originates disease per se ; there must be a
cause for the onset of disease; and this rule applies to the
brain as well as to all the other bodily organs. What, then,
are these causes which make for disease of the highest nervous
structures ? The first and most generally accepted cause is
predisposing, and is spoken of as hereditary predisposition. It
must be clearly understood that a man never inherits actual
mental disease from his parents, but he inherits a defect of
constitution which renders the most highly organised portions
of his nervous system liable to attacks of disordered function
from causes which would not affect a man of sound constitu¬
tion, and it is not necessary that the patient should have had
insane progenitors. It is sufficient that his parents, through
disease, accident, or disregard of the laws of health at the period
of his conception, failed to supply him with that necessary
balance of mind and body which constitute the true condition
of health. Further, such parental defects as alcoholism,
tubercular disease, extreme nervousness, vagabondage, eccen¬
tricity, hysteria, criminality, inequality in mental development,
such as extreme brilliancy in one direction combined with
deficiency in others, and any weakness of the defences of the
body against toxic and bacterial invasions, may produce in the
offspring as great an hereditary predisposition to mental diseases
as may actual attacks of mental disease in one or both parents.

Regarded, therefore, from this broad standpoint, hereditary
predisposition, meaning an unstable nervous system, is the
great predisposing cause of all insanities.

With regard to the exciting causes, I will, in these lectures,
confine myself to the exciting causes of maniacal states which
are now very generally believed to be toxic in origin, and I go
further and say that the toxines are bacterial toxines, and that
the bacteria are of the class cocci and allied to the Micrococcus

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212

THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

rheumaticus . It is difficult, perhaps impossible, to wholly
substantiate such a statement with regard to the causation of
mania on the postulates of Koch—that to prove a disease to
be bacterial one must find the specific organism in every case,
reproduce the disease in animals, and recover the organism
from the diseased animal. I may say at once that I have not
found a specific organism in every case, but I have found
evidences of specific bacterial invasion in every case. Secondly,
I have never been able to reproduce mania in the lower
animals, but I have produced evidences of lesion in the lumbar
enlargement of the spinal cord in rabbits, showing that the
toxines of these bacteria have a chemical affinity for nerve
tissues. Further, I have found that the injection of vaccines
made from the organisms isolated from the cases of mania,
when tentatively used as a method of treatment in such cases,
produced a marked exacerbation in the symptoms of the
disease if the dose of vaccine was too large. The same results
follow the use of vaccines made from the Micrococcus rheu¬
maticus, when injected into patients suffering from rheumatism.
These observations will be referred to again in a later lecture.
I have demonstrated that the changes in the blood serum of
infected rabbits closely resemble those which I have been able
to demonstrate in man, and, lastly, a pure culture of the orga¬
nism has been obtained from inoculated rabbits in one case so
long as one month after infection.

There are, therefore, many links in the chain of evidence
wanting, but such evidence as is already in my possession is
sufficient to warrant the general conclusion being drawn that
the diseases known as mania are due to bacterial toxaemias,
which are in many ways comparable to the bacterial toxaemias
of rheumatism.

The question at once arises, if the toxaemias of mania are
comparable to the toxaemias of rheumatism—a very common
disease in this country—is there any evidence that the sane, as
well as the insane, suffer from similiar toxaemias ? There is
evidence to this effect.

My colleague, Dr. C. J. Shaw, and myself, when working at
the opsonic indices of persons suffering from insanity, which
necessitated the mixing of the serum of the patients with the
washed red blood-corpuscles from a healthy subject, noticed
that the blood serum of certain forms of insanity, particularly

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BY LEWIS C. BRUCE, M.D.

213

1908.]

cases of mania, whose symptoms pointed to the evidences of
bacterial toxaemia, agglutinated the red blood- corpuscles of healthy
persons. The washed red blood-corpuscles of one case of
mania, on the other hand, were not affected by the serum of
another case of mania, although the serum of both patients
acted with vigour upon the red blood-corpuscles of a healthy
man. In other words, the red blood-corpuscles of a person
who gives this reaction are protected against the agglutinating
substance.

Out of 54 cases of mania examined 50, or 92 per cent., gave
this reaction.

On further investigating this reaction, we found that it
could be demonstrated in many sane patients suffering from
known bacterial invasions, and my thanks are due in this
respect to Drs. C. B. Keir and T. Mitchell, who supplied me
with many samples of serum from patients admitted into the
hospitals of which they had charge. (The washed red blood-
corpuscles of these sane, but sick, persons were also immune
to the action of agglutinating sera obtained from maniacal
patients.) On further extending the observation to persons
supposed to be in a state of health—for instance, all the mem¬
bers of the asylum staff and others—I found that 50 per cent . of
the sane and apparently healthy gave the reaction. The washed
red blood-corpuscles of these persons also were immune to the
agglutinating action of sera taken from cases of mania.

This reaction, therefore, although almost universal in the
maniacal patients, is evidently not confined to mania, and is not
a diagnostic of mania. In further observations I found that the
agglutinating substance in the serum was thermostable, i.e., it
still acted after being heated to 6o c C. for 30 minutes. It was
found that if equal portions of normal red blood-corpuscles and
the serum of a person giving this reaction were mixed in vitro ,
allowed to stand for 1 $ minutes, then centrifuged and the
supernatent fluid pipetted off, that the pipetted serum, if now
mixed with a fresh supply of normal red blood-corpuscles, had
no further power of action. It is clear, therefore, that the
agglutinating substance is either destroyed or exhausted, or had
linked itself to the normal red blood-corpuscles with which it
had been originally mixed.

To assist in explaining this reaction it was now necessary to
attempt to reproduce the condition artificially, and this was done

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214 THE symptoms and etiology of MANIA, [April,

with rabbits. A control rabbit was chosen whose washed red
blood-corpuscles, when tested against the serum of fourteen others,
gave no reaction. Four of these rabbits were inoculated with a
diplococcus or short streptococcus isolated from the blood of a
case of acute mania of the confusional type ; three with a coccus
obtained from the bone-marrow of a patient who died in the
typhoid stateduring an attack of acute mania; five with a Bacillus
coli communis ; two with a Bacillus paralyticans —the diphtheroid
bacillus of Ford Robertson, McRae, and Jeffries. The serum
of all the rabbits infected with the coccal organisms, as soon as
a ggl ut inins to the infecting organism could be demonstrated
in the serum, agglutinated the washed red blood-corpuscles
of the control rabbit. None of the rabbits infected with the
bacilli gave the reaction. The agglutinin to the red blood-
corpuscles present in the sera of the rabbits inoculated with the
coccal organisms was only present for a few days in each case,
but could be reinduced by reinoculating the rabbit with the
coccal organisms. From this series of observations I conclude
that whenever the blood serum of one person agglutinates the
washed red blood-corpuscles of a person in health that the
person supplying the serum is probably suffering from a coccal
invasion. It is true that many of the persons who gave this
reaction were apparently healthy, but, so far as I was able to
go into the physical state of such persons, my belief is that
many of them were not in a state of health. Many of the
women were suffering from anaemia or chlorosis, others had
recurrent attacks of tonsillitis. Two of the sane persons who
gave this reaction at a later date contracted typhoid fever,
and both suffered severely, not so much from the typhoid as
the sequelae of typhoid, and convalesced slowly, while a third,
contracting pneumonia, died after forty-eight hours* illness.

If, then, the sane with the insane show evidence of bacterial
toxaemias, we are driven back to the constitutional taint, the
inheritance of an unstable nervous system, as the chief factor
in the production of mania. In other words, the sane and the
insane may suffer from similar toxaemias, but whereas the brain
of the sane man is stable the toxines produce no mental sym¬
ptoms, the brain of the insane man is unstable and readily
becomes disordered by toxic action. Further, it is probable
that the subjects of mania have also a constitutional failure in
their bacterial defences. Dr. C. J. Shaw, my late colleague,

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1908.]

BY LEWIS C. BRUCE, M.D.

215

demonstrated most clearly the fact that patients suffering from
acute insanity, particularly cases of acute mania, have a lower
resistive power to the tubercle bacillus, as gauged by the
opsonic index, than sane persons of the same age, and yet
several of his control cases gave the agglutinative reaction with
the red blood-corpuscles of a healthy man. When the resistive
power of these maniacal patients, as gauged by the opsonic
index, was tested to the Bacillus coli communis , the Staphy¬
lococcus aureus , and to two varieties of streptococci, it was found
to be lower than the average index obtained in the control
cases.

Chart 2.

10,000

8,000 sal

Case A

Case B 9

CaseC*

Case D

p yjr i^wi:»w>aCTMiaKrii:Biri

aMPWMMBW

• 0,000 56

4,000 37

2,000 b-H M mrm m _

Temperature and polymorphonuclear charts in four controls.

Turning, then, from the causes of mania to the physical
symptoms of the disease, I show two charts of the body-
temperature in cases of mania, with confusion and mania of
the manic-depressive type respectively (Charts 3 and 4). It
will be noticed at once that there is practically no febrile
reaction in either case, and yet the synchronous polymorpho¬
nuclear leucocyte record is a most marked departure from that
of health. We have on these charts a graphic representation
of a marked toxaemia without any corresponding rise in the
body-temperature, a state of affairs which, until a few years ago,

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Polymorphonuclear leucocytes per c.mm. H Polymorphonuclear leucocytes per c.mm.

Polymorphonuclear leucocytes per c.mm.

1908.]

BY LEWIS C. BRUCE, M.D.

217

was considered an impossibility. Repeated observations on
similar cases, however, have proved this fact beyond doubt, that
in cases of mania such conditions as a virulent toxaemia and an
afebrile temperature co-exist. There are also temperature and
leucocyte charts in two cases of mania with confusion which

Chart 5.

Temperature and polymorphonuclear chart; mania (confusional type,
chronic). 9 •

never developed excitement, but in whom a gradual mental
change took place (Charts 5 and 6). They changed in
character, became slightly confused, irritable, and delusional,
and, judged by their mental symptoms, might have been regarded
as cases of delusional insanity. The physical symptoms, how¬
ever—the leucocytosis, the presence of bacterial agglutinins in
the blood, and the discovery of a local uterine lesion in each
case—leave no doubt as to the diagnosis. These two cases,

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218 the symptoms and etiology of MANIA, [April,

which are both of peculiar interest, will be again referred to
when the blood changes are described. Chart 6 A is shown so
that the temperature and leucocytosis in a case of sub-acute
rheumatism may be compared with those of cases of mania.

The alimentary system in all forms of mania is in the early
stages of the disease disordered. The lips, teeth, and tongue
readily become covered with sordes, and over 90 per cent . of
the patients admitted to the Perth District Asylum had carious
teeth. The theory has been advanced that carious teeth alone

Chart 6 .

Temperature and polymorphonuclear chart; mania (confusional type, chronic). ? .

may, in a predisposed person, produce such a condition of
toxaemia as to induce an attack of mania. I have seen cases
in which the history of onset strongly supported this view. If
one considers the absorptive capacity of the mucous membrane
of the mouth for such toxines as nicotine, it is reasonable to
suppose that the bacterial toxines produced by carious teeth
will be absorbed with equal readiness. We make a point of
removing all carious teeth in our maniacal patients, and the
physical and mental improvement which follows such a pro¬
cedure suggests that the toxines arising from carious teeth may
well act as an accessory cause of toxaemia in such cases. It is

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Lecture III.— Chart i. Lecture i.—Chart

JOURNAL OF MENTAL SCIENCE, APRIL, 1908.

To illustrate Dr. Lewis C. Bruce’s paper.

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Ad lard &• Sdn, Im.pt.

Bacteria from faeces. Bacteria of saliva.

BY LEWIS C. BRUCE, M.D.

219

1908.]

a popular belief that the bite of an insane person is particularly
poisonous, and, like many popular beliefs, there is in this a
substratum of truth. When we come to examine the bacterio¬
logy of the saliva we find that the organisms are extremely
numerous in the saliva, particularly in cases of confusional
mania. I show by lantern slides tubes of nutrient media
which have been inoculated from the saliva of such cases, and
also a tube inoculated from the saliva of a man in health. It

Chart 6a.

Temperature and polymorphonuclear chart; sub-acute rheumatism.

will be noticed that the characters of the growths vary con¬
siderably, the colonies being more numerous, larger, and more
uniform in the tubes inoculated from the saliva of cases of
mania than in that inoculated from the sane person. Before
these cultures were made the maniacal patients had had all
carious teeth removed (Chart 7).

The digestive power of the gastric juices during attacks of
acute excitement is practically in abeyance, but this is followed
later by great digestive activity. In a state of health the
gastric juice has a powerful bactericidal action. In states of
mania, however, this action is sometimes deficient. From the
stomach contents of several such patients I have isolated
Liv. 17

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220 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

cocci which were extremely virulent to rabbits. The same
remark applies to some of the organisms isolated from the
saliva, whereas the organisms which I have isolated from
healthy saliva are not toxic to rabbits even in large doses. It
is possible, however, that these virulent organisms found in the
stomach contents of cases of mania had been carried from the
mouth to the stomach by means of the stomach-tube used to
extract the stomach contents.

The digestive and assimilative power of the small intestine
is probably also deficient, as maniacal patients, even if fed
artificially with an abundant supply of nitrogenous food, con¬
tinue to lose weight rapidly.

One further fact regarding the bacteriology of the intestinal
tract may be touched upon here. If stroke cultures are made
upon agar tubes from the faeces of man or the lower animals
the resulting growth of the Bacillus colt communis is so great
that all other organisms are obliterated. In over 50 per cent
of the cases of mania whose faeces were examined in this way
I was struck by the fact that the Bacillus coli communis was
not present in great numbers and that colonies of cocci were
numerous. For instance, six agar tubes were inoculated from
the faeces of a case of recent and acute confusional mania, and
in none of the tubes was a single colony of the Bacillus coli
communis to be detected, the only organisms present being
streptococci. I have had lantern-slides made from tubes
inoculated from the faeces of several cases of mania which will
demonstrate much more clearly to you this peculiar change in
the bacterial flora of the intestinal tract. Out of twenty-seven
cases of mania in whom the faeces were bacteriologically
examined fifteen showed this peculiarity. The patients, during
the period at which these observations were made, were being
fed on milk and farinaceous food.

The circulatory system, with its complicated nervous
mechanism, reacts very readily to the toxines circulating in the
blood of maniacal patients. The heart’s action is, I believe,
always affected centrally—that is to say, the toxines act upon
the cardiac centres. Valvular lesions are stated to be more
common in the insane than the sane, but the symptoms which
have attracted my attention most are the attacks of syncope,
sometimes fatal, to which maniacal patients are liable, and
the rapid, irritable pulse-rate which precedes and follows,

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1908.]

BY LEWIS C. BRUCE, M.D.

221

particularly attacks of mania with confusion. During the
actual period of acute excitement the pulse-rate is largely
affected by the excessive movements of the patient, but before,
and particularly after, maniacal attacks the pulse-rate is a most
valuable indication of the state of health. I have repeatedly
seen patients, apparently recovered, with a pulse-rate varying
between 90 and 120 per minute, and so long as such a sym¬
ptom persists the patient is most liable to a relapse if great care

Chart 8 .

Hour - !*n /-4 h8 M2 H6 h20

/50

| ms

2 140

I mo

1 >25

Chart showing the rise in arterial pressure at the onset of an attack of
acute mania.

is not taken. My rule is never to allow a maniacal case out
of bed so long as the pulse-rate is above 7 5 per minute.

The arterial tension is also altered in these cases. Maurice
Craig states that the arterial tension is always low in maniacal
states. This is partly true, but at the onset of acute excite¬
ment the arterial tension frequently rises. The chart thrown
upon the screen shows the arterial tension of an adolescent
male just at the onset of an acute maniacal outburst. The
readings were taken With a Barnard and Hill's sphygmometer
(Chart 8).

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222

THE SYMPTOMS AND ETIOLOGY OF MANIA,

[April,

Observations on the urinary excretion are interesting inso¬
far that they demonstrate that maniacal states are very similar
to febrile conditions, in the fact that the nitrogenous waste
products of the body are greatly in excess of the nitrogen
ingested in the food, and in that the excretion of the chlorides
in the early stages of the illness is greatly diminished. In
estimating the nitrogenous output I used Southey’s ureometer,
and in calculating the nitrogenous ingestion I relied upon
standard physiological tables of the nitrogen value of various
food stuffs, the quantity of food which each patient took
being carefully recorded at each meal. A certain amount of
error can hardly be avoided in using such a method, but the
results obtained throughout a series of observations which
extended over two years were so uniform that even admitting
of error I submit that the records so obtained are of clinical
value.

We were able to examine the urine in twenty cases of mania
of all varieties. The longest observation extends over a period
of six months and the shortest for fourteen days. In many
cases the records were intermittent, as delirious patients often
pass urine involuntarily, but even intermittent records when
supplemented by complete ones are of value, and the result of
the whole series of observations amounts to this, that during
the early days of the illness the excretion of urea-nitrogen
is far in excess of the urea-nitrogen value of the food ingested,
and during this period the patients steadily lose weight. Then
follows a stage when the nitrogen ingested and the nitrogen
excreted balance, and the weight remains stationary. This is
followed by the period of convalescence, when the urea-nitrogen
excreted is far below the amount of urea-nitrogen value of the
food ingested, and during this period the patient gains weight.
The termination of convalescence was marked by stationary
weight, and a return of the balance of the nitrogen excreted
and the nitrogen ingested in the food.

The charts thrown upon the screen demonstrate this more
clearly than any verbal explanation (Charts 9, 10,11, and 12).

Chart 9 shows the urea excreted, the urea-nitrogen value
of the food ingested, and the weight in lbs., in the case of
a male adolescent suffering from mania of the confusional type.
During the first week, the urea excreted averaged 47 5 gr. per day,
as against 225 gr. of urea-nitrogen value in the ingested food.

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BY LEWIS C. BRUCE, M.D.

223

1908.]

The weight decreased 5 lb. For the next five weeks the urea
excreted and the urea-nitrogen value of the food ingested ran

Chart 9.

parallel. The weight remained stationary. During the
seventh week of the illness the urea excreted was only 400 gr.

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224 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

per day, as against 500 gr. of the urea-nitrogen value of the
food ingested. There was a corresponding increase in weight.
From the seventh to the sixteenth weeks the patient was in a
state of lethargy, frequently wet, and the record was broken.
During the sixteenth, seventeenth, eighteenth, and nineteenth
weeks the urea excreted remained below the level of the urea-
nitrogen value of the food ingested, and the weight increased
from 135 lb. to 152 lb. For the next two weeks the

Chart io.

Weeks- 123456 789jgin2l3»lSl§J7

J 650 -

6 „ 4S

0 600-^/SO

i •$

3, 550--v. 120
■s It

§ 500-&no

►

c 4.50 _

22*

'ER>

X-

•r

b 400 -

I 3B0 -

1 300 -

D 2S0 -

dOO -'

(MAI
1 1

v/c-

iS/

V£

[

12?

£6

CEA

Urea excreted x ■ ■■ ■ ■ X

Urea-nitrogen value of Food:- #——•

excretion and ingestion balanced and the] weight remained
stationary. ^

Chart 10 shows the urea excreted, the urea-nitrogen value
of the food ingested, and the weight in lbs., in the case of
a male adolescent suffering from mania of the manic-depressive
variety.

For the first three weeks the nitrogen excreted was constantly
in excess of the nitrogen ingested, and there was a loss in body-
weight. During the fourth and fifth weeks the patient was wet.
During the sixth, seventh, eighth, ninth, tenth and eleventh

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1908.]

BY LEWIS C. BRUCE, M.D.

225

weeks, the nitrogen excreted and ingested fluctuated. During
the twelfth, thirteenth, fourteenth, fifteenth and sixteenth weeks,
the nitrogen excreted was less than the nitrogen ingested, and
there was an increase in weight.

Chart 11 shows the urea excreted, the urea-nitrogen value
of the food ingested, and the weight in lbs., in the case of
a female adult suffering from mania of the confusional type.

The acute stage of the disease lasted for one week, during
which the average daily urea-nitrogen excreted was 320 gr. as

Charts ii and 12.

Urea excrefed:-X ——X
Urea-nitrogen value of
Fooof:-% \' — #

Urea excreted:-* —X
Urea-nitrogen value of
Food:-* ■ ■ #

against 190 gr. of the urea-nitrogen value of the food ingested.
The weight fell 5 lb. During the second week, the nitrogen
ingested and the nitrogen excreted practically balanced.
During the third and fourth weeks the nitrogen excreted was
far below the nitrogen ingested in the food, yet the weight
remained stationary. During the fifth week the excretion and
ingestion of nitrogen balanced.

Chart 12 shows the urea excreted, the urea-nitrogen value
of the food ingested, and the weight in lbs., in the case of

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2 26 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

an adult female suffering from mania of the manic-depressive
variety.

During the first two weeks of the illness the excretion of
nitrogen was far in excess of the nitrogen ingested in the food,
and there was a loss in weight During the succeeding fivs
weeks the excretion and ingestion practically balanced o*e
another. The weight slightly increased.

Summary of Lecture /.

(1) It is a commonly accepted belief that maniacal states
are conditions of brain toxaemia or brain poisoning.

(2) It is also commonly accepted that hereditary predisposi¬
tion is the chief predisposing cause of all insanities.

(3) As to the exciting causes of mania there are evidences
of bacterial toxaemia.

(a) In the blood serum of over 90 per cent of patients

suffering from mania one can demonstrate the
presence of an agglutinin which agglutinates the
red blood-corpuscles of healthy persons. An
apparently similar agglutinin is present ir the
blood serum of many sane and apparently h^dthy
persons.

By infecting rabbits with streptococca? and
staphylococcal bacteria a similar agglutinin makes
its appearance in the blood serum of the infected
rabbits.

The presence of such an agglutinin in the blood
serum would, therefore, apparently indicate some
form of streptococcal or staphylococcal invasion.

As both the sane and the insane may show this
symptom of bacterial toxaemia, there must be some
further factor in the production of states of mania,
and this further factor is, probably, an inherited or
acquired unstable nervous system. In other words,
the sane and the insane may suffer from similar
toxaemias, but, whereas the brain of the sane man
is stable, and the toxines produce no mental sym¬
ptoms, the brain of the insane man is unstable and
readily becomes disordered by toxic action.

(b) Although the bodily temperature shows little evidence

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1908.]

BY LEWIS C. BRUCE, M.D.

227

of toxic disorder a simultaneous observation of the
white blood-corpuscles of the patient demonstrates
that a state of marked toxaemia exists in nearly
every case.

(r) The disorders of the alimentary tract are such as one
would expect to find in persons suffering from toxic
diseases. Further, the bacteriological flora of the
whole alimentary tract is altered in at least 50 per
cent, of the subjects of mania.

(rf) Lastly, the nitrogenous excretion by the urine in the
subjects of mania indicates an excess of metabolism
similar to that found in known infective diseases.

Lecture II.

To-day, by a description of the changes to be found in the
solid and liquid constituents of the blood, further light can be
thrown upon the obscure causation of the various forms of
mania.

The blood-serum in a state of health contains certain anti¬
bacterial substances, amongst others, agglutinins and opsonins.
The action of the agglutinins can be readily demonstrated in
vitro. If the serum of a healthy man be mixed with a broth
culture of the Staphylococcus aureus in the proportion of 1 part
of serum and 19 parts of broth and the mixture be examined
under the microscope, it will be found that the cocci are
agglutinated generally within thirty minutes. The rapidity and
the completeness of agglutination varies in different persons, and
the serum of any given person varies in its agglutinative power
from day to day. In twenty members of the asylum staff* who
were examined as controls, this staphylococcal agglutinating
substance was present in every case. Similar agglutinins
which act upon many of the streptococci can be demonstrated
in the serum of healthy persons.

In addition to these normal agglutinins the blood may
contain agglutinating substances directly the result of disease.
We know, for instance, in typhoid fever, a disease due to a
specific bacillus, that the blood serum contains an agglutinating
substance which acts only upon the typhoid bacillus, and we
also know that this agglutinin is rarely present in persons who

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228 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

have never been infected with typhoid. Since Grunbaum and
Widal made this discovery other observers have recorded the
presence of specific agglutinins in the blood serum of persons
suffering from such conditions as Malta fever, Bacillus coli
infection, etc., conditions, in short, where the organism causing
the disease can be isolated from the patient and grown arti¬
ficially. It is evident, therefore, that if in any patient suffering
from an obviously toxic disease one can demonstrate the
presence in the serum of a specific agglutinin to an organism
which has been isolated from that patient or another suffering
from a similar disease, which agglutinin is not found in the
serum of persons in a state of health, this fact alone is
suggestive that the patient is suffering from, or has recently
suffered from, bacterial invasion by the organism which the
blood serum agglutinates. In certain disease conditions, such
as typhoid, the demonstration of the presence of a specific
agglutinin in the blood serum to the typhoid bacillus is enough
to clinch the diagnosis in a doubtful case. There are, however,
certain organisms, particularly of the streptococci group, whose
behaviour when mixed with serum is so uncertain that some
workers go the length of saying that no reliance can be
placed upon results based upon such observations as strepto¬
coccal agglutination. The fact that agglutinating substances
to many of the streptococci group of organisms normally exist
in the serum of healthy persons has apparently complicated this
line of research. While admitting the difficulties to be
encountered and the errors which may occur in such work, I
have no hesitation in saying that specific agglutinins to
certain of the streptococci group can be demonstrated in the
blood serum of patients suffering from mania, and that this
agglutinin is rarely present in the serum of apparently healthy
subjects or in the subjects of mental diseases other than states
of mania.

Some four years ago I isolated from the blood of a case of
mania of the confusional type, in a typhoid state, a short
streptococcus. The patient recovered, and out of curiosity I
tested the blood serum of the patient to a broth culture of the
organism in a dilution of I in 30, and agglutination was com¬
plete in thirty minutes. I found that agglutination occurred
in dilutions of 1 in 100, but the reaction was slower. The
sera of two control cases failed to give a reaction after twelve

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1908.]

BY LEWIS C. BRUCE, M.D.

229

hours. Since then I have tested the serum reactions of some
204 patients, suffering from all varieties of mental disease, to this
streptococcus. Ninety-three of these patients laboured under
either one or the other of the two varieties of mania mentioned
in the first lecture. Over 70 per cent . of these patients gave a
definite agglutinative reaction. Of the 101 patients who
suffered from mental diseases other than mania only 10, or
9*8 per cent ., gave agglutination. Further observations upon
the bacteriology of patients suffering from mania yielded some
five other strains of streptococci, very similar to that isolated
from the blood of the case previously mentioned.

By using all the strains of streptococci thus obtained in
these agglutinin observations I found that the presence of a
specific agglutinin could be demonstrated in the serum of
nearly every case of mania.

If one calls the members of the asylum staff and all the
mental cases not maniacal in character, controls, then aggluti¬
nation to one of the six varieties of streptococci was only
obtained in 20 out of 126 cases, or 1 5*8 per cent .

Another interesting point is that over 60 per cent . of the
maniacal patients were deficient in the normal protective
agglutinin to certain strains of the Staphylococcus aureus ,
which agglutinin appears to be always present in healthy
serum. My observations upon the leucocytosis in insanity have
already been recorded, but as the present lecture would not
be complete without reference to this branch of the investiga¬
tion into the symptoms of mania, and as later observations have
placed further interesting facts in my possession, I will describe
the leucocytosis in mania as briefly as possible.

Before recording the white blood-corpuscles or leucocyte
changes which occur in the blood of patients suffering from the
various forms of mania, it is necessary that I should shortly lay
before you the presently accepted views regarding the forms and
the numbers of these cells which are to be found in healthy
persons.

The leucocytes or white blood-corpuscles, according to
recent observations, vary in health between 5,000 and 10,000
per c.mm. of blood. They often exceed 10,000 in women
with a tendency to anaemia, and every now and then one
encounters an apparently healthy person with a leucocytosis
averaging 12,000 or 14,000 per c.mm. In some of these

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230 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

cases, however, one finds a cause for the hyperleucocytosis
unknown and unsuspected by the patient.

The leucocytes consist of at least six varieties of cells :

(i) The multinucleated leucocytes with neutrophile granules,
commonly spoken of as polymorphonuclear leucocytes, or
shortly, as polymorphs. These cells are relatively and actually
increased in many known diseases due to bacterial invasion,
and now when making a leucocyte count it is recognised that
it is more important to know the actual number of the
polymorphonuclear leucocytes per c.mm. than to know only
the number of leucocytes in a c.mm.

Chart i.

. 16,000
| 16,000
o n,ooo

8. 13,000
8 12,000
u,000
| to,ooo

~ 9,000

8 6,000

7,000 --

| BfiOO
I” 5,000
E 4,000
•3 5,000
* 2,000

male:

FEMALE MALE

Polymorphonuclear leucocyte charts in three control persons.

The actual number of polymorphonuclear cells per c.mm. in
eight control persons examined varied between 7,000 and 2,500,
and the average in these persons was 4,829. All the charts
which will be shown to-day are based on this system of calcu¬
lating the polymorphs per c.mm.

These cells are actively phagocytic in function. They
increase in the blood prior to the appearance of agglutinins,
opsonins, and immune bodies in the serum, and it is probable
therefore that they are glandular cells which secrete these
substances.

(2) The small lymphocyte.

(3) The large lymphocyte.

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BY LEWIS C. BRUCE, M.D.

231

(4) The hyaline or mononuclear cell. These three varieties
tend to run into one another, and their relative proportion
in leucocyte counts are affected by the personal equation of the
observer. Their functions are but little understood, beyond the
fact that the large lymphocytes and hyaline cells are actively
phagocytic.

(5) The eosinophile leucocyte. A bi-nucleated or multi-
nucleated cell with large eosinophile granules. These cells
increase in the blood during convalescence from some bacterial
invasions, and are frequently increased after injections of
bacterial vaccines. They become actively and selectively
phagocytic after injections of bacterial vaccines, and it is

Chart 2.

Polymorphonuclear leucocyte chart in a case of puerperal mania (confusional).

probable that they also secrete some of the protective anti¬
bacterial substances. In the control cases they never exceeded
300 per c.mm. of blood, and I regard anything over 400 per
c.mm. as abnormal.

(6) The mastellan leucocyte or mast cell. A leucocyte with
a single lobed or double nucleus, the surrounding protoplasm
containing large violet granules when stained by Jenner’s
stain. Their function is unknown.

During the last four or five years I and my assistants have
examined the leucocytosis in 36 cases of mania of the manic-

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232 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

depressive type, and 31 cases of mania of the confusional type.
The observations made upon these patients were continuous,
extending in some cases for periods of over six months in each
case. Isolated observations are practically useless in throwing
light upon these obscure disease conditions.

Taking the average polymorphonuclear leucocytosis as 7,000
per c.mm., we have found a hyperleucocytosis of these cells in
every case of mania examined.

In cases of recent mania of the confusional type, the leuco¬
cytosis is always high, and the higher the leucocytosis the more
hopeful is the prognosis. In a patient who suffers from a short.

Chart 3.

Polymorphonuclear leucocyte chart in a case of mania (confusional type).

sharp attack of mania, and makes a rapid recovery, the poly¬
morphonuclear leucocytosis is uniformly high, even after
recovery is complete. And this hyperleucocytosis persists
apparently indefinitely. In one female adolescent patient
whose blood I have had opportunities of examining at intervals
during the last three years, during which she has enjoyed
sound mental health, I have always found a polymorphonuclear
hyperleucocytosis present (Chart 2).

In cases of confusional mania who convalesce more slowly,
the polymorphonuclear cells are at first greatly increased in
number, then they subside somewhat, only to increase again as
complete recovery takes place (Chart 3).

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BY LEWIS C. BRUCE, M.D.

233

In patients who do not recover one of two things happens.
Either the patient suffers from chronic mania with recurrent
exacerbations of excitement, or the patient becomes demented.
If the disease takes the form of chronicity with recurrent
exacerbations the polymorphonuclear leucocytosis varies con¬
siderably, but presents distinct waves corresponding to the
recurrent attacks of excitement (Chart 4). If the patient
becomes demented then the polymorphonuclear leucocytosis
falls belows the normal, as if to indicate that the patient was
exhausted and unable to cope further with the toxaemia

Chart 4.

Polymorphonuclear leucocyte chart in a case of chronic mania (confusional
type). This is a continuous daily record for thirty-six days.

(Chart 5). I have seen a few of such cases recover, however,
if their leucocytosis was accidentally or artificially stimulated
(Charts 6 and 7).

In cases of mania of the manic-depressive type, the symptom
of hyperleucocytosis is often present and corresponds to the
period of excitement; thereafter it falls to normal, and with the
exception of an occasional rise remains at normal until another
attack of excitement or an attack of depression sets in (Chart
8). In many of these cases of manic-depressive insanity,
however, there is a regular sequence of events in the leucocyte
curve which I am only able to show you in chart form in
patients who suffered from short attacks. The period of
excitement in many of these cases of manic-depressive insanity

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234 THE symptoms and etiology of mania, [April,

is so prolonged, lasting perhaps three and four months, that it
is impossible to represent the leucocytosis in a lantern chart
(Chart 9).

Chart 9.—The patient, a male, set. 50, had suffered from
short recurrent attacks of the manic-depressive insanity since
adolescence. The attack, the leucocytosis of which is repre¬
sented in the chart, commenced with depression, which lasted
for a little more than a day, and the polymorphonuclear
leucocytosis was 11,000 per c.mm. The following day it
had fallen to 6,000, and the patient complained of pains

Chart 5.

in the joints which he ascribed to rheumatism. On the
third day he was maniacal, and the polymorphonuclear leuco¬
cytosis had risen to 10,000 per c.mm. For the next nine days
he was in a state of great elevation and excitement. It will be
noticed that at the commencement and termination of the
maniacal attack there were marked rises in the polymorphonuclear
leucocytes, but that at the very height of the attack the poly¬
morphonuclear leucocytes fell below 7,000 per c.mm. Recovery
followed the last rise, and the leucocytosis at once returned to
about 7,000 per c.mm. Subsequent attacks in this patient
always presented the same sequence of symptoms and the same

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235

1908.] BY LEWIS C. BRUCE, M.D.

leucocyte curve, and similar records have been obtained in other

Chart 6.

Polymorphonuclear leucocyte chart in a male, aet. 24. Admitted May 27th,
suffering from mania with confusion. Apparently recovered by Tune 6th.
Relapsed June 13th. July 14th, suffering from dysenteric diarrhoea.
Again sane. Relapsed July 17th. Similar attacks on August 5th and
October 4th.

Chart 7.

Polymorphonuclear leucocyte chart in a female, aet. 30. During June. 1905,
the condition was acute. By November she was apparently demented.
No change, occurred until August, 1906, when she was treated with
nucleinic acid. The polymorphonuclear leucocytes immediately increased,
simultaneously there was mental improvement and subsequent recovery.

cases where the attacks were so short as to facilitate continuous
examination.

LIV. l8

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Polymorphonuclear leucocytosis per c.mm.

236 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

As interesting comparisons I show you two charts of hyper-
leucocytosis occurring in sane persons.

Chart 8.

3,000

Polymorphonuclear leucocytosis in a case of mania (manic depressive).

Chart 9.

10.000

Polymorphonuclear leucocyte chart in a case of recurrent mania (manic-depressive),
showing the leucocytosis throughout the course of an attack.

Chart 10 is a case of rheumatic arthritis. The leucocytosis
is shown for a period of fourteen days when the patient was

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BY LEWIS C. BRUCE, M.D.

1908.]

237

suffering from a recurrent attack of pain in the joints together
with general malaise.

Chart 10.

* 6,000
*5,000
| 14,000
“ 13,000

j 12,000

§ U.000

I 10,000

I 9,000
| a, 000

f. 7,000

g 6,000

4,000
3J300

Polymorphonuclear chart in a case of chronic rheumatic arthritis.

Chart ii.

Polymorphonuclear leucocyte chart in a case of fissure of the tongue.

Chart 11 is a member of the nursing staff who volunteered
to act as a control to certain observations which we were

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238 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

making on the tuberculo-opsonic index. It was noticed that
her polymorphonuclear leucocytosis became high, the pulse
was a little fast, but otherwise the subject appeared to be in
excellent health. There was no disturbance of temperature.
Her serum strongly agglutinated the washed red blood-
corpuscles of a healthy person. It was only accidentally that
we discovered that this control volunteer was suffering from a
fissure of the tongue. A lesion only £ in. long and $ in. deep,
and yet the resulting bacterial toxaemia, as indicated by the
leucocytosis, is most marked.

In many cases the results obtained from leucocyte observa-

Chart 12.

3,000

Polymorphonuclear leucocyte chart in a case of supposed delusional insanity.

tions are of value in indicating the disease process when practi¬
cally no diagnosis can be made from the mental symptoms
alone.

Chart 12 shows the leucocytosis in a case of peculiar
interest.

The patient, a married woman, aet. 34, was admitted suffering
from delusions of suspicion. She was thin and poorly nourished,
and the husband stated that he had observed a gradual change
coming over her. She became irritable, changed in character,
and at times exhibited violent temper on little or no apparent
provocation. Then she suffered from hallucinations of hearing,

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BY LEWIS C. BRUCE, M.D.

239

which led her to suspect the presence of other people in the
house, and finally she became suspicious of her husband,
believing that he was trying to poison her. On admission she
simulated a case of delusional insanity. She was apparently
quite clear and sensible, answered questions, and expressed her
delusions freely. On physical examination nothing could be
detected beyond the fact that there was a hyperleucocytosis,
which is not, as a rule, a symptom of delusional insanity.
Further questions elicited the fact that she had been delivered
of a child some two years prior to admission, and that since
then she had occasionally suffered from a vaginal discharge.
Upon examination she was found to be suffering from a fissure
of the cervix about ± in. deep and £ in. long. The discharge
from the fissure when inoculated upon agar gave a rich growth
of streptococci. Her blood-serum strongly agglutinated a
streptococcus obtained from a case of confusional mania. The
local lesion was treated and healed in two months, and the
patient made a perfect recovery. She remembered everything
that had happened prior to and since her admission, but she
stated that the period of her existence corresponding to her
illness seemed to her to be like a dream. It was quite evident,
therefore, that there had been a considerable amount of mental
confusion, and I regard this case as one of confusional mania
in whom the symptom of maniacal excitement had been sup¬
pressed.

Chart 13 is a very similar case, occurring in a married
woman, act. 50. For several years she had been irritable,
delusional, and morbidly suspicious of her husband. She
searched his clothes, read his letters, and had all his move¬
ments secretly watched, because upon one occasion she had
discovered a hair upon his topcoat, which was certainly not her
own. She was sent to me as a case of chronic delusional
insanity.

On admission the only symptom which we could detect was
a hyperleucocytosis, and she looked thin, pinched, and badly
nourished.

The nurse reported, however, that the patient had a vaginal
discharge, and upon examination she was found to have an
intra-uterine fibroid. The discharge from the uterus was
swarming with organisms, chiefly streptococci. Her blood
serum contained agglutinins to a streptococcus isolated from

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Polymorphonuclear leucocytes per c.mm.

240 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

an undoubted case of confusional mania. In this case, as in
the previous one, we demonstrated the presence of a bacterial
toxaemia, with the probable local lesion. The patient was
removed by her friends.

Chart 14 throws some light upon the vexed question as to
whether alcoholism is a cause or a symptom of insanity.

The patient, a male, aet. 34, was admitted suffering from
hallucinations of sight and hearing, and also delusions. His
history was that for years he had been drinking heavily ; was

Chart 13.

16,000
f 5,000
14,000
15,000
/ 2,000

3,000

arrested by the police, found to be insane, and transferred
from the prison to the asylum.

On admission he appeared well nourished and healthy. He
had undoubtedly vivid hallucinations of sight and hearing, and
he was dangerously impulsive. Upon two occasions he made
sudden unprovoked attacks upon the night-attendants who
were in charge of the dormitory in which he slept Such
attacks are very typical of alcoholism. He presented a very
marked hyperleucocytosis, but no temperature. From his

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Polymorphonuclear leucocytes per c.mm.

I9O8.]

BY LEWIS C. BRUCE, M.D.

24I

urine my assistant, Dr. Howard, isolated a streptococcus which
was agglutinated by the patient’s serum in a dilution of 1
in 20 within an hour, while the sera of control persons gave
no reaction. The bacterial examinations of the faeces gave an
almost pure growth of streptococci, the Bacillus colt being
practically absent.

He recovered after a residence of four months, but during
the whole period of his stay in the asylum he presented this
symptom of hyperleucocytosis.

Chart 15 shows the leucocytosis in a similar case occurring
in a male, act. 20. The patient was of the degenerate type. He

Chart 14.

Polymorphonuclear leucocytes in a case of so-called alcoholic insanity.

had been three times discharged from the army for drunkenness.
He was admitted suffering from hallucinations of hearing and
sight. Beyond general tremulousness of the muscular system
he presented no symptoms except a hyperleucocytosis. His
serum contained agglutinins to several strains of streptococci
isolated from cases of undoubted confusional mania. During
his residence in the asylum he suffered from several slight
attacks of restlessness, associated with a return of the halluci¬
nations of hearing. He was eventually transferred to a neigh¬
bouring asylum.

Both these patients were undoubtedly cases of alcoholism,
but the fact that they presented definite symptoms of bacterial

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242 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

toxaemia suggests that the alcoholism was a symptom rather
than a cause of their mental state. Since these observations
were made three additional cases of chronic alcoholism have
been examined, and they all presented the same physical
symptoms.

Chart 16 shows the leucocytosis in a female, aet. 26. The
girl was sent to the asylum because she was unmanageable
at home.

On admission, the patient showed the very common symptom
in adolescent cases of arrested development, but no mental or

Chart 15.

f6,000

/ 5,000

3,000

Polymorphonuclear leucocyte chart in a case of so-called alcoholic insanity.

physical symptoms of disease could be detected. Her blood
was regularly examined, and very shortly after admission a
hyperleucocytosis was noted, together with a quick pulse of
over 100 per minute. She became irritable and quarrelsome,
sometimes refused food, and behaved like a petulant child.
This condition lasted for about a week or ten days, and then
passed off, the leucocytosis falling to about 7,000 per c.mm.,
and the pulse-rate to between 60 and 70 per minute. Her
serum showed agglutinins similar to the cases already cited.
Several similar attacks have occurred with similar physical
symptoms. If no observations had been made upon the

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1908.]

BY LEWIS C. BRUCE, M.D.

243

leucocytosis and serum reaction, these periodic attacks would
have been ascribed to fits of bad temper, whereas all the
symptoms point to the patient as being a masked case of
confusional mania.

The consistency of the results shown by these blood observa¬
tions alone are, in my opinion, suggestive. They suggest
bacterial invasion and that the victims of confusional mania
suffer from a chronic insidious toxaemia, not only during the
maniacal attack, but for a subsequent indefinite period. The
mania, in fact, may be only an accidental symptom of the
disease; while the manic-depressive cases suffer from recurrent

Chart 16.

Polymorphonuclear leucocytosis in a case of atypical mania of the
confusional type.

attacks of toxaemia. But whatever the significance of this
symptom may be these observations are facts, not fiction, which
future workers may relegate to their proper sphere when the
great problem of the causation of mania is solved.

Doubts have been thrown upon the accuracy of these records,
but I know of no observer who has conducted similar observa¬
tions, dividing the various forms of mania from one another, or
made continuous observations extending over weeks and
months. There is also this additional fact, that six different
workers in the Murthly Laboratory, several of whom were
sceptical, have corroborated these results, and further, ou

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244 THE symptoms and etiology OF MANIA, [April,

collective observations upon the leucocytosis of healthy persons
tally with those of accepted published records.

Summary of Lecture II.

The blood serum in health contains protective agglutinins
to certain strains of staphylococcal and streptococcal organisms.
These protective agglutinins cannot be demonstrated in the
blood serum of over 60 per cent . of maniacal patients.

In addition to these agglutinins which we may call normal
agglutinins, the blood serum may contain agglutinins directly
the result of disease, an example of which is the typhoid
agglutinin which appears in the blood serum as the result of an
attack of typhoid fever. Such agglutinins are known as
specific agglutinins because they act only upon the infecting
organism.

In the blood serum of patients suffering from mania, specific
agglutinins to certain organisms of the streptococcal group can
be demonstrated to exist, and similar agglutinins are rarely
present in the blood serum of apparently sane and healthy
people. The streptococcal organisms with which these observa¬
tions were made were isolated from the blood, urine, and faeces
of maniacal patients.

The leucocytosis, or the number of white blood-corpuscles in
the blood of maniacal patients, is greatly increased, and this
increase is largely due to an actual and relative increase in the
polymorphonuclear leucocytes. A hyperleucocytosis of the
polymorphonuclear leucocytes is generally regarded as an
evidence of bacterial toxaemia.

Continuous blood observations in cases of confusional mania
reveal the further fact that after recovery from the maniacal
attack the patients present this symptom of hyperleucocytosis,
and it is reasonable to suppose that this evidence of toxaemia
was also present before the maniacal attack. In other words,
in the type of mania which I call confusional, the disease is a
chronic, insidious toxaemia of which the maniacal attack is only
an incidental complication.

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BY LEWIS C. BRUCE, M.D.

245

Lecture III.

In the first lecture I dealt with the physical symptoms which
occur in cases of mania. I drew attention to the commonly
accepted belief that maniacal states are conditions of brain¬
poisoning. It was shown that the blood serum in over 90 per
cent of maniacal patients contained an agglutinin which
agglutinated the red blood-corpuscles of healthy persons. This
agglutinin can also be demonstrated in the serum of over
50 per cent . of persons who are sane and apparently healthy,
and can be artificially produced in the lower animals by
infecting them with coccal organisms. The presence of such
an agglutinin in the blood serum was therefore taken to
indicate some form of coccal invasion, but as the sane as well
as the insane present this symptom some further factor must
assist in the production of maniacal states, and this further
factor was stated to be an inherited or acquired instability of
the nervous system, which would render it peculiarly liable to
disorder from states of toxaemia.

The evidences of general failure of nutrition, the disorders
of the alimentary tract, and the character of the nitrogenous
excretion by the urine are all such as would lead one to expect
that maniacal states are closely allied to the diseases known as
infective.

In the second lecture I mentioned the fact that the blood
serum of healthy persons contains protective agglutinins to
certain strains of coccal organisms, and that these protective
agglutinins cannot be demonstrated in the blood serum of
over 60 per cent . of patients suffering from mania. In addi¬
tion to these normal agglutinins the serum of maniacal patients
was shown to contain specific agglutinins to certain strains of
streptococci isolated from the blood, urine, and faeces of such
patients.

The hyperleucocytosis found in patients suffering from
mania was described, and it was pointed out that the increase
of the polymorphonuclear leucocytes was strong evidence of
bacterial toxaemia.

I divided cases of mania into two great classes : mania of
the confusional type, and mania of the folie circulaire type or

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246 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

manic-depressive insanity. In this lecture I merge all manias
into one great group.

If, as indicated in my first two lectures, the diseases known
as mania are due to bacterial toxaemias, then the natural ques¬
tion arises, what organism or class of organisms produce the
toxaemia, and how do they attack the patient? To answer
these questions it is necessary to describe in detail the various
observations undertaken to discover the organism.

My first observations were conducted as follows : I argued
that if the organism was circulating in the tissues it might be
possible to obtain it in pure culture from a sterile necrotic
area. I knew that the subcutaneous injection of certain irritants
produced a hyperleucocytosis which frequently improved the
condition of the patient, and I combined this method of treat¬
ment with bacterial investigation. I injected, therefore, with
aseptic precautions from *5 to 1 c.c. of terebine subcutaneously.
In the course of a week an abscess formed, and from 1 to 2 c.c.
of the abscess contents were then withdrawn hypodermically
with a needle attached to a syringe. The pus so obtained was
mixed with nutrient broth and incubated at 37 0 C. for twenty-
four hours. The whole operation was conducted painlessly
with local anaesthesia. Out of fifteen such abscesses I isolated
a short diplo-bacillus in seven cases. The remaining abscesses
were sterile. I merely mention this work to dismiss it, because
after working with this organism for some six months I came
to the conclusion that it had nothing to do with the disease,
and was possibly an accidental contamination.

I next directed my attention to the blood, and by means of
a 10 c.c. glass syringe attached to a needle, 10 c.c. of blood
was withdrawn from any prominent vein in the forearm and
transferred to two flasks each containing 250 c.c. of sterile
bouillon. In some instances these flasks were immediately
placed in the incubator at 37 0 C.; in others twenty-four hour9
were allowed to elapse prior to incubation to allow the leuco¬
cytes to die and so inhibit their phagocytic action. The blood
was examined in this manner in fifteen cases of mania—all
acute recent cases. In twelve of the observations the flasks
were sterile at the end of seventy-two hours, two were acci¬
dentally contaminated, and only one yielded a short strepto¬
coccus, which was eventually proved to be in some way con¬
nected with the disease process. As mentioned in the previous

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BY LEWIS C. BRUCE, M.D.

247

lecture, it was found that the blood serum of the patient from
whom this organism was obtained agglutinated the organism
in dilutions up to 1 in 100, and that similar agglutinins were
found in over 70 percent . of all the cases of mania subsequently
examined, while control persons and insane patients who were
not suffering from mania only gave agglutination in a propor¬
tion of 15*8 per cent . This single successful blood observation
was of immense service in stimulating further research, but it
was obvious that blood observations alone would not yield
satisfactory results.

With the help of my assistants I therefore turned my atten¬
tions to the bacterial examination of the urine. In the male
cases the urine was passed directly into sterile urine glasses,
and in the women urine was drawn by means of a sterilised
catheter. By neither of these methods can sterile urine be
obtained, because the urethra invariably contains organisms
which are either washed out by the urine or infect the catheter
employed. I trusted to the fact, however, that if we obtained
an infecting organism the blood serum of the patient would
agglutinate it, and this was the test which we employed in every
case to separate the infecting from the non-infecting organisms.
Control serums were, of course, used in every case.

The first fact which we noted in the urine observations was
that the urine of patients suffering from mania contains, when
examined microscopically, a very large number of various forms
of organisms. To control these observation we examined the
urine of healthy males and compared the results with those
obtained from the examination of the urine of male patients
suffering from mania. The method of examination was con¬
ducted as follows: The urine, immediately after being passed,
was taken to the laboratory ; 30 c.c. were divided equally
between two sterile centrifuge glasses and subjected to centri-
fugalisation for ten minutes. The supernatent fluid was then
pipetted off, leaving 1 c.c in each glass. A sample was taken
from each glass and examined microscopically, and the
remainder was then distributed equally between two agar
plates, allowed to solidify and placed in the incubator at 37°C.
to incubate for twenty-four hours. The urine of the maniacal
male patients was found to present microscopically great
numbers of bacteria, chiefly coccal organisms, while the urine
of five control males showed only a very small proportion of

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248 THE SYMPTOMS AND ETIOLOGY OF MANIA,

[April,

organisms. In spite of the fact that the urine of the maniacal
patients, when examined under the microscope, presented a
large number of organisms, in several instances the number
which actually grew upon the agar plates was very small in
proportion. On the other hand, the urine of the control males
when incubated on agar plates presented often as many as
300 colonies in each plate. It is inferred from this that a
large percentage of the organisms in the urine of the maniacal
patients were dead and had probably been excreted by the
kidneys, while the organisms in the control urines were living
and had probably been washed out of the urethra. Counting
both male and female cases the urine was bacterially examined
in twenty cases, and from the organisms so obtained only two
were agglutinated by the blood serum of the patient yielding
the organism. Control sera failed to agglutinate either of
these organisms. Both organisms were short streptococci. In
none of these patients was the urine offensive, nor did we
suspect bacilluria until microscopic examination was made.
According to the researches of Adami the presence of organisms
in the urine may be explained as follows: Adami found that
if the livers and kidneys of apparently healthy animals were
removed with antiseptic precautions and placed in agar and
incubated, that organismal growth was obtained in nearly
every case. He believes that under ordinary conditions the
leucocytes pass out through the mucosa on to the free surface
of, more especially, the alimentary tract, some of these cells
there undergoing destruction, while others, now laden with
various foreign matters, including bacteria, pass back into the
submucosa and find their way into either the lymphatic
channels or into the portal venules. Such isolated bacteria
which may have escaped leucocytal destruction or removal by
the lymphatic glands, or by the endothelium of the portal
system, may pass either through the thoracic duct or through
the liver and enter the systemic circulation, from which they
are eliminated chiefly by the kidneys. Such a condition is
known as “ latent infection ” or latent microbism,” and is com¬
patible with perfect health.

The intestinal tracts of patients suffering from mania, present
post-mortem y cdXdLVx\\a\ areas. Dr. Ford Robertson, the Pathologist
of the Scottish Asylums, examined such a condition in the ileum
of a very acute case of mania of the confusional type, who died

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1908.]

in the typhoid state. His report is as follows: “ In the ileum the
mucosa was narrowed, the villi were diminished in number,
fibroid and atrophied. There was great increase of inter-
glandular fibrous tissue, and the bases of many of the glands
were, in consequence, widely separated from one another, while
the submucosa showed fibrous thickening.” In his opinion
the condition was one of severe chronic atrophic catarrh.
There was also, in this case, fatty changes in the epithelial
cells of the liver. I have noticed similar changes in the small
intestines of nearly every case of mania examined post-mortem .
The presence of such lesions may possibly explain the presence
of such numbers of organisms in the urine, as a catarrhal con¬
dition of the intestine would naturally favour the presence
of leucocytes, which would be attracted to the area by
chemiotaxis.

The fifteen blood and twenty urine bacterial observations
had so far, therefore, yielded only three organisms which were
agglutinated by the blood serum of the patients from whom the
organisms were obtained, but beyond the fact that they all
belonged to the streptococci group they differed somewhat from
one another in their growth characteristics and in their aggluti¬
nating sensibility when tested with the serum of various cases of
mania. The researches of Adami, however, naturally suggested
the intestinal tract as a field for bacterial investigation. We,
therefore, made cultures from the faeces of cases of mania.
The technique was as follows: A small portion of the faeces
was taken immediately after being passed. A straight platinum
needle, sterilised by flame, was charged once from the centre of
the mass, and successive stroke cultures were then made on a
series of six agar tubes, three strokes being made upon each
tube. These tubes were then placed in the incubator and
incubated at a temperature of 37 0 C. for a period of twenty-four
hours. Twenty-seven observations were made on twenty-seven
different cases, and it was noted that colonies of cocci were very
numerous in the bacterial flora of fifteen of these maniacal patients
(Chart 1). Upon examination it was found that these colonies
of cocci were in almost every case streptococci. Control
observations made upon the faeces of healthy persons and
cases of insanity other than the subjects of mania, very rarely
yielded more than one or two colonies of streptococci, whereas,
in some of the maniacal patients the streptococci were by far

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2 50 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

the most numerous organisms present Houston, in examining
the bacteriology of the faeces in twenty healthy persons, found
streptococci in excess in one case. Subcultures were made
from these colonies of streptococci obtained from the faeces, and
each individual patient’s serum was tested to broth cultures of
these organisms to ascertain if specific agglutinins were
present. Control sera from healthy persons were used in
every case to check the agglutinating experiments. Organisms,
to which such agglutinins could be demonstrated to exist in
the patient’s serum and to be absent from the sera of control
persons, were found in six of the maniacal patients. In one
case the same organism was isolated both from the urine and
the intestinal tract. The mere presence of large numbers of
streptococci in the intestinal flora was no indication that
specific agglutinins would be found i;i the blood serum of the
patient. For instance, in one patient ten different colonies of
streptococci were isolated from the faeces, but the patient’s
serum agglutinated only one of these. In another case fourteen
colonies of streptococci were examined, but none of them were
agglutinated by the patient’s blood serum. In many instances
the streptococci obtained were agglutinated both by the patient’s
serum and the control sera, while in other cases the control
sera produced rapid agglutination, but the organism was not
affected by the patient’s serum.

The characteristics of these eight organisms obtained from
the blood, urine or faeces, are as follows:

Microscopically they appear as short chains of four, five, six,
seven and eight cocci, or just as frequently as diplos. They
stain readily with all aniline dyes, and they hold Gram’s stain.
They all grow at the ordinary atmospheric temperatures
except No. i, obtained from the blood, which, when first grown
on artificial media, showed no capacity for growth at the room
temperature, but was capable of long life under such conditions,
as an inoculated agar tube, after being kept for a month at
room temperature, upon being incubated for twenty-four hours
at 37 0 C., produced a characteristic growth. After passing
through several subcultures this organism was found to have
acquired the power of growing at ordinary temperatures. In
broth they all form an uniform turbidity in less than twenty-four
hours, and they turn the media acid. Stab cultures in gelatine
grown at 2 2° C. show as a pale, clear streak, which in all

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1908.]

eventually becomes feathery along the edges. There is little
surface growth. No. 1, after being subcultured for two years,
was found to liquify gelatine—a characteristic which it did not
possess when first obtained. Stroke and smear cultures on
sloped nutrient agar tubes grow as thin, bluish-white streaks or
smears, which, under magnification, are seen to consist of
numerous small translucent colonies. The size and opacity
of these colonies differed considerably in some of the organisms
when first obtained, but after several subcultures had been
made they all tended to one type of growth. All grew in
litmus milk, which was curdled by four of the eight organisms,
while the blue litmus was changed to red by seven.

When tested on animals their action was obscure. Intra¬
venously in rabbits in doses ranging from * 1 t c.c. to 2 c.c. they
produced a slight febrile reaction. Intra-peritoneally in rabbits
in doses ranging from *5 c.c. to 5 c.c. they produced no outward
result, but young rabbits so infected almost invariably developed
paralysis of the hind quarters in from one to two months from
the date of infection. Several of these infected animals died,
but no lesion could be demonstrated post mortem . In one,
however, a pure culture of a streptococcus was isolated from the
heart-blood, which, in appearance, growth, characteristics, and
to a slighter degree in its agglutinating properties, resembled
the infecting organism.

Subcutaneous injections of doses ranging from * 1 c.c. to 2 c.c.
produced no suppuration, but repeated injections produced rapid
loss of body-weight, although the animal continued to take
food well, and did not appear to be ill. The fact that these
organisms are not pus producers separates them from the
pyogenic streptococci, and allies them to the Micrococcus
rheumaticus . Attempts were made to immunise two goats,
with the view of obtaining an anti-serum, but both animals
rapidly lost weight, and the injections were discontinued.
Neither appeared to be ill; they took food greedily, and were
active and energetic. Both died some months after the injec¬
tions had been discontinued, apparently of some intercurrent
disease, the nature of which I did not understand.

A sheep, which was immunised by weekly injections of doses
commencing at 1 c.c. of mixed broth cultures of four of the
organisms, the dose being gradually increased to 4 c.c. at the
end of six weeks, very rapidly lost weight, but was otherwise

LIV. 19

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252 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

apparently healthy. Serum was taken from both the goats
and the sheep and tested in the laboratory, and also used in
the treatment of cases of mania. In the laboratory no immune
body could be demonstrated in vitro , and when injected into
cases of mania in doses ranging from 10 c.c. to 20 cx. the only
result noticed was a fall in the pulse-rate. Although these
attempts to produce anti-serums were unsuccessful, I still believe
that there is a field for the use of anti-serums in such cases.
According to Ehrlich’s theory, in a condition of toxaemia
the patient’s blood contains toxine molecules, which gradually
stimulate the cells of the body to throw out antitoxine mole¬
cules, which, by combining with the toxine molecules, render
them inert. When one immunises an animal against toxines,
these antitoxine molecules are in excess in the blood serum of
the immunised animal, and it is probable that the injection
of a large dose of such antitoxic molecules into a patient
suffering from mania would produce a temporary remission
sufficiently prolonged to allow of the natural defensive processes
of the body to come into play. A polyvant serum would, of
course, be a necessity, as the streptococci found in connection
with these disease processes are not identical.

Having failed to obtain an efficient anti-serum, it occurred
to me that the patients might form their own immune bodies
if dead cultures of the organisms which they agglutinated were
injected subcutaneously. The earliest of these observations were
made before Wright published his researches on opsonins and
pointed out the necessity for the exhibition of small doses. The
initial doses of vaccine used at Murthly were all too large. It was
found that the injection of a ’5 cx. dose of a broth culture of these
organisms when injected subcutaneously into a maniacal patient
produced an exacerbation of the mental symptoms, correspond¬
ing to Wright’s negative phase. This was followed by a
temporary improvement corresponding to Wright’s positive
phase, but the results were very transitory, and in several
patients, after a period of treatment extending over six weeks,
no immune body could be demonstrated to exist in the blood
serum when tested in vitro . During and corresponding to the
positive phase the polymorphonuclear leucocytes were always
increased.

After Wright published the results of his researches upon the
opsonic indices in tubercle and Staphylococcus aureus , we

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BY LEWIS C. BRUCE, M.D.

253

examined the opsonic power of the blood serum in our maniacal
patients, using as the testing organism the variety of strepto¬
coccus which each particular patient agglutinated. These
observations were continuous in each case, and in some
instances we were fortunate enough to obtain records through¬
out the whole period of short attacks of manic-depressive
insanity and of confusional mania.

With the help of my assistant, Dr. C. J. Shaw, I made con¬
trol observations on members of the asylum staff.

I am also able to show you opsonic index charts in the case
of chronic rheumatic arthritis and the control who suffered from
a fissure of the tongue. The testing organism used in the case
of rheumatic arthritis was the Micrococcus rheumaticus , a culture
of which was kindly given to me by Dr. Dowson, of the Wellcome
Research Laboratory. And the testing organism used in the
case of tongue fissure was a variety of streptococcus which the
patient's serum partially agglutinated.

In estimating the opsonic index we followed the technique
introduced and described by Wright. An emulsion was made
from a twenty-four hours' agar culture of the organism, which,
when necessary, was shaken up with sterilised glass beads to
insure subdivision of the cocci. Blood-corpuscles, usually taken
from a control person, were washed in 1 per cent . citrate of soda
solution and then in normal saline. A sufficient quantity of
serum was obtained from the patient and also from a control
subject. It is certainly more accurate to mix two or three
control sera, but we were not able to do this frequently, but we
tested our control sera every now and then against one another
and found them fairly steady in their reaction.

Equal quantities of emulsion, blood-corpuscles, and serum
were then mixed, drawn into a capillary tube, and incubated
for fifteen minutes at 37 0 C. The contents of the capillary
tubes were then blown on to slides, made into a film, dried, and
stained. The films were then examined under a microscope,
the oil-immersion lens being employed, and the number of
organisms ingested by 30, 40, 50, or 60 polymorphonuclear
leucocytes were counted in both the patient's and the control
films. The number of organisms ingested by the polymorpho¬
nuclear leucocytes in the patient's film were divided by the
number of organisms ingested by an equal number of poly¬
morphonuclear leucocytes in the control's film, the result being

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254 THE symptoms and etiology of mania, [April,

the opsonic index of that patient to the particular organism
used in the observation.

The average opsonic index of health, as found by Wright
and other observers, to tubercle and staphylococci varies
between # 8 and 1*2, and in the charts which I will show you
I have adopted these limits as the limits of the opsonic index
in health to these streptococci, as to the best of my knowledge
no data exist as to the average index in health to any of the
organisms of the streptococci group.

Chart 2 shows the opsonic indices of members of the
asylum staff to one of the streptococci isolated from a case
of confusional mania. The sera of Cases A and B both aggluti¬
nated the red blood-corpuscles of healthy persons, which reaction,

Chart 2.

• 7 A

•e

•4

•

T A

\ .

\ /

- v/ v \ /

• \

\ s'

: N

••

Opsonic indices in control cases.

as stated in an earlier lecture, is presumptive evidence in favour
of some form of coccal toxaemia, although both were apparently
in perfect health. The serum in Case C did not agglutinate
the red blood-corpuscles in healthy persons. It will be noticed
that the variations in the opsonic index of these control persons
are marked, much more so than in the case of tubercle, but
when one comes to compare these charts with the charts of
cases suffering from mania, the fluctuations in the indices of
the maniacal patients are more marked than in the control
persons.

Chart 3 shows the opsonic index in the case of a female
adolescent suffering from acute mania of the confusional type.
The patient was admitted in a state of wild delirious excite¬
ment, and a culture made from the faeces gave a rich growth of
streptococci, one colony of which the patient's serum aggluti-

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BY LEWIS C. BRUCE, M.D.

I 908 .]

255

nated in dilutions up to 1 in 50. This organism was used in
estimating the opsonic power of the patient’s serum.

For the first four days the patient was maniacal and
delirious, and the index was low. On the fifth day the index
rose to i*6, and on the sixth day-to 2. On that—the sixth—day
the patient became conscious of her surroundings. Two days
later the index had fallen to normal, and this was again
followed by a marked rise or positive phase and a subsequent
fall. During the whole of this period the patient was sensible,
quiet, sleeping well, and progressing favourably. On the seven¬
teenth day I injected seven and a half millionsof dead streptococci,
killed by heat. The following day the index fell to 7, and the

Chart 3.

patient was slightly dull and apprehensive. This was followed
by a marked positive phase which lasted for three days, during
which the patient was in good mental health. I then injected
fifteen million dead streptococci, and this dose was followed by
a prolonged negative phase, lasting for three days, during
which the patient was dull and confused. This was succeeded
by a marked positive phase, associated with mental clearness.
The patient made an excellent recovery without suffering from
any relapses, which are extremely common in adolescent cases,
but whether in spite of, or because of, the treatment, it is im¬
possible to say.

Chart 4 shows the index in a very acute case of delirious

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256 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

mania in a young male epileptic. For the first seven days the
index was never above 1, and on two occasions as low as *4.
Then a sudden rise to 2 occurred, with some mental improve¬
ment. On the eleventh day I injected seven and a half million
streptococci, and this injection was followed by a fall or
negative phase, which lasted for two days, and this was
succeeded by a positive phase lasting for two days. On the
sixteenth day another injection of seven and a half million dead
streptococci was given, and was followed by a marked fall or nega¬
tive phase with exacerbation of the mental symptoms, and this

Chart 4.

was succeeded by a marked rise or positive phase reaching
2*4, accompanied by decided mental improvement.

Chart 5 shows the opsonic index in a case of chronic mania
of the confusional type, occurring in an adult woman who had
been ill for more than two years. The organism used in this
case was the streptococcus obtained from the blood of the case
of acute confusional mania. It will be noticed that the positive
and negative phases follow one another with great regularity,
and whenever the index fell below normal a marked exacerba¬
tion occurred in the mental symptoms. Such a chart, inter¬
preted according to our present knowledge of the opsonic index,

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1908.]

BY LEWIS C. BRUCE, M.D.

257

would read as follows : The chart commences with a positive
phase, succeeded by a mild auto-intoxication, which stimulated
another positive phase. Then follows a more marked auto¬
intoxication, producing a decided negative phase accompanied
by excitement and noise. This is again succeeded by a positive
phase with comparative mental improvement. Lastly, a still
more marked auto-intoxication, producing a negative phase
lasting for four days, and again a reaction of the body to the
toxines represented by a positive phase.

It will have been noticed in all the charts which I have

Chart 5.

*<4

shown that the positive phases are extremely short, whether
they occur as the result of auto-intoxication or as the result of
the injection of dead bacteria.

Chart 6 shows the opsonic index throughout an attack or
manic-depressive insanity. The patient, a woman, aet. 55,
suffered from repeated attacks every three or four months.
Each attack was short, rarely lasting for more than two of
three weeks. The index throughout two separate attacks was
observed and was practically identical on both occasions. On
the first day the mental symptoms were those of depression
with an index of *7, then follows a marked rise to 2 followed

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258 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

by a fall to ’5. The patient became maniacal on that, the
third day of her illness, and with the exception of a rise of the

Chart 6.

Chart 7.

•5

•7

•6

•4 Opsonic index (Fissure of Tongue)

index to r6 on the fourth day the index was low for eight
days, during which the maniacal symptoms were most acute.
This period was followed by a sudden rise to 2 with marked

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1908.]

BY LEWIS C. BRUCE, M.D.

259

mental improvement and a subsequent index which closely
approached the normal line associated with a rapid convalescence
and recovery. This chart reads as follows : Auto-intoxication
with a negative phase and a subsequent positive phase. A
further auto-intoxication with an abortive attempt at a positive
reaction followed by a long negative phase lasting seven days.
A mastering of the toxines shown by the return of the
positive phase with a subsequent persistence of high opsonic
power associated with recovery.

Chart 7 : As an interesting comparison I show the opsonic
index in the control case suffering from fissure of the

Chart 8 .

tongue. The subject, a member of the asylum staff, volun¬
teered to act as a control in some observations which were
being made on the tuberculo-opsonic index, and at the same
time the opsonic power of the blood serum was tested to one
of the streptococci isolated from a case of confusional mania.
The leucocyte chart, which was shown during the previous
lecture, indicated that there was some source of toxaemia
unknown to us, and we subsequently discovered that the
lesion was a fissure of the tongue. It will be noticed that the
index in this control upon two occasions rose much above the

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260 the symptoms and etiology of mania,

[April,

limits of health. The subject was apparently in excellent
health, but the blood serum agglutinated the red blood-
corpuscles of a healthy person.

Chart 8 is also an interesting comparison with those of
maniacal patients as being the index of a sane person suffering
from chronic rheumatic arthritis due to the Micrococcus rheu -
maticus , who was also injected with vaccines of the organism. The
chart starts with a marked positive phase succeeded by a prolonged
negative one, during which the patient suffered from nausea,
intestinal disorder, and acute pain and swelling in the joints.
The chart restarts with a positive phase, and on the fourth day
an injection of seven and a half millions of dead Micrococcus
rkeumaticus was given. This was followed by a decided negative
phase during which the patient suffered from a rheumatic
attack, and this was followed by a positive phase with a return
to comparative comfort. Next day another injection of seven
and a half millions of Micrococcus rkeumaticus was given, which
was followed by first a rise and then a prolonged fall of the
index, and again the patient suffered from malaise and
rheumatism.

When one compares such a chart made in the case of a
person suffering from a disease which is almost certainly
bacterial in origin with those made in the subjects of mania,
there is a very marked similarity between them, both in the
extreme variations of the index and the association of the
rheumatic and maniacal symptoms with the periods of
the negative phases.

Summary of Lecture III.

As the result of bacterial observations on the blood of
fifteen patients suffering from mania, a streptococcus was
isolated from the blood of one case of confusional mania.
The blood serum of this patient agglutinated the organism in
a dilution of i in ioo, while the serum of few control persons
gave agglutination. The blood of the remaining fourteen cases
of mania was sterile. It may be surmised, therefore, that
organisms are not frequently present in the blood of maniacal
patients.

As the result of bacterial observations upon the urine of
twenty patients suffering from mania, it was noted that the

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1908.]

BY LEWIS C. BRUCE, M.D.

26l

urine of these cases when centrifuged and examined micro¬
scopically presented a large number of organisms, chiefly cocci. .
The urine of five control males when centrifuged and examined
microscopically presented very few organisms. Cultures made
from the centrifuged urine of the maniacal patients presented
comparatively few colonies of organismal growth considering
the number of organisms seen microscopically. On the other
hand, the urine of the five control males when inoculated on
agar plates and incubated for twenty-four hours at 3 7 0 C.
showed a large number of organismal colonies. It is inferred
from this that that the organisms in the urine of the maniacal
patients were largely dead, and had been probably excreted
through the kidneys, while the organisms in the urines of the
five control males were living, and had probably been washed
out of the urethra. The excretion of organisms in the urine of
maniacal patients may be explained from the fact that the
small intestines of these patients when examined post-mortem
present evidences of atrophic catarrh, which would favour
phagocytic action by the leucocytes. Two streptococcal
organisms were isolated from the urines of the maniacal
patients. These streptococci were agglutinated by the blood
serum of the patients yielding the organisms, while the blood
sera of control persons gave no agglutination.

A bacterial examination of the faeces in twenty-seven
patients suffering from mania demonstrated the fact that in
59 per cent, of these cases streptococci were very numerous, so
numerous that in two instances no Bacillus coli were present.
Houston, in examining the bacteriology of the faeces in healthy
persons, found an excess of streptococci in one case out of
twenty examined.

Six streptococci, which were agglutinated by the blood
serum of the patients yielding the organisms but not by the
sera of control persons, were isolated from the faeces of the
twenty-seven maniacal patients examined.

As the result of animal inoculations with these various
streptococci isolated from the blood, urine and faeces of maniacal
patients, it was found that these organisms were not pus
producers, which separates them from the pyogenic streptococci
and allies them to the Micrococcus rheumaticus .

Attempts to produce anti-serums to these organisms by
inoculating two goats and a sheep failed.

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262 THE SYMPTOMS AND ETIOLOGY OF MANIA, [April,

Attempts were made to immunise the patients by injections
of vaccines made from these organisms. It was found that
large doses produced an exacerbation of the mental symptoms*
Several patients were treated for periods of six weeks with
weekly injections, but when at the end of that period their
blood serum was examined no immune body could be demon¬
strated in vitro.

The opsonic indices of several maniacal patients when
tested against some of the streptococci above mentioned are
very suggestive of a bacterial toxaemia, particularly the negative
phase which follows the injection of vaccines made from these
streptococcal organisms.

As the result of these observations, I believe that the
diseases known as mania are conditions of brain poisoning, the
poison or toxine in every case being a bacterial one. The
bacteria causing these toxaemias are probably streptococci, and
the point of attack is almost certainly the intestinal tract,

My explanation of the disease process is as follows : Owing
to some lowering of the bacterial defences, certain strains of
cocci become unduly increased in the intestinal tract. These
cocci do not actually enter the blood-stream, but they form
toxines in the intestine which are absorbed by the blood-vessels
and lymphatics in such quantities as to escape destruction in
the liver and lymphatic glands, and they thus pass into the
general circulation. These toxines have a selective affinity for
the most highly-developed nerve structures of the brain to
which they are carried by the blood-stream. When the toxine
molecules are present in the blood-stream in sufficient quantity
to produce an acute brain intoxication, then an acute attack
of mania is the outward result. When the poisoning is
more gradual there is a gradual deterioration of the brain-
tissues, showing itself in eccentricities and changed character,
which may lead finally to a chronic delusional state. The
presence of toxine molecules,, however, in the blood-stream
inevitably leads to the formation of antitoxine. The toxine
molecules stimulate the cells of the body to throw out
antitoxine molecules, which, by combining with the toxine mole¬
cules, render them inert. When a maniacal patient makes an
apparent recovery the antitoxine molecules have for the time
being neutralised the toxine molecules, and so we have a cessa¬
tion of the symptoms. On the other hand, a lowering of the

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BY LEWIS C. BRUCE, M.D.

263

general bodily health or a failure on the part of the cells to
form a sufficient number of antitoxine molecules immediately
allows of the toxine molecules again to go free ; further
poisoning takes place, and another attack of mania is the
result. The cause of the whole process, the streptococci in
the intestinal tract, remain a source of danger, as they are
unaffected by the formation of antitoxines which cannot reach
them in the intestine. This is not a mere hypothesis, because
on examining the bacterial flora of the intestine in the cases of
two patients who had recovered from confusional mania, I still
found streptococci in almost as great numbers as when the
patients were acutely maniacal.

It has been urged as an argument against the bacterial
origin of mania, that such a disease as pneumonia will some¬
times cause a condition of delirious mania and sometimes arrest an
attack of mania. This is perfectly true, but one must remem¬
ber that pneumonias are not always due to the action of one
organism. The only case of pneumonia causing mania which
1 have been able to observe died, and post mortem a pure
culture of a streptococcus was isolated from the pneumonic
patches in the lung. This organism was not the pneumoccccus,
but a short streptococcus closely allied to the group which I
have isolated from cases of mania. It was not fatal to rabbits
by intra-venous, intra-peritoneal or intra-pulmonary injection.
A small quantity of the blood serum, obtained from the
patient the day prior to death, rapidly agglutinated this
organism in dilutions up to 1 in 100. The intestinal tract
in this patient presented the appearances of chronic catarrh
similar to those observed in cases of uncomplicated mania
dying from exhaustion. This was evidently a case in which
the pneumonia was the last straw in precipitating the maniacal
attack. The pneumonia and mania were, in short, only the
terminal stages of a prolonged intestinal toxaemia.

The cases of pneumonia which promote recovery in states of
mania are always, in my experience, associated with high fever
and hyperleucocytosis, and were probably caused by the
pneumococcus or some allied pyogenic organism.

In spite of all that has been said to the contrary, acute in¬
flammatory conditions undoubtedly cut short attacks of mania,
but these inflammatory conditions are always associated with
high temperature and hyperleucocytosis. The high temperature

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264

AMENTIA AND DEMENTIA,

[April,

alone has some bactericidal action of which we are at present
only dimly conscious. Aurebach noted that a temperature of
108 0 F. rendered alkaline culture media bactericidal, and he
argues that in acute infections the pyrexia, although it
diminishes the alkalinity of the blood, at the same time may
be beneficial in that it also increases its bactericidal power. A
genuine inflammatory or infective leucocytosis, plus fever, is a
much more potent defensive agent than a leucocytosis excited
artificially with which there is no fever. I have undoubtedly
cut short attacks of mania by injections of vaccines made from
virulent cultures of Streptococcus pyogenes , turpentine and
similar agents, which promote recovery by the hyperleu-
cocytosis which they induce, but such injections often fail, and
they fail, I believe, because one does not produce the tempera¬
ture and leucocyte reaction of a true inflammatory process.

Amentia and Dementia: a Clinico-Pathological Study .
By Joseph Shaw Bolton, M.D., M.R.C.P., Fellow of
University College, London; Senior Assistant Medical

Officer, Lancaster County Asylum, Rainhill.

PART III.—DEMENTIA {continued).

PAGE

[Introduction .Lil. 221]

[ The general pathology of mental disease and the functional regions of

the cerebrum .Lil. 224]

\Mental confusion and dementia ........ lii. 428}

[ Varieties of dementia .lii. 7i i]

\_Group I—Primarily neuronic dementia .lii. 716]

[(a) Senile or ” worn out” dementia ..... lii. 717]
[(b) Presenile or ” climacteric” dementia .... liii. 84]
[(c) Mature or ” adult” dementia . ..... liii. 107}

[(d) Premature dementia {dementia prcecox) . . liii. 423]

[Group II—Progressive and secondary dementia ..... liv. 1}

[(a) Progressive senile dementia .Liv. 10]

[(b) Dementia paralytica ....... liv. 22}

Group III—Special varieties of dementia .Liv. 265

(a) Dementia following sense deprivation .... liv. 269

[(b) Dementia following epilepsy ...... ]

[(c) Dementia following cerebral lesions .... ]

[General review and summary . . J

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BY JOSEPH SHAW BOLTON, M.D.

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1908.]

Special Varieties of Dementia.

Introduction .

In the case of the two great groups of “ Primarily Neuronic
Dementia ” and “ Progressive and Secondary Dementia,” which
have been described, dissolution or involution of the centre of
higher association results primarily in consequence of a more
or less markedly deficient durability of the higher cortical
neurones. In the first of these groups, whilst the result may
follow a mere inability to survive on the part of these neurones,
the onset of dissolution is usually incited, or at any rate pre¬
cipitated, by one or more of the numerous extra-encephalic
causes which have already been discussed. In the second, the
result is achieved under the additional influence of certain
intra-encephalic but extra-neuronic agencies, namely, degene¬
ration of the cerebral arteries, excessive reparative reaction on
the part of the non-neuronic elements of the encephalon, or a
combination of both these factors.

The group at present under consideration differs from both
these in the fact that it includes, not a special pathological
type, but the residue of the series of cases of dementia which
is under description. This method of treatment has been
adopted, not owing to any real heterogeneity on the part of the
cases included in the group, but as a matter of convenience in
consequence of their relative rarity.

The group, which includes thirty-eight cases only, contains
three well-defined classes, which, were they considered solely
from the aspect of scientific precision, might equally have been
described as homologues of the groups of “ Primarily Neuronic
Dementia ” and “ Progressive and Secondary Dementia.”

These classes are as follows :

M. F. T.

(1) Dementia following Sense Deprivation 6 4 10

(2) Dementia following Epilepsy - - 12 8 20

(3) Dementia following Cerebral Lesions 358

21 17 38

Whilst few preliminary remarks are required in the case of
the second and third of these classes, a more lengthy intro-

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266 AMENTIA AND DEMENTIA, [April,

ductory reference to that of 44 Dementia following Sense-Depri¬
vation ” is necessary.

Amentia following sense-deprivation or idiocy of deprivation
is a commonly recognised type of mental disease, and is more
or less fully described in the various works on psychiatry. It
includes such cases of idiocy as have ensued in consequence of,
or in association with, the congenital absence of one or more
of the important avenues of sensation.

The writer has, however, met with but one author, namely
Clouston, who specifically refers to the existence of what he
terms 44 Insanity from Deprivation of the Senses.” The des¬
cription given by this author, being sufficiently brief for
reproduction here, is as follows : 44 I saw a gentleman, L. M.

B— , some years ago, who became melancholic and suicidal
coincidently with his loss of sight from cataract, and who
improved greatly after the operation for removing it was
partially successful, so that he could again see even in a dim
way the outer world. It is very common indeed for those who
are deaf to become quiet, depressed and irritable. It is also
common for such persons to become subject to hallucinations
of hearing, and so insane as to need to be sent to asylums. I
have now at the Royal Asylum four or five such cases. It
seems as if they were so cut off from social intercourse and
the outer world by their deafness that their subjective expe¬
riences became objective realities to them. In the case of all
men the senses correct many 4 delusions, and the impressions
from the senses, streaming in on the mental areas from the
outer world, are the best preservatives of mental health.* ”
{Mental Diseases , 6th ed., pp. 666—7).

It is, of course, usual to find sense-deprivation included
amongst the numerous and heterogenous 41 causes ” of insanity.
For example, the schedule of 44 causes and associated factors of
insanity,” authorised by the Medico-Psychological Association
and adopted by the Commissioners in Lunacy, contains a
heading, 44 Deprivation of Special Sense —smell and taste (either
or both), hearing, sight.” It would, however, be difficult to
decide under what heading of the authorised schedule of “Forms
of Insanity ” it would be possible to insert 44 Dementia following
Sense-Deprivation ” ; and the writer has hitherto been unable
to discover such a form of mental disease in any of the publica¬
tions on the subject of psychiatry which have come under his

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BY JOSEPH SHAW BOLTON, M.D.

267

notice. He is, however, convinced that the dementia which
develops in certain cases of sense-deprivation is worthy of
recognition as a distinct type of mental disease, and he purposes
to produce his reasons for this opinion during the course of the
present section.

Of the 728 cases of mental disease under description, he has
classified ten under the heading of “Dementia following Sense-
Deprivation.” In the majority of these cases the patient
appears to have arrived at the adult period of life before
deprivation of one or more of the special senses has occurred.
In others the disability dates from an earlier period or from
birth. In all the cases, however, mental symptoms have developed
and have been followed by a greater or lesser amount of
dementia.

From the aspect of dementia alone, as more or less dissolu¬
tion or involution of the centre of higher association has
occurred in the absence of intra : encephalic but extra-neuronic
causative factors, the cases under consideration might be in¬
cluded under the group of “Primarily Neuronic Dementia.” This
course is, however, impossible, as the cerebra of these cases are
“maimed ” in the neuronic sense, since loss of one or more of the
special senses has resulted in the development of extensive
atrophic or involutive states of the respective projection spheres,
and in gross functional (if not structural) modifications of the
lower associational systems of the cerebrum. Further, the
permanent, if non-progressive, cause, or the special type of
permanent stress induced by this cerebral disability, differs
altogether from the numerous and temporary, inciting or preci¬
pitating, causes which evolve the various types of “ Primarily
Neuronic Dementia,” although, as in dementia of any kind, the
primary cause, deficient durability of the higher neurones of the
cortex, is common to both.

The writer, therefore, considers himself justified in describ¬
ing “ Dementia following Sense-Deprivation ” under a special
heading.

In the case of “ Dementia following Epilepsy,” whilst equally
cogent reasons exist for the formation of a special class, these
are of a very different nature.

In the section on epileptic insanity ( Journ . Merit. Sci. y
January, 1906, pp. 5-7), the writer has produced evidence that
epilepsy most frequently occurs in association with mental

Liv. 20

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AMENTIA AND DEMENTIA,

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disease in those types of the latter in which cerebral degeneracy
is most marked. He considers, therefore, that both epilepsy
and amentia are degeneracies, and that the general effect of co¬
existing epilepsy is harmful in all types of the latter. “ The
epileptic idiot or imbecile is more spiteful and degraded, the
epileptic high-grade ament is more vicious and impulsive,
the epileptic maniac is more treacherous and dangerous, and
the epileptic dement becomes progressively more demented, than
occurs in the cases of the corresponding types of mental disease
when this complicating factor is absent ” (loc. ciu y p. 7).

He is thus of the opinion that dementia is not a consequence
of epilepsy per se } but that it occurs in such epileptics as
possess higher cortical neurones of deficient durability. In
cases, therefore, which are developing or have developed some
grade of dementia, this is aggravated by epilepsy. Further, the
amount of neuronic dissolution and dementia is increased, as is
often also the frequency of the fits, by the extra-neuronic
reparative reaction, which is a frequent feature of cases of
epileptic dementia. In such cases certain of the morbid
appearances, especially the thickened and fibrous pia-arach-
noid, the wiry cortical arteries and the pial adhesions, often
much resemble those present in dementia paralytica. Both the
grade of the dementia and the frequency of, the fits are probably
also in many cases increased by the development of the small
multiple thromboses, which are described by Turner as common
and often permanent.

Cases of “ Dementia following Epilepsy ” may, therefore,
justifiably be provisionally considered to occupy a special group,
which pathologically is midway in position between the groups
of “Primarily Neuronic Dementia” and “Progressive and
Secondary Dementia.”

The third class of “ special ” dementia which is under con¬
sideration requires no justification for its position or existence,
consisting, as it does, of cases which present various types of
focal gross lesion of the cerebrum. In certain of the cases focal
lesions occur in conjunction with dissolution of the centre of
higher association of any of the types which have been
described. Other cases included in the class, though fairly
common in asylums, do not necessarily fall into the domain of
psychiatry. Focal maiming of the cerebrum, even when limited
to the post-Rolandic and infra-Sylvian parts of the brain, may

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BY JOSEPH SHAW BOLTON, M.D.

269

1908.]

so affect the psychic content and so influence the processes of
lower association as to make the patient, for practical clinical
purposes, a gross dement, even although his centre of higher
association, from the neuronic aspect, is intact.

This truth is, in fact, so clearly recognised by neurologists
that an influential school exists which discounts the importance
of the prefrontal centre of higher association, and holds that
severer grades of mental impairment result from lesions of the
posterior than of the anterior portions of the cerebral hemi¬
spheres.

Special Varieties of Dementia.

(a) Dementia following Sense-Deprivation.

The present group contains ten cases of congenital or
acquired deprivation of one or both of the senses of sight and
hearing, in which a greater or lesser degree of cerebral dissolu¬
tion and dementia has developed.

The cases are of various types, and on the whole, in spite of
their small number, form a fairly satisfactory series. The rarity
of the type under description is indicated by the fact that the
present group forms the small proportions of 2’2 per cent, of the
cases of dementia and 1 *4 per cent, of the total series of cases
of amentia and dementia. The writer, however, hopes to pro¬
duce, during the following description, satisfactory reasons for
classing the cases of dementia following sense-deprivation under
a special heading, instead of including them amongst the cases
of “ Primarily Neuronic Dementia.”

As will be briefly indicated, the senses of sight and hearing,
especially the latter in ordinary uneducated individuals, are so
necessary to, and play such an important part in both the
evolution and the conservation of the normal functions of the
cerebrum, that deprivation of one or both of these senses in
congenital or early cases grossly modifies, and in adult cases
necessitates an entire readjustment of, the associational processes
which constitute the physical basis of psychic function. On the
other hand, in modern civilised races at any rate, the senses of
taste and smell play but a small part in the evolution and per¬
formance of the psychic functions. It is doubtful, therefore, if
congenital or early deprivation of one or both of these senses

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AMENTIA AND DEMENTIA,

[April,

would in any important measure influence the psychic functions ;
and it is probable that such deprivation, when occurring during
adult life, would be unable, per se } to produce either insanity or
dementia even in predisposed individuals, although it might
take part in the determination of the special symptomatology
exhibited by the sufferers when they became insane. There is
no reason to suppose that partial and even total abolition of the
tactile sense has any real influence on the psychic functions,
except in so far as it may interfere with the proper execution
of voluntary movements and thereby induce a certain amount
of physical “stress.” The present group, therefore, both in
fact and in the intention of the writer, contains cases which
exhibit deprivation of one or both of the senses of sight and
hearing.

The writer also excludes such cases as suffer from the various
physical disabilities which interfere with the earning of a liveli¬
hood, e.g. t the loss or maiming of limbs and the develop¬
ment of chronic diseases of the bones and joints. Such
disabilities produce various grades of physical “ stress ” ; and
when occurring in high-grade aments they may thereby induce
mental symptoms, and when in patients who possess cortical
neurones of deficient durability they may induce the onset of
dementia. In the first case, a potential lunatic becomes an
actual one ; and in the second, an individual with a deficiently
durable cerebrum becomes a case of “ Primarily Neuronic
Dementia,” though naturally both conditions and results may
occur in the same person.

Such disabilities do not, however, directly modify or reduce
the performance of the psychic functions. Normal individuals
often develop really surprising capabilities in the employment
of maimed limbs, and at times the physical disability appears
to act as a stimulus to the cerebrum, and to bring into activity
mental powers which would otherwise remain latent. On the
other hand, when these disabilities occur in high-grade aments,
or in individuals with cerebra of deficient durability, they add
such persons to the population of the workhouses or asylums.

In the class of cases now under consideration the conditions
are different. On the one hand, the patient suffers a permanent
loss of one or both of the important avenues of special sensa¬
tion, and on the other, all kinds and degrees of structural and
functional impairment develop in the cerebrum in consequence

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1908.]

BY JOSEPH SHAW BOLTON, M.D.

271

of the deprivation. Not only does secondary atrophy of the
particular afferent fibres to the cerebrum result, but the complex
associational relations between the special projection area or
areas and the rest of the cerebrum are seriously affected. The
special sensory-memorial images dependent on the lost sense or
senses pass more and more permanently into the sphere of the
subconscious. The physical bases of even the most elementary
existing (/.*., already experienced) percepts require readjustment
to the altered conditions. Finally, the mechanism for the
development of new and the correction and continuation of
existing (*>., already experienced) percepts, which normally
involves the majority of, if not all, the projection or sensory
areas of the cerebrum, together with their related memorial
spheres, becomes imperfect or “ maimed.”

These results follow acquired blindness or deafness, but
similar and more severe developmental defects are existent
when either of these disabilities is congenital or is acquired in
early life. The psychic functions, in fact, are either very
imperfectly evolved or are performed, as will be remarked later,
in an entirely abnormal manner. In such cases deafness is a
more serious deprivation than blindness, as for the evolution of
the functional activity of the cerebrum an entirely new develop¬
ment of associational spheres to replace those normally
employed for auditory and spoken language has to be
acquired. In the case of congenital or early-acquired blind¬
ness, on the other hand, the complex sphere of language, with
all its psychic components, can be employed in a perfectly
normal manner, and almost exactly as it is brought into use in
the case of persons who neither read nor write.

Hence cases of congenital or early-acquired deafness are
more liable to imperfect mental development, with which is
associated mutism, than are cases of congenital or early-
acquired blindness.

Further, from the dissolutive aspect, both in the cases in
which the sense-deprivation is congenital or acquired early in
life, and in those in which it is acquired after adult life has
been reached, cerebral involution is a priori more likely to
occur in the case of the deaf than in that of the blind. This
statement is supported by the cases which are cited later, for,
of the ten, three are deaf and dumb, two are deaf, four are
almost or totally deaf and blind, and only one, a well-marked

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272 AMENTIA AND DEMENTIA, [April,

high-grade ament who had been certified for thirty-seven years,
is blind.

The writer has laid much, and feels that he cannot lay too
great, stress on the disablement or maiming of the complex
associational processes which exists in the cerebra of the blind
and especially of the deaf.

The whole of the higher intellectual processes are dependent
on and develop pari passu with the evolution of language. Till
of recent years the majority of, and even now many, individuals
depend on the sense of hearing for the acquisition of the greater
portion of their (human) psychic content, though persons who
read and write perhaps gain an equal amount by means of the
sense of sight, and the more intellectual members of the race
probably acquire the greater part by means of the latter sense.

Language, therefore, as the instrument of thought, or even
as its compeer, for the higher refinements of thought depend so
entirely on, and draw so much of their inspiration from, the
possession of a highly elaborate vocabulary, is of fundamental
importance for the performance of the higher, as of the less
complex, psychic functions.

Language, according to the type of sensorial or sensori¬
motor avenues through which it is acquired and stored, and by
means of which it is employed, possesses four chief physical
bases in the cerebral cortex, namely, the auditory, visual,
cheiro-graphic and articulatory. For the sake of simplicity no
attempt is made to separate the kinaesthetic from the purely
motor divisions of the latter two, though, in fact, these are
probably differently located. It might, therefore, be supposed
that loss of any one of the four afferent avenues to these
would not, owing to the commissural connections between the
several spheres, be of serious import, apart from the non¬
reception of sensations through the absent channel. That such
a view is incorrect can, however, readily be demonstrated.
The spheres referred to, with their commissural connections
and their afferent and efferent projection systems, merely form
a convenient mechanism for the mechanical acquisition and re¬
production of language, which would be meaningless unless
during the employment of its mechanism there occurred an
active associational participation on the part of practically the
whole mantle of the cerebrum. The writer would here remark
that he does not wish to be understood to predicate the exist-

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1908.] BY JOSEPH SHAW BOLTON, M.D. 273

cnce of special “ concept *' and “ percept ” centres , and he pur¬
poses shortly to make his meaning clearer.

Words may be described, without serious error, as mental
algebraic symbols which, without interpretation into their con-
ceptive, their perceptive, and finally their sensory-memorial
equivalents, are meaningless. Language, in other words, may be
compared to the symbolic system employed by mathematicians,
and the ever-varying sensory-memorial complexes which words
symbolise may be likened to the numerals of arithmetic.

A word, per se , represents merely an auditory, or visual
sensation, or a cheiro-graphic or articulatory kinaesthetic im¬
pression, unless it is employed as a symbol on which to
integrate the percept or concept which it signifies, and for this
the cerebral mechanisms or associational systems connecting
the different projection and sensory-memorial regions of the
cortex are needed.

Further, both these developed percepts and concepts, and
also the associational processes involved in their formation,
differ not fundamentally but in detail on every occasion on
which they are evolved or employed.

Words may arise into consciousness through any one of the
four language-spheres. When, however, they are voluntarily and
silently reproduced, i.e., thought of, words are invariably
awakened through the articulatory word-centre under normal
conditions. They cannot be voluntarily repeated in thought
by means of the cheiro-graphic centre if the hand is not actually
moved, unless such hand movements are replaced by slight
movements of the head, or even of the lower jaw or the eyes,
through the agency of their respective motor-spheres. If
words should spontaneously arise in the visual or the auditory
word-centre, the condition is so abnormal as to constitute a
hallucination, which the subject may or may not be able to
distinguish from a true visual or auditory sensation.

However they may arise into consciousness, words naturally
possess very different symbolic values. Articles, pronouns, pre¬
positions, conjunctions, interjections, and the simpler adjectives,
adverbs and verbs, when thought of alone (articulatory word-
centre), as a rule arouse little beyond their respective visual or
auditory word-images, which, in themselves, are meaningless.
Adjectives, adverbs, verbs, and abstract nouns, when thought of
alone (articulatory word-centre), arouse first their respective

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AMENTIA AND DEMENTIA,

[April,

visual or auditory word-images. These, however, are meaning¬
less until by complex associational processes they are defined
and illustrated through the sensory-memorial spheres attached
to the various sensory or projection areas. Common or proper
nouns, when thought of alone (articulatory word-centre), may
first arouse their visual or auditory word-images, but they fre¬
quently at once awaken a whole series of associational processes,
and thereby determine the reproduction of sensory-memorial
images attached to one or more of the several sensory or pro¬
jection areas. It may be remarked that any such series of asso¬
ciational processes differs in detail on each occasion on which it
is evolved. For example, the mental processes induced by the
word “ cat,” whether this be thought of (articulatory sphere) or
be heard or seen (auditory or visual sphere), are different, not
fundamentally but in detail, on each occasion on which they are
aroused. This ever-varying perceptive content is consequent
on the revivification of, and the modification of the complex
relations of, the numerous existing sensory-memorial images of
which the word is symbolic, which are constantly taking place
under the influence of even apparently unrelated afferent
impressions.

Hence the auditory, visual, cheiro-graphic, and articulatory
word-centres merely signify the cortical regions in which lie the
physical bases of mental algebraic symbols. These, unless
they serve as inciting agents from which spread, in different
directions throughout the cerebrum, complex impulses of asso¬
ciation, signify no more than unmeaning sounds, shapes, and
musculo-kinaesthetic sensations.

Language is produced by the suitable co-ordination of the
verbal content of the auditory and articulatory word-centres.
It is originally acquired by imitation under the influence of
auditory sensations, and in educated persons language is more
highly evolved owing to education of the visual and cheiro-
graphic spheres. When once it has been acquired, however,
language (/>., functional activity of the several word-centres
with their commissural systems) is not necessarily employed
as the instrument of thought, although it has been primarily
evolved for this purpose.

Examples are common in which the mechanism of language
is employed in a purely mechanical manner. Imbeciles can at
times learn by rote long paragraphs, of the meaning of which

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BY JOSEPH SHAW BOLTON, M.D.

275

1908.]

they are ignorant. Children learn a large portion of their
lessons in this way. Adults, even, may learn the Lord’s
Prayer backwards, or sentences in an unknown foreign
language. Direct evidence of the purely mechanical nature of
these performances is often afforded by the inability of the sub¬
jects to complete their feat, if they are stopped during its
course, unless they start again at the commencement. Occa¬
sionally quite remarkable examples of mechanical memory and
of mechanical employment of the word-centres are met with.
From the former aspect may be mentioned the reproduction of
long verbal or musical compositions after a single reading or
hearing, and from the latter the performances of “ calculating
boys.”

Examples of this mode of employment of the mechanism of
language may be readily drawn from every-day life. Many
word-complexes, which are frequently repeated, e.g ., daily
prayers, are often gone through in a purely mechanical manner,
whilst the individual reproducing them is perhaps thinking of
something else. Again, it is appreciated by few that language, as
normally employed, is very largely a purely reflex, or, at any rate,
automatic function, and that the significance of what is spoken
is but feebly appreciated by the speaker. In the majority of
persons the word-vocabulary which is in common use is very
limited, and the phrase-vocabulary is both extremely limited,
remarkably stereotyped, and in many instances quite
automatically employed. In educated, and particularly in
“well brought up” persons, on the other hand, the word and
phrase vocabularies, though equally stereotyped, are much more
extensive in range.

The voluntary employment of the language-mechanism is
attended by greater executive difficulties than is the reflexly-
induced and automatically-performed mode which has just been
indicated, and it is at times involutarily incited, to the detri¬
ment of the performer, by emotional disturbances. For
example, nervous persons, when in the presence of their real or
imaginary, social or intellectual, superiors, speak haltingly and
from a limited vocabulary owing to the attempt to converse,
not automatically, but to order. On the other hand, in the
voluntary employment of written or spoken language for the
evolution and reproduction of the highest psychic products, eg. y
the production of an abstruse thesis, the language-mechanism is

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AMENTIA AND DEMENTIA,

[April,

made use of solely for the purpose for which it has been evolved,
namely, as the instrument, and the important assistant, of
thought.

The writer has endeavoured by the above observations to
indicate that language, though so commonly employed in a
largely automatic manner and with but a feeble appreciation of
its signification, is nevertheless in essence a symbolic mechanism
for the integration of sensory-memorial images, and analogous, as
an instrument, to the symbolic system employed by mathema¬
ticians.

By its use it is the servant, and the necessary servant, of
thought: by its abuse it becomes the compeer, or even the
supplanter, of thought.

It has been necessary to deal at some length with the subject
of language in order to make clear on the one hand how neces¬
sary for the proper performance of the psychic functions is a
symbolic mechanism for the integration of sensory-memorial
images ; and on the other how the separate symbols of this
mechanism are of psychic value solely in so far as their repro¬
duction serves to evolve a series of associational processes,
which arouse into the sphere of consciousness the varying and
heterogeneous collection of sensory-memorial images, of which
they may be described as the algebraic representations.

The writer will now proceed to apply these observations to
the subject under consideration, namely, the gross modifications
of cerebral function which are the necessary consequences of
congenital or acquired deprivation of the senses of hearing and
sight.

In cases of early or congenital deafness, the complex
mechanism for the reception, storage, and reproduction of
language, or the symbolic representation of the results of
sensorial excitation and of psychic association, is incapable
of evolution unless the patients are laboriously educated
through other avenues of sensation. It is hardly necessary to
add that mutism is a necessary consequence of early or con¬
genital deafness, though a considerable development of lip
language can often be induced by education. Such patients,
in fact, unless educated by special methods, would necessarily
possess mental functions relatively little removed from those of
the lower primates.

The writer therefore feels justified in laying stress on the

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277

gross modifications of general cerebral association—with the
markedly deficient mental content that is their consequence—
which are necessarily existent in the congenitally or early deaf,
as a frequent cause of dissolution, or involution from disuse, of
the centre of higher association in such subjects. On the other
hand, the congenitally or early blind can obtain a large and
important part of their mental content by means of the sense
of hearing, just as do ordinary uneducated (*.*., non-reading and
non-writing) persons. That the former can supplement their
methods for the acquisition and communication of information
by means of the deaf-and-dumb alphabet, etc., and the latter
by means of the tactile-motor sense, does not affect the funda¬
mental difference between them, which is based on the fact
that a highly important part of the mental content is normally
(in the uneducated) acquired by means of the sense of hearing
and not by that of sight.

Deprivation of sight or hearing, when occurring later in life,
results, in the educated, in relatively less cerebral disability, and
in probably an approximately equal amount in the case of
either of these senses. In the uneducated, however, loss of
hearing produces greater cerebral disability than does loss of
sight.

In all these types, however, both sensory and also extensive
and grave associational deprivations exist; and the cerebrum, as
a machine, is maimed not only in its most stable and earliest
acquired regions, namely, in one or more centres of projection
or sensory areas, but also throughout its intricate, later evolved,
and more important (from the psychic aspect) systems of
lower association.

The onset of dissolution or involution of the centre of higher
association in the prefrontal region therefore occurs, in such
cases, under totally different causes and conditions from those
which induce dementia of the “ primarily neuronic ” and “ pro¬
gressive and secondary ” types, and the writer therefore feels
justified in classing cases of dementia following sense-depri¬
vation under a special heading.

In congenital cases the onset of involution of the centre of
higher association, with the resulting dementia, whilst due to a
deficient durability of the neurones which it contains, is even¬
tually incited by the stress of prolonged sense-deprivation and the
consequent abnormal modes of psychic association which result.

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278 AMENTIA AND DEMENTIA, [April,

In other words, the abnormally working psychic machine sooner
or later breaks down.

In persons who acquire sense-deprivation later in life, the
mental stress involved on the one hand in the sense-disability,
and on the other in the more or less unsuccessful attempts to
revive the related memories which tend to pass more and more
into the permanently sub-conscious, or to replace the absence
of these memories by the integration of percepts and concepts
on an unusual sensory-memorial basis, often, or perhaps invari¬
ably, results in the development of irritability, or depression,
or general emotional instability. In cases like that cited by
Clouston, partial removal of the sense-deprivation by operation
may result in a return to normal psychic life. In the case,
however, of individuals who possess higher cortical neurones of
deficient durability, insanity followed by dementia ensues.

In such cases the symptomatology which is presented, and
the period of life at which the morbid process makes its
appearance, are dependent on different factors. The symptoma¬
tology exhibited depends on the one hand on the nature of the
sense-deprivation, and on the other on the psychic configura¬
tion of the particular subject. The period of life at which
insanity followed by dementia occurs depends on the duration
and severity of the mental stress produced by the sense-
deprivation, and on the resistance presented by the higher
cortical neurones. Examples of the dementia following sense-
deprivation may, therefore, presumably occur which form the
homologues of any of the four classes of “ Primarily Neuronic
Dementia,” namely the premature, the mature, the presenile and
the senile. That this presumption is correct is suggested by the
fact that the ages, at which mental symptoms first appeared in
the ten cases which are cited later, were respectively 16, 27,
28, 28, 30, 37, 42, 50, 53, and 74 years. Three of the ten
cases were discharged and re-certified one or more times. The
ages of certification in the present, and in seven cases the only,
attack are as follows: five cases were aged between 28 and
37 years, three were aged between 50 and 54, one was
aged 62, and one was aged 74. The writer does not wish
these figures to be regarded as other than suggestive, owing to
the fact that several of the histories are imperfect.

As will be evident during the description of the cases in¬
cluded in the group under consideration, the grade of dementia

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279

which is present is very different in the several individuals.
Though the actual dementia depends primarily on a deficient
durability of the higher cortical neurones, the probability that
the sufferers would not necessarily have become insane in the
absence of the sense-deprivation causes the type and degree of
sense-disability which is present to be important exciting factors
as regards the grade of dementia which is induced.

On the whole, though each case requires consideration on
its merits, deafness is a more important disability than blind¬
ness, for, of the ten cases, nine are partially or totally deaf, and
only five are partially or totally blind.

Three of the cases are deaf and dumb. All these exhibit
definite dementia, and in two of them it is well marked.

Two of the cases are deaf. In the one, the deafness is total,
there is considerable dementia, and the patient, who has been
certified for twelve years and has shown symptoms for sixteen
years, has gradually forgotten how to speak in an articulate
manner. In the other, the deafness is marked but not total,
and the patient has developed a mild degree of dementia
during her year of residence.

Four of the cases are partially or totally deaf and blind.
In two of these the deafness and blindness are total, there is no
hyper-activity of the tactile sense, and there is well-marked
dementia. In one case the deafness is total and the blindness
is almost total, the disability developed relatively early in life,
there is marked hyper-activity of the tactile sense, and there is
very little dementia. In one case the blindness is total and
the deafness is almost total, the disability developed relatively
late in life, there is no hyper-activity of the tactile sense, and
there is definite dementia.

The final case is totally blind and is a marked high-grade
ament who has been certified for thirty-seven years (since the
age of twenty-eight). She exhibits no hyper-activity of the
tactile sense, she has gradually forgotten how to speak in an
articulate manner, and she shows much dementia.

It is evident, therefore, that, whilst deafness markedly over¬
shadows blindness as a causative agent of dementia, the latter
disability becomes of importance if it is not replaced by hyper¬
activity of the tactile sense. There is no evidence that mere
duration of the sense-disability has a direct influence on the
grade of dementia.

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The cases included in the group under consideration will
now be summarised, with especial reference to the question of
symptomatology. For convenience, they will be considered
under four headings.

(i) Deaf and Dumb .

Case 691.—Male, aet. 31, single, engraver. Previous attack.
Father insane. High-grade ament and developing dementia.

Case 692.—Male, aet. 33, single, working jeweller. Showed
symptoms for some years before admission. High grade ament.
Has developed more dementia than Case 691.

Case 693.—Male, aet. 64, single, cooper. Epileptic ; pre¬
vious attacks since the age of 42. Paralysis on paternal side.
High-grade ament, and of less original intelligence and educa¬
tion than Cases 691 and 692. Is developing cerebral involution
and dementia.

Remarks .—All the cases are high-grade aments. The
mental symptoms exhibited are those of dementia. None of
the cases show irritability, excitability or stubbornness.

(2) Deaf

Case 694.—Male, aet. 46, married, plasterer. Certified twelve
years, and showed symptoms for four years previously. Mother
very deaf. Is poorly educated and has largely ceased to speak
in an articulate manner, under the influence of deafness and
slowly progressing cerebral dissolution. Is garrulous, excitable,
irritable, and quarrelsome, and exhibits a moderate grade of
dementia.

Case 695.—Female, aet. 54, widow, laundress. Certified
one year. Is practically deaf. Is irritable, unstable, bad-
tempered and quarrelsome. Is solitary and moody. Suffers
from severe hallucinations of hearing and delusions of persecu¬
tion. Has developed some, but relatively little, dementia.

(3) Deaf and Blind.

Case 696.—Male, aet. 65, single, milkman. Certified eleven
years. Previous attacks at the ages of 54, 53 and 50. Showed

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symptoms at the age of 16. Scarlet fever at the age of 25.
Is quite deaf and practically blind. Is irritable, excitable, and
quarrelsome. Exhibits marked hyper-activity of the tactile
sense. Shows remarkably little dementia, considering his age
and his severe sense-deprivation. This is probably largely due
to the adult onset and the long duration of the sense-depriva¬
tion, and to the employment of the tactile sense.

Case 697.—Male, aet. 45, single, farm labourer. Certified
eight years. Is stated to have had fits from birth. Is quite
blind and quite deaf. Is irritable and stubborn. Is probably
of originally low intelligence. Has developed a well-marked
grade of dementia.

Case 698.—Female, aet. 81, married, housewife. Certified
seven years, and was previously in a workhouse. Quite blind
and very deaf High-grade ament. Irritable, unstable, and
excitable. Probably originally possessed more intelligence
than Case 697 and less than Case 696. Has developed con¬
siderable dementia, but much less than Cases 697 and 699.

Case 699.—Female, aet. 57, single, of no occupation.
Certified seven years. Quite blind and quite deaf High-grade
ament. Is irritable, excitable, resistive, and spiteful. Speech
largely unintelligible. Is probably of decidedly deficient
original intelligence. Has developed much dementia. Resembles
Case 697, but is more maniacal.

Remarks. —All the four cases are irritable and excitable.
Cases 697 and 699, who are quite blind and quite deaf, and
who are probably both of originally defective intelligence, have
developed a well-marked grade of dementia. Case 698 is
quite blind and very deaf, is a high-grade ament, and has
developed considerable dementia, but less than Cases 697 and
699. Case 696 is quite deaf and practically blind. He has
developed remarkably little dementia, and exhibits marked
hyper-activity of the tactile sense, in this resembling an ordinary
blind man.

(4) Blind.

Case 700.—Female, aet. 65, single, of no occupation. Certi¬
fied thirty-seven years. Is quite blind. High-grade ament.

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Speech, except at times, quite unintelligible. This is probably
due to the combined influence of blindness, mental degeneracy,
prolonged residence in an asylum, a constant habit of talking
to herself, and dementia. She is irritable, excitable, resistive,
and quarrelsome, and exhibits much dementia.

General remarks .—It may be pointed out that, with the
exception of the three deaf-and-dumb cases, all the examples of
sense-deprivation which have been referred to are irritable, excit¬
able, and unstable. It is therefore probable, as has already been
indicated, that these symptoms arise in consequence of the
stress involved in the loss of a sense or senses which have
already been employed, and in the more or less unsuccessful
attempts of the sufferers to revive the related memories which
tend to pass more and more into the permanently subconscious,
or to replace the absence of these memories by the integration
of percepts and concepts on an unusual sensory-memorial basis.
On the other hand, in congenital or very early cases (deaf and
dumb), either the mental content is extremely defective, or
abnormal modes of psychic association have gradually been
evolved, and consequently such symptoms of “ stress” do not
arise.

Illustrative examples of the group of cases under considera¬
tion will now be inserted, and as the subject appears to the
writer to be of sufficient importance, he purposes to depart from
the method of selection which he has hitherto adopted and to
insert the whole of the ten cases which are included in the
group.

These are as follows :

(i) Deaf and Dumb, Cases 691-3.

Male, at. 31 ; Deaf and Dumb; High-grade Ament; certified ten months;

Former Attack of a Year’s Duration , two and a half years ago ;

Definite Dementia.

Case 691.—T. A. J— , male, single, engraver, aet. 31. Certified ten
months. Was previously sent to an asylum two and a half years ago,
and remained there for twelve months. Father insane. Notes taken
four days after his admission.

Patient is deaf and dumb. He exhibits considerable facial asymmetry,
the right side of the face being the larger. He has a dull and despon¬
dent expression, and unless notice is taken of him he shows little
interest in his surroundings. When his attention is drawn to written
questions he at times understands them if they are written in a simple

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1908.]

manner, and also at times writes replies. He, however, understands
the questions much better if they are slowly written letter by letter, in
which case he appears to spell them to himself (by translation into the
deaf and dumb alphabet) as they appear on the paper. He is decidedly
feeble-minded, and his vocabulary is very limited. He soon gets
fatigued under examination, and his attention is difficult to retain. He
appears to have no desire to reply to questions in the deaf and dumb
alphabet, and pays little or no attention when it is performed in his
presence. On the other hand, he can be stimulated to attend to the
writing of questions, and in some instances to indite replies, which are
written in a slow and halting manner. These replies are fairly
grammatical, but very little attention is paid to such details as capitals
and stops.

The following are examples of some of the questions put to him and
of his replies:

What is your name ? “ T— A— J—”

What work have you done ? “ engraver is my trade ”

How much a week f 11 1 last earned jQi . 10 . 4J”

When did you leave work l “last October 14th, 1902.” (He was
admitted to an asylum or the day following this date.)

Why did you leave ? “I did not feel well ”

Were you miserable ,, and if so why ? “I was rather dull.”

Had you any strange fancies ? “ What is it ”

When “ideas” and “ thoughts ” are written in place of “ fancies,” he
does not reply, but shakes his head.

I saw something about Satan on the papers sent with you . What was
itt “ I have a trouble as I am deaf and dumb as I hardly under¬
stand”

Does the word “ Satan ” mean anything to you ? “ My deaf and

dumb people called me Satan I could not understand what is Satan ”

Did they call you “ Satan ” by the deaf and dumb alphabet on their
hands ? “Yes”

During the eighteen months he was under observation he exhibited
not the slightest mental change unless in the direction of increased
dulness. He was, however, a useful worker.

Male , cet, 33; Deaf and Dumb ; High-grade Ament; certified oneyear ;

Symptoms for Four Years previously ; Well-marked Dementia .

Case 692.—W. R —, male, single, working jeweller, aet. 32. Certi¬
fied one year and had shown symptoms since the age of 27. Notes
taken two days after admission.

Patient is deaf and dumb. Hair greyish-black with several white
patches. Palate high; tongue points to the right when protruded.
Right naso-labial fold present, left absent. He has a wide-awake appear¬
ance as regards the eyes, but his face is expressionless when in repose.
He is emotional, being at times rather depressed and at others mildly
excited. He occasionally laughs in a foolish manner. He takes prac¬
tically no interest in his surroundings, and it is difficult to attract his
attention and still more difficult to retain it even for a few moments.
He is able to read and seems to understand written questions, but he can
LIV. 21

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284

AMENTIA AND DEMENTIA,

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rarely write a satisfactory reply even to the simplest. He has obviously
possessed some considerable degree of intelligence and education, as
when he is presented with the written question: “ Where are you ? ”
he writes in reply: “I am in the asylum.” When asked where he has
came from he writes, after an interval, the first letter of the name of his
last asylum and then stops. When asked when he came he writes : “ I
come,” and again stops. When asked the day (Monday) he puts down
a “T,” and half writes a second letter. He then makes several
attempts at commencing a reply to a question as to why he is in an
asylum, but does not get a single letter written. To the question put in
a different form he attempts no reply. When asked if he has always
been deaf and dumb he writes, “No.” When, however, he is asked how
long he has been deaf and dumb, he does not write a reply to this
question, but first crosses out the “No” he had answered to the
previous question and then re-writes it. To further questions he makes
no response, but he continues to try to read the notes I am writing,
apparently more because he has hitherto been reading my questions
than from curiosity. He gives one the impression that he reads and
understands what is placed before him, but he is either incapable of
thinking of, or unable to initiate, a reply. He invariably smiles in
response to a smile. He exhibits much mental hebetude, and during
examination he in not a solitary instance initiates any motor phenomenon
beyond an occasional foolish laugh.

Whilst under observation he continued dull, listless, uninterested in
his surroundings and entirely unemployed.

Male, at, 64; Deaf and Dumb; Epileptic; High-grade Ament; certified
two years ; Previous Attacks at the Ages of 60 and 42 ; Well-marked
Dementia .

Case 693.—S. H—, male, single, cooper, set. 64. Certified two
years. Previous attacks at the ages of 60 and 42. Epileptic. Para¬
lysis on paternal side. Notes taken two days after admission.

Patient is deaf and dumb and is stated to suffer from epilepsy. He
is an old man of pleasant appearance, who smiles in a knowing way.
He at once writes replies to written questions. The following are
examples of these:—

“ What is your name ?” “ S. H—”

“ What age?” “bom 1837 cooperate—with my father when he
dead but doctor take me up here ”

“ How long have you hadfits?” “but born 1837 October at C—
with my parents deaf and dumb asylum 10 years but holiday every
summer at with my father ”

“ Fits ?” “ forget all away last 10 years time but any ( ? my) Sister

can tell you about me all right ”

“ What day to-day ? “ September 23 ” (correct), adding what appears
to be “sheep farm 21 ” or “ sleep fair 21 ” (he was admitted on Sep¬
tember 21st).

“ What a week did you earn as a cooper ? ” “ the same with my

father about 12 years then he dead out away but doctor Turner Take
me up to L—...(?)...mary nimon”

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1908.]

The above replies indicate an originally defective intelligence, some
degree of inattention to the questions asked, and a certain amount of
mental decadence. The defective composition of the replies, and also
the misplaced and missing capitals, and, except in a solitary instance,
the absence of stops will be noted. The spelling, on the other hand, is
correct.

Whilst under observation he was dull, apathetic, uninterested in his
surroundings, and unemployed, though he was able and willing to
attend to his own wants.

(2) Deaf, Cases 694-5.

Male, at 46 / Deaf; certified twelve years; Symptoms for Four Years

previously ; Mania ; Forgetting how to Speak ; Moderate Dementia .

Case 694.—D. H—, male, married, plasterer, aet. 46. Certified
twelve years and had shown symptoms since the age of 30. Mother
very deaf. Notes taken four days after his admission.

Patient is a happy-looking and very garrulous man, who looks and
speaks in a childish manner. He is almost completely deaf. He talks
rapidly about himself and his work, but pronounces his words very
badly. He states whence he has come and when he was admitted to
that asylum. As far as can be understood he speaks quite intelligently.
He acknowledges that he is at times excited, but he speaks so quickly,
and the words are so imperfectly articulated and so rapidly pronounced,
that it is not always possible to understand him. As he cannot hear,
or, at any rate, cannot be got to understand questions, these have to be
written down. When asked his name in this manner, he writes:
“Mr. D. H— from the Parrash of C— near E—.” When then asked
if he worked at his previous asylum, he insists on writing down this
reply also, as follows: “at times at Cleaning han Bead Making han
hother odde Jobs.” His writing is halting and of an uneducated and
self-acquired type. It is obvious that, owing to his inability to hear his
own voice, his articulation has gradually degenerated until his speech
has become almost unintelligible. At the same time he speaks unusually
rapidly, and, frequently, his phrases become little more than gibberish.
In other words, in consequence of his deafness, together with his chronic
mania, he has gradually ceased to be able to speak properly.

Whilst under observation he remained garrulous, excitable, irritable
and quarrelsome. He was a useful ward helper.

Female , at. 54; almost totally Deaf; certified one year; Mania ;
Hallucinations of Hearing; Delusions of Persecution ; Mild
Dementia.

Case 695.—S. C. D—, female, widow, laundress, aet. 54. Certified
one year. Notes taken on the day after admission.

The patient shows no obvious stigmata of degeneracy. Her palate
is high. There are skin-cracks on the abdomen. The breasts are
normal, but the patient states that the right was “gathered” on two
occasions.

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The patient is totally deaf on the right side, and very deaf on the left.
She uses an ear-trumpet in the left ear, and with this can, though with
difficulty, hear what is said to her.

She is of intelligent appearance, and readily answers questions and
volunteers information about herself. She knows where she is, and
states that she long ago read in the papers about this (new) asylum.
She knows the day and gives the date correctly by reckoning forwards
from last Sunday, the date of which she remembers. She informs me
correctly when she went to her previous asylum. Before going there
she began to think that people did things to try to get into her sister-
in-law’s house, in which she resided. She also thought that some of the
things in the house were changed whilst she was out. She has heard
curious noises in her ears for a considerable time. Some four or six
weeks before leaving her sister-in-law’s for the asylum she had a
quantity of wax removed from her ears. Since this operation was per¬
formed the noises have sounded more plainly, and she is therefore
sorry now that it was done. The noises sound “like a lot of steam and
water rushing.” Whilst at her sister-in-law’s house, which was near the
police station, she asked whether there was a prison there, and if the
noise was caused by the prisoners. Whilst in her previous asylum she
slept badly. She “ used to be awakened at night by people talking
and ill-using other people—a young man or young girl calling out
‘mother.’” She heard this every night at G— Asylum. Last night
she heard a “ curious noise ” here. “ I don’t know what it sounded
like.” She thinks it probable that these noises and voices are produced
“ for annoyance, but I don’t know who.”

Whilst under observation the patient was a good and useful worker,
particularly at sewing. She was irritable, unstable, bad-tempered and
quarrelsome. She was solitary and moody, but tidy and careful of her
appearance.

(3) Deaf and Blind, Cases 696-9.

Male, cet. 65; Deaf and Practically Blind; certified eleven years;
Previous Attacks at the ages of 54, 53, and 50 ; Symptoms at the
age of 16; Hyper-activity of the Sense of Touch ; Mania ; very
little Dementia .

Case 696.—J. M—, male, single, milkman, aet. 65. Certified 11
years; previous attacks at the ages of 54, 53, and 50; showed sym¬
ptoms at the age of 16; had scarlet fever at the age of 25. Notes taken
on the day after admission.

Patient is quite deaf and practically blind. The right pupil is
occluded, and there is a marked corneal opacity on the inner portion
of the left cornea. He appears to see slightly through the outer por¬
tion of the left eye. Palate narrow. Eyes close together.

Patient is a vacant-looking man, who appears to be some years younger
than his stated age. He informs me that his name is G. M—. He
indicates that he can see very slightly with the outer part of the left eye
and not at all with the right He tells me that his eyes have been
operated on three times. He informs me, “ I don’t know what to say,”

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1908.]

as, owing to his deafness, he cannot hear questions. He squints and
turns his head round, as I am sitting on his right side, in order to try
to get a glimpse of me, and tries to get me to clearly understand that he
cannot communicate with me owing to his blindness and deafness. He
points out that he has no pain anywhere, and endeavours in every way
in his power to supply me with information about himself. When I
touch his mouth he opens it, puts out a tremulous tongue, and tells me
that he possesses only eight teeth (correct). He responds to the least
tactile suggestion. When I open one of his shirt buttons he takes off
his shirt, lies down flat, keeps on breathing deeply during my examina¬
tion of his chest, and then puts his shirt on again. He shows much
more intelligence than is exhibited by most patients possessed of the
ordinary faculties, and is both very anxious to do what he thinks I
require, and very smart over its performance.

Whilst under observation he was unemployed owing to his sense-
deprivation, but could find his way about and look after his own wants.
At times he became excited and quarrelsome, and he was, as a rule,
irritable and unstable, and liable to fall out with anyone in contact
with him.

Malt, at. 45 ; Deaf and Blind; said to have had Fits since Birth ;
Probable High-grade Ament; certified eight years ; Mania; Much
Dementia.

Case 697.—T. G—, male, single, farm labourer, set. 45; certified
eight years. Is stated to have suffered from fits since his birth. Notes
taken four days after admission.

Patient is quite blind and quite deaf. External strabismus. The
right side of the face exhibits more puckers than the left.

He is a dull-looking man of fatuous aspect. He breathes heavily.
It is quite impossible to communicate with him except by tactile sug¬
gestion. He is very dull and slow in his movements. He reacts to
stimuli in a dull and listless manner. If his coat is half taken off he
will complete the process. If his coat is given to him and an arm is
inserted into a sleeve he will then put on the coat. He will completely,
though very slowly, dress himself if his socks are given to him and the
rest of his clothes are placed near him. He is clean in his habits and
he feeds himself. He is at times irritable and stubborn. For example,
he always endeavours to begin his meals as soon as the food is placed
before him and before grace is said, and he resents being made to wait.
This is obviously caused by his inability to either see or hear what is
going on around him.

Female , at. 81 ; Blind and very Deaf; High-grade Ament; certified
seven years; previously in a Workhouse; Mania; Considerable
Dementia.

Case 698. —A. D —, female, married, housewife, set. 81. Certified
seven years, and was previously in a workhouse. Notes taken three
days after admission.

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A pleasant-looking old woman. Her forehead is narrow and reced¬
ing, and she is quite blind and very deaf. She gives her name and
states that she has been twice married. She says that she was 78
years of age on the nth of May last. She states that she came here
the day before yesterday (three days ago), and that the day was Thurs¬
day (correct). The present day is Sunday (correct). She persists in
the statement that she has only been here two days, and even alters the
day of her admission to Friday (incorrect) from Thursday (correct) in
order to make the latter agree with it. She has come from “H—
Hospital, and some said Asylum. I don’t know which for I can’t see
and can’t tell you.” She was there for more than six years and went
in a February (correct). She thinks that she was put there “as I had
a fever and didn’t know what I said ... I never told a story
the whole time, and behaved myself ... I gave a penny to
one, and twopence to another, and sweets to another.” She acknow¬
ledges that when she was first taken to H— Asylum she was excited.

Whilst on the way to this asylum, both in the train and elsewhere,
she gave away everything she possessed.

During the period that she was under observation she was usually a
decent and well-behaved old woman, who gave away everything in her
possession or that she could get hold of. She was, however, irritable
and unstable, and frequently lost her temper and became excited. She
was unemployed owing to her age and sensory defects, but was able to
do a good deal for herself.

Female, at. 57; Deaf and Blind; High-grade Ament; Certified seven

years; Speech largely Unintelligible; Mania ; Much Dementia.

Case 699.—E. S—, female, single, of no occupation, aet. 57. Certi¬
fied seven years. Notes taken on the day after admission.

Comeae occluded by thick leucomata. Right pupil pin-point and
immobile, and left pupil invisible. Very little hair on the pubes.
Abdomen covered with skin-cracks. Breasts very large. As the
patient is a very stout woman the skin-cracks do not necessarily
indicate a former pregnancy, although they are suggestive of this.

The patient is quite blind and totally deaf. She is an excitable and
spiteful old woman, who speaks quite unintelligibly and in an explosive
manner. She is very sensitive to, and strongly resents, any attempt to
touch her. She shrieks and yells when an endeavour is made to
examine her, and strikes out blindly in all directions. She shouts out
something which one interprets as “Can’t you be quiet?” She
several times loudly passes large quantities of wind per rectum .

When undressed last night she struggled violently with the nurses
and told them that a policeman was coming for them. She also
remarked, “ You must not terrify poor Lizzie.”

Whilst she remained under observation this patient continued
excitable, spiteful, and resistive. She fed herself, but did nothing
else.

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(4) Blind, Case 700.

Female, at. 65 ; Blind; High-grade Ament; certified thirty-seven years ;

Speech, except at times , quite Untelligible ; Mania ; Much Dementia,

Case 700.—E. P—, female, single, of no occupation, set. 65. Certi¬
fied thirty-seven years, since the age of twenty-eight. Notes taken on
the day after admission.

Pupils entirely occluded by leucomata. Palate high and broad. A
beard and moustache of moderate dimensions. Red oedema of the feet.
The second toe of each foot is small and lies on the dorsal surface of
the adjoining toes. Skin cracks on the abdomen.

The patient is an old woman of dull and fatuous aspect, who lies with
her eyes closed and mutters to herself in an entirely unintelligible manner.
Such words as, or words resembling, “ Lord,” “ devil,” “ you know,” “ I
know,” can be made out. When asked her age she remarks, relatively
clearly, u Don't you be a fool.” Every now and then she laughs to her¬
self at something she says. She rarely or never takes notice of what is
said to her, and her attention cannot be retained. She has obviously
forgotten how to pronounce, or ceased to be able to pronounce, words
properly except by accident, perhaps in consequence of her blindness,
her habit of talking to herself, and her prolonged residence in an
asylum.

She strongly resents any attempt at physical examination. She eats
bread and butter, but feeds herself with her fingers. She is irritable and
quarrelsome and resistive, and is often excited. She is very dirty in her
habits and is unable to attend to her own wants.

Whilst this patient remained under observation her condition con¬
tinued quite unaltered.

(To be concluded!)

Recidivism regarded from the Environmental and
Psycho-Pathological Standpoints . By J. F. Suther¬
land, M.D., F.R.S.E., Deputy Commissioner in Lunacy
for Scotland.

The Insanity Test of Criminal Responsibility.

There is little use in going back a century to Lord Hales’
test of responsibility, viz., that in order to exempt from punish¬
ment there must be total deprivation of understanding and
memory. It is discredited by jurists as well as alienists. Lord
Mansfield’s attitude to the test in 1812 is a decided advance
on Hales’ in so far that to be answerable the accused must

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RECIDIVISM,

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possess a mind capable of distinguishing right from wrong
generally, and not in relation to the particular act. But in
1843 point was again raised in an acute form, and the
House of Lords propounded certain questions to the judges
with reference to the law of insanity with the view to an
authoritative exposition which would in future guide courts of
justice. These answers, constituting the law of England upon
the point, were to the effect that to establish a defence on the
ground of insanity it must be proved that at the time of com¬
mitting the act accused was labouring under such a defect of
reason of the mind as not to know the nature and quality
of the act he was doing, or, if he did know it, that he did not
know he was doing what was wrong. The question of right
and wrong in the abstract is here abandoned. It was to be
put, not only in reference to the particular act charged, but also
at the time of committing it. Some jurists, and most alienists,
are dissatisfied with the insanity test as it stands, but, whatever
individual views may be of the criminal law in relation to
responsibility thus laid down, it must be apparent to the most
ordinary observer that, by the acceptance of the authorised
test itself, the intoxicated authors of crime, especially homicides,
manslaughter, serious assaults, and these form 80 per cent, of
such crimes—implying violence and recklessness, would not be
held responsible—there is no gainsaying that—and would either
be dealt with as insane or punished by long confinement in
prison ; in either case society would be protected against such
potentially dangerous elements in its midst.

jEtiology of Recidivism.

The causes of recidivism, operating singly, or, as they often
do, in combination, are given as nearly as possible in the order
of their significance.

I. (a) External.

(a) Slumdom, with its rookeries, “ farmed out ”
houses, and one-roomed dwellings.

(h) Intemperance.

( c ) Illiteracy, and lack of proper training in childhood
and youth.

(< d) Idleness after school life, resulting from that

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1908 .] BY J. F. SUTHERLAND, M.D. 291

incapacity for work which would yield a living
wage, due to lack of manual training.

(B) Inherent.

Physical and mental degeneracy of the hereditary
and acquired types.

II. The dominant mental characteristics of avarice, acquisi¬
tiveness, malice, and lust.

III. Penal systems, and criminal and delinquent laws.

Of one-roomed dwellings, etc., there were, in 1907, in Glas¬
gow, 23*8 per cent. \ in 1880, when John Bright delivered his
rectorial address to the students of Glasgow University, 30 per
cent In Manchester, in 1907, the percentage was only 1*90.

The Board of Trade Return for 1907 is so remarkable, is,
indeed, staggering, as to the relative positions of these two

cities in the matter of housing,

as to justify its

reproduction

in full: Q)

Glasgow.

Manchester.

per cent.

One-roomed houses .

23-8

vgo

Two-roomed houses.

479

6 ‘og

Three-roomed houses

1 75

4'43

Four-roomed houses

4215

Five and upwards .

45 44

Penal Systems in Relation to Recidivism .

This in itself is a very wide subject, and as it assumes so
many different forms in the same and different countries it is
quite impossible to do more than touch the fringe of one or two
of the main features as they bear on recidivism. Transportation
no longer obtains except in the three European countries of
Russia, France, and Portugal. Germany, strange to say, con¬
templates its adoption as part of its penal system. Imprison¬
ment and penal servitude suffice for most civilised nations. In
some of the States of the American Union “ indeterminate
sentences” are in operation for young felons from sixteen to
thirty, and are carried out in the reformatories of Elmira,
Concord, and Pennsylvania. There is this proviso attached to it,
that the sentence shall not exceed in duration the maximum
sentence possible under the law for the specific crime committed.
These have rightly engaged the attention of thoughtful reformers

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RECIDIVISM,

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in other lands. A beginning has been made in this direction
in’England at Borstal and Lincoln prisons, set apart for juvenile
felons up to twenty years. But whether the sentence be “ deter¬
minate ” as it is in every other country, or “ indeterminate"
there are several considerations in penal discipline which bear
on the criminal and on the problem of recidivism. These are,
in the order of their importance, cellular or associated confine¬
ment and the duration of solitary cellular confinement, hygiene,
discipline, industry, and diet in relation both to the task set
and to the daily sustenance of the ratepayers taxed to main¬
tain prisons and reformatories. It is assumed that in every
country the diet is sufficient to maintain health and to enable
the prisoner to perform his task. In some of the United States
prisons the menu is more like that provided for an epicurean,
being rich, varied, and more expensive than the food of a large
section of the sober, honest, and industrious taxpayers. This
should not be. It is calculated to attract rather than repel
the recidivists, and puts a premium on crimes and offences.

That penal systems past and present have much to do with
the vitality of recidivism is not seriously disputed. For a
century and more prison and social evolution has been pro¬
ceeding in the right direction and on right lines, in some
countries more rapidly than others. Each generation has pro¬
duced its reformers, taking up the problem where their pre¬
decessors left it, and it would seem now as if we are nearing
the final lap when that evolution will have reached its culmi¬
nating point. Prison reform, which is indissolubly woven with
social reform, has had at all times many advocates in the
legislature, in departmental administrations, in the press, and
in works of fiction. Quite recently an eminent fiction writer
conversant with the problem, but not with human nature on its
erring side, produced a scheme for present day uses in which
excellent elements are strangely blended with discarded ones.
An outline of his panacea is as follows: A modern statesman
with the capacity and dynamic will of a Napoleon, and with
fewer of his scruples, has arisen. The honest working and
industrial classes are to be freed from the perpetual and ever¬
growing burdens of prisons, workhouses, asylums, and reforma¬
tories by the establishment of a paying penal colony in the
hinterland of Cornwall. The idea is excellent. The army of
“ unfits,” “ unemployables,” and “ incorrigibles ” in society.

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293

1908.]

after a sifting trial, in which it must be said full justice is to be
done them by competent judges, are to be sent there, and, like
the ancient Athenian under the decrees of Atimia, deprived of
all civil rights. The evidence of unfitness for freedom and civic
rights, like the object in view, leaves nothing to be desired. A
military martinet was to rule the place, and the “perpetual
slaves ”—the term is ominous and bad—were to be compelled
to work the disused tin mines to profit. The voice of humanity
is not heard in this hinterland. There is no pretence of that.
The clanging of chains, the click of rifles, the shooting of bolts,
the suppressed moans from the “ triangle ’’-room, alone break
the silence and monotony. The turnkeys (guichetier ) of the
Paris prisons of the Revolution, with his bull-dogs, the felon-
tamers of some of the prisons of the Western States of the
American Union in the third decade of last century were to be
revived in a measure. Like all such experiments made in this and
other countries with the prospect of being self-supporting and
something more, this one ends in mutiny and disaster. There
can be no retracing of this track. It has been tried again and
again in the past, in the hulks, galleys, and bridewells, and failed.
Even here, with the mental flaws and stigmata of heredity and
degeneracy on all sides, or the acquired flaws of vice and
disease, the victims of soulless oppression combined to purpose,
as political prisoners have frequently done in Siberia and else¬
where. The plan failed to recognise the fact that a large number
of criminals and delinquents who are feeble-minded and mentally
warped are either the pliable creatures of circumstances or the
variations or “ sports 99 of nature.

Great Britain and Ireland.

A better knowledge of, and a pardonable belief in the penal
systems and the criminal laws of one’s own country, and of the
evolutions both have passed through, will be sufficient justifica¬
tion for briefly dealing first with it, next with the Anglo-
Saxon experiments in the United States, and last, of Continental
methods.

Within a century, without going further back, one may learn
the story of legal and penal evolution in Great Britain and
Ireland, in which the prevention of crime, like the estimates of
criminals themselves, and the springs of crime in relation to

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society, have undergone frequent and important changes all for
the better, and suggestive of truer conceptions of all three—
conceptions destined ere long to bring about happier and
better results.

Towards the close of the eighteenth century Howard's monu¬
mental work to bring about judicial and penal reform was begin¬
ning to tell. The doctrines of Paley and his followers, who
multiplied capital felonies until 220 stood on the Statute Book,
were passing away. Philosophers and jurists, following the
lead of Montesqieu (*) and Beccaria( 8 ), not without cause
denounced our criminal laws and our penal system with their
many barbarities. Jeremy Bentham, with his strong belief
“ in the greatest good to the greatest number,” was the leader
of this school, and contested the doctrine of Paley that the
security of society, secured by sanguinary laws, was the para¬
mount object, punishment fitting neither the crime nor the
criminal, but the facility of its commission and the difficulty of
detection. At this time the hulks, bridewells, and county
gaols were forcing hot-beds of abominations, fevers, disease and
unspeakable cruelties. Judges and magistrates discreetly, in
the course of official duty, inspected them from the outside .
There was no thought of isolation, separation or reformation.
Detention and security was all that was looked for. The idea
of the punishment fitting the crime, not to speak of the
criminal, had not taken hold of the legal or public mind.
All were herded together, convicted and unconvicted, and
debtors, irrespective of age, sex, or crime, the silly and crazy
inmates, of which there were many in those days, affording
sport for the sane miscreants. Alike for the insane and the
criminal these were the dark ages.

The beginning of the nineteenth century, when banishment,
the hulks and gaols in which felons were herded together, and
fettered at the will of the gaoler, were considered by the ruling
classes as the panaceas for criminality—the first epoch—brought
into being strenuous reformers, such as Blackstone, Romilly,
Fowell Buxton, Elizabeth Fry, Wilberforce and Mackintosh.
They led a successful crusade against the penal system and the
congeries of capital felonies on the Statute Book, Romilly
rightly contending that a merciless code was provocative of
crime.

The idea of Beccaria and Paley was that the sole function of

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BY J. F. SUTHERLAND, M.D.

295

1908.]

the law was the protection of society by the punishment of
crime, regardless of the fact that society, as then constituted,
and to a less extent now, is a part sharer in those crimes, and
will continue so long as ignorance, idleness, slum-dwellings, and
intemperance are permitted to continue.

The Benthamite philosophy was but a development of the
Beccarian, and the theory of punishment passed through three
stages, selfishness being the guiding principle: first, the selfish¬
ness of a minority; second, the selfishness of a majority, and
third, the catholic selfishness of the whole.

The philanthropic school now in the ascendancy, which held
that the chief object of the State is to prevent crime, and that
the reformation of the criminal is the best way to accomplish
this, punishment to bear a part in the reformatory treatment, but
not one whit more to be applied than was absolutely necessary.
For this view there is much to be said.

Lord Eldon (John Scott), a famous Scotsman, and a still
more famous lawyer, who entered the arena as an opponent of
penal reform, retarded for a time needful and urgent reforms,
but about 1820 the era of cold obstruction's apathy and
Eldonite obstinacy was drawing to a close. Equally great
minds and hearts were working in an opposite direction.
Henry Brougham, whose famous speech “ on the present state
of the law” took six hours for its delivery, Robert Peel, and
Mill, Bentham's greatest disciple, were untiring in their efforts
for reform. Many of the dreadful evils, more like those of
Moroccan Kasbas of the present day, the weight and cruelty
of fetters which are now only visible in museums and in
exhibitions of torture appliances, varied directly as the
insecurity of the prisons. There were one or two exceptions
in Gloucester and Sussex in which the separate cellular system
was tried, on the initiative of the Duke of Richmond, whose
house for generations has produced penal reformers. As
the outcome of these experiments, promiscuous herding was to
give way to separation and classification, as far as these could
be carried out in the separate cells available, in separate boxes
in chapels with masks, and in separate airing yards.

Mill considered industry carried on under the separate or
silent system as the great reforming agency; Sydney Smith
deterrence by punishment; and Elizabeth Fry, industry with
religion tacked on. To Sydney Smith industry was like a red

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rag to a bull. Peel’s well-known Gaol Act of 1823, laid great
stress on “hard labour,” and the corrective potency of the
“ walking wheel ” or “ everlasting staircase,” as the felons
termed it, a day’s work on the wheel producing nothing in
the way of results, being equal to a double ascent of
Ben Nevis.

Under the “silent” system convicts slept in separate cells
but worked and fed together, not a word of speech being
allowed. In 1835 the Duke of Richmond passed a Bill, the
two main provisions of which were, uniformity of discipline,
and the appointment of five Government inspectors, whose
duty it was to devise something different from the cruel
austerity in force in some prisons, and the extreme laxity
in others. But it was not until 1842—the second epoch—that
the separate or cellular system had a fair chance, Pentonville
being the model for England and Perth Penitentiary for Scot¬
land. The advocates of encellulement believed in the reforming
potency of solitude. The objections put forward were—the
cost, the lowering of physical and mental health, and the
failure to reform. As “cellular” prisons were much more
costly than the “ congregate,” Carlyle fulminated from his
Olympus at Chelsea, and declared that the “ diabolic
canaille ” should be dropped over London Bridge into the
Thames sludge. In 1847 Ead Grey and his Ministry, acting
upon the report of Lord Brougham’s Committee, accepted the
“ separate ” system as the most efficacious method of discipline,
imprisonment being the first stage of reformation; a pro¬
bationary period of association in the public works at home
the second; and shipment to the Colonies on tickets-of-leave
the third.

In 1850 Directors of Convict Prisons were appointed with
excellent results.

In 1859 the hulks in England and at Gibraltar were
abandoned.

The “ silent ” system found a notable opponent in Captain
Maconochie, R.N., who preferred the “ mark ” system, which he
had worked so successfully in the Australian penal settlements.
Instead of a “time,” it inflicted a “labour” sentence, in order
to earn back freedom, restraints being gradually relaxed as
conduct improved and power of self-control increased. There
is a good deal to be said in favour of the “ mark ” system, but

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297

its chances of success were better in Australia, in which at the
time honest industry of such a profitable kind awaited convicts
on discharge as to make crime a bad speculation ; and, more¬
over, all the females and many of the males were ultimately
absorbed into the free population.

In 1850 discussions in Parliament and in the press were
hostile to the separate system, as carried out, and the public
failed to see the difference between methods of true kindness
and those of indulgence. Mr. Pearson, M.P., advocated at this
time a “ labour and appetite ” proposal, his main planks being
industry, food, and the “ mark ” system. The municipal mind
of the day, strongly reliant on common sense, the treadmill,
and the crank, as strongly believed in the deterrence of penal
grinding in the solitary cell, the only companion of the felon
being his crank-handle, a primum mobile , no greater than a
rush of water or a puff of steam.

1853 witnessed the passing of the first Penal Servitude Act,
which inflicted shorter sentences of penal servitude for trans¬
portation. It failed of its purpose, and in 1857 a second Act
was passed, in which a large remission of sentence was made the
reward of industry and good conduct. In this year the
“separate” system was in force in 120, or a third, of the
English prisons.

But the criminal and penal problem, in spite of all the plans
put forward from time to time to cope with it, no doubt more
rational and humane as the years passed on and as experience
was gained, was still unsolved when the Prisons Act of 1877,
the splendid work of Sir Richard Assheton Cross, the Home
Secretary (now Lord Cross), became law.

This may be termed the third reform epoch. It was a
veritable Magna Charta for the prisoner quite irrespective of
the benefits to society and the taxpayer. By this act the control
of prisons was removed from a variety of local authorities and
placed under the control of Prison Commissions responsible to
Parliament and to Secretaries of State for Home Affairs.
A local or provincial system made way for a national system.
A uniform system of discipline was introduced, and scores of
prisons were closed with benefit to the ratepayers and to
prisoners. The benefits of centralisation and nationalisation
and of the better government and control of the prisons, although
resisted at the time, are now fully acknowledged. The good

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work done by the English Prison Commission has been already
referred to. It remains to be said that in the matter of
discipline, hygiene, diet, the staffing of the piisons by an
intelligent and superior class of officers, and justice to prisoners
the Scottish Prison Commission ( 4 ) has at least as excellent a
record. The staffs are, as a rule, adequately remunerated, and
in addition to security of office, never enjoyed prior to 1877,
can look forward to a pension. The complaints of prisoners
as to treatment are investigated by an independent body, the
Prison Commissions, who are assisted in the work by Visiting
Committees appointed by burghal and county authorities.
The benefits to the central administrative authority of the co¬
operation of local authorities are fully recognised. It remains
to be said that cranks and tread-wheels were dispensed with in
Scotland several years before this took place in England.

The country is now on the threshold of the fourth epoch
when Ministers of State concerned with home affairs, the
executive officers of the law, judges of eminence, psychiaters,
prison administrators, magistrates, and social reformers have
come to recognise that much still remains to be done in
justice to the criminals and offenders themselves as well as
to society. This may be termed the turn of legal, medical,
and sociological psychologists, who are looking at the question
in all its bearings, from new points of view, and approaching
it with confidence. Every penal reformer is nowadays more
or less of a psychologist. Except for the “ professional ”
and “ incorrigible ” criminals, most prisons might well be
turned into labour settlements, labour colonies, industrial
reformatories, and inebriate retreats. The lines of reform
proposed, embracing an extended classification, would begin
roughly here, further classification of young and old, of first
criminals and offenders, and “ repeaters,” having regard to the
usual nature of their crimes and offences, following after the
first sorting has taken place. And as each repeater will be
physically and psychologically carefully analysed in order to
detect physical or mental stigmata, traceable either to heredity,
vice, degeneracy, or environment, or to all three. Twenty-two
out of every twenty-four hours lived by prisoners in silence and
solitude for long periods, it is hoped, will be a thing of the past,
as everything so unnatural ought to be. The room or apart¬
ment will, by its construction and furnishings, be more human-

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299

1908 .]

ising. Associated labour with safeguards, and the safe exercise
of the faculty of speech would be allowed. Works of an
industrial and educative kind would be engaged in and taught ( 5 ).
Education of a thorough-going kind could not fail to be a
feature of the penal evolution, which, profiting by the past, it is
believed would bring us as near the tie plus ultra as possible.
Its advent will be hastened by legislation of a social kind,
bearing chiefly on intemperance, and slum dwellings, and the
prevention of juvenile delinquency. The separate sleeping
apartments, unless for medical or special reasons, would con¬
tinue. To it the recidivists and long-term prisoners could
retire daily for two or three hours for meditation, light work,
and reading.

“ Indeterminate ” sentences, it is expected, will shortly be
grafted on our statutes as well as the provision of a different
mode of supervision and guardianship on absolute or conditional
liberation. The revival of something approaching Sir Walter
Crofton’s experiments in Ireland of “intermediate prisons” and
individualisation of prisoners would, with modifications, be good
policy. Although it failed in Ireland, for reasons not fully
understood, it contained the germ of a sound penal policy.
Isolation in two cellular prisons there formed the first stage of
discipline. From it, with a good conduct and industry sheet,
he passed on to a public works’ prison, where he passed through
three grades, each remove bringing a change of garb and
increasing rewards. The most important feature in the grading
was the gradual relaxation of restraint, and the.right to self-
government was thus restored by degrees. The “ intermediate”
prison acted as a moral sieve, retaining the bad and letting the
good pass through. The remissible portion of the sentence
and other inducements provided the necessary stimuli, and the
discipline was thus worked with a strong motive power. In
the two “ intermediate ” prisons, one with a farm and the
other with a factory attached, there was the smallest amount
of supervision, and the convicts, surrounded by many of the
temptations of ordinary life, found themselves with hardly a
vestige of the moral “ go-cart ” left to lean upon.

United States.

Fourteen years ago the writer made a visitation of inebriate
retreats, asylums, workhouses, reformatories, and prisons in

Liv. 22

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the United States and Canada. Among the prisons visited
were those of Elmira, the New York State Reformatory, The
Tombs, and Blackwell Island Penitentiary (New York), Sing¬
sing, Baltimore, Philadelphia, Chicago, Boston, and Massa¬
chusetts. In the United States there are only four government
or federal prisons; the others are either under the different
states or municipal management, the result being two prison
systems of the most opposite character were in full swing, the
“ separate ” and the “ congregate,” each having the strenuous
advocacy of its managers as well as of its patrons, who seemed
to have a good time on the whole. In American prisons there
was much to learn and much to avoid. The state prison of
Auburn, New York State, which is a good type of a “ con¬
gregate ” prison, was the famous prison which seventy years
ago produced the felon tamers or wardens who dispensed with
high walls, chevaux-de-frise , and bars and bolts, the cowhide
thong and the rifle taking their place.

The “ congregate ” prison with its extensive and well-
equipped workshops suggests a factory as much, or even more
than, a prison. Cherry Hill Penitentiary, Philadelphia, is
probably the best type of the “ separate ” system, and resembles
our own. Attached to some prisons are large farms, stone
quarries, and brick works. The “ doubling up ” and in¬
discriminate association day and night, especially at night, is
rightly considered bad policy in this country. One thing which
should be insisted upon if a modification of the “separate”
system during the day and during work is meditated in this
country, viz., the privacy of a separate sleeping apartment will
continue. The principal features of United States prisons and
reformatories differing from British are the workshops, which
give one the idea of a factory, the large farms attached to
many, the legal “ eight hours shift ” for the warders, the use of
tobacco for chewing (not in the reformatories for young felons),
the many opportunities for conversation, the instrumental band
in the chapel, the prison newspaper, edited and printed by
prisoners, dining en masse , the cells made of steel twice the
thickness of boiler plate, armed sentries with repeating rifles,
walls thirty-five feet high and fourteen broad at the base, the
female certified nurse in charge of a male hospital assisted by
male prison orderlies, ablutions before meals, the all but entire
absence of denominationalism in the services, the cell furni-

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1908.] BY J. F. SUTHERLAND, M.D. 301

ture, the diet, and the mode of employment. The last two
call for some remarks. The cell furniture allowed to well-
conducted and industrious prisoners, unlike ours, consists of a
cupboard, table, small mirror, photographs of relations,
pictures, engravings, drapery, cage birds, etc. The menu is
certainly very different from ours, and looks very tempting,
and may well explain the return of their own accord of several
prisoners on parole. But an ordinary dinner of five courses—
mutton broth, roast mutton, stewed potatoes and buttered
parsnips, rice pudding, coffee and bread—is enough to make
the teeth of a British autolycus to water. With regard to
employment, Colonel McHardy, C.B., Chairman of the Scottish
Prison Commission, who visited thirty-two of these institutions
in 1902, informed me of the two systems in operation of the
“ contract ” and “ state account ” for the state or city, spoke
of its great importance in treatment. By the former an
agreement is made with contractors to supply them with
prisoners at a fixed price per head to manufacture articles of
which the contractors are merchants. The State provides the
prisoners and the workshops or factories, and the contractor
provides the whole suite of machinery and the raw material,
as well as instructors competent to teach the prisoners. To
the head of the Scottish prison administration the result of
this system seemed “excellent and infinitely better than a
system of idleness,” and in this most penologists will be dis¬
posed to agree. For extra work the prisoner is paid money,
which goes to his credit, and the financial results are remark¬
able, Baltimore gaol not only being self-supporting, but
having a balance to the good of nearly £3,000. The provision
of work by the State affords a solution of the difficulties of
dealing with a managing contractor provided a sufficient supply
of orders can be obtained for the various public departments to
keep the prisoners busy. In most prisons the prisoner is some¬
what of a profit sharer, and he is allowed to send money to his
relations, or even to subscribe when a prisoner without funds is
being liberated. This should tend to industrial effort and to
better feelings. Originally, in all the prisons work was looked
upon as an essential, but this has, remarks Colonel McHardy,
“remained the dogma in a few”; the voice of the trade unions
has been so strong as materially to check labour in others.
One remarkable feature is the number of visitors who are

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allowed to inspect these institutions. Two hundred in a day
when excursion trains are running to the gaol town, as much
as a quarter of a dollar being charged for admission! This
reminds one of Jeremy Bentham’s economic and beneficial
plan of a hundred years ago, to erect a panopticon prison with
a central argus chamber for the prison officers, a combination
of reflectors to keep the prisoners under continual inspection,
and the admission of the general public on the principle that
thieves in posse might take warning by contemplating the
plight of thieves in esse .

Uniformity, under one controlling and administrative
authority, exists in Great Britain. From what I saw, it would
appear that in the United States flourishing side by side are
two kinds of prisons and two systems of prison discipline
diametrically opposed to one another. In addition to the
prisons to which reference has been made there are the five
adult reformatories of recent growth, of which Elmira is pro¬
bably the oldest and best example. The governing principle of
these is a repudiation of the doctrine of the “ punishment
fitting the crime,” and the adoption of “ indeterminate
sentence,” under which the length of sentence is not pro¬
nounced, nor its duration fixed, except by the condition that
the individual cannot be kept in custody longer than the maxi¬
mum sentence allowed by the law for the particular crime
committed. This principle is now partially embodied in an
Act for England and Scotland, by which imprisonment prisoners
of two years and under may, like convicts, get a proportionate
remission of sentence if reported industrious and well-behaved.

There is, further, a trade school, so complete that each
prisoner may learn and practise the occupation best suited for
him to follow on release, a school of letters covering instruction
from the kindergarten to the academic grade, together with
courses of lectures on natural science, historical, economic, and
ethical questions, followed by a free discussion in which prisoners
have put to professors of ethics and political economy hard nuts
to crack; military organisation and drill, physical culture and
well-appointed gymnasia with baths, swimming-baths, and mas¬
sage appliances to compensate asymmetries and physical defects;
music, vocal and instrumental to refine and quicken suscepti¬
bilities. One may ask, is all this necessary ? In the reformatories
for the youthful and more hopeful felons there are three grades.

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1908.]

The first dine by themselves, can order their own menu, and have
additional furniture in their rooms. All the three grades work
together, and there is in consequence a great deal of association.
Before final discharge the individual is handed over while on
parole to a suitable and selected guardian, and upon his report
depends absolute liberation. Eighty per cent., it is claimed, have
been reformed, but independent observers consider the figure
much too high. Half of it or less would be good work, and wel¬
comed in this country. All this is achieved within two years’ time.

France.

France has 500 prisons and a daily population of 50,000.
These figures might imply double the criminality of Great
Britain and Ireland, but it would be an incorrect inference.
Its penal code speaks of (1) “contraventions,” the pettiest
offences met by a week in prison or fine; (2) “debts” for
imprisonments exceeding a week and under five years ; and
(3) “ crimes.”

By this arrangement the title given to the offence or crime
is regulated by the sentence. That the arrangement is not
satisfactory may be judged by the “ debts,” which would cover
almost anything, and certainly some of the worst crimes known
in this country.

In this country there is no uniform system, both cellular
and associated confinement being recognised. Of the former
Paris has its Mazas and La Sant£, travaux forch. The evils
of association are said to be minimised by classification, and
as almost all the associated prisons have separate cells these
are used for the worst (the releguts ), and for the best prisoners.
In the larger prisons many and varied industries are carried
on, and many are employed in making toys, puzzles, bon-bon
boxes, hosiery and cabinet-making.

In the Corsican settlements reclamation of land, clear¬
ing of forests, cultivation of the orange, the vine, the olive, and
mulberry trees for the silk-worm, are engaged in. France, in
1851, after it was abandoned by this country, began deporta¬
tion to New Caledonia and Guiana, and still clings to it.
Although still pursued by the French criminal authorities the
hope is not entertained that either penal settlement will become
a prosperous colony as was the case with Tasmania or

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RECIDIVISM,

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Australia. Juvenile delinquency has, as might be expected,
received considerable attention at the hands of the French
authorities. Two kinds of institutions exist, the first , punitive
or correctional, the second, simply reformatory. To the first
are sent all youths convicted of offences committed with full
knowledge of their criminality, and those relegated from the refor¬
matories as insubordinate ; to the second, children not respon¬
sible for their acts, and ill-behaved children whose parents or
guardians are unable to manage them. For boys there is the
La Petite Roquette, Paris, as an example.

In France it is alleged that serious crimes, such as murder
parricide, poisoning, in spite of strict cellular confinement and
banishment, has increased at an alarming rate. These crimes
would not be considered the measure of Britain's criminality.
That is measured by crimes against property and against the
person to obtain property. In 1897 Alfred FouilMe wrote:
“ Crime has trebled in the last fifty years in France, although
the population has hardly increased." Before accepting this
one would like to know what is meant by “ crimes." French
statistics, like British, have got to be carefully analysed before
they can be seen in their true setting and anything like their
true value realised. A propos of this the Spectator comment¬
ing upon crime statistics, very truly remarks : “ It is unfortunate
that statistics cannot be compared on their face value ; they
are misleading without reference to the conditions under which
they were compiled, and that reference opens up a vast field for
the play of bias and preconception.”

The “ Loi Berenger,” providing for arrests of judgment
when extenuating circumstances can be pleaded, remission of
“ penalties ” in the case of minors who appear to be reclaim-
able, and suspension of sentences in cases of good behaviour,
anticipated our First Offenders' Act and the Probation of
Offenders' Act by several years.

Spain.

In the Saladero, Madrid, association in prison and at labour
is the rule, and the discipline is lax, especially in the presidios
at Carthagena and Granada, where a system much like what
was in vogue in this country sixty years ago may be seen.
The discipline in force is not deserving of the name, at least in

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BY J. F. SUTHERLAND, M.D.

305

1908 .]

the Granada one visited by the writer in 1903. Prisoners
convicted of grave crimes are deported to the Balearics and the
penal settlements at Ceuta and Melilla.

Italy.

In a country rich in criminal anthropologists and jurists, the
penal system is better than in most European states. In the
ordinary prisons a gradual amelioration of condition is secured
by good conduct ; in the bagnios , or hard-labour prisons, in
addition to exemption from fetters, convicts may gain the
privilege of completing the last half of their sentence in one or
other of the agricultural colonies on the Tuscan Islands, or in
the intermediate prison on the island of Capri, in which a
state of semi-liberty exists. This plan was in vogue forty
years ago in Irish prisons, under Sir Walter Crofton. Why it
failed there it is difficult to understand. The principle under¬
lying it was sound. It is claimed that in Italy associated
convict labour has given good results. In the prisons or
penitentiaries the labour is industrial and contractors have
control of it.

Russia.

Crimes for the most part in Russia are political, for which
50,000 are yearly exiled to the penal settlements of Siberia.
These crimes are a protest against despotism, rapacity, and
oppression of the worst kind. Crimes against property are
bound to increase in Russia while there remains such a gulf
between the ruling classes, few in number, the professional
classes, also few in number, but in sympathy with the third,
comprising the multitude who are uneducated and have no
political rights at present. In the cities of Russia drunkenness
and disorder, due to the drinking of impure vodka among the
poorest, prevails, and in this respect resembles the seamy side
of social life in British cities and towns. The Mujak and
Ostiak of Russia are objects of commiseration.

Portugal.

At Lisbon, Coimbra and Santarem, there are cellular prisons,
and the system of strict separation for years, when first adopted

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RECIDIVISM,

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in 1884, was expected to reform and deter. The anticipations
have proved as illusory as the benefits of deportation, for the
releguts to the penal colonies on the West Coast of Africa. In
prisons on the associated plan the discipline is lax and little
good results.

Switzerland.

From the Swiss there is much to be learned in regard to the
methods of dealing with vagrants, inebriates, and recidivists.

The prisoner passes through three stages: first, isolation;
second, employment in association; and third, comparative
freedom. The labour is chiefly industrial, but there is
a form of penal labour, which includes street-cleansing,
road-making, and dykeing the rivers, carried on, not by con¬
tractors, but by the prison administration itself. Eacl
recidivist or inebriate, on discharge, is provided by societies
with a patron, personal sympathy and interest being con¬
sidered of more value than mere money, which is the easiest
way to many of ridding themselves of responsibility, and this
personal relationship begins before he or she has left the prison.
The patron sees that his protege is placed in a new environment
removed from harmful influences. The surveillance, as might
be guessed, is quite different from that of the police, and
resembles that in operation in connection with our First
Offenders Act. The results are said to be very satisfactory. The
penitentiary system of Switzerland is well thought out. At first
there is cellular confinement, then there is progressive life in
common, and finally conditional liberation.

With the vagrant class Switzerland has better methods and
better success than most continental countries. The colonies
are mostly compulsory, only three being of the voluntary type
and managed by philanthropic societies, but those who gain
admission require to rest for one or two months. Nearly every
canton has a compulsory colony managed by the cantonal
council. The vagrant is liable to imprisonment for a period of
from two to six months, or to detention in a forced labour colony
for a minimum term of two months and a maximum of two years.
These colonies are small, as a rule never exceeding two hundred
inmates. The farms are worked economically, and from the
workshops articles of commerce are turned out. The result is

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1908.]

BY J. F. SUTHERLAND, M.D.

307

that begging and vagrancy have greatly diminished, and the
success of the colonies from the economical and reformatory
points of view has been gratifying.

Belgium.

In this country absolute separation, no matter what the
length of sentence, prevails. It is carried to the chapel and the
triangular airing yard. In support of the system its advocates
claim two things, first, that the prisoner lives in association
with the prison staff, and second, that there has been a steady
diminution of crime. The first is a fiction, no matter what
its advocates in Belgium and this country may say, and the
second might have occurred under a different penal regime in
a country as prosperous as Belgium. Although cellular or
solitary imprisonment has received the closest attention in
Belgium, a new school has arisen which dissents from this
hitherto accepted principle, directing attention to the mental
and physical wreckage resulting.

Holland.

Cellular or separate confinement is restricted to two years
in prisons worked upon this system. But in other prisons
association is allowed. The labour in both is industrious, not
penal, and a variety of handicrafts are carried out under con¬
tractors. Trades are taught to those undergoing long sentences.
Properly trained in school, and to manual labour after leaving
school, this would not have been necessary, but the chances
are if he had been equipped for life’s work he would not have
been under restraint.

Prophylaxis or Prevention.

The prophylaxis or prevention, both of crimes and offences,
is a matter quite independent of, and takes precedence of,
judicial and penal reform, for it is rightly assumed that first ,
all juvenile, second , most juvenile adults, and third , some adult
criminals and offenders may by means of the social reforms
sketched, escape or be detached from careers of wrong-doing,

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RECIDIVISM,

308

[April,

and become industrious and respectable members of the com-
munity.

It will be admitted that for the three classes, healthy decent
homes are an absolute necessity. This connotes a summary
ending of rookeries and slumdom, and that provision both
by municipalities and by private philanthropic enterprise, which
for some years has been successfully in evidence in large
cities, of plain sanitary dwellings amid healthy environments
exposed to light and air, and that publicity which no honest
law-abiding citizen fears. In the slums material as well as moral
hygiene and race efficiency have not had much chance. The
sudden transference from darkness to light, from squalor
and indecency to comfort and sanitation, may, to begin with,
be too much for the submerged twentieth, and there might
be the risk of property deterioration unless something is
done to educate them to the duties and obligations of the new
situation. Obviously this education can best be secured by
the appointment of competent and tactful visitors of the
volunteer and remunerated class, who would give instruction
in ventilation, cleanliness, ablutions, cooking, and domestic
order. Unless this is seen to, relapses, in many cases, may be
looked for. By some such step as this, unfortunate young
children will in reality have the “ chance ” in life that every¬
body at present is talking about. For the safeguarding of the
health, habits, and morals of the children thus handicapped,
legislative interference is needed to secure that, on proof of the
unfitness of parents or guardians, removal to proper care can
be effected by the supervising authority. The blemishes
calling for action would be an immoral atmosphere, habitual
drunkenness, cruelty, neglected education, and idleness, or
employment after school life is ended of a kind not calculated
to be helpful and self-supporting in adult life.

When all this is done it will be found that by reason of
physical or mental defect, or both, that a proportion cannot
stand alone. For them guardianship and helpful visitation is
required, just as guardians and probation officers are for
habitual offenders and criminals who can no longer be con¬
sidered juveniles.

Dr. H. B. Donkin ( 7 ), speaking with the authority of a
hospital physician and of a prison administrator, pointed out
that a good many of the mentally defective school-children are

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1908.]

BY J. F. SUTHERLAND, M.D.

309

likely, following the path of least resistance, to drift into
delinquency and crime, and that among criminals a large
proportion are found to be congenitally feeble-minded, and
that among minor offenders in local prisons the proportion of
prisoners of weak mind was from 10 to 15 percent. The relation
of heredity to crime is, he adds, simply through mental defect,
and a readiness to succumb to environment.

It has been asserted by a few able writers that all crime is
more or less of a disease ; by the vast majority of observers this
is not admitted. It is a view which has alarmed the public
mind. Jules Morel, Chief Physician to the State Insane Asylum,
Mons, Belgium, holds that the “ incorrigible ” does belong to
the domain of pathology. There is much to be said for this
view. Verily, our prison population contains a considerable
proportion of pathological products. Critics of the doctrine
that all crime is more or less of a disease contend that it is one
based on the assumption that mental and physical degeneration
is invariably the cause, and not the effect, of crime and vice.
The truth is, it occurs both ways. But what, it may be asked,
in the light of treatment, does it matter? The distinction is
unimportant. Both products have to be specially dealt with in
any penological system, perhaps with this reservation, that
the genetous specimens being in no way to blame, might
receive a little more consideration. In the aetiology of insanity
just as with the inmates of asylums, heredity and acquired
mental states are met with, some of the acquired traceable to
vice, yet in regard to treatment no difference is made.

But all this, on behalf of the three classes, entailing cost,
labour, and anxiety, will be fruitless and Sisyphian, unless the
legislative axe is laid at the root of the two social trees
of slumdom and intemperance with the concomitant evils
of ignorance, poverty and parasitism. This is the great
sociological factor of the recidivist problem, and of vastly
greater moment than the judicial and penal reforms to be
alluded to.

Among the prophylactic and remedial measures put for¬
ward by mistaken race enthusiasts and social therapeutists is the
Spartan-like one of sterilisation of the “ unfit ” among recidivists,
degenerates, imbeciles, and sexual perverts. The writer has no
place for it, and there is not the remotest chance of a British
legislature entertaining or sanctioning such a proposal, and

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3 io

RECIDIVISM,

[April,

if there was, it is doubtful if qualified public mutilators could be
found. The suggestion may be set aside as not only impractic¬
able but not calculated to serve the end in view—the mental and
physical well-being of the race. Medical certificates of fitness
for wedlock are equally absurd.

Something can be done effectively to check the procreative
proclivities of feeble-minded women who rear a brood of illegiti¬
mates, some of whom are imbeciles or “ soft,” and the females
among them in turn perpetuate the evil so that it is no un¬
common experience to find three such generations under the
same roof. The evil referred to, in so far as it is not due to mental
weakness, is attributable to life in an atmosphere inimical to
chastity and decency.

Before the drastic remedy of sterilisation is entertained society
would first require to know the effect upon such of better
housing, better sanitary conditions, compulsory seclusion in
inebriate retreats and reformatories and labour colonies, and of
better methods than those at present in operation, not only to
keep in check but to terminate a scandalous state of society.
Many of the other obsessionists referred to.do little harm in the
way of perpetuating their kind. Their habits and their mode of
living is inimical to life and to lineal succession. But nowhere
is the argument weaker as to the transmission of hereditary or
acquired defects than it is in regard to the vast majority of
“ professional ” criminals who live by crime, and in spite of the
risk of lengthened loss of liberty make a good thing of it, the
“swag,” often considerable, enabling them to indulge in luxury,
idleness, and debauchery. They do not lack brains or intelli¬
gence. Of these they have more than their share, but it is put
to a bad use. In the case of such “ professionals,” by wiping
out the rookeries and haunts in which they are hid away, by
compelling able-bodied, dishonest, and idle fellows to work and
live in the light of day, the theory of hereditary or acquired
transmission in their case either falls to pieces or hangs by a
slender thread. It would be no infringement of individual
liberty if the police regularly visited such in their haunts and
had them under surveillance.

Sir Robert Anderson ( 8 ), late Chief of the Criminal Investiga¬
tion Department, Scotland Yard, regarding crimes against
property makes the following observations : While ordinary
crimes against property are decreasing, crimes of this kind by

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1908.] BY J. F. SUTHERLAND, M.D. 3 I I

the “ professional ” class are steadily on the increase and have
become a serious public danger. This class, few in number
when compared with the seven classes of criminals tabulated in
judicial statistics, to use his words, “keeps the community in a
state of siege.” They are not particular whether in achieving
their ends they maim or kill. Their watchword seems to be,
“ Your money or your life.” For them no extenuating circum¬
stances are put forward. They are not constrained by necessity,
and, unlike habituals driven to crime by hunger or by inherent
or acquired weakness of moral character, they live in luxury.
The protection of life and property can best be secured by the
“ indeterminate sentence ” carried out in a penal settlement.

From what has already been written it must be apparent
that the main line of treatment and prevention lies in two very
different directions— first , an adjustment of the social position
and condition more in accordance with every canon of justice
and right for many who are to be found in the ranks of
recidivism and for many qualifying for it; and second , for others
a psychological and psycho-pathological investigation into each
law breaker who has qualified and is qualifying in criminal or
delinquent habits, in order to determine approximately how far
the will, affected by mental warp or defect, is free, and then
settle for them their mode of life and work, and the degree and
kind of supervision and moral support called for. And there
can be no possible hardship or infringement of personal liberty
to authorise suitable persons to supervise those criminals and
petty delinquents who, with or without the apparent excuse of
mental or bodily defects, or without visible means of honest
subsistence, live a parasitic, debauched life in slums and do no
honest work, preferring to be idle and debauched, or to plunder
as opportunity presents itself.

Juvenile delinquency, whether due to environment or to
mental and physical degeneracy, or to both, is undoubtedly to
a very great extent preventive; philanthropists have proved
that. As a cause of adult recidivism, it is possible to tap much
of it at its source. This kind of delinquency is said to be
decreasing, and statistically that is certainly the case, and in
reality to some extent it is true, but it should be made plain
that much of that delinquency in evidence in criminal courts
and in prisons a quarter of a century ago and later is now more
fittingly lodged in reformatories, industrial schools, and train-

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RECIDIVISM,

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ing ships. The Children’s Bill, linking together the whole
scheme of reformatory and industrial schools, just introduced
into the House of Commons, is one of many steps in the right
direction. It provides that no child under fourteen years of
age shall be subject to imprisonment, and none under sixteen
to penal servitude.

The lines which prevention should take have been dealt with
at some length in the course of the article. These may be
briefly summarised as follows:

(а) For children of tender years, decent and healthy moral
homes, under respectable parents, or guardians in the case of
orphans and deserted and neglected children likely to go astray,
would give them a chance.

(б) Removal from such homes or guardians, on proof of
unfitness, by the supervising authority and boarding-out in
respectable rural homes under proper safeguards; or to industrial
schools, truant schools, etc.

(i d) For children of an older growth, and for their years too
well acquainted with criminal and delinquent ways, industrial
and truant schools, training ships, and reformatories.

(e) Education and training in industrial work is indispensable
for all: likewise ethical and religious teaching. Much of the
crime and delinquency of every land is due to a neglected, ill-
regulated childhood, spent for the most part in the street, and in
abodes of infamy and immorality, parental responsibility and
example being a minus quantity.

(/) A summary ending of slum dwellings, and of the land
laws and the economic conditions creating and perpetuating
them. Municipalities, like philanthropic agencies, to be em¬
powered to provide and supervise cheap, healthy dwellings.
Attention to the alcoholic problem in its relation to slum
dwellings and crimes and offences.

( g ) For those who have so far graduated in criminal and
delinquent ways, and for those who may fairly be set down
as recidivists, rational and humane treatment in prisons,
inebriate reformatories, shelters, and labour colonies ( 9 ); the
fewer in aggregation in the last three institutions so much
the better.

(h) Special homes and special treatment for the weak-minded

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1908.] BY J. F. SUTHERLAND, M.D. 3 I 3

and those with mental warp either in certified or State inebriate
reformatories, in shelters and labour colonies.

(t) Suitable help and supervision, both of young and old, on
discharge from all places of detention, by means of Probation
Officers. ( 10 ) An “ after-care ” association would, in a general
sense, and the Probation of Offenders Act ( 13 ) with the develop¬
ments foreshadowed by Lord Advocate (Shaw) would, in a
special sense, meet this.

(j) The provision of work for the unemployed, and shelters
for those of them requiring it. ( 12 )

A memorandum, issued in March, 1908, by the Home
Secretary, Mr. Gladstone, in regard to the probation officers
to be appointed under the Probation of Offenders Act, 1907,
for juvenile delinquents and adults of respectable antecedents,
has been submitted to justices and magistrates. It sets forth
that police officers employed are not to wear uniforms, that
honorary volunteer officers will be available in many districts,
that female probation officers should be appointed for boys
and girls of school age, as well as for women and girls over
sixteen, and rarely, if ever, police constables, and that the
work found should be of a skilled kind and not casual.

Lord Advocate Shaw, speaking of the purposes of the Pro¬
bation of Offenders Act, 1907 ( ls ), said the object was “to seize
all possible cases of the beginning of a career of crime, lift them
out of the hard and fast category where the punishment and the
punishment alone was made, as it were, to fit the crime, and
hand them over to some authority which would.impose some
new test in the situation, and which would give a humane touch
of helpfulness and foresight, and which might retrieve the man
in danger of being a criminal from a life of crime. ,,

Jurisprudence and Penology.

The attitude of the criminal laws and of judges towards
recidivism and the treatment of the recidivist by police and
prison authorities are as uncertain, unscientific, and as varied
in the same and in different countries as the types of habituals
themselves. The personal equation of the judge counts for
much. Sentences, too, often assume a cast-iron type and
appear, as a rule, to fit the crime, and in no sense, or very
slightly, the criminal, about whom judges as a rule know

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RECIDIVISM,

[April,

next to nothing as to bodily and mental condition, temptations,
antecedents, customs, and environment, etc. The trained legal
mind would be greatly enriched by the study of sociology.

Lord Guthrie, one of the senators of the College of Justice,
Edinburgh ( u ), in making an appeal for the introduction of the
“ indeterminate ” sentence, showed the absurdity of the present
system of judicial punishment by citing the case of the man
who would be reformed long before his sentence expired, whilst
another unreformed, and undeterred, was allowed to go free
to resume his old career. He further said he believed much in
environment and little in heredity, and that if the stream of
crime was to be dried up the country must be prepared to deal
drastically with the causes, one being intoxicants, and to
remove the children from the influences of criminals and
drunkards. These views will find ready acceptance.

Colonel McHardy has said that “there is no crime at all to
speak of in Scotland ; it is all a question of whisky. The day
may come when all but a few of our prisons may become
inebriate homes/* A good many observers will not go this
length or anything near it, believing that to the worst criminals
who attack property and the person for gain this dictum does
not apply. It is true, no doubt, of the great army of petty
offenders, such as drunkards and prostitutes, and of major
crimes against the person, such as homicides, bad assaults,
and cruelty to children.

The idea tacitly acquiesced in by the public that criminal
courts in residence and on circuit must have pabulum—sensa¬
tional or sorbid—regularly provided for them will, it is hoped,
by-and-bye be no more a reality than that the high officers of
State in Japan, as grotesquely represented in the “ Mikado,**
must provide for the ruler of that country, the victim for a
public execution when he made state entry into a town.

The laws ordain imprisonment, penal servitude, and trans¬
portation as the penalties for recidivism. Transportation with
its long track of failure and cruelty is now only carried on by
Russia, France, and Portugal. It is a confession at once of
impotence and fear. Great Britain abandoned it forty years
ago. It is known to have made recidivists more inhuman, more
hardened, and more determined than ever. There is nothing
to be said in its favour. Public safety for life and property is
assumed because thousands of miles of land and sea intervene

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1908.]

BY J. F. SUTHERLAND, M.D.

315

between convicts and the Fatherland, and because they are
worn down by unhealthy climates, rigorous discipline and
scarcely refined cruelty, all the more reprehensible that it is
hid from the view of the nations still adhering to this barbarous
plan of punishment. Reformation and regeneration is not
dreamt of.

It is a moot ethical question, what is the first duty of society
to recidivists, whether blameworthy in whole or in part, or, as
in some cases, not at all.

It is acknowledged that society can and must protect itself
against the law breaker, but it is not creating a fine distinction
to say that there is a great difference between society protecting
itself and society punishing the criminal, in the more or less
irrational way it does by means of that unworthy motive , the
fear of penalties, many of which cannot be defended. It has
been shown that of every 100 who go to prison for the first
time 30 come back, but of every 100 who have been five times,
79 return ! Terrorising rather than reclamation, whatever may
be aimed at, is the result, and there can be no doubt that the
more punishment in certain harsh directions is practised the
more is the human element in criminals starved, and in pro¬
portion as individuality is ruthlessly suppressed in the routine
life of months and years of all but absolute silence, and mono¬
tonous labour of anything but an inspiring kind—the recidivist
becomes a well-disciplined and, as a rule, well-behaved human
automaton. Apropos of this, Michael Davitt, a political Irish
prisoner and a litterateur , with much truth and force remarks,
“ The human will must be left outside the prison gate where it
is to be picked up again five years afterwards and refitted to the
mental condition which penal servitude has created in the
animalised machine which is discharged from custody. . . .

Working on such lines, on the lines of greatest resistance, it is
no wonder that penal servitude is a fruitful nursery of recidivism
and a patent instance of expensive failure.” Preferable would
be the compulsion to lead that orderly, industrious, and as nearly
normal life as is possible in a prison. That is more dreaded by
the average criminal than any treadmill, air-grinding crank, or
degrading uninteresting and non-educative labour.

The Lord Advocate for Scotland (Shaw) said of him, “ In a
parliamentary assembly I should command the assent of all
shades of opinion to this, that no greater prison reformer has

Liv. 2 3

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RECIDIVISM,

[April,

316

ever impressed his views more consciously and more vividly
than Michael Davitt.” Everyone who has had the privilege of
discussing prison reform with Davitt will appreciate the eulo-
gium.

Society always may be counted upon to assert its obvious
right, and undeniable might, to punish its noxious and offending
members. But this should not be all. There is its obvious
duty and true interest to transform as many law breakers as
possible into useful and law-abiding citizens. It is recognised
in this country and on the Continent, that the industrial tendency
of social evolution points conclusively to the transformation of
prisons into industrial centres. The Departmental Commission^ 6 )
of 1894 (England) recommended “ the practice of association for
industrial work,” and it is being gradually introduced among
women prisoners and juveniles. The right of society to protect
itself is admitted by all, to punish by a majority. But what is
punishment ? The daily task is not viewed as a punishment.
The writer holds that although punishment should begin and
end with loss of liberty, of friends, of indulgences, and of
amusements for long periods, severe enough if one contem¬
plates what it all means, it should not involve an all but
abnormal life for months or years inside a cell of four brick
walls unrelieved by anything to suggest the normal life outside,
such as a mirror, a bookshelf, an engraving or oleograph, a
photograph of family or friends, a cell from which, owing to the
height and size of the barred window, with its opaque or fluted
glass, the solar rays, and the orb and the eyes of the night
cannot be seen; a cell in which the faculty of speech is repressed
except for a few minutes daily. It is bad physically and
mentally for those who spend twenty-two out of every twenty-
four hours in this way. This system is not so bad, no doubt,
as that which preceded it, viz ., promiscuous association of
prisoners day and night with all its iniquities and contamina¬
tions, but the cellular and separate prison system in its refined
and subtle ways presents objectionable features as all systems
must inevitably do in proportion as they depart from the
ordinary modes of living of free citizens. The evils of pro¬
miscuous association are glaringly exemplified in the prisons
of Spain, Portugal, and in some of the prisons of France, and of
the United States. Cellular separation is met with in British,
Belgian, and in some of the French and American prisons.

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1908.] BY J. F. SUTHERLAND, M.D. 3 I 7

It is inevitable there must be some differences between the
living of the free and the bond.

It is not to be thought that a reversion to association after
careful classification except at work is advocated. The writer
is convinced that in prisons as well as in barracks ( 16 ) every
individual should have the privacy of a separate sleeping apart¬
ment unless the physician on medical grounds orders otherwise.
His cell or room should be made as homely as possible in the
manner indicated if the human element in their hearts is to be
conserved and reformation accomplished. No artificial method,
no matter how long practised and believed in in spite of
failure, will avail. By all means let the separate sleeping-room
be retained, but convert prisons into industrial institutions,
houses of detention, or reformatories. In Elmira and Concord
(United States), the principle has been recognised that up to a
certain age almost any criminal is salvable, and is to be
regarded as potentially having the making of a good citizen.
The writer, who is no optimist, and has seen in all its reality
something of the seamy side of society, is of opinion that many
of the adult criminals and delinquents under a rational penal
system and under better social conditions may be regarded in
the same light. It has been asserted that after three or four
convictions an offender is almost sure to return again to prison
and become a recidivist. This may be true of criminals under¬
going long sentences, but it is not true of thousands of persons
committing petty offences who fulfil this definition. So far, then,
it will be conceded that recidivism is the outcome of irrational
and unnatural penal systems, but to what extent it would be
difficult to say. Healthy industrial life should be made the basis
of a reformatory system. Japan, the gateway of the day, has
reached something like the zenith of industrial life and work in
prisons. According to capacity work is arranged, and some
make cloisonne , others carve, do carpentering and casting, grind
rice, and break stones.

And what could be more humanising than that a prisoner
should be employed at educative and remunerative labour,
labour that would tend both to form and reform character, out
of the earnings of which he might be permitted to send a small
contribution to his family circle from time to time ? Of course
this implies a different kind of work from that at present in
vogue, work unhampered by trade unions, which, owing to the

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31 8 RECIDIVISM, [April,

paucity of prisoners compared to the general population, have
in reality nothing to fear. It would be true economy to the
nation in the long run.

In a communication ( 17 ), cleverly critical of the defects of
some of the methods in operation in Scotland, some pertinent
observations are made. But, it may be observed, destructive
criticism, although valuable, does not carry us far.

Summary of penal reform .—(i) The conversion of prisons into
industrial reformatories with associated labour and conditions
favourable to physical and mental health. This, of necessity,
implies an end of the solitary system during working hours;
special housing and treatment of the feeble-minded, as is now
the case at Aylesbury Prison for females.

(2) Cultivation and afforestation of land in connection with
reformatories and labour colonies.

(3) The adoption of the “ indeterminate” sentence and of the
probation system as practised in connection with Borstal
juvenile-adult prison (England) and in the United States.

(4) The appointment of a specially qualified medical man to
plan and supervise the anthropometric, physical, psychical, and
psycho-pathological investigation into the case of each prisoner
qualifying for recidivism, and of a competent observer of the
great environmental factor in all its bearings. Such an official
as the first has been recommended by three Government Com¬
missions for Ireland, England, and Scotland ( l8 ).

(5) The appointment of male and female officers with ex¬
perience of the insane and in possession of the certificate of the
Medico-Psychological Association.

(6) More fining and smaller fines for petty offences, and more
frequent admonitions. This would tend to make the police
the friend of the petty offender, and instead of dragging every
drunk and disorderly person to a police cell, his place of
residence might be ascertained, to which he could, before or
after attaining sobriety, be taken in a cab or on an ambulance
stretcher, the cost being met at the time or afterwards, time
being allowed to the offender for payment.

(7) It has been suggested by Colonel McHardy that the
education of prisoners should be undertaken by School Board
teachers, with the consent of the Education Department and
School Boards, and the work directed and supervised by
inspectors of schools.

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1908.] BY J. F. SUTHERLAND, M.D. 319

In the rope of rescue suggested by these seven strands there
is no weak spot.

In regard to the new buildings which might be required,
a word of caution may not be out of place in this country any
more than it is in the United States, where architectural gloire
has been much in evidence in regard to prisons and asylums.
Speaking of gaols, H. Hill ( 19 ) hopes “ that the fashion which led
to the erection of gaols in fine architecture will soon pass away,
and that we shall rid ourselves of that strange kind of vanity
which causes us to make a parade of moral deformity ” ; and
Dr. Bleyer adds, “ this applies equally to our magnificent
lunatic asylums. Should we make a parade of mental
deformity ? ”

The Departmental Commission of 1894 for England, already
quoted, while giving credit for all that has been done since the
passing of the Prisons Act of 1877, by administrators of prisons
in the matter of hygiene, health, discipline, orderliness, economy,
and high organisation, remark, “ The moral conditions in which
a large number of the prisoners leave the prisons, and the
serious number of re-committals have led us to think that
there is ample cause for a searching inquiry into the main
features of prison life f 80 ).” The “ solitary ” system has been
proved devoid of any touch of humanity, of few, if any, of those
influences which might soften the hard or heal the broken heart,
nothing but silence, monotony, despair, and a starvation of the
mental faculties resulting.

For long it was maintained in Great Britain that nine months
was the longest period of solitary confinement which could be
well endured without injury to mind and body. It is now
reduced to six . But it is still too long. And it is no excuse
that this severe strain is greater in France and Belgium, where
it runs up to years, and is defended by its advocates, medical
and administrative. In the view of the writer it is indefensible.
Criminals are not monks under vows of silence and seclusion,
nor recluses, although in time some of them may approximate
the latter in eccentricity and deviation from the normal.

It is not in the nature of a counsel of perfection to hold that
it is only through the gates of labour that the vagrant and idler
can pass into the possession of the rights of citizenship, and
thus the value of workshops and technical education in places
of detention becomes apparent.

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RECIDIVISM,

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It is the case that some of the American prisons visited by
the writer in 1893 as well as other public institutions are not
only self supporting, but yield a profit (Baltimore). These are
those in the Eastern States in which the labour of convicts is
hired out to contractors, who send their plant and instructors
into prisons where work is carried on to the full on the associated
plan. This system is fruitful of contamination and in the long
run is not economical. In the Southern States the convicts are
leased out in gangs and placed in camps of contamination,
the safety of the prisoner being secured by rifles, cowhides and
chevaux dc frise . There are no high walls, and no bolts and
bars. The system is one neither to be approved nor copied.

Judicial and Penal Reform.

In the preceding chapters the nature of these have so been
indicated that a summary will now suffice. Both for habitual
criminals and habitual offenders, legislative action of a kind
that will have an intelligent regard as to what is implied by
punishment, deterrence and reformation is called for. Punish¬
ment implying involuntary detention and seclusion, and
reformation applies to all habituals, deterrence only to some.
For instance, there can be no doubt that punishment, in some
cases, just as the presence of a policeman in all cases, is a
deterrent to the convicted housebreaker, garotter and thief, and
to others of the same genus contemplating these crimes, while
to the drunkard neither punishment nor the policeman counts
for anything. When he begins his bout these two factors do
not enter into his conceptions, and when he has finished his
mental vision is so obscured that he cares nothing for either.
This striking distinction should not be lost sight of by those
who administer the criminal law and lay great stress on punish¬
ment and deterrence.

Following a series of daring burglaries in Glasgow, and the
presence in the city of a number of dangerous felons, the Lord
Provost (Bilsland), speaking at the Discharged Prisoners’ Aid
Society, remarked very truly that once prisoners had shown
ingenuity in crime they should be detained indeterminately for
the purpose of reformation, and on no account should liberty
be restored until there was clear evidence of an intention to
live an honest life.

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1908.]

It is evident from the recent trend of opinion coming from
the fountain-head of justice—the Home Office—and from some
judges and magistrates, and from prison administrators alive to
the true line of policy to be pursued in the light of past
failures of our criminal laws and penal system, that fresh legis¬
lation may be expected to fit especially the criminal and
offender, however much it may fit the crime or offence,
legislation which for the future will take proper cognisance of
the physical and mental condition of accused, of their heredity,
of their environment with its conditions and temptations, fatal
to education, morality, and a decent upbringing. The
“ indeterminate ” sentence for habitual criminals other than
the “ professional/ 1 for habitual petty offenders of the inebriate
and vagrant type, could not but form a main plank in any
enactment to bring about better and more economical results.

Likewise, legislative sanction would be required to convert
most of our present penal institutions into selective depdts and
industrial centres, and to set up labour colonies or settlements
so as to admit of a classification not hitherto attempted, a
classification based upon such important considerations as age,
the usual type of crime or offence, moral character, mental
capacity, capacity for work, and the nature of the work. The
inculcation of industrious habits might be expected after a time
to instil a healthy desire to work rather than to st^al, drink or
beg. It would be impossible to overrate the benefits of
extended classification gone into carefully on these lines, and
when this has been done many beneficial changes within the
walls, cells, and workrooms would follow.

Such changes point to .first, association under safeguards in
the schoolroom, at work in the shops, in the field, in quarries,
etc., but not in the sleeping apartment. There would, in addition
to the brief and occasional conversations now possible between
prisoner and chaplain, schoolmaster, and warder, be reasonable
opportunity afforded for the exercise of the faculty of speech
in legitimate ways, and for varying periods of time daily, for
all persons undergoing detention for a month or upwards (the
present system is no hardship for sentences under a month) ;
second, the work would be of a kind that would interest,
elevate, and be helpful on discharge (this could not be said of
oakum-picking, more fitted for machinery than human fingers
and brains) ; third, the construction of the sleeping apart-

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RECIDIVISM,

[April,

ment with a view to adequate light for work and reading by
day or night, and with furnishings, such as a bookshelf, bit of
floor-matting, a mirror, oleograph, photographs of relations,
which would sensibly relieve the monotony of four bare brick
walls. The concession of these things, small yet significant,
can in no sense be said to pamper les detenus . The absence of
them in the past has been explained as part of the punish¬
ment, which it would be difficult to justify on a rational and
intelligent conception of what is meant by punishment, which
in its main features has always been, and must continue to be,
deprivation of liberty and compulsory labour. Rightly under¬
stood, this is severe enough. Anything beyond this of a repres¬
sive and unnatural kind is calculated to do hurt rather than good.

In 1894, during an interview with Sir Algernon West, K.C.B.,
at one time a Director of English Council Prisons and a Member
of the English Prisons Departmental Committee, 1894, and
who was also a visitant of American prisons, he was strongly
impressed with the significance and humanising effect of the
small but significant and humanising things, such as a small
mirror, book-shelf, photographs, etc., and was anxious to see
them introduced into the prisons of this country. Changes of
the smallest kind come slowly, and only now or lately have
some of them been introduced into our penal system.

The Report of the Scottish Departmental Committee ( 8l )
appointed in 1894, by the Secretary for Scotland, Sir George
O. Trevelyan, Bart., to investigate some aspects of recividism,
contains some valuable recommendations in regard to habitual
offenders, habitual drunkards, and vagrants, some of which
remain unfulfilled. The Secretary for Scotland’s remit did not
cover either professional or habitual criminals. As to habitual
offenders , it declares inter alia : (1) That penalties much smaller
than the maximum of those competent under existing laws
are sufficient in the great majority of cases to deter. (2) That
petty offenders should be released at any period of detention
by part payment of the fine imposed, proportionate to part of
sentence still to be undergone ( 22 ). (3) The establishment of

reformatory institutions to which habitual offenders might be
sent on their discharge from prison. (4) A register of habituals
on which the names would remain for thirty months, with the
proviso that if at any time during this period he offended he
would be sent to the sheriff, who, in addition to a sentence of

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1908.]

BY J. F. SUTHERLAND, M.D.

323

imprisonment, would order detention in an adult reformatory
from twelve to thirty months. (5) Labour settlements or
reformatories in which out-door work and skilled and unskilled
labour could be carried on for women habituals, who are in the
vast majority, in addition to laundry work, sewing, knitting
and weaving, etc. (6) Inmates to be liberated conditionally or
unconditionally, or licensed out to approved institutions
or persons. (7) Weakminded or disabled habituals to be
detained in a poorhouse for periods and on conditions similar
to labour settlements for which they are unfitted. (8) The
sheriff to have power, instead of sentencing, to release on bonds
or recognisances with or without sureties being entered into.
(9) The utilisation of prisons and poorhouses for labour
settlements.

Vagrants and beggars (®), of whom, exclusive of tinkers,
there are censussed by the police twice a year about 10,000.
Putting in force the Public Health Act, the Prevention of Crimes
Act, 1871, Prevention of Trespass Act, 1865, the application
of the Vagrancy Clause of the Burgh Police Act and Special
Police Acts, to counties, with restricted penalties and power to
send the children to Industrial Schools, was recommended.

Habitual inebriates .—Two kinds ( a ) those who find their
way into the hands of the police, and (b ) those who don’t.
For (1 a ) adult reformatories, poor-houses and labour settlements—
this, in part, has been given effect to by legislation ; for (b) com¬
pulsory as well as voluntary seclusion in inebriate retreats for
those defined in the Inebriates Act of 1879. Nothing has been
done for the latter ( 24 ). It may be assumed with certainty that
the element of compulsion would lead to more frequent voluntary
application. To establish retreats for those who cannot provide
all the funds necessary for maintenance it was recommended
that in addition to voluntary contributions, town councils,
county councils and parish councils should be empowered to
contribute towards the support of licensed retreats, and like¬
wise that it should be made an offence for a license holder
knowingly to supply drink to inmates of retreats or persons
under sentence of commitment to an adult reformatory, labour
settlement, or poor-house. The Inebriates Act of 1898 gives
these bodies authority to contribute. One town council, that
of Glasgow, and one county council in Scotland, that of
Lanarkshire, have set up certified inebriate reformatories

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RECIDIVISM,

324

[April,

under the Inebriates Act of 1898, and receive grants-in-aid from
the Treasury.

It has to be admitted that dipsomaniacs—a large class—
if they don’t breed true to themselves breed something akin,
viz.y a neurotic offspring which may eventuate in one of the
many neuroses, in actual insanity, or in the true “ drink crave,”
which, in spite of the views of sceptical writers, is as real as the
drink itself or other manias.

The “ liberty of the subject,” one of those apparently simple
axioms which transcend ordinary intelligence, is at once
trumpeted whenever it is proposed to deal fairly and righteously
with habitual inebriates. It would be more correct to speak
of the unbridled license of the subject. Of two antithetical
truths, the rights of the individual and the rights of society,
some people have no difficulty in appreciating the one, but find
it all but impossible to grasp the other. It is evident the rights
of the individual must be subordinated to the rights of society.
That is the object of government. But some of our laws present
striking incongruities, and none more difficult to justify than
the refusal to accept intoxication as an excuse for crime, and
the treatment of repeated intoxication as beyond the jurisdiction
of the law, although, with so many, the sure road to crime and
delinquency.

Any statement on penology, however brief, would be
incomplete without an acknowledgment of the work of the
Howard Society through a long series of years, and especially
of the advocacy of its late secretary, Mr. William Tallack, and
its present, Mr. Holmes, on behalf of prison reform, and such
an acknowledgment is also due to the Bureau of Education,
Washington, U.S., with so accomplished a penologist at its
head as Mr. Arthur Macdonald.

Conclusion.

Both prophylaxis and treatment in the past has everywhere,
more in some countries than others, been a dismal failure,
recidivism and the cost of checking it going up by leaps and
bounds. The bill of costs for Great Britain and Ireland in
one year to maintain the judiciaries, the prisons and the
police reaches something like £10,000,000. No notice is taken
in this of what it costs the Poor Law. And no doubt it is on

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1908.]

BY J. F. SUTHERLAND, M.D

325

the same lavish scale in the United States, and in Continental
States. In any country with free institutions, with enlightened
statesmen, law givers, penologists, political economists and
social reformers, surely a better way might be found by an
abandonment of the judicial and penal methods of the past,
and the adoption of the more humane, rational, and intelligent
methods, adumbrated, it is to be feared imperfectly, in the com¬
munication now submitted for criticism and consideration.

It would be folly, if not something worse, and would
assuredly lead to disappointment to hold out the alluring
prospect presented by different and more rational methods
of preventing and treating criminality and delinquency sketched
here, and elsewhere, of a considerable and immediate reduction
of cost to localities and to the national exchequer. In time, no
doubt, it would come, the time when many prisons would be dis¬
mantled, and the army of officials greatly reduced; but if farm
and labour colonies were established and, where possible, exist¬
ing prisons converted into the latter or utilised as observation
and sifting dep6ts, it need not be a difficult task to ascertain the
relative cost of maintainance of present and prospective under
the old and new conditions. The fact that detention and treat¬
ment would be for long period should do something in the way
of reducing a standing army of police, numbering nearly
50,000 picked men ( 26 ), in bringing about a reduction of the
judiciary and paid magistracy of the country, and of the
entourage of criminal and police courts. Instead of half a
million apprehensions and citations in a year for petty thefts,
drunkenness and disorder, prostitution and vagrancy, those
for England being 386,000, and for Scotland 115,000, one
would expect at least a reduction to one half, if not more, in
the near future. The felon would not appear once in the
dock for every six times he does now, and the petty offender
not once for every dozen times. Better results would shortly
be seen, and many would cease to appear. A good many of
both types, the noxious and the nuisance, might be expected
to return to society fitted for citizenship with or without the
need of helpful patronage; but a large number already in esse,
and a large number in posse, as might be gathered from the
trend of opinion in regard to the constant productions of
physical and mental “variations” of a degenerate type as
things are, may, unless something is done for them, be con-

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RECIDIVISM,

[April,

sidered unsalvable, and requiring detention and supervision of
varying degrees. This term is preferable to “ incorrigible,”
having regard to the small share of responsibility which attaches
to many recidivists themselves. For the rest of the responsi¬
bility, heredity and social conditions (society) must accept and
apportion their respective measure of blame.

Amid the prevailing gloom which the perusal of these pages
predicate gleams of light are breaking through, not least those
issuing from the latest returns for England and Wales. In fifty
years the population increased from 19,250,000 to 34,500,000,
or 79 per cent ., and proportionately to population thefts had
diminished to the extent of 40 per cent . The total number of
indictable offences in 1906 was 59,079, and the annual average
for the quinquenniad 1902-1906, 59,200. Crimes of violence
have fallen in this period from 1,737 to 1,443. The figures for
robbery show a gradual decrease ; those for arson have been
stationary.

As might be expected, crimes of burglary and housebreaking
have increased. The same is true of sexual crimes, the numbers
having risen from 421 to 1,103, or 180 per cent . Much of this
is due, not to a greater prevalence of these crimes, but to the
creation of new crimes, and a stricter enforcement of the law.
Prosecutions for attempted suicide have steadily and con¬
tinuously increased, a fact not of happy omen, so far as the
mental well-being and stability of the nation is concerned.

The decrease of crimes generally, and especially those, such
as larcenies, which are four-fifths of the whole, with acquisitive¬
ness as the motive power, in 1906, coincides with, and may be
attributed to a large extent to, increased national prosperity
and increased wages. Roughly speaking, crimes against the
person and crimes against property are affected in different
directions by economic conditions, those of theft diminishing,
those of violence and drunkenness increasing with prosperity,
and, on the other hand, when times are dull and trade bad the
opposite is the case.

Sentences to satisfy public opinion would, as a rule, for
first or second offences, require to be brief if justice is to be
tempered with mercy, but for repeated offences, when it is found
that the environment is wrong and that there is evidence of
mental warp or mental defect, then other places than prisons
are required, such as Lord Guthrie, in the address referred to,

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BY J. F. SUTHERLAND, M.D.

327

1908.]

mentioned, viz., reformatory establishments for the “ reclaim-
able,” and places of permanent detention for the “ irreclaim¬
able.” In this connection I do not include that large number
of industrious workers who are foolish occasionally and may be
several times in the hands of the police. Careful discrimination
is required, if these latter are not to be swept into the net.

(*) Not less interesting in this connection is the return issued by the authority of
the Secretary for Scotland (Mr. Sinclair) showing the percentage of population, in
Scottish towns having more than two in a room. The figures are as follows:
Glasgow, 547 ; Paisley, 58 7 ; Greenock, 541 ; Dundee, 49 4; Leith, 43*8 ; Aber¬
deen, 38*1 ; Edinburgh, 32*9 ; and Perth, 28 ‘2 per cent. —( J ) Esprit, des lois .—(*)
Dei Delitti e delle pene. —( 4 ) Three names are pre-eminent in this connection,
those of Mr. Beatson Bell, advocate, the first, and for twenty-one years Chairman ;
Colonel A. B. McHardy, C.B., its present Chairman ; and Mr. William Donaldson,

C. B., the late Secretary. —( 6 ) Trades Unions need not fear competition with prison
labour. It is safe to say that after deducting the sick and infirm, the cleaners,
garden and field workers, laundry and cookhouse workers, and those engaged in
dressmaking, bootmaking, and clothing for the service, not 1,800 out of a daily
population of 2,880 would be found at any time competing with the free labour of
tens of thousands.—( 6 ) February 8th, 1908.—( 7 ) Dr. Donkin, Prison Commissioner
on the 11 Feeble-minded Criminal,” at the conference of the After-care Committee
of the Birmingham Education Authority.—( 8 ) Criminals and Crime. —( 9 ) Glasgow
was the first city to establish, mainly through the enlightened efforts of treasurer

D. M. Stevenson, a labour colony for forty inmates at Mid-Locharwood near
Dumfries. The Social Work Committee of the Church of Scotland, of which
the Master of Polworth is Convener, has set in this matter an excellent example
to churches and philanthropic bodies by establishing a small labour colony at
Cornton Vale near Stirling, and shelters and labour bureaus in cities and towns.
—f 10 ) To the city of Glasgow is the credit due of first instituting in this country
this class of person, Treasurer D. M. Stevenson and Bailie Bruce Murray being
the first to recognise its prophylactic value.—( 13 ) Distress Committees have been
formed in conformity with the Workmen’s Unemployed Act of 1905. Supported
by allocations from the Queen’s fund, by government grants and voluntary sub¬
scriptions, labour exchanges for the registration of the unemployed, “ help ”
factories, and farm colonies have been provided and have been a success in a way
charitable agencies have never been, and the fair wage earned is not looked upon
as a charity dole.—( is ) The Probation of Offenders Act repeals the Probation of
First Offenders Act of 1887, and section 12 of the Youthful Offenders Act of 1901,
and provides where an offence is charged .before a Court of Summary Jurisdiction,
and the court thinks the charge is proved, it may dismiss the charge or bind the
offender over with or without sureties to appear for conviction and sentence when
called on at any time within three years if it is of opinion that, having regard to
the character, antecedents, age, health, or mental condition of the person charged,
or to the trivial nature of the offence, or to the extenuating circumstances under
which the offence was committed, it is inexpedient to inflict punishment, or any
other than a nominal punishment, or that it is expedient to release the offender on
probation. Probationary officers may be remunerated by town and county councils
when their services are not voluntarily given. The probation system is an
attempt to reform a prisoner outside prison, in which a carefully-selected and
discreet officer supervises, in a friendly way, the prisoner in his own home or in
the home of his guardian and finds work.—( 14 ) Address to Scots Law Society,
November, 1907.—( ,4 ) Personnel: The Right Hon. H. Gladstone, M.P., Chairman,
The Right Hon. Sir Algernon West, K.C.B., The Right Hon. R. B. Haldane,
K.C., M.P., Sir John Dorington, Bart., M.P., John Henry Bridges, M.B., F.R.C.P.,
Arthur O’Connor, Esq., M.P., Albert de Rutzen, Metropolitan Police Court
Magistrate, Miss Eliza Orme.—( 16 ) In barracks this will be possible when the
soldier for years in garrison towns is quartered in his own home or in lodgings
beyond the gates and is summoned to duty in the same way as any other worker.
—( 17 ) Dr. Devon, “ The Study of the Criminal,” Royal Philosophical Society,

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Glasgow.—( 18 ) Royal Commission on Irish Prisons : Sir Richard A. Cross, Chair¬
man. Departmental Commission on English Prisons: The Right Hon. H.
Gladstone, M.P., Chairman. Departmental Committee on Scottish Prisons, Lord
Elgin, Chairman. —( ,9 ) H. Hill on " Crime,” and Dr. Bleyer, ” Treatment of Social
Offenders,” in the Medico-Legal Journal of New York. —(*°) In 1895 Sir E.
Ruggles Brise, enlightened penologist, was appointed Chairman of the English
Prison Commission.—( S1 ) Sir Charles Cameron, Bart., M.P., Chairman ; Lieut.-Col.
A. B. McHardy, C.B., R.E., Chairman of Prison Commission; The Right Hon.
R. Farquharson, M.D., M.P.; Sir Colin Scott Moncrieff, Under-Secretary for
Scotland; Sheriff Dore Wilson, Aberdeen; Dr. J. F. Sutherland, Deputy Com¬
missioner in Lunacy for Scotland; Miss Flora C. Stephenson, Chairman of the
Edinburgh School Board.—( M ) This has been given effect to by legislation.—(*)
Fletcher, of Saltoun, a hundred years ago, put them at 100,000 for Scotland.—(*)
Lord Herschell’s Inebriates Bill of 1894 was rejected by the House of Lords on
the second reading because it made no provision for a jury and the right of appeal.
—(*) 49 » 34 ° strong: England 33,940, Scotland 5,670, and Ireland 9,730.

The Unity of Insanity and its Bearing on Classification.
By Thomas Drapes, M.B., Medical Superintendent of
the Enniscorthy District Asylum.

Attempts at a definition of insanity have been made by
many writers on the subject, and some of the ablest have con¬
fessed their incompetence to formulate a satisfactory definition.
A veritable will-o’-the-wisp, it seems to elude all efforts to crib,
cabin, or confine it within the limits of our phraseology. In¬
sanity, like unhealthiness, is a negative term. Both terms must
have reference to the condition of which each respectively is a
negation—sanity and health. And as an adequate definition of
either health or sanity has yet to be discovered, it is small
wonder if their opposites suffer from a similar disability. The
fact is, all these terms are merely questions of degree, and it is
impossible to predicate any complete and absolute proposition
with respect to any one of them. They also imply conditions
as regards which anything like unanimity of opinion is unattain¬
able ; and while one class of mind—that of a psychiatric expert,
for instance—may regard a certain individual as mentally
deranged, another class, such as that of the average juryman,
or even the judge himself, may come to an exactly opposite
conclusion, and hold that he is perfectly sane. I need hardly
say that incidents of this sort were, no doubt in former times
more than at present, of not at all infrequent occurrence, but
even nowadays such occasionally happen. The fact is that
there is no absolute standard either of health or of sanity, and
each person who is called upon to make a decision in any
particular case forms a hypothetical criterion for himself, and

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1908.] BY THOMAS DRAPES, M.B. 329

then proceeds to exercise his judgment as to whether the case
in question conforms to or deviates from that arbitrary
standard. And as everyone’s standard differs—even psycholo¬
gists are not always in agreement—there is abundance of room
for difference of opinion. Probably the wider the characterisa¬
tion, and the more general the terms in which a definition of
insanity is couched the better—or perhaps I should say the less
unsatisfactory—it is likely to be. And a definition of it which
has been suggested by more than one writer as the failure of an
individual to adjust himself to his environment is perhaps as
free from objection as most that have been proposed. But
would it be acceptable, if indeed it would be comprehensible,
to a judge and jury ?

Definitions of insanity, however, are not at all necessary for
a study of insanity. On this head Spitzka, who himself
formulated a rather elaborate definition of insanity, makes one
pregnant remark: “ It is significant in this connection that none
of the most recent German writers on insanity attempt to give
a definition of insanity. The chief discussion as to the
possibility of concocting such a definition has taken place in the
Anglo-Saxon countries, and this, for reasons it is not necessary
to dilate on, indicates that the chief need for a definition is a
medico-legal one. . . . That a clearly formulated definition

of insanity is not indispensable to the scientific psychiatrist is
illustrated by the incontestable fact that mental pathology has
made more progress in Germany, Italy, and France, where little
stress is laid on such definitions, than in England or America.”

But while an adequate definition of insanity must in the
present state of our knowledge be deemed impracticable, some
conception as to what the term means from a clinical stand¬
point is absolutely necessary if there is to be any advance in
our knowledge of the subject. And here the question of
classification comes in, where, as in the case of definitions, we
are at once met by the discouraging fact that authorities up to
this have been absolutely unable to come to any agreement,
not merely as to the categorical terms of the classification, but
even as to the basis or principle on which it should be founded.
No better proof, perhaps, can be adduced of the essential
difficulties—we might almost say the insurmountable difficulties
—inherent in this question than the fact that the Statistical
Committee of our Association, acknowledged experts in this

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UNITY OF INSANITY,

[April,

branch of science, have found themselves unable to make more
than a very few alterations of importance in their scheme of
classification from that which was adopted by the Association
some twenty years ago. With respect to the principle, or no
principle, on which that scheme was founded, there has been
during that comparatively protracted period absolutely no
advance.

Having regard to this last point, while the adoption of a
new basis which would have involved material changes, with a
more logical and scientific classification, would have been
welcomed, perhaps, under the circumstances, it is just as well
that the Committee have not made any sweeping changes in
the old table, and in their action, or inaction as it may appear
to many, have proved themselves wise in their generation. Who
is there, if he is candid with himself, that would not confess that
in many of the highly elaborate schemes of classification which
have been from time to time propounded, especially by foreign
authorities, he has found more hindrance than help, more con¬
fusion than elucidation, [iu his study of insanity? Are such
schemes of the least assistance to us in our grasp of the nature
of any particular case, or do they give us any enlightenment as
to the treatment of such that we might not acquire just as well
without them ?

Not a little confusion has arisen from the practice of regard¬
ing the term “ insanity ” as denoting a disease. Insanity is
not a disease; it is merely a symptom of disease, quite
analogous to, but infinitely more complex than such symptoms
as cough, vomiting, or headache. And as one fundamental
error in terminology invariably leads to others, so we find
writers speaking of insanity taking a certain course, as if it was
a disease analogous to phthisis, typhoid fever, or Bright’s
disease. Insanity cannot be said to follow any regular course
any more than the symptoms of cough, vomiting, or headache
can be said to do so. It is the disease which underlies these
symptoms which runs a certain course, and similarly, as
regards insanity, it is the disease or diseases of which it is the
symptom or manifestation which can alone be properly said to
run a course. Now, unfortunately, the pathology of the large
majority of the so-called forms of insanity is unknown to us, in
which it differs radically from most of the ordinary forms of
disease with which we are familiar. And so, while in what are

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331

1908.]

popularly called bodily diseases, clinical symptoms and signs
are an indication as to the morbid processes in operation at
various stages of the disease, so that in a vast number of cases
we have valuable indications for treatment, and when there is
a fatal result are fairly confident as to what condition of organs
will be found on post-mortem examination, we have no such
means of determining the specific changes in nerve cells and
fibres which underlie any particular form of insanity, except
perhaps in the terminal stage of all insanity, dementia, when,
however interesting such knowledge may be from a pathological
standpoint, it is not, of course, of the slightest use as regards
the future of the patient.

The so-called “ forms ” or “ varieties ” of insanity are not at
all analogous to the same terms when employed in the case of
disease of other organs than the brain. When we speak of
croupous or catarrhal pneumonia, of cirrhotic, amylaceous, or
cancerous disease of the liver we know that these terms denote
distinct varieties of disease, with definite signs and symptoms
during life attached to each. They are not, as a rule, inter¬
changeable, and follow a fairly uniform course even in different
individuals. But it is otherwise with the “ varieties ” of
insanity. They are merely phases of mental derangement,
which may be transient or of various degrees of persistence;
they are interchangeable, and the same patient, whatever he
may be labelled, may be at one time maniacal, at another
melancholic, at another stuporous. Are there any varieties of
insanity which can be said to follow a uniform course, or with
respect to which we can make any reliable forecast as to what
phases of disordered mentality they are likely to pass through
in a way similar to what can be done in, say, a case of
Bright’s disease or phthisis ? I may be told that general
paralysis is a case in point. Well, we may pretty safely pre¬
dict a fatal termination at no very distant date, but I doubt if
any medical man of however great experience would venture
to prophesy what phases of insanity any particular case of that
disease will present in its downward course. In any case
general paralysis is, I think, admitted to be a quite exceptional
form of insanity, having, what no other form of insanity has,
a special pathology of its own. And to my mind the term
“ form of insanity ” applied to general paralysis is a complete
misnomer; it is a form of brain disease of which insanity is
Liv. 24

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332

UNITY OF INSANITY,

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one symptom, and to describe the disease in terms of one of
its symptoms is about as reasonable and logical a proceeding
as to designate pulmonary consumption as a form of cough.
The cases are perfectly parallel.

The one constant characteristic of all forms of insanity is
their inconstancy. This is the real difficulty, the crux of the
whole question of classification. In any scientific classification
the division into orders, genera, and species, etc., is based on
certain constant characters invariably, or almost invariably,
present in all the members of each division or sub-division, and
each unit can then be without difficulty allocated to its own
class, genus, or species, as the case may be. But if the special
attributes of, say, animals or plants were fleeting in character,
and those in one division were to resemble or be interchange¬
able with those of another, or of several others, according to
the particular time at which they were observed, then scientific
classification would be just as impossible in the case of animals
and plants as it is in the case of insanity. This is the one
great difficulty which up to this we have failed in any way to
negotiate. Spitzka is the only writer I am acquainted with who
has attempted to arrange the forms of insanity into classes,
orders, and genera, on a similar principle to that underlying
every scientific classification, and, clever as his scheme must
be admitted to be, it has not met with any general acceptance.
It is not his fault nor the fault of anybody who makes a similar
attempt. Facts are against them, and perhaps, in this instance,
so much the worse for the facts.

Let me not be thought to disparage in the smallest degree
the labours of the Statistical Committee. I feel that we are
under the deepest obligations to them, and owe them unstinted
gratitude for the enormous amount of time, and trouble, and
brain-work which they have so freely devoted to this difficult and
harassing task. One has only to study some of the excellent
new tables which they have drawn up to judge what expenditure
of energy they must have entailed. And if the principles
embodied in these tables are once fairly grasped, and if they
are given a thorough trial, they will probably be found to be
of the greatest use and convenience. The table of classification
is an exception. But that is hardly the fault of the Committee;
it is entirely due to the circumstances of the case, which were
too strong for them. I don’t suppose it would be possible for

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BY THOMAS DRAPES, M.B.

333

1908.]

any body of skilled psychologists, however able, to devise any
scheme of classification which would be entirely acceptable to
more than a minority of their colleagues. Classification is the
rock on which every framer of tables is bound to founder, and
the Committee have fared no worse than others. It is no
harm to make at least an effort to ascertain the cause of so
signal a failure.

May I be permitted here to indulge in an illustration which
will, no doubt, be regarded as belonging to the “popular
lecture” class; but if it exemplifies what I am anxious to
convey, it will serve the purpose intended better, perhaps,
than a dry scientific recital of facts.

The mechanical arrangements of mental action may not
inaptly be compared to a vast railway system, where junctions
are counted, not by dozens or hundreds, but by tens of thousands,
and individual lines, main, local, or side tracks, run into millions.
Let us make for the nonce a scientific use of our imagination,
and suppose such a railway system to exist, and that this branch
of engineering science had reached such a pitch of perfection
that all the arrangements worked automatically, so that officials,
such as engine-drivers, guards, and signalmen, were all dispensed
with as no longer necessary, and everything worked with the
utmost ease, smoothness, precision, and regularity.

Now, let us suppose that at some two, three, or more of the
junctions, owing to some adventitious circumstance, the points
went astray in their action, that consequently lines were blocked
which ought to be open, and left open where they ought to be
blocked, we can imagine the confusion and disaster that would
result; of limited extent if only a side-track was affected, more
serious if a local line was implicated, but of widespread dis¬
organisation if a main line were involved. The mischief would
not be limited to the immediate vicinity of the junctions where
the trouble originated, but would be propagated indefinitely
along the whole system; each successive train being shunted
to a wrong track would, at the next junction, arrive on the
wrong one, and be sent still further astray by the action of the
points there, and so on, the original deviation from normal
being multiplied at each stage of its journey with cumulative
effect until a collision or some other equally destructive catas¬
trophe should put a stop to its career. Once the first inter¬
ruption of the regular working of the system occurred, any

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UNITY OF INSANITY,

[April,

number of subsequent errors would follow in its train, and
would the most skilled engineer be able to predict what exact
route any particular train would follow, or on what line it
would eventually be found ? And if he were asked to give a
specific name to the erratic course each train would take, he
would soon find his vocabulary exhausted. The point of this
illustration is easily grasped. There are innumerable junctions
of nerve-fibres and associated nerve-cells in the substance of the
brain, through which are constantly passing currents which are
travelling, not minutely but momently, along myriads of paths
of association, the whole forming one coherent system of inter¬
communication. Suppose one or several of such junctions to
be interfered with by some lesion which destroys or deranges
the working of them, a similar course of events will take place
as in the case of the railway system. Currents will be
deflected from their normal path, and will pass along routes
they were not intended to traverse, no doubt along the lines of
least resistance, exciting into activity centres other than those
they would normally have reached, and to which their passage
is now blocked, and passing on from them through other
junctions farther and farther removed from their regular course,
thus throwing the whole system into disorder. Does not some¬
thing like this occur in every case of insanity, be it slight or
severe; and who will say in any particular case what direction,
under such circumstances, nerve-currents, with their correlated
psychological operations in the realms of thought, feeling, or
will may follow, or what will be their ultimate effect ?

Mind, mentality, is one and indivisible, a great complex
of operations parcelled out, no doubt, for convenience sake,
into certain departments of thought, feeling and will, but still
one in constitution, one in working; for our intellectual,
emotional, and volitional activities are inextricably intermingled,
and one does not act independently of the others. Continuous
interaction is the condition of all our various faculties, corres¬
ponding exactly with the intricate network of innumerable
intimately associated cells and fibres of which the cortex of the
brain consists. They are bound closely together into one con¬
solidated whole, and probably furnish an example of the very
highest harmonised organisation that has yet been evolved.
Complex, and of multitudinous elements, it is, no doubt,
to the very last degree, but nevertheless bound up, com-

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335

1 908 .] BY THOMAS DRAPES, M.B.

pacted, and cemented together into one consistent unity and
solidarity.

Now, suppose that some disruptive agent throws into dis¬
order this highly organised system, constituted, as it is, of
myriads of inter-communicating and inter-dependent elements,
fitted with the most delicate adjustments conceivable, is it
probable a priori that such disorder will follow a uniform
course in any two instances ? Surely it is just the contrary
which is likely to occur. We have good grounds for believing
that, although similar in plan, the cortical structural arrange¬
ments differ in detail in the brain of every man or woman born
into this world. No two persons think, feel or act in the same
way, no two take the same view of any question, no two can
hardly be said to even observe the same object in an identical
manner or from the same standpoint. The intellect of each
works on different lines in correspondence with the beaten
tracks of neural currents which permeate their cerebral organi¬
sation, the result of inherited proclivities, individual experience,
and education. It is this which forms the basis of distinct
individual personality, this personal equation being a fact too
frequently lost sight of in the study of insanity. And if the
mechanism of any individual’s mental system becomes deranged
and dislocated, need we be surprised if similar differences, as
compared with other individuals, occur in the operations of
that system under conditions of disease or disorder to those
which exist and are manifest under normal conditions? In
other words, the insanity of one individual may be expected to
differ as much from that of another as one healthy mind differs
from another. And in point of fact it does. Where, then,
the reasonableness of picking out a few cases in which can be
detected a more or less rough resemblance in their course, due,
probably, rather to coincidence than to any essential similarity
in the order of occurrence of morbid processes, and lumping them
together into one of the so-called varieties of insanity, knowing
well that, although for a time, perhaps for weeks or months, the
apparent resemblance may continue, at any time, sooner or later,
such cases may deviate widely from each other as regards the
varying phases of insanity through which they may suc¬
cessively pass. It is not difficult to assign any case to some
particular “ form " of insanity at some definite moment of
time, say the date of their admission to an asylum, as in

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UNITY OF INSANITY,

[April,

Table B. 5 of the Statistical Committee, but who will under¬
take to enter anything but an insignificant minority of cases
under its appropriate heading in Table D. 3, in which we are
asked to show the “ Total duration of the present attack of
mental disorder in the deaths, arranged according to the form
of mental disorder on admission 99 during any particular year. A
patient may have been admitted in a condition of melancholia or
mania without delusions, may have passed through various phases,
such as confusional states, stupor, etc., and have systematised
delusions at the time of death, or be in a condition of dementia.
How can such a case be entered in any column in this table
with any semblance of accuracy or accordance with fact ? Take
the case of a patient who has been under my own observation
for the past seventeen years. He was admitted in a condition
of acute mania, characterised by paroxysms of frenzy, destruc¬
tiveness, and the wildest conduct generally, passed rather
suddenly after a year into a condition of profound melancholia,
in which he made a desperate and all but successful attempt at
suicide, emerged from that into a practically sane condition for
many years, during which periodic brain-storms occurred every
ten days, characterised by epileptiform paroxysms mainly of
sensory centres, and accompanied by vivid hallucinations ; for
the past two years has become the subject of fixed delusions of
a persecutory type, and now, in the end of his days, has de¬
veloped a condition of mind closely resembling, if not actually
identical with that of a general paralytic (owns £800,000,000,
has bought up several country houses with their estates in the
neighbourhood, and only a few days ago informed me that he had
just purchased the winner of the Derby from “ Boss ” Croker
as a present for my daughter, with a host of other similarly
extravagant ideas). How shall we designate the form of
insanity to which this case belongs ? It is a living satire on
our schemes of classification ! Probably every asylum physician
could supply, if not perhaps quite so striking a case as this, not
one, but many cases differing from it only in degree, or in the
order of the successive states of mental derangement.

I have urged that insanity is a symptom. It may be also
legitimately regarded as a state or condition of mind, a state,
like mind itself, characterised by unity with diversity—unity,
as being the outward expression of the inward highly organised
operations of a single organ, the brain; diversity, as repre-

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1908.1

BY THOMAS DRAPES, M.B.

337

senting all the differences in detail of the structure and
functions of each individual cortical system; and the only
complete classification which would seem to be possible is
for each individual case of insanity to form a class to itself,
which is, of course, a reductio ad absurdum.

May I suggest that the too evident failure to devise a satis¬
factory classification of insanity is due in great measure to the
too great attention, shall I say the almost exclusive attention,
which has been given to the diversities which it exhibits, too
little, if any, to its oneness, its essential unity. Finding a
vast number of heterogeneous and differing phases of mental
derangement, men sought to reduce those to some sort of
coherence and order, to, in fact, evolve cosmos out of chaos;
but unfortunately, in every scheme hitherto propounded a
consistent basis of classification has been conspicuous by its
absence. And in the various essays of this kind which have
been up to this attempted we find varieties based on such
diverse considerations as duration of illness, or degree of per¬
sistence, intensity, aetiology, pathology, curability or incura¬
bility, correspondence with developmental epochs, etc., jostling
each other with an irritating incoherence.

Such a table as Table E. 2 of the Statistical Committee,
which is similar to one previously in use, giving a classifica¬
tion of patients resident in an asylum on December 31st in any
year, is one which involves nothing but bootless labour. It
would be difficult to show what useful purpose it could possibly
serve, or ever has served. A patient melancholic on that date
may be maniacal or stuporous six months later, may be so even
one day later, and such a record, to use Dr. Claye Shaw’s apt
illustration, is about as useful as a return from a number of
general hospitals of the number of cases of pneumonia on any
particular date in the stage of hepatisation, and the number
of those in the stage of resolution.

The term “ manic-depressive ” or “ maniacal-depressive,”
which has come into vogue of late years, as denoting a special
form of insanity, although not of any value if it is meant to
imply some variety not yet described, is yet of some value as
indicating an acknowledgment of the fact—hitherto ignored in
all schemes of classification—that there is such a thing as
mixed insanity. In reality such cases are merely those which
constitute a large proportion of ordinary chronic insanity. We

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33 8 UNITY OF INSANITY, [April,

might extend this nomenclature still further and describe cases
as manic-depressive-stuporous, and even manic-depressive-
stuporous-delusional-demented, if we want to give a more
complete clinical description of quite a number of cases. The
fact is, these fanciful so-called “ varieties ” are all nothing but
clinical descriptions of the one disordered mental condition,
insanity, while it is passing through certain more or less
transitory, or a succession of transitory, stages, and to attach a
separate style and title to such temporary conditions, or to any
combination of them, is nothing but to create confusion in our
conception of insanity. However, as the old time-honoured
“ varieties ” of mania and melancholia are retained, and as these
undoubtedly alternate in many cases irregularly, as contrasted
with the regular cyclic periodicity of “ folie circulate,” which
I presume the term “alternating insanity” in the table is
meant to represent, it is a pity that “ mixed insanity ” was not
given a place in the schedule.

A classification to be really useful should be formed on a
uniform basis, or on a number of uniform bases, each with its
separate compartments, in one or other of which any particular
case could be readily and immediately located, not, as in most
schemes hitherto compiled, resting on a plurality of bases
intermingled confusedly together.

For instance, the division of insanity into the two great
classes of congenital and acquired has the sanction of long
usage and general approval of most, if not of all, authorities, and,
what is of more importance, it expresses a fact. The con¬
genital may be sub-divided as heretofore into cases with and
without epilepsy. The addition of “ moral insanity ” to the
congenital forms, as has been done in the new table, will also
probably meet with general approval.

When we come to the class of acquired insanity we have a
number of bases to select from, each of which can form an
appropriate heading under which all cases of acquired insanity
can be included ; e.g. f we can take such bases as “ duration of
illness,” “intensity,” “predominant symptom or condition,”
“ epochal periods,” etc. But all the cases should be entered under
each of the headings , showing that each heading implies a different
qualifying condition from any of the others, but that all cases can
be arranged under its sub-divisions. Such a scheme would be
simple in principle, and sound, easy of application, conveying a

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339

fairly accurate description of a case, and free from confusion of
any kind. It might be drafted in a tabular form such as I
submit here. For an annual return the arrangement would be
slightly different. The “ varieties ” of insanity included under
the heading “specific designation 99 would be placed on the
left of the table in vertical column, the remaining columns
remaining as they are. Other columns, each with its respective
heading, could, of course, be added at will, e.g., “ aetiology,”
which would include as sub-divisions such forms as alcoholic,
syphilitic, traumatic, toxic, etc., but the principle I am con¬
tending for should be adhered to throughout, namely, that all
cases should be included under each specific heading, with a
column for “ unknown ” at the end if necessary.

It is hardly conceivable that anyone would find any difficulty
in placing a patient in his proper niche under this scheme.
Thus, one would be entered as a case of acquired, sub-chronic,
mild insanity, occurring during the period of maturity, and
characterised by depression with fixed delusions. Another as
a case of acute, recent insanity occurring during adolescence,
and characterised by stupor. Anyone who is enamoured of the
term “ dementia praecox” can, if he chooses, give such a case this
designation, but it should be entered in a separate column with
“ specific title ” or other appropriate heading at the top,
although this would not be likely to afford any additional know¬
ledge as to the nature of the case. For the sake of complete¬
ness, and to show the adaptability of a table of this kind, I
have included under the heading of “ specific designation ”
the various forms of insanity adopted by the Statistical
Committee, and it is a distinct advantage that by a glance at
the previous headings it will be seen from what class of insanity
a patient entered under one of the “ title ” columns is suffering.
The totals at the foot of the columns also will enable it to be
seen at a glance how many patients were admitted in, say, an
acute state, how many were recurrent cases, how many were in
a state of adolescence or senility, etc.

The point I am anxious to emphasise is this: In all modern
schemes of classification there is no one underlying consistent
basis. Dr. Maurice Craig says most truly : “ Every classifica¬
tion of insanity is apt to confuse the student unless he carefully
studies the basis on which it has been drawn up.” The basis !
To which of our most up-to-date classifications do these words

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UNITY OF INSANITY,

[April,

“ the basis ” apply ? To not one. Then God help the student.
His fate will be, and is, confusion. In every system yet
devised, even in that suggested by Dr. Craig himself, as he is
quite ready to admit, there are two or more bases. It is not
the plurality of bases in itself that is objectionable , but that they are
mixed up together in the classification. It is there where the con¬
fusion lies ; it cannot be otherwise. Now, what I venture to
maintain is that this confusion is not necessary. There is no
reason whatever why it should not be got rid of; and in this
way : Have as many bases as you please , but keep each as a distinct
department of classification , with its own heading , its own sub¬
divisions , and see that all forms of insanity are included under each
heading. There will then be no confusion. All plants may be
classed according to the Linnean system, where the basis is the
number of stamens and pistils in the flower ; or according to
the natural system, where the basis is certain essential charac¬
teristics inherent in the plant, and having relation to its whole
plan of structure. A botanist who would describe one plant as
belonging to the pentandrous monogynia class, and another as
a thalamifloral, polypetalous, epigynous exogen, and were to
publish a botanical work in which plants were arranged on a
hotch-potch system like this, would in the present day probably
be considered as suffering from one of the forms of insanity—say
confusional—which are classified for us on just the same
principle on account of the adoption of which by him he would
be regarded as mentally deranged. Yet we who would con¬
demn the botanist adopt and tolerate psychopathic systems of
classification similar to his, and count ourselves sane men.

I am not vain enough, or shall I say not mad enough, to hope
or expect that such a scheme of classification as I have outlined
will ever be generally adopted, but of this I feel firmly convinced,
that unless our methods of research be developed to such an
amazing degree as to enable us to discover the special patho¬
logical condition underlying each of the named “ forms ” of
insanity, if we can ever agree as to what are forms—a consum¬
mation which I fear is likely to be postponed to the millenium—
no rational system of classification will be devised which is not
based on the principle which I have ventured to bring under
your notice in this paper.

I feel that some apology is due to the members for bringing
such a well-worn theme before them on this occasion. Some

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BY THOMAS DRAPES, M.B.

341

1908.]

justification, however, for my doing so may be found in the
fact that any topic about which men disagree, and which is
still the subject of contention and controversy, will always have
a certain amount of interest attached to it until the question is
finally settled. And everyone will, I think, agree that such is
not the case in the present instance, and that by no means the
last word has yet been said on the subject of classification.

Discussion,

At the Irish Divisional Meeting in Dublin, November 5th, 1907.

After some remarks from the Chairman :

Dr. Donelan expressed agreement with Dr. Drapes.

Dr. Leeper thought the difficulty of classification was due to attempting to
classify by symptoms instead of causes. If insanity is due to toxines its forms
would eventually be classed according to the definite toxines causing them. He
failed to see the necessity for such complexity as was sometimes shown in classi¬
fications, and thought that Dr. Drapes deserved praise for trying to simplify.

Dr. Nolan did not see that Dr. Drapes’ classification advanced us much.
Varieties were merely labels, and useful as such, and a certain amount of diagnosis
and consequent prognosis was possible. As to errors in diagnosis, such were also
presented by diseases other than mental.

Dr. O'Neill expressed himself as rather hopeless of a solution of the difficulty.

The Chairman agreed that it was a pity that in Great Britain and America
insanity was so largely a medico-legal subject, as the legal mind was incapable of
grasping symptomatology. For instance, a certain Master in Chancery had been
unable to understand that disorientation and inability to converse indicated
insanity. Insanity was not a disease, and the difficulty of classifying it by sym¬
ptoms was exemplified in the case of general paralysis, which he held to be a
microcosm of insanities, although a definite disease. The crux was that one form
of poison produced a great variety of symptoms. Still, we should get no further
if insanity were merely to be divided, as by Sankey, into " general paralysis ” and
"other insanity,” and although it showed a multiplicity of symptoms many cases also
exhibited a perplexing resemblance— e.g. y the occurrence of delusions of persecu¬
tion. Why should perhaps the majority of chronic cases display a regular
development of persecutory paranoia ? We should expect all cases to be different,
but why were so many alike ? Delusions of persecution followed bv delusions of ex¬
altation, as in Dr. Drapes' case, had been described by Maignan as " delire chronique.”
Manic-depressive insanity was only an extension of folie circulaire. On the other
hand, classification by causes led to a host of difficulties. If microbes alone are
the cause, how explain cases caused or precipitated by mental trouble? In Dr.
Drapes’table "youth” and "senility” were found as causes, but to prove the
former a complex calculation would be required. Senility he believed in as a
cause, with other things contributing. Again, it was hard to see how obsession
could be caused by physical means, when it was curable by hypnotism. But all
these attempts at classification helped in prognosis, and afforded indications for
treatment, and, therefore, though very unscientific, were of value.

Dr. Drapes, replying, said that his particular point had been misunderstood, as
his headings were merely descriptions of the state on admission, and he did not
see that calling a case " dementia przcox ” helped rather than saying that the case
was stuporose and of the adolescent period. It was conceivable that a purely
mental cause might produce a morbid change in the brain-cells. Dr. Nolan had
misunderstood him : he did not say that diagnosis and prognosis were impossible
in insanity, but he did not think that they were aided by calling the condition by one
of these names. This classification would present no difficulty in placing the case.
He thought toxines would assume a very important place in causation, but did
not think they would always produce the same symptoms. This was shown by
the variety of the symptoms in alcoholic insanity, and one could never predict the
course of a case from a knowledge of the toxine.

Digitized by L^ooQle

Scheme of Classification of Insanity.

1908 .]

BY THOMAS DRAPES, M.B.

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N.B.—It is to be understood that the sub-divisions under the headings ** prominent symptoms ” and “ specific designation ” are not meant
to be exhaustive. Additional items can be included at discretion. Those most in use are inserted in the Table.

344

INJECTION OF TUBERCULIN,

[April,

/.—Clinical Results following the Injection of Tuber¬
culin . By C. J. Shaw, M.D., Senior Assistant Medical

Officer, Montrose Royal Asylum ; formerly Assistant
Medical Officer, Perth District Asylum, Murthly.

Observations on the Temperature and Pulse-rate\

In no case was there any marked reaction either in tempera¬
ture or pulse-rate following the injection of tuberculin.

In one control case there was a slight rise of temperature,
but this was probably due to an attack of coryza and not to
the injection of tuberculin, as no negative phase occurred.
Two cases showed an increased pulse-rate. One, in whom a
negative phase followed the injection, had a pulse-rate of 76
beats per minute on the evening of injection. The rate next
morning was 92 per minute. There was no other symptom
whatsoever. The other case gave no negative phase, and the
pulse-rate on injection was 74 per minute. Next evening it
was 92 and the evening following 102. This increased pulse-
rate was not accompanied by a rise of temperature. Beyond
a slight feeling of stiffness in the flank at the site of inocula¬
tion there was no local irritation in any case. This soon
passed ofi and al. performed their usual duties without the
slightest inconvenience.

The temperature chart of the insane frequently shows
greater variation than that of sane healthy persons.

The comparison of the temperature charts and pulse-rates,
before and after injection, of those patients to whom a dose of
mgr. T.R. was administered, shows no greater variation
than had occurred in the same case during the week preceding
injection.

Only two of all the eighteen cases injected wdth yjg- mgr.
T.R. showed a rise of temperature above normal. One was a
general paralytic whose temperature rose to 99 0 F. on the
second day after injection, but, as sudden rises of temperature are
common in such cases, no weight can be attached to this. The
other case was a demented patient whose temperature rose
steadily from 98*2° F. on the evening of injection to 99*2° F.
the second evening thereafter ; but there was no corresponding
change in pulse-rate and no negative phase was produced.

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1908.]

BY C. J. SHAW, M.D.

345

This patient was inclined to be restless at the time of injection
and was inoculated in the interscapular region instead of the
flank, as in all the other cases, but no local irritation was pro¬
duced and she did her usual work in the laundry next morning.

Only one case showed any increase in pulse-rate after being
injected with -7^ mgr. T.R. This was a case of general
paralysis whose pulse-rate on the evening of injection was
77 per minute. The following evening it was 89 per minute,
and on the second evening after injection, when he was restless,
rolling about in bed and picking the bedclothes, it was 94.
He showed evidences of old lung disease, but gave no negative
phase after injection, and no local or other constitutional
symptoms were present.

The absence of local and constitutional symptoms was very
marked, and in striking contrast with the effect produced by
the large injections of Koch's old tuberculin, formerly used for
diagnostic purposes. With such injections rise of temperature
and increased pulse-rate, accompanied by malaise, headache,
and local irritation, occurred even in healthy persons, while in
tubercular subjects these symptoms were more marked. With
smaller doses, for diagnostic purposes, the patient was confined
to bed and injected with 1 c.c. of a 001 solution of tuberculin.
The temperature was taken every three hours. If the tempera¬
ture rose 2° F. or more within twelve hours tubercle was
diagnosed.

If, as Wright suggests, the production of a negative phase
by the injection of a much smaller dose than produces that
result in the healthy individual can be used for the purposes of
diagnosing tubercular disease, the benefit conferred on humanity
will be very great, as there will be no risk of stirring up old
foci of disease or producing disagreeable symptoms.

Observations on the Quantitative and Qualitative Leucocytosis .

It is possible that the quantity and quality of the opsonic
body in the blood serums may, in some way, be connected
with the activity of the white blood-corpuscles in the blood, as
in infective conditions there is almost invariably a rise in the
number of leucocytes.

I estimated the leucocytosis, both qualitatively and quantita¬
tively, daily in all the control cases and in seventeen insane

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346

INJECTION OF TUBERCULIN,

[April,

cases during these observations. In two other insane patients
the blood estimation was only carried out for three days prior
to injection, but was performed for six days after.

In all cases the technique employed was the same. Blood
for purposes of leucocyte estimation was obtained at the same
time as that used for opsonic observations. No pressure was
applied to the ear while blood was being withdrawn. An
ordinary haemocyte pipette was then filled to the mark I with
blood, and the bulb filled to the mark ioi with ordinary
leucocyte diluting fluid, *3 per cent\ acetic acid coloured with
methyl green. The whole was then thoroughly mixed. For
enumeration the slide of a Thoma-Zeiss haemocytometer was
used, care being taken that the drop on the slide was the
correct size to fill the cell. The entire square was counted in
three separate fields and the average calculated. The result,
multiplied by 1,000, represents the total number of white blood-
corpuscles in 1 c.mm. of blood. For convenience a movable
stage was fixed to the microscope and the ordinary high power
lens employed. Films for qualitative estimation were made on
slides and stained with Jenner’s eosine and methylene-blue
stain. An oil-immersion lens was used for enumeration.
Never less than 300 cells were counted. The total number of
leucocytes per c.mm. of blood being obtained, and the percent¬
age of each variety calculated, the total of each variety per
c.mm. of blood was found, and all comparisons between the
various varieties are made on the totals so obtained.

The following varieties of white blood-corpuscles were
recognised:

(1) Polymorphonuclear leucocytes with neutrophile granules.

(2) Small lymphocytes ; cells about the size of a red blood-
corpuscle, with a deeply-stained nucleus which occupies nearly
the whole of the cell, the perinuclear protoplasm being of very
limited extent and staining with basic dyes.

(3) Large lymphocytes ; cells larger than a red corpuscle,
with a nucleus which stains less darkly than in the ordinary
lymphocyte, the perinuclear protoplasm being well marked
and staining with basic dyes. We also include under large
lymphocytes the hyaline or large mononuclears, cells which
vary from 8—12 /u in diameter. The nucleus is large and
stains faintly. The cell protoplasm also stains very faintly
with the basic dyes.

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1908.]

BY C. J. SHAW, M.D.

347

(4) The eosinophile leucocyte.

(5) Mast cells with large violet granules.

The normal number of white blood-corpuscles and of the
several varieties per c.mm. of blood varies within wide limits ;
but the usual total given is 7,000, with the different varieties
in the following percentage: polymorphonuclears 70, small
lymphocytes 20, large lymphocytes 8, eosinophiles 2, mast-
cells *5 to 1.

In the four male control cases the average total leucocyte
count was 7,978 ; the percentage was : polymorphonuclears
56 2, small lymphocytes 32*1, large lymphocytes 9, eosino¬
philes 2*5, mast-cells *2. This result is considerably below
the number usually quoted for polymorphonuclears, but higher
in lymphocytes. For the two female control cases the average
was 7,817. The differential percentage was: polymorpho¬
nuclears 64*5, small lymphocytes 29, large lymphocytes 5*2,
eosinophiles ri, mast-cells *2. This percentage shows little
change from that usually quoted. The average leucocytosis
per c.mm. obtained in all six control cases was 7,824, the per¬
centages being, polymorphonuclear 597, small lymphocytes
30*5, large lymphocytes 7^5, eosinophiles 2*1, mast-cells • 2.

The blood of seven female patients suffering from acute
mental symptoms showed an average total leucocytosis for five
days of 9,492, with a percentage of 66*4 polymorphonuclear
cells, 25*5 small lymphocytes, 6*3 large lymphocytes, 17
eosinophiles, and *i mast cells. The total and the polymor¬
phonuclear percentage are higher than those recorded for the
two female control cases.

Three cases, also females, suffering from subacute mania,
showed a considerable increase in their average total over that
recorded in the control cases, the figure reached being 10,798,
though the percentage of the different varieties of cell, poly¬
morphonuclears 63*1, small lymphocyte 27 6, large lymphocyte
8, eosinophile 1*3, shows little difference from the control
figures.

In six chronic cases, all females, whose leucocytes were
enumerated daily, the total average was 9,881 with a per¬
centage of polymorphonuclears 62*5, small lymphocytes 27*1,
large lymphocytes 8*6, eosinophiles 1*5, mast cells *3. The
total number of white blood-corpuscles per c.mm. of blood in
the female insane patients is slightly above the normal, but does

Liv. 25

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348

INJECTION OF TUBERCULIN,

[April,

not reach pathological limits. The percentage of each variety
does not differ greatly from the control figures. In two cases
of general paralysis, both males, the total leucocytosis was
10,705, with a percentage of polymorphonuclears 70*5, small
lymphocytes 20*4, large lymphocytes 8*2, eosinophiles *8, mast
cells 'i. The total number of leucocytes is above the ordinary
healthy level of the male, and shows a considerable increase on
the total and also on the percentage of polymorphonuclear
leucocytes found in the control cases. In one male chronic
case the average total leucocytosis was 7,808, the percentage
being, polymorphonuclears 65*3, small lymphocytes 21, large
lymphocytes 9 6, eosinophiles 4, mast cells *1. There is an
increased proportion of polymorphonuclear and eosinophile
cells, but otherwise little change from the control count.

After injection with mgr. T.R., three of the control
cases showed an immediate increase in the number of leucocytes
and reached their maximum of about 12,000, with 9,000
polymorphonuclears per c.mm. of blood by next day. The
only other case injected with this dose showed no increase in
the number of white blood-corpuscles till two days after injec¬
tion, when a slight rise occurred. The maximum was reached
on the third day. No negative phase followed injection in
this case.

With the exception of the large lymphocytes, the other
varieties of white blood-corpuscles followed a curve very
similar to that of the polymorphonuclear cells. The large
lymphocytes showed a considerable relative increase for one
day at least, but this rise did not occur on the same day as the
increase of polymorphonuclears. The increase in leucocytosis
did not last for more than two days.

The seven cases with acute mental symptoms were injected
with mgr. T.R. In two of these there was practically no
leucocyte reaction. In one case the reaction was very slight
and not beyond ordinary healthy limits. In the other four
cases the number of leucocytes was increased, but in no case
was the maximum reached on the day following the injection.
In two the maximum leucocytosis was recorded on the second
day after injection. In the other two cases the highest count
was obtained on the fifth and sixth days after injection. The
curve described by the total leucocytosis is closely followed
by all varieties of cells, except in four cases, where there was

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1908.]

BY C. J. SHAW, M.D.

349

an increased rise of large lymphocytes. The injection of
tuberculin was followed by a negative phase in all the cases.
Only one subacute case inoculated with 3-33- mgr. T.R. was
examined. There was no effect on the total leucocytosis pro¬
duced, and the only variety in which any alteration occurred
was the large lymphocytes, which rose from 1,110 per c.mm.
on the day of injection to 1,300 per c.mm. the day following.
A marked negative phase followed the injection, but no rise of
leucocytes occurred during the succeeding rise in opsonic
power. Two chronic cases injected with 3-J3 mgr. T.R. were
examined for only three days prior to injection. In one of
these the reaction was slight, the rise being complete the day
after injection ; but in the other case the rise occurred on the
third day, the polymorphonuclear cells numbering 19,000 per
c.mm. of blood. The reaction only lasted two days. Two
cases injected with this dose, one acute and one chronic, showed
evidences of old tubercular disease. Their curves were very
similar. The day after injection there was a rise of 1,000
polymorphonuclear cells followed by a steady fall for four
days. The only difference in the leucocyte reaction of the
sane and acutely insane after a dose of 3^3 mgr. T.R. is in
the reaction time. The insane, as a rule, take longer to react,
and their maximum leucocytosis is not reached so soon after
injection.

Two control cases were injected with mgr. T.R. In
one case there was no reaction, either in the quantity or quality
of the leucocytes. The other showed a slight rise in total and
also in polymorphonuclear leucocytes, the maximum being
attained next day. There was a rise in the large lymphocytes
per c.mm. the second day after injection.

Of the nine patients injected with -7-^3 mgr. T.R. whose
blood was examined, one gave no reaction and two gave only a
slight reaction, the maximum being reached next day. Each
of the remaining six cases exhibited a rise of varying amount,
but none reached the maximum level before the third day after
injection.

The leucocyte reaction following the injection of tuberculin
is, therefore, delayed in all forms of insanity. It has been
observed also that after the subcutaneous injection of terebine
for therapeutic purposes in the insane, the hyper-leucocytosis
induced does not occur till at least forty-eight hours after

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INJECTION OF TUBERCULIN,

35 °

[April,

injection, and in some cases seventy-two hours elapse before
the maximum leucocytosis is obtained.

There appears to be no marked difference between the
various classes of cases examined, as regards either quantity or
quality of the leucocytosis produced after injection of tuber¬
culin. The large lymphocyte cells showed a considerable
relative increase compared with the other varieties of leucocytes,
and this was especially marked in the more chronic cases.
These were, for the most part, cases of adolescent insanity, and
Dr. L. C. Bruce has found that this variety of cell is frequently
increased in the various forms of insanity occurring at that
period of life.

I have not been able to discover any constant relationship
between the total leucocyte curve or that of any special variety
of leucocyte and the opsonic curve, after injection.

Observations on the Urinary Excretion of the Insane Cases
Before and After the Injection of Tuberculin .

The injection of old tuberculin produced constitutional
symptoms with rise of temperature and increased metabolism.

I made an attempt to estimate any such change which might
occur from the injection of Koch’s new tuberculin T.R.
For this purpose the urinary excretion of those patients who
were confined to bed during the period these observations were
being carried on was collected and examined daily.

A knowledge of the amount and quality of the food taken is
necessary before any estimate of the amount of metabolism
going on in the body can be arrived at by the examination of
the waste products excreted. For this reason the diet of each
patient whose urine was collected was carefully noted and
weighed for a week before tuberculin was injected and for a
week thereafter.

The albumen value of the food taken was estimated from
physiological tables compiled by Haig. The urea value of the
albumen ingested was fixed at one-third of the total albumen
as stated by the same author.

The amount of chloride excreted is supposed to have a
relationship to the amount of albuminous metabolism taking
place in the body. The quantity of chloride ingested in the
food and excreted by the urine was also estimated. A specimen

Digitized by L^ooQle

1908.] BY C. J. SHAW, M.D. 35 I

of each article of diet was taken, and the amount of chloride
estimated in a given quantity. A table of the chloride values
of all varieties of food given was then drawn up, and from this
table all chloride estimations were calculated. The urine
excreted by each patient in the twenty-four hours was collected
daily. A specimen of the whole twenty-four hours* collection
was examined.

None of the patients received any drugs while these observa¬
tions were being made.

The urea excreted was estimated in the usual way with
hypobromite of soda and Southall’s ureometer. The number
of grains of urea per ounce of urine so obtained was multiplied
by the number of ounces of urine passed that day and the total
urea excretion estimated.

The amount of chloride excreted was estimated by Mohr’s
method. Ten c.c. of urine were taken and mixed with
100 c.c. of distilled water. A few drops of chromate of
potassium solution were added. The mixture was then
titrated with a decinormal solution of nitrate of silver until
a pink colour appeared, the mixtures being well stirred
during the operation. On the addition of the silver salt
the chlorine combines with the silver, forming a white precipi¬
tate of silver chlorine. When all the chlorides are precipitated
silver chromate goes down, but not while any chloride remains
in the solution. Silver chromate is of a red colour, therefore
the silver salt was added until a pink colour appeared through¬
out. To prevent error from the presence of other compounds
in the urine, more precipitable than the chromate formed, 1 c.c.
was subtracted from the total quantity of decinormal nitrate
of silver used. Each c.c. of decinormal nitrate of silver used
represents *0058 grm. of sodium chloride. The number of
c.c. of decinormal nitrate of silver used multiplied by this figure
represents the weight of sodium chloride present in 10 c.c. of
urine. The number of grammes of sodium chloride in the total
urine excreted per day was then calculated.

As the amount 6f albumen and chloride taken in the food
during any one day may not be excreted during the same day,
the average daily ingestion and excretion of each was calculated
for a week and comparisons of ingestion and excretion are made
on the figures so obtained.

The average quantity of fluid taken per day was calculated

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[April,

352 INJECTION OF TUBERCULIN,

from the total for the week, as was also the amount of urine
excreted.

The ratio of the amount of fluid ingested to the amount of
urine excreted remained fairly constant throughout, and did not
affect the average daily excretion of chlorides.

No albumen or other abnormal constituent appeared in the
urine of the cases examined during the time these observations
were made.

Ten cases in all were examined ; five of these were classified
as suffering from acute mental symptoms and were injected
with -g-J-g- mgr. T.R. Each of these cases showed a loss of weight
after injection, varying from i to 8 lb.

The case in whom the maximum loss occurred suffered from
acute mania and had evidence of old tubercular disease of the
lung. During the two weeks preceding injection she lost 3 lb.
in weight; the same amount of loss occurred during the two
weeks succeeding the termination of the observations, while
during the intervening two weeks she lost 8 lb. in weight
The loss of weight was, therefore, greater during the two
weeks immediately following the injection of tuberculin than
during the same period either before or after that event.
There was a considerable diminution in the amount of urea
excreted after injection in this case. During the week prior to
injection the daily average amount of urea excreted had been
28 9 gr. greater than the estimated urea value of the food
ingested. During the week immediately following the injection
of tuberculin the average daily excretion of urea fell 60 gr.,
and was 5 5 gr. less per day than the urea value of the food
taken for the same period. In the second week after injection,
however, the urea excretion reached its former level, so that, on
the daily average, 22 gr. were excreted in excess of the amount
ingested.

The excretion of sodium chloride followed a similar curve,
and while *9 grm. per day was being excreted in excess of
ingestion during the week prior to injection, in the succeeding
week 75 grm. less per day was excreted than had been taken
in as food. During the second week after injection 78 grm.
more than had been ingested was excreted. There was no
increased restlessness or marked exacerbation of mental sym¬
ptoms to account for the increased loss of weight after injection.

One of the cases lost 2 lb. during the two weeks follow-

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1908.]

BY C. J. SHAW, M.D.

353

ing the injection of mgr. T.R., and showed no further
loss of weight during the succeeding weeks. In this case
the excretion of urea increased after injection, but not in
proportion to the increased amount of albumen ingested.
Before injection the excretion of urea per day exceeded the
urea value of the food taken by 12 gr. In the course of the
following two weeks, although there was an increase in the
output of urea, there was a daily average diminution in the
amount excreted compared with the amount ingested of 4 and
16 gr. per day during each of these weeks. There was a
slight fall after injection in the excess of chlorides excreted
over the amount ingested.

Two of the five cases injected with mgr. T.R. showed an
increased excretion of urea as compared with the elimination
before injection. One of these patients, who suffered from
melancholia, lost 1 lb. in weight during the week before injection,
but lost 5 lb. in the following two weeks. Before injection the
average output of urea per day was less than the average
amount taken in the food by 2 1 gr. The week after injection
20 gr. per day in excess of the amount ingested were excreted.
During the second week after injection ingestion and excretion
of urea practically balanced each other. There was no increased
output of urea as compared with intake during the three weeks
over which the observations extended. This patient gained
3 lb. in weight during the week after the observations were
concluded. The other case who showed an increased output
of urea only lost 1 lb. in weight. The urine was lost during
the second week, but in that time there was a further loss in
weight of 1 lb. Before injection the excretion of urea per day
was 20 gr. less than the amount ingested. While the amount
ingested was the same during the following week the quantity
excreted per day increased and exceeded the value ingested by
40 gr. The excretion of chlorides also increased, so that while
before injection excretion was slightly less than ingestion the
following week excretion slightly exceeded the amount taken in.

In the fifth case injected with ^ mgr. T.R. the average out¬
put of urea per day for the week preceding injection was
52 gr. in excess of ingestion. No alteration occurred during
the succeeding week. There was a marked increase in the
excretion of chlorides, however, for while there was no altera¬
tion in the amount ingested during the weeks before and after

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INJECTION OF TUBERCULIN,

[April,

injection the excretion increased during the latter week, so that
the excess over ingestion was raised from *86 grm. per day to
4*34 grm. per day.

In all five cases injected with -g-J^mgr. T.R. a loss in weight
occurred during the week immediately following injection.

After injection two cases showed an increased excretion of
urea as compared with the urea value of the food taken. Two
showed a diminution, while one showed no change in the
relative amounts ingested and excreted.

Two cases showed an increased excretion of chlorides as
compared with the amount ingested. Two showed a diminution,
while in one case no change was observed.

No definite result can therefore be arrived at as to the effect
produced on the metabolism of insane patients by the injection
of mgr. of tuberculin.

Five of the cases whose urine was examined received an
injection of mgr. T.R.

Three of these were cases of general paralysis, and in none
of them was any alteration in weight recorded while under
observation. In all three cases, during the week prior to
injection, the average daily excretion of urea was greater than
the urea value of the food ingested. In two of the cases
during the week succeeding the injection the daily excretion
was a few grains less than the estimated amount ingested ; but
in the course of the following week the daily output was
greater than the amount taken in. Both of these patients had
formerly suffered from tubercular disease of the lung. In the
third case of general paralysis examined the excess of urea
excreted per day was slightly increased. In all three cases,
before injection, the daily excretion of chloride was less than
the estimated amount ingested. This difference between
excretion and ingestion was increased during the first week
following injection.

The other two patients, injected with mgr. T.R. during
the week before injection, were excreting less urea per day
than the estimated amount ingested. During the following
week the amount of urea excreted in excess of the urea value
of the food ingested per day was considerable. Before injection
both were excreting less chloride than they were ingesting. In
the course of the succeeding week, in one case the difference
between intake and output was increased, while in the other

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1908.]

BY C. J. SHAW, M.D.

355

the daily excretion of chloride exceeded the amount estimated
to have been taken in food. This latter case gained 3 lb.
in weight during the week following injection, but this may
have been due to rest in bed. The other case gained 2 lb.
in the same time.

All three cases with evidences of former lung disease had a
diminished daily excretion of both urea and chlorides after the
injection of tuberculin, compared with the amount of each
ingested.

No very definite conclusions can be drawn from these
observations.

Observations on the Mental Symptoms produced in the Insane
after the Injection of Tuberculin .

It has been frequently noted that an acute fever, a local
inflammation, a crop of boils, a septic poisoning, has cut short
and even cured an attack of insanity. To obtain the same
result, severe blistering was formerly resorted to. The treat¬
ment of insanity by the administration of large doses of thyroid
extract, as recommended by Dr. L. C. Bruce, produces very
much the same effect, while the remedy is under the control of
the physician using it. Wagner, of Vienna, got very beneficial
results in many cases of insanity by giving large doses of Koch’s
old tuberculin.

The doses of both remedies used produced constitutional
symptoms such as rise of temperature, increased pulse-rate, and
sweating, in all the cases where benefit resulted from the treat¬
ment. The production of fever with increased metabolism
would therefore seem to be the cause of the improvement and
not the specific action of the drug.

The mental symptoms were noted in all the cases injected
with tuberculin by me.

There was no difference produced in the mental state of any
of the patients injected with mgr. T.R.

Seven acute cases were injected with mgr. T.R. In two
no mental effect was produced. Three cases showed aggra¬
vated mental symptoms. One of these on admission had been
restless, noisy, singing snatches of songs, or talking almost con¬
tinuously. Her remarks were quite incoherent. She had no
interest in what went on around her, was lacking in attention,

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356

INJECTION OF TUBERCULIN.

[April,

and her habits were defective. Before injection she had been
quieter, resting in bed, and not noisy. She could tell her name
when asked. The day after injection with mgr. T.R. she
was noisy, singing and talking by turns, rolling about in bed,
and paid no attention to what was said to her. She could not
give her name, and was absolutely incoherent. This condition
lasted two days, when she became quieter and passed back to
the condition she was in before inoculation. One case of
mania with confusion was brighter and more talkative on the
day following injection, but next day was again confused. A
third case was irritable, inclined to be impulsive, obstinate, and
sullen after injection. During the days preceding the injection
she had been quieter and more contented than since her
admission.

Two melancholic cases showed signs of mental improvement
after injection. One of them, who had not spoken for days
before injection, spoke quite clearly and answered questions,
though slowly, the day following injection. The second day
she was not quite so bright, and by the third day she had
relapsed to the condition she was in prior to injection. The
other case of melancholia occupied a corner bed in the ward.
She lay with her face to the* wall, refusing to speak, and wept
at times. She resisted all movement. The day after being
injected she sat up in bed and answered questions slowly and
in a very low voice. The improvement did not persist in this
case for longer than four days.

One subacute case injected with 3-^ mgr. T.R. showed a
mental reaction. This patient had been resident in the asylum
for over a year. She suffered from acute mania on admission.
Before injection she showed marked symptoms of mental
enfeeblement. Her movements were slow, her sensibility dulled,
and her mental reaction delayed. Her emotions were blunted,
and she hardly spoke to her children when they visited her.
The day following injection she was brighter, talked more freely,
and was more acute mentally. The next day she was more
talkative and passed remarks on anything which attracted her
attention. She did not sleep well, however, that night, was
restless, getting out of bed, and she had hallucinations of sight
and hearing. She developed delusions of identity, recognising
in some members of the staff of the institution old acquaintances,
and talked to them of incidents which had occurred years

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1908.] on the onset of melancholia.

357

before, but of which they knew nothing. The delusions per¬
sisted for a few days, although the patient became less talka¬
tive, and by the eighth day after injection was in practically
the same mental condition as before inoculation.

The dose administered was not sufficient to produce any rise
of temperature or increase of pulse-rate. Neither did it cause
any constitutional symptoms, and the mental effects produced
by the injection were neither definite nor lasting.

Of the Onset of Melancholia . By R. R. Leeper, F.R.C.S.I.,

Medical Superintendent, St. Patrick’s Hospital, Dublin.

OUR present-day conceptions as regards the causation of
melancholic states are largely based upon the theory that an
auto-toxine is the cause and producer of many of the symptoms
of the disease of melancholia ; the idea is as old as the fathers
of medicine, the very name of the disease testifying to the fact
that from time immemorial defective organic function was
recognised as a cause of this diseased condition.

The excretions have been diligently and most minutely
examined and analysed with the object of isolating this toxine,
the supposed cause and source of anguish to men’s souls. One
could make a very long list of the insanities said to be due to
an excess in the system of the various normal substances found
in the excretions by the physiological chemist.

As yet I am unaware of the discovery of a melancholic
microbe, but doubtless we shall hear of him, and I trust that
whenever his recognition occurs that this discovery will be
promptly followed up by some such decisive measures as have
been used in the prevention of the production of the malaria
parasite, and let us hope that future generations may be enabled
to rid the world for ever and utterly annihilate and destroy
the, at present, suppositious microbe of melancholia in its
natural matrix—the slough of despond.

In the old register of St. Patrick’s Hospital one reads of
patients described in the quaint language of the eighteenth
century as “ unhappy lunatics ”—surely no bad name for the
melancholiac—and as this disease is the most distressing to
witness and the most anxious and difficult to treat of the

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358

ON THE ONSET OF MELANCHOLIA,

[April,

many forms of mental unsoundness one has daily to deal with,
I have decided to put some thoughts of mine before you.

Let us call to mind a case of acute melancholia occurring in
one’s practice. We find such a patient has almost invariably
a neurotic or insane heredity as a predisposing cause of the
illness ; next, we generally find him physically debilitated. He
or she has been subjected to some sudden grief, some mental
shock, some sudden plunge into poverty or its apprehension.
This is the soil, these are the fertilisers which may cause an
outburst of melancholia.

As each one in life experiences sudden shock, griefs, fears,
and apprehensions, which, when experienced, are reasoned with
and met with whatever mental powers we possess, so the un¬
fortunate about to become the victim of melancholia is over¬
come by some imperative conception of woe, some fixed
depressing belief becomes crystallised in the sensorium, and
from this he falsely reasons through his illness in the feral
condition of crucifying his soul in this life, and possibly haunted
by the gloomy prospect of eternal damnation in the next.

In the acute cases to which I intend to briefly refer I wish
to draw your attention to this imperative initial conception,
this sudden depressing belief which heralded the melancholia,
because I think that such a symptom is not without interest in
considering the auto-intoxication theory of the production of
this disease. In the cases I am about to mention this sudden,
depressing, overwhelming belief immediately heralded the
melancholia and caused the disease to be recognised, and I there¬
fore fancy not wholly inappropriately gave to this mental
state the name of the “ stage of psychical rigor, 1 ” which marks the
period of the time of the invasion of the disease. How can we
define this period, and what are the physical signs which
herald and accompany it ?

Such patients have usually an abnormally high arterial
tension. If such a condition be marked and co-existing
with other suspicious symptoms, one is bound to look upon the
case as one of grave danger. I have at present under my
care a mild case of melancholia. He is perfectly sane and
happy for days at a time, sleeps and eats well, when he suddenly
becomes agitated and exciting by the depressing belief that he
will never recover and will suffer from some incurable disease. His
normal pulse-tension is I io Hg., as estimated by the modified

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1908.]

BY R. R. LEEPER, F.R>C.S.I.

3 S 9

Riva-Rocci. Just when he has one of his melancholic seizures he
runs up to 140 Hg. or higher. And as soon as the arterial
tension falls he seems to lose his anxieties, and to become
again calm and self-controlled and sensible of his insane fancies
being unreal and absurd. In forming an opinion as regards
the mental state and possibility of an attack of melancholia
supervening upon an ordinary “ fit of the blues,” an examina¬
tion of the condition of blood-pressure at different intervals
during the day may be a means of helping us as regards the
prognosis of the case. Undoubtedly a high and continuously
maintained abnormal blood-pressure would go far to prove
that the patient was in for an attack of melancholia or
dangerous depressive state. The information obtained by the
sphygmomanometer would also help us by influencing our
early treatment. I have been told by a distinguished professor
of physiology that no drug will reduce blood-pressure as
speedily as fresh air and exercise, but these very simple
remedies are often very difficult to secure for a patient in the
early and home treatment of a man, say, overwhelmed by
anxieties, and whose livelihood may depend upon his spending
hours and days in offices and harassed by business anxieties
and want of physical exercise. Unfortunately medical aid is
seldom sought until this initial stage has passed and my stage of
“ psychical rigor ” has been reached.

Here is a case in point:

A medical man with a bad heredity led a very lonely home
life after the death of his wife. His practice entailed the
drudging and hardships essential to the calling of the active
practice of medicine in a poor locality. He had managed to
rear his family in respectability and comfort by a hard struggle,
and this struggle had been successfully got over. His practice
fell off from natural causes; his neighbouring brother prac¬
titioners did worse for a while than he did, nevertheless he
suddenly was seized with the fear of his being a pauper, that
dire poverty was upon him. This fear attacked him, he states,
suddenly. When in his house he used his telephone to com¬
municate with his solicitor who looked after his monetary
affairs and collected debts for him ; unfortunately the lawyer
was out This was the state which I have called “ psychical
rigor” from which the true melancholia dated. His next
action was to swallow a large dose of a virulent poison from

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36 o

ON THE ONSET OF MELANCHOLIA,

[April,

the effects of which his life was saved with great difficulty, and
he passed into a condition of acute melancholia with more or
less fixed delusions that he was ruined and could never again
free himself from pecuniary difficulties or practise his pro¬
fession. He recovered within a twelvemonth, and is now
again in practice.

My next case is that of an accountant in a large mercantile
firm, aet. 2 2. He had to post up difficult account books,
which he always did most accurately. He studied art in his
off time, and was most passionately fond of drawing, to which
he devoted his evenings in a technical school after his day’s
work was over. He ate little and worked hard, and upon
returning home one evening he told his family that he had
devoted too much time to his study, that great mistakes would
be found in his books and defalcations, and that he was ruined.
This was his period of “ psychical rigor.” His books were
found to be perfectly in order, and the poor man was sent to
an asylum a day or two after his return from the last visit to
that office where his artistic soul had long warred with the
drudgery of his life. He got slightly better in the private
asylum where he was sent to, but quickly relapsed, and was
admitted to St. Patrick’s Hospital. On admission it was
found that he suffered from a number of small boils and pimples
on his back. A large sore formed on his neck and another
on his cheek, and as there was reason to suppose he had con¬
tracted a septic infection cultures were made from the pus of
the sores, when it was found that the pneumococcus was the
organism present. As the sores were nearly healed when this
discovery was made we await any re-appearance to use the
proper serum in this case. His present mental state is one of
intense melancholia with stupor.

My third case is a very distressing one. A young pro¬
fessional man, after passing his final professional examinations,
went on what is popularly known as “a spree,” and contracted
syphilis ; he consulted his family physician upon the advent of
the Hunterian chancre, who told him he had contracted venereal
disease. He immediately rushed off to a leading surgeon, who
confirmed the diagnosis. He there and then became acutely
melancholic, said he was ruined in this world and the next.
With the diagnosis of syphilis the psychical rigor stage was
reached, and he became actively suicidal, and tells me " his

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1908.]

BY R. R. LEEPER, F.R.C.S.I.

361

very bones are full of misery. 0 After treatment with thyroid
extract and other ordinary methods he has recovered and
been discharged.

My fourth and last case, which I wish to mention, not
because it is the last presenting this symptom of imperative
conception, but for fear of wearying you, as one of peculiar
interest.

A lady, who nursed her husband with great devotion
through a long and fatal illness. During her married life
she had no financial cares or anxieties ; but upon her hus¬
band’s death the management of a large estate fell upon her
at a time when she was feeble in health and much depressed
by her widowhood. A relation called to assist her in managing
her affairs, and she went upstairs to get the books and papers
necessary. There she was overcome by the sudden belief that
she had squandered her money and was the cause of the
ruin of her name and family. She swallowed a large dose
of a poisonous liniment which she found alongside the
account-books in her room, and the stage of psychical
rigor was followed by this suicidal act, which, fortunately,
had not a fatal result, but marked the invasion of an attack
of agitated melancholia. Her urine, on admission, was found
to contain indoxyl, and invariably gave a colour reaction
to the test employed. After the bowels had been carefully re¬
gulated this reaction ceased, and in this and other cases we
have found that indoxyl is present only in those cases of
melancholia where there is much constipation, and that when
this is remedied the indoxyl disappears from the urine, and
that no marked change occurs in the melancholic state. Her
blood-pressure was abnormally high. Galen says : “ It is vain
to speak of cures or think of remedies until such time as we
have considered of the cause.” If melancholia be produced by
auto-intoxication, then this toxine or toxines must so weaken
the mind that imperative conceptions spring up, marking the
period of invasion when the disease, by producing insanity,
becomes recognisable. Whether vaso-motor disturbances are
produced thereby, or whether these of themselves are capable
of producing this disease, it is abundantly evident that physicians
should be more frequently consulted than they are in cases of
mental depression in their initial stages, and we should, so far
as we are capable, shield patients from undue stress whose nervous

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362 CRIMINAL LUNACY IN THE PUNJAB ASYLUM, [April,

organisations are unstable, and in whom one has reason to
suppose that defective phagocytosis or auto-intoxication is
present or likely to arise.

In these days, when the increase of lunacy seems at times to
cause some alarm to the nation, and even to be a subject of
much interest to the public for brief periods, it is very astonish¬
ing to find how little, if any, effort is made to combat and
prevent any of the well-known and every-day causes of
mental disease.

Statistical Notes on Criminal Lunacy in the Punjab
Asylum . By Major C. J. Robertson-Milne,

M.B., C.M., Medical Superintendent, Bengal Central
Asylum.

On March 31st, 1906, there were in the Punjab Asylum
591 patients of both sexes ; of these no fewer than 121 were
criminal lunatics. This proportion seems very high, but it is
less than in most of the other provinces of India, as a reference
to the following table (Table I) will indicate. I have added the
figures for two British colonies and for England for comparative
purposes.

TABLE I.— Showing the Relative Numbers of Civil and Criminal
Insane Confined in the Asylums of British India (1904).

Province.

Civil insane.

Criminal insane.

Total

Male.

Female.

Male.

Female.

insane.

Bengal

Assam

Burma

Madras

Bombay

Central Province
United Provinces
Punjab

393

194

320

552

M 3

641

354

138

, 3 I

166

257

i °5

495

198

121

IOI

249

107

1,101

1^5

448

586

836

290

1,183

576

India

3,679

928

i »397

181

5.185

1,578

Cape Colony (1904) .
Jamaica (1904) .
England (1905) .

1,033

54,475

764

64,442

694

218

i,86o

1,240

119.829

912

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1908.] BY MAJOR C. J. ROBERTSON-MILNE, I.M.S. 363

Table II .—Detail of Civil and Criminal Insane in the Punjab
Asylum on March 31 st f 1906.

Civil insane. Criminal insane. Total insane.

Male. Female. Male. Female. # Male. Female.

355 . 115 • 109 . 12 *. 464 . 127

Apparently the chief reason for this comparative pre¬
ponderance of criminal lunacy in India is the fact that the
majority of the insane population are kept in their village homes
by their friends ; it is only when they either come within the
clutches of the law as having committed crimes or have become
homeless vagabonds and a danger to the public that they can
be confined in an asylum. The law in India states that only
those persons who can be declared dangerous to themselves or
to others, or those who are wandering about without proper
guardianship and unable to take care of themselves, are to be
sent to asylums. These rulings would appear to have been
strictly adhered to. It ought to be observed also that the
undeserved stigma attaching to the name “ asylum ” is as great
in India as elsewhere. The friends of the insane consequently
prefer to keep them outside as long as possible. The opening
of the new central asylums has, to a slight extent, induced
some to bring their afflicted friends for treatment, but the bulk
of our patients are those who have come in under magisterial
orders in accordance with the provisions of the lunacy acts.

It is to the criminal insane, however, that I wish to draw
attention, and I have accordingly prepared the following
analytical statement of criminal lunacy as I have found it in
the Punjab Asylum.

Official Classification of the Criminal Insane.

In India the criminal insane are confined in gaols or asylums
under one or other of three sections of the law, and conse¬
quently there are three classes into which they are divisible.
These are simply known as Classes I, II, and III.

Class I includes those persons who, being accused of having
committed serious crimes at an inquiry held by the magistrate,
before whom they have been arraigned, are found incapable,
after due observation and certification by a medical officer, of
either understanding the nature of the proceedings against them
or of making a defence ; in other words, they are reckoned as

LIV. 26

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364 CRIMINAL LUNACY IN THE PUNJAB ASYLUM, [April,

unfit for trial. Their cases are then remanded under Section 466
of the Criminal Procedure Code for the orders of Government.
The lieutenant governor, when these cases are brought before
him and approved of, then issues an order through one of his
chief secretaries, under the same section of the law, authorising
the detention of the accused in an asylum until they are
declared fit to stand their trials or until further orders.

In Class II are those who, having been tried for their crimes
and found guilty, are declared to have been insane at the time
of the crime and unable to realise its nature and its effects.
They are then “ acquitted on the ground of insanity ” ; if the
crime has been a minor one they may then be discharged on
the security of their friends ; but if the crime has been a major
offence the judgment of the case is transmitted to government,
who, after the due consideration of the case, issue an order for
the detention of the accused in a provincial asylum until
further orders under the provisions of Section 471 Criminal
Procedure Code.

Class III comprises those who, having been convicted of
crimes and sentenced to various terms of imprisonment, have
become insane while in gaol. These are transferred to asylums
only by an order of the local government, and the authority
for this transfer is contained in Section 30 (i) of Act III of
1900.

The following table shows the official classification of the
121 criminal lunatics in the Punjab Asylum.

Table III .—Official Classification .

Class

II
III

109 12

Male.

Female.

5
3

General Social Particulars of the Criminal Insane .

Of the men 68 are Mussulmans, 40 are Hindus, of whom 4
are Sikhs, 6 are Brahmans, while the remainder belong to
various castes. There is one doubtful personage, a man with

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1908.] BY MAJOR C. J. ROBERTSON-MILNE, I.M.S. 365

an English name who is probably a native Christian. Of the
women 7 are Hindus, while 5 are Mussulmans.

The majority of the men and all the women hail from the ^
Punjab, the North-West Frontier Province, or the Western
Rajputana States. There are 3 Afghans, 2 Kashmiris, and 2
Hindus from the United Provinces.

With regard to districts, the greatest number—13—have
come from Rawal Pindi ; Peshawar and Delhi have each sent
10, Lahore with 8, Amritsar with 7, Ambala, Multan, and
Dera-Ismail-Khan with 6 come next. The districts showing
the smallest numbers are Jullundur, Hissar, Jhang, Kangra, and
Mianwali. No district at present enjoys the distinction of not
having a criminal lunatic in the asylum.

Classifying the men according to occupations, there are 43
cultivators or agricultural labourers, 19 beggars or fakirs, 5
shop-keepers, 4 sepoys from the native army, 2 Government
clerks, 2 railway employees, and 1 police-constable, while the
remainder, with 12 exceptions, belong to various trades. The
12 exceptions are those in whom no previous occupation can
be ascertained. Of the women, 1 is a labourer, all the others
being domestically employed in their own house.

The Crimes Committed by the Criminal Insane.

Table IV .—The Crimes committed by each Class ,

Crime. Class I. Class II. Class III.

Murder and culpable homicide. 20 . 38 . 19

Attempted murder . . .2.5.1
Abetment of murder. . 1 . — .2

Grievous hurt . . . .6.3. —
Suicide (attempted) . . . 2 . — . —

Kidnapping . . — ■— 1

House trespass. . .1.1.--

House-breaking . . . — 1 . —

Theft and robbery . .6.2.2

Mischief by fire . . . — . 1 . —

Failure to give security . . . ^ . j

Total.

2
1

It will thus be seen that out of 117 criminal insane no fewer
than 77, or nearly 66 per cent ., have actually committed
murders. Eight of them have attempted to murder, while three

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366 CRIMINAL LUNACY IN THE PUNJAB ASYLUM, [April,

have abetted murders. Two of the latter crimes were particu¬
larly brutal and revolting: in one instance a woman held her
daughter-in-law's limbs while her son strangled his wife ; in the
other, an unprincipled son hired a band of ruffians to kill his
father and assisted them in the deed. Many of the cases of
grievous hurt almost amount to attempts to murder.

Of the women eight committed murders ; two of these killed
their husbands, and six their children. One woman abetted her
daughter-in-law's murder, as noted in the previous paragraph,
two committed thefts, while the remaining female criminal had
kidnapped a female child to sell her for immoral purposes.

In 38 of the murders the victims were related to their
assailant, and the following table gives the degree of relation¬
ship in these cases, and general particulars of the remaining
43 -

Table V .—The Victims in the Murder Cases .

Relatives, 38.

Father . . 1

Mother . . 3

Sister . . 2

Brother . . 1

Husband . . 2

Wife. . . 12

Son . . .3

Daughter . . 6

Grandson . . 1

Uncle . . 1

Niece . . 1

Cousin . . 1

Sister-in-law . 1

Son and daughter 2
Wife and mother 1

Other than relatives, 38.

Men . . 19

Boys . . 6

Women . . 7

Girls . . 4

Mullah (priest) 1
Asylum (patient) 1

Details unknown, 5.

Relationship, etc.,
unknown. . 5

This table is comparable with Table IV of Dr. Nicolson's
article on criminal lunacy in England in Clifford Allbutt's
System of Medicine , vol. viii. It will be seen thus that out of
190 English male criminal insane who had committed
murders, twenty-eight had killed their wives, and three wife
and children ; in the Punjab Asylum, of the 73 insane
male murderers twelve killed their wives and one his wife and

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1908.] BY MAJOR C. J. ROBERTSON-MILNE, I.M.S.

367

his mother. Only six women and five men killed their
children. At Broadmoor the proportion of parents who have
killed their own children is very much higher. The number
of instances in which relatives have been killed by the insane
is also greater in England.

It ought to be observed that the. Punjab figures refer only to
the primary murders. Two male patients in Class I, originally
indicted for murder, have killed other patients in the asylum
since admission; two of those in Class III killed fellow-
convicts in gaol after detention there for their previous
murders. All four were dangerous homicidal maniacs ; one
of them, the oldest criminal in the asylum, was admitted in
1881, having killed his sister with a hatchet in the previous
year ; he was then a dangerous maniac and continued to be
regarded thus for several years. In October, 1883, he was, by
error of an attendant, shut up in a room with another patient
for a night and was found in the morning to have killed and
partially eaten the other. He is now a quiet dement.

An interesting statement results if we compare the English
figures with those of the Punjab as regards the psychological
genesis of the crimes committed.

Propensity in criminal

Table VI.

Percentage of cases.

Dominant mental

activity.

Punjab. Broadmoor.

origin.

I. Violence to person
or property .

86 .

Malice.

2. To sexual acts

5 •

Lust.

3. Thieving, fraud, etc.

9 •

Acquisitiveness.

The absence of criminals in the second class in this country
will be remarked. The different standards of morality pre¬
vailing in the two countries explains this to a certain extent.

The practice of unnatural sexual acts is, for example, not
considered either vicious or criminal by certain classes in the
Punjab. Every Pathan and many of the other Punjabis in the
asylum, especially those suffering from mania, endeavour at
every conceivable opportunity to indulge in them. The
suppression of this is one of our most difficult problems and I
personally doubt whether, in this, our attendants can be relied
upon to help.

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368 CRIMINAL LUNACY IN THE PUNJAB ASYLUM, [April,

In the next Table, No. VII, the main types of insanity
presented by the Punjab criminal insane will be found classified.

In Table VIII there is further subdivision of the cases of
mania.

Table VII .—Types of Insanity among the Punjab Criminal

Insane .

Mania ...... 80

Melancholia . . . . .27

Dementia ...... 6

Imbecility ...... 1

Sane, malingering, doubtful ... 6

Table VIII.— Subclassification of Cases of Mania .

Acute or chronic mania . . .41

Epileptic mania ..... 7

Toxic mania (hemp drugs) . . .12

Delusional mania .... 9

Moral mania ..... 1

Puerperal mania ..... 1

Homicidal mania .... 8

Alcoholic mania ..... 1

The cases of acute or chronic mania, which form half of the
total number, are those whose aetiology is obscure and who
present no distinguishing feature in their symptoms. Some,
indeed, are probably cases of mania due to hemp drug indulg¬
ence.

The epileptic cases call for no comment; their proportion
to the epileptic insane in the asylum is about 12 per cent.
The case of moral mania is an interesting example of a man
who can best be described as being insanely vicious. He is a
tall, powerful Punjabi Mussulman with a low type of head and
face, thick, deformed ears, and thick lips. He is covered with
scars of previous encounters. He was originally an habitual
thief and dacoit. In the asylum he helped to murder an unfor¬
tunate patient who had refused his advances. He has no idea
of right or wrong ; these are only measurable to him in the
light of punishment or reward. He is a vicious bully, the
terror of his section. He can work well when he chooses, and

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is our champion weaver; but he generally prefers to play
cards or indulge in vicious talk.

Four of the eight homicidal maniacs continue to require
constant supervision. One is a man who has not spoken for
fourteen or fifteen years, but who is possessed of an intense
desire to kill. He has manufactured lethal weapons out of
pieces of tin and nails brought to him by other patients, and
with these he has frequently attempted to attack attendants and
others. Another homicidal maniac killed a man with whom he
had a trivial quarrel after they had both been drinking " bhang ”
at a shrine ; he seemed quiet enough on admission, but some
months after he had been here a patient was found beaten to
death in a remote corner of the criminal section, and evidence
pointed to this man as being the murderer. The victim had, it
turned out, selected the place of daily retirement which this
maniac considered his own. Hence the occurrence! It is
really marvellous that we do not have more such serious crimes
in this asylum. Pathans and Punjabi Mussulmans are exceed¬
ingly irritable and easily enraged ; they possess when sane but
little regard for human life, as their constant blood feuds show ;
it is still less when they are insane.

The solitary alcoholic maniac is a case similar to those de¬
scribed by Clouston as " mania a potu ”; he is a weak-minded
Dogra whose crime was 44 mischief by fire.” He set fire to his
neighbour’s rice store when suffering from the effects of an
alcoholic bout.

The interesting cases of mania are, however, those labelled
41 toxic,” and resulting from indulgence in the preparations of
canabis sativa v. indica. The preparations in common use in
the Punjab are 44 bhang,” which is a cold decoction of the leaves
and capsules of the male and female plants, and 44 charas,” which
is the resinous exudate from the female flowering tops. Charas
is smoked along with tobacco and sometimes eaten. The
following are short records of those cases in which the insanity
and the crime were definitely attributable to excess in these
deleterious products :

Case i.— S. A — , a Mussulman sweeper from Hoshiarpur, murdered
his wife by beating her on the head with a large stone. It was proved
at the inquiry that S. A— had been for years an inveterate hemp
smoker, constantly in the society of those who thus indulged. A chronic
maniac now becoming demented.

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CRIMINAL LUNACY IN THE PUNJAB ASYLUM, [April,

Case 2.—M. S—, a Sikh of Amritsar, notorious for his indulgence in
“ bhang ” and “ charas ”; a case accepted by the Hemp Drugs Com¬
mission. While in a state of mania, as the result of his indulgence, he
attempted to assault a sessions judge with an axe.

Case 3.—S. G—, a Hindu Brahman from Kamal, who had become
a fakir, and was proved at his trial to have indulged deeply and fre¬
quently in “charas.” In September, 1904, he pushed a boy, who had
refused to give him “charas,” into a well, 24 ft. deep, from which
the lad was with difficulty rescued. He was found unable to make
a defence and remanded. A weak-minded, foolish, stupid man, whose
behaviour and speech is that of a child.

Case 4.—P. S—, a Hindu kahar from Amritsar, murdered his wife in
a fit of intoxication following “ bhang ” drinking, to which he was proved
to be addicted. His mental condition is now one of weakmindedness.

Case 5. — E. D. N— , a Pathan of the Peshawar district, formerly a
sepoy in the 27th Baluchis; a confirmed charas smoker. Discharged
from the army on account of his indulgence in charas, which had
rendered him weakminded and frequently maniacal. In December,
1900, while in a state of charas intoxication he fired four shots with a
revolver at his wife, but missed her and wounded his mother-in-law. He
is now, after six years’ abstinence from the habit, fairly sane.

Case 6.—D. D—, an old man, a Hindu shopkeeper of Jhelum, who
was proved in court to have indulged in drugs, “ bhang,” “ charas,”
“ opium,” for some time, and to have become altered in consequence,
was indicted for having killed one boy with a club, and attempted to
kill three others. He is fairly sane, but liable at intervals to fits of
curious excitable depression, in one of which he recently attempted
suicide by beating his head against a wall.

Case 7.—S. B—, a Hindu sweeper from the Hoshiarpur district, who
killed his wife in 1898, and who was proved at the inquiry to have been
under the influence of charas at the time, and then declared unfit to
stand his trial. He improved, and was tried after three years’ residence
in the asylum and acquitted. He was now a dull, foolish, weak-minded
man.

Case 8.—B. G—-, a Mussulman, who, while intoxicated with “ bhang,”
threw his sister’s child from the roof of a house to the ground, killing
her instantly. This was in 1894. He was sane on admission, and has
remained so except for a mild attack of mania in 1900.

Case 9 —S. S—, a Pathan beggar, well known for his addiction to
bhang and charas; on October 22nd, 1899, he strolled into the house
of a woman, picked up her infant son, carried him across the road and
dropped him into a well. He furnishes another example of weak-
mindedness following indulgence in Indian hemp.

Case 10.—P. I—, Brahman beggar from Sialkot, who was entered in
1897 in the police registers as a bad character, given to indulgence in

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1908.] BY MAJOR C. J. ROBERTSON-MILNE, I.M.S.

371

drugs (charas, etc.). In 1898 he strangled his wife with a turban when
she was asleep. Sentenced to transportation, but afterwards found to be
insane. His condition is one of chronic mania.

Case ii. —K. N—, admitted in 1893, having, without provocation or
motive, killed a man. History of indulgence in charas. In a state of
sub-acute mania on admission; continued thus for some years, and is
now becoming gradually demented.

Case 12.—S. S. H—, while intoxicated from bhang drinking, in
which he indulged daily, attacked his wife with an axe. A garrulous,
chronic maniac.

Of the crimes committed by these 80 cases classed as
maniacs, 57 were murders, 2 abetments of murder, 9 cases of
grievous hurt, while 6 were thefts. The thefts were, in four of
the six cases, of a curious character : (1) Church ornaments
from a Catholic church valued at £1 ; (2) three annas (three
pence) worth of potatoes and two grave-stones ; (3) two dogs ;
and (4) a camel.

Twenty-three of the twenty-seven melancholiacs are ordinary
acute or chronic cases. In three, delusions are extremely
prominent, while the remaining man is an epileptic.

Fifteen of the melancholiacs were murderers ; the crimes of
the remainder were either grievous hurt, attempted suicide,
house-trespass, or theft.

Four of the six cases of dementia certainly presented that
condition on admission. One, an old man, had murdered his
step-grandson ; two had committed the offence of house-tres¬
pass ; while the fourth robbed a child of her silver ornaments.
The two remaining cases are men admitted as criminal lunatics
of Class I, having committed murders more than twenty-five
years ago ; both were possibly cases of mania originally; both
have been demented for many years. It should be added that
several of the cases of mania and one or two of those of
melancholia are on the high road to dementia.

The solitary imbecile was found in possession of a bullock.
He is congenitally defective, and his case has been represented
to Government with a view to his being handed over to the
custody of his friends.

Of the six cases classed as doubtful, three had been so
recently admitted that a diagnosis of their mental condition
could not be made. Investigation has since shown them all to
be cases of mania. Of the remaining cases two are certainly

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[April,

malingerers, while I am inclined to think that the third also
falls under this category.

I have recently represented to the Governments of the
Punjab and of India the need which exists for a special
criminal asylum, and I understand that the project is being
considered.

In conclusion, I must express my indebtedness to Dr.
Nicolson’s exhaustive article on “ Criminal Lunacy in England,”
contained in vol. viii of Allbutt’s System of Medicine. It was
the perusal of that article which prompted the above short
study.

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.]

The Thaw Case.

This case, which has excited more interest, both in America,
where it occurred, and in this country, than any case that has
been tried for some years, has been the subject of two trials.
The first, which took place in the early part of last year, and
was spun out to an intolerable length, ended in the disagree¬
ment of the jury. The second trial, which was much more
business-like, and which, perhaps on that account, attracted
much less attention, ended in an acquittal on the ground of
insanity; such a verdict being still possible in New York,
though it is no longer a part of the law of this country.

The facts of the case were as follows :—Thaw and his wife
went, on the 25th June 1906 to a theatrical entertainment at a
“ roof garden ” in New York. Here they met friends with
whom Thaw conversed long and rationally. As they were
leaving in a party, Thaw left the party, walked over to where
Stanford White was sitting, placed a revolver to his head, and
fired three shots, two into his head and one into his neck, upon
which White fell dead on the floor. Thaw then coolly gave
himself up to the police. Before doing so, he kissed his wife
and said, “ It is all right, I have probably saved your life.”
When charged, he admitted the crime, and asked for a match
to light his cigar.

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RECENT MEDICO-LEGAL CASES.

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It was alleged at the trial that Stanford White had, years
before the marriage of Thaw, seduced by means of drugs, and
under very heartless circumstances, the girl, then only 16,
who subsequently became Thaw’s wife ; that White either was
in the habit of seducing girls in this way, or was believed by
Thaw to be so. That Thaw was constantly getting his wife to
repeat the nauseous story of her seduction, and would get very
excited when he heard it; and that he betrayed a constant and
bitter hatred of White ; believed White was injuring him soci¬
ally, by keeping him out of clubs and so forth ; and that a great
part of Thaw’s time was occupied in talking and thinking about
the alleged villianies of White.

It was proved that one of Thaw’s maternal uncles was insane;
another a congenital imbecile; a paternal aunt epileptic ; that
Thaw had chorea as a child, and was always of a “highly
nervous temperament,” slept badly, and so forth.

Several experts were placed in the box for the defence, and
to each of them was put a “ hypothetical question ” of enormous
length, running to 39 p.p. of octavo print, and containing a
complete history of the crime and of Thaw’s career, his relations
with White, the alleged seduction of Mrs. Thaw, and a great
deal more; and upon this question the witness was asked, “ In
your opinion was H. K. T.” (the initials by which Thaw was
designated throughout the question) “ labouring under such a
defect of reason that he did not know the nature and quality of
his act, or that that act was wrong ? ” The question was in
each case allowed by the Court. Dr. Hammond answered
“ He was labouring under such a defect of reason.” Dr. W. A.
White answered in the same sense. Dr. S. E. Jelliffe answered
that Thaw “did not know in the legal sense that the act was
wrong, and he was suffering from a defect of reason.” Pressed
as to the difference between the insane knowledge Thaw had
of his acts and ordinary sane knowledge, he said, “ It differs in
many respects. It differs largely in the motives; in the manner
of its execution ; it differs in the manner of choosing the time
and place of the act; and it differs very largely in the act that
precedes it. It differs very largely from the acts that come
after, very much.” The report purports to be a verbatim
report; but it is difficult to believe that the witness gave such
an answer.

All three witnesses were asked what precise kind of insanity

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374 RECENT MEDICO-LEGAL CASES. [April,

the prisoner exhibited, and none of them was able to give a
precise answer.

Dr. Austin Flint gave it as his opinion that Thaw was at
the time of the trial and at the time of the crime insane and
suffering from paranoia, but that “ his mental state was such
that he knew the nature and quality of the act he was doing,
and that it was wrong . . . and that he then and there knew
that such act on his part was against the current morality of
the people of the State, and in violation of laws ” and that
Thaw “ is now and for some time past has been in such a state
of lunacy or insanity as to be incapable of understanding the
proceedings against him or making his defence.” Dr. W. Mabon
and Dr. Carlos F. Macdonald gave evidence identical with that
of Dr. Flint.

At this point Counsel for the prosecution moved for a lunacy
commission to inquire into the state of the prisoner’s mind,
prefacing his application by an account, which seems to us
extraordinary, of his personal conversations with the expert
witnesses for the defence ! The judge granted the application,
and appointed a Commission of three, to investigate the state
of the prisoner’s mind at the time of the investigation, and
report whether he was “ capable of rightly understanding his
own condition, the nature of the charges against him, and of
conducting his defence in a rational manner.” The Commis¬
sioners were two of them lawyers—one an ex-judge—and one
doctor, who, it appears, was not an alienist. This Commission
unanimously pronounced the prisoner to be sane, and the trial
went on.

The speech of counsel for the defence is so obscured by the
fustian description of the newspapers, that it is impossible to
discover whether he insisted on the plea of insanity or not;
but apparently he did not. The only part of his speech that is
reported, is a frank appeal to the jury to express their approval
of Lynch Law, and amounted to this :—“ Mrs. Thaw is a pretty
woman. Stanford White wronged, her, and therefore deserved
to be shot. Thaw has only done what many Americans have
done before with impunity; juries have acquitted them, and
you will acquit the prisoner.”

The judge placed before the jury the law of homicide of New
York State, and from his charge it appears that homicides are
classed as murder in the first and second degrees, and man-

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slaughter in the first and second degrees. Murder in the first
degree is homicide with design, deliberate and premeditated.
Murder in the second degree is homicide with design, but without
deliberation or premeditation. Homicide without a design to
effect death, or as we should say, without intent to kill, inflicted
in the heat of passion and with a dangerous weapon, would be
manslaughter in the first degree.

The judge explicitly states that the defence in this case was
that the prisoner was insane at the time of the commission of
the crime. (The prisoner is called “ the defendant ” throughout
the proceedings, and this is the custom in New York.) The
defence is provided for by the Penal Code of New York, which
is founded upon our own Common Law, and is as follows:—“ A
person is not excused from criminal liability as an idiot, an
imbecile, lunatic, or insane person, except upon proof that at
the time of doing the alleged criminal act he was labouring
under such a defect of reason as either not to know the nature
and quality of the act he was doing, or not to know that the
act was wrong.” The following instructions, among others,
were given to the jury by the judge : “An irresistible impulse
to commit crime, where the offender has the ability to discover
his legal and moral duty, has no place in the law, nor is it a
weak and disordered mind that can be excused from the conse¬
quences of his crime.”

“ If there existed in the mind of the defendant an insane
delusion with reference to the conduct of the deceased, it will
not excuse the homicide unless the delusion was of such a
character that, if it had been true, it would have rendered the
act excusable and justifiable. . . . The settled law of the State
is that if A deliberately draws a pistol, and cocks it and points
it at you, and discharges its contents into your body, and alleges
his insanity as a defence, the inquiry is if A knows when he
cocked and fired that pistol and discharged its contents into
your body, that the act is such as would probably destroy your
life, and did he know that the act was forbidden by law.”
“ The settled law of the State in the test of responsibility for
criminal acts, ... is the capacity of the defendant to distin¬
guish between right and wrong at the time of and in respect to
the act.”

The following remarks upon expert evidence are interesting.
“The examination of the experts was directed to his mental

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376 RECENT MEDICO-LEGAL CASES. [April,

condition at the time they saw him, and from the conclusion
they then reached, and the medical and other facts proved
which would be competent [i. c. evidence], to give in the trial
an opinion on his sanity or insanity, at the time of the homicide.
The jury are entitled to the facts upon which a sanity expert
bases his opinion, and when those facts are the result of his
own interviews with the defendant, it is not only competent,
but it is necessary that they should be laid before the jury’.”
“ The opinions of experts are presented as an aid to the jury,
and are to be considered by the jury with all the evidence in
the case. The quality and not the quantity of such evidence is
to be considered.” Mr. Justice Fitzgerald.

In the second trial, Mr. Justice Dowling, put it to the jury.
“ The only question for you to decide is whether the defendant
was or was not insane on the evening of June 25, 1906. But
the testimony of family history, of prior life, illness and condi¬
tions, and of subsequent mental and physical state, is received
to cast light upon the defendant’s mental condition at the time
in question. In this connection, proof of the insanity of rela¬
tives is received because it is an accepted pathological fact that
some varieties of insanity may be, and even tend to be, trans¬
mitted.” “ A man who reasons himself into a frame of mind
wherein he is satisfied that his act is justified, is not thereby
excused from the responsibility of his criminal acts.”

The interest taken in this very brutal crime was not so much
on account of its brutality or singularity, as on account of the
position and reputation of the criminal and his victim respec¬
tively. Both were men of very great wealth and very prominent
persons in a certain section of New York society. In the first
trial, the defence was utterly mismanaged. The trial was
unnecessarily protracted to a most inordinate length. Insanity
was pleaded, but counsel for the defence appeared to resent
the conversion of prosecuting counsel to this view, and opposed
to the uttermost the motion for the appointment of a lunacy
commission. As far as appears from the reports of the trial,
the defending counsel did not once refer in his speech for the
defence to the alleged insanity of the prisoner. It appeared
that the defence was willing to admit that the prisoner was
insane at the moment of pulling the trigger, but that he was
sane up to that moment, and recovered his sanity the moment
after. They wanted him acquitted on the ground of insanity,

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RECENT MEDICO-LEGAL CASES.

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but they wanted to escape the inevitable result—committed to
a lunatic asylum; and between the two stools they fell on a
disagreement of the jury.

At the second trial the defence was in different hands, and the
defending counsel, taught perhaps, by the fate of his prede¬
cessor’s efforts, elected to plead insanity in serious earnest. A
great deal more evidence bearing on the unsoundness of mind
of the prisoner or defendant, was brought before the court,
and the result was acquittal on the ground of insanity, and the
committal of the prisoner to the State criminal asylum. The
nature of this evidence is not given in the account furnished to
me, but I hear privately that it was very cogent. It is curious
that, at the second trial, the prosecuting counsel had changed
his opinion, and opposed with all his might the plea of
insanity.

The procedure of the trial was very curious in English eyes.
How many weeks it lasted I am not sure, but it was very long,
although the facts were extremely simple, and were admitted.
English observers are entitled to contrast it with a very similar
case that occurred in this country subsequently, in which a
man named Rayner placed a pistol to the head of Mr. Whiteley,
and shot him dead on the spot. Insanity was not actually
pleaded in this case, but an attempt was made to show dimi¬
nished responsibility of the prisoner on the ground of mental
defect. The prisoner was tried, convicted and sentenced in
one day, and there was never a whisper of a suggestion that
the proceedings were too summary. In Thaw’s case it took
many days merely to impanel the jury, no fewer than 337
jurymen being told, on one pretext or another, to stand aside.

One of the expert witnesses in the Thaw case was in no
proper sense an expert. He broke down deplorably in cross-
examination, and discredited not only the defence, but all the
other expert witnesses, and expert evidence in general; so
that, shortly after his cross-examination, a bill was brought in
to the Assembly of Albany to abolish hypothetical questions;
and do away with calling of experts in any criminal case in
which insanity is pleaded. As far as the abolition of hypothe¬
tical questions is concerned, my sympathies would be with the
enterprising legislator who brought in the bill.

The interposition, in the middle of the trial, of a request on
the part of the prosecution for a lunacy commission to examine

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RECENT MEDICO-LEGAL CASES.

[April,

the prisoner, is a curious procedure to which there is no
parallel on this side of the water; and the result does not
encourage us to introduce it here. The Commission unanim¬
ously found the prisoner sane, yet at the second trial the jury
unanimously found him insane, and there is no reason to
doubt that the second verdict was proper, and was justified by
the facts. The composition of the Commission—two lawyers
and one doctor who was not an alienist—goes far to show the
estimation in which the alienist expert is held in certain legal
circles in New York. We have found in this country how much
harm one incompetent person can do to the reputation of a
whole branch of a profession.

Of course, if the competence of a prisoner to plead was
questioned in the course of a trial in this country, a jury would
be specially empanelled to try the issue, and they would try it
in open court, on parole evidence, subject to cross-examination
in the usual way. The substitution of a Commission of three,
to investigate the matter in camera, does not, a priori or by its
result, seem a better proceeding.

The law of New York as to insanity in Criminal cases is that
laid down by our Judges in 1843, and was stated by the Judge
in its narrowest sense—the sense in which, as an eminent judge
has said 44 hardly anyone is mad enough to come within it.”
Neither of the Judges is reported to have placed any stress on
the meaning of the word 44 Know” or to have assisted the jury
in its interpretation. In these circumstances it is surprising
that the prisoner was found insane.

The judge’s charge, that a person of weak or disordered mind
cannot be excused from the consequences of his crime, is far
behind the practice in this country, in which, though the prisoner
may be found guilty of the act, his weak or disordered mind is
always considered on the infliction of punishment, and usually,
if the mind is conspicuously weak or disordered, the verdict of
44 guilty but insane ” relieves him of the worst consequences of
his act.

While the test of responsibility, though nominally the same
as in this country, seems in fact to be more narrow and rigorous,
the admission of evidence in the State of New York gives the
witness very much greater latitude. The 44 hypothetical ques¬
tion ” seems an abuse of the time of the Court. Here, a witness
would be asked, 44 Having heard the evidence in Court, what

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RECENT MEDICO-LEGAL CASES.

379

opinion have you formed of the state of mind of the prisoner ? ”
But even then he would not be allowed to answer, as the
experts in the Thaw case were allowed and expected to answer,
the very question that the jury had to decide—that is to say,
whether at the time of committing the crime he knew what he
was doing and whether it was wrong.

The net results of the trial seem to have been in the main
these two. First the frantic endeavour of the defending counsel
in the first trial to induce the jury to violate their oaths, and to
give the prisoner a general acquittal on the ground that his
victim was a wicked man and deserved his fate, met with a
very satisfactory defeat. According to the American custom,
members of the jury were interviewed after the trial, and what
purport to be statements made by them are published in the
newspapers. If these are to be believed, it appears that the jury
paid no attention to the rhodomontade of the defending counsel,
or to his appeals to the sanctity of Lynch law, and considered
the case on its merits alone.

The second result of the trial is undoubtedly the discrediting
of expert evidence in insanity in New York, and to a less
degree, no doubt, in other countries. Whether this result is
desirable or no, opinions will be divided.

C. Mercier.

By the courtesy of Dr. Mabon, Dr. Smith Ely Jelliffe, of
New York, has kindly sent us the following comment:

The Second Thaw Trial .

To even a casual observer the second Thaw trial presented
a marked contrast to the first. There is little doubt that the
dilatory tactics indulged in in the former trial would not have been
countenanced by public sentiment, and it was evident from the
first hour that Judge Victor J. Dowling went on the bench that
the procedure was to be a different one from that followed at
the former trial. Thus, he announced that in the obtaining of
jurymen the court would sit at night, and the examination of
talesmen was conducted with such relentless expedition that in
a week a jury was found who thought that they could review
the evidence in the case impartially and do their duty by their
Liv. 27

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RECENT MEDICO-LEGAL CASES.

[April,

oath. Even the counsel for the defence, who had calculated
that two weeks would be necessary for the obtaining of a jury,
were surprised at the celerity of the process. Several hundred
talesmen were examined.

With the opening of the trial proper, and the presentation of
the case by the prosecution, Assistant District Attorney Garvin
did not depart from the mode of presentation at the former
trial. The prosecution placed its chief reliance upon the evidence
of one witness, J. Clinch Smith, a brother-in-law of Stanford
White, with whom Harry K. Thaw had had a more or less pro¬
tracted conversation on the night of the tragedy. The proving
of the shooting, of the defendant’s manner and acts immediately
following, were put in in a clear, concise, though somewhat frag¬
mentary manner.

The prosecution rested its case after three or four hours.

It may be remembered that, according to the testimony of
Clinch Smith, the defendant held a conversation with him just
prior to the shooting, and that in this conversation he referred to
various matters. He referred to the value of stocks, as to what
would constitute a good or bad buy in the market ; he spoke
of his going to Europe, of his ability to introduce Clinch
Smith to a buxom brunette, and he also referred to another
matter concerning an escapade in which one of his companions
had figured, but dismissed it, saying he (Clinch Smith) was too
young at the time, Clinch Smith being a man fully fifteen or
twenty years the defendant’s senior, although a well-preserved,
well-groomed man. Clinch Smith was not cross-examined at
the former trial by Mr. Delmas, but Mr. Martin W. Littleton,
who conducted the case for the defence on the second trial, put
him through a very searching cross-examination, and raised a
doubt in the minds of the jury on at least three or four points,
namely, that possibly the defendant mistook him for another
man in maintaining that he was younger than he himself was;
that he was engaged in stock market transactions as a trader,
which he was not, being a man of leisure; and that he was a
man about town and somewhat of a sport, which was naturally
denied.

The cross-examination of Clinch Smith was the only attempt
made to weaken the side of the prosecution.

It very soon became evident that the long, tiresome rhetorical
and oratorical displays on the part of both the District

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Attorney and the counsel for the defence, which were very
striking features of the first trial, were to be absent on this, the
second trial. The counsel for the defence, Mr. Littleton, pre¬
served a very quiet, dignified attitude throughout the entire
trial, indulged in no argument whatever, either before the
Judge or the jury, took his exceptions to the Judge's rulings in
monosyllables, and allowed the District Attorney no oppor¬
tunity for controversial bouts. The District Attorney was
equally dignified in his handling of the case.

The material facts as brought out at the second trial were
presented in a much more logical and orderly manner than
at the first. Thus, a large mass of evidence bearing on the
heredity of the defendant which was excluded at the first trial
was put in at the second—namely, that on both the maternal
and paternal sides there were members of the family who had
had attacks of mental disorder. In both branches of the
family the dominant type of mental disorder consisted
of manic excitement. A large amount of new evidence,
bearing on the early years of the defendant, were in¬
troduced at the second trial, all going to show that
he was a highly nervous, excitable, and distinctly psycho¬
pathic individual. That he had St. Vitus' dance, and had
frequent attacks of it, that he was very unstable, having nervous
spells as a boy from five years of age on, and that throughout
his entire life, as evidenced by his nurse who had charge of him
until the age of five years, his kindergarten teacher, who took
charge of him from the age of five to seven, the teacher in a
school, a Mr. Beck, who had charge of him at the age of ten,
another teacher who had him at the age of fifteen, and a friend
of the family, a woman of rare intelligence, a professed psycho¬
logist, who had observed him continuously throughout fifteen
years of his young life ; all this testimony tended to show that
one had to deal with a distinctly different kind of an individual
than normal. Thus, a letter sent by his mother to his teacher
when he was ten years of age showed that even at that time
his abnormalities were so marked that his parents feared what
might result.

The following letter, written at this time, shows clearly what
the attitude of mind of his mother must have been when he
was fifteen years of age :

“ Mr. Beck, Dear Sir, —Yours of yesterday received. To

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attempt to describe how much distress both it and Harry's
letter gave me is needless. Can you bear with him a while
longer ? To yield to his wishes now (as he would think if sent
home) might ruin him. I did not think him capable of such
behaviour, and begin to fear it may not be all badness and
rebellion, but that his mind is more or less unbalanced. Do
you think there is any danger of that ? The uncle to whom I
refer as having been weak-minded was, when a child, subject
to just such outbreaks of temper, and therefore I cannot help a
horrible feeling of dread. Deal gently with him if possible, for
my sake as well as his own. His father will be home on
Thursday and can help advise me. I have written just now.
How would it do to avoid noticing him in any way for one
day? I really <do not know what to suggest. He is so
different from the other four children, and ought to have been
more closely reared and trained.”

The teacher became convinced of the irrational nature of
the acts and appearance of H. K. T. at the time of his nervous
attacks.

Further testimony was introduced to show that his education
was desultory and irregular, and necessarily so as a result of
his nervous, unstable organisation.

All this evidence was presented by the defence, not as
evidence of insanity itself, but, as the counsel for the defence
put it, to show the kind of timber of which the defendant was
made, and he then presented some testimony to show the stress
to which this timber was subjected and the effects upon the
mind of the individual in later years.

Further, new testimony of Dr. Burton Brown, at one time
physician to the British Embassy at Rome, was introduced,
showing that at the age of twenty-six he had had, according to
Dr. Burton Brown, a short attack of hypomania, lasting at least
ten days, during which time he was under the care of a
physician and a nurse.

New testimony was also introduced to show that a year or
two later, while at Monte Carlo, he suffered from an attack
with maniacal symptoms; that one or two years later, while
in London, he had an attack of acute excitement, lasting for
some eight to ten days, and that during this time he was
attended by Dr. Russell Wells, of London, who testified on the
stand that the patient was suffering from an attack of acute

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383

manic excitement, which he diagnosed as the manic phase of
manic-depressive insanity.

The testimony then passed over to the history of his meeting
with Evelyn Nesbit, and of the years of courtship and of
association with this young woman, all of which was fully
covered at the first trial, and at the second trial departed in no
essential details from the story as previously told, the only new
point noticed being that in 1905 the defendant, H. K. T., while
in a very distinctly depressed condition, the result of slanders
told about his so-called degeneracies and difficulties that he
had in persuading Evelyn Nesbit to marry him, attempted to
commit suicide in a hotel in Paris. This evidence was only
partly corroborated by the statements of a Dr. Gauja, who
came from Paris and testified that he had treated the defendant
for a severe attack of poisoning, the exact nature of which he
was not willing to diagnose. He said that he washed out the
patient’s stomach, and that he recovered from symptoms which
were extremely alarming at the time, namely, very thin rapid
pulse, slow breathing, extreme collapse, thin pinched nose, and
coma. Dr. Gauja testified that the case was not one of
alcoholic poisoning; he was not willing to say that it was opium
poisoning. He could not obtain a history, as the patient
himself could not speak, and others in attendance spoke no
French.

The cross-examination of Evelyn Nesbit’s testimony by the
District Attorney was not so relentless as at the former trial,
although his manner towards her permitted the council for the
defence in his summing up to make a very strong argumentative
detail.

The testimony of the mother and of the family physician
to the effect that he had a severe attack of depression in 1903,
when an estrangement took place between H. K. T. and E. N.,
was repeated, and new details of peculiar irrational acts added
by testimony of his butler.

Important new testimony was adduced tending to show that
the defendant was in a very excited condition in the Whist
Club the day before the shooting, and also on the same day.
The butler of the Whist Club testified to many peculiar acts,
in the morning and afternoon preceding the shooting, particularly
that he dragged a screen about him while playing, the day
being very warm, and there being no draughts, and that he

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frequently went to the telephone, telephoned very frequently,
and came out saying, “ This is awful.” That he went out of the
Club, then turned, rang the bell, and gave an attendant at the
door a small package, requesting “ that it be put in the safe.”
The package contained three ordinary cigarettes. There was
testimony that he played whist that afternoon with some
prominent players, but they were not called upon to testify
by either defence or prosecution.

Testimony bearing on the appearance and conduct of defen¬
dant on the roof-garden on the night of the tragedy was largely
amplified by a number of witnesses who had not testified before.
Some ten to twelve pebple had seen him, and each and all
testified to the fact that he was in a very unusual condition;
that he gave evidence of intense, though suppressed, excitement,
and that in their opinion his acts and appearance impressed
them as irrational. The general purport of their testimony was
similar to that of others at the first trial, that although no dis¬
tinct signs of mania were present, yet his appearance was so
unusual as to stamp him as a man of unsound mind. Much of
the testimony of these witnesses tended to refute and distinctly
contradict a number of details in the testimony of Clinch Smith,
particularly that portion in which Clinch Smith maintained that
the defendant kept his eyes constantly on a certain spot in the
audience, which later on, he, Clinch Smith, found was the spot
in which Stanford White sat—a point very material for the
prosecution as the only evidence they had presented which in
any way tended to show premeditation. The testimony of
one young woman is worth repeating, as bearing on his con¬
dition at this time, and that was that “ immediately upon the
shooting H. K. T. broke his revolver, raised it in the air,
with his face pale and distorted, one side of his mouth drawn
up and the other side drawn down, with his teeth set and all
the gums exposed, looking like a waxen figure, his eyes bulging
and glassy, the veins standing out upon his forehead, his body
absolutely rigid, walked away from the scene of the shooting
holding the pistol in the air.”

Further testimony showed that the defendant was oriented
as to time, place, that he remembered that he had shot a man
and knew whom he had shot. His only explanation at this
time was—“ He ruined my wife.”

New testimony was introduced which tended to show that

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on being taken to the Station House, immediately after the
event, the defendant was suffering from illusions or hallucina¬
tions. These were testified to at the former trial, but were not
so clearly presented as on this occasion. It was evident that
these illusions or hallucinations were transitory, as they dis¬
appeared after about thirty-six to forty-eight hours.

One very strong point made by the defence at the second
trial, which was entirely neglected at the first, was the calling
of the coroner’s jury, all of whom had had an opportunity to
observe the defendant forty-eight hours after the shooting.
Of the twelve men who sat on the coroner’s jury, ten testified
that in their opinion the acts and the manner of the defendant
H. K. T., at the time of their observing him, forty-eight hours
after the shooting, while before the coroner’s jury, were
irrational. The cross-examination of the coroner’s jury by the
District Attorney was uneventful, and did not shake their
testimony. This very important bit of evidence, as contributory
to the other evidence bearing on the defendant’s state of mind
near the time of the shooting had been entirely disregarded by
the former counsel.

The expert testimony on the second trial by Drs. B. D.
Evans and Chas. G. Wagner differed in no essential particular
from that observed on the first. They described the defendant
at their examinations three months after the shooting as sus¬
picious, as excited, voluble in speech, divertible, circumstantial
in thought, euphoric, highly self-appreciative, and that occa¬
sionally his conversation would take on a character known as
“ flight ” ; he expressed ideas of reference, ideas of persecution,
and some ideas of influence, but that those ideas, which were
somewhat delusional in their character, were loose and un¬
systematised and could be influenced by argument.

The only other expert who testified in response to the
hypothetical question was Dr. Smith Ely Jelliffe. There was
no cross-examination of the experts for the defence by the
District Attorney, save a short one of Dr. Wagner, bearing on
an affidavit which he had made at the time of the proceedings
at the first trial before a commission to determine whether the
defendant was able to confer with counsel.

The prosecution offered practically no rebuttal. There was
no rebuttal on expert testimony, so that in this respect the
unfortunate picture presented at the first trial was absent.

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The summing-up of both the counsel for the defence and for
the prosecution was masterly. Mr. Littleton spoke for about
five hours, and Mr. Jerome for about three hours and a half.
Mr. Littleton’s summing-up was a wonderful display of
oratorical and logical presentation, forceful and effective in the
highest degree, thoroughly straightforward and dignified. It
was particularly masterly in its iteration and reiteration of the
real issues of the case, that is, the evidence bearing on the
mental state of the defendant, and, further, extremely successful
in that it would tend to force the District Attorney, in his
answer, to make certain admissions, which an analysis of the
District Attorney’s summing-up showed were made.

District Attorney Jerome’s final words were effective and
very masterly. He, however, admitted three things which un¬
doubtedly had weight with the jury. These were that Stanford
White undoubtedly met his just deserts ; that the statement
of Evelyn Nesbit to her husband, barring the matter of her
being drugged, was undoubtedly true ; and, thirdly, that the
Hummel affidavit (which had been relied upon by the prosecu¬
tion as tending to upset the testimony of the defendant’s wife)
was undoubtedly a dishonest instrument. These three admis¬
sions on the part of the District Attorney were practically
forced from him (from the writer’s standpoint) by the masterly
summing up of Mr. Littleton.

The Judge’s charge was impartial, direct, and able. In one
important particular the charge was directly in opposition to
the claim of the prosecution, that the burden of proof lay with
the defence to show that the defendant was insane beyond a
reasonable doubt, the Judge holding on this point that the
burden of proof was upon the prosecution to show that beyond
a reasonable doubt the defendant was sane at the time of the
commitment of the act. This material change of instructions
on the part of the Judge, supporting, as it did, the claim of Mr.
Littleton, had undoubtedly some weight with some of the jury.

The whole trial was conducted in an exceedingly masterly
and systematic manner ; indeed, it went along so fast that on
two occasions the defence was unable to get its witnesses in
time, and had to ask for half a day’s postponement. The
whole trial took only four weeks, including the getting of the
jury, and fully four times as much testimony was put in
evidence as on the previous trial.

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The general theory of the defence tended to show that the
defendant had had periodic attacks of mental unsoundness, that
such periodic attacks had occurred at infrequent intervals, and
were of the general manic-depressive type.

A verdict was reached, after some fifty-six hours* deliberation,
of “not guilty on the ground of insanity,** and Judge Dowling
remanded the defendant for observation to the Matteawan
State Hospital for Insane Criminals at Fishkill Landing, on the
Hudson, seventy-five miles north of New York.

Occasional Notes.

The Late Dr. Conolly Norman .

Death, happily sudden and painless, has deprived our
Association of the services of a man, whose merits are so
ably described in the opening pages of this journal, that
we shall make no attempt to add thereto. His many
friends know how difficult is the task of adequately
expressing a full appreciation of his worth. For years
Dr. Conolly Norman has been an editor of this journal.
The record of his work, and his love of it, are to be found
in innumerable contributions, but beyond these his co¬
workers have unforgettable memories of his love of truth
and honour, of his bright wit and kindly humour, intensi¬
fying their personal sense of loss.

Dying in harness, he has missed the fullest public
recognition of the success of his life’s work that would
have come to him had he been spared for a few more
years. The degree of Doctor of Medicine recently
bestowed on Dr. Norman by the University of Dublin
was probably but a foreshadowing of greater honours to
come.

Our regret that Dr. Norman had not reaped the harvest
of his deserving is increased by the anticipation that some
of the good work he has done may be marred by the

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recrudescence of retrogressive tendencies against which he
had striven so long.

Our consolation is, that though

“ The path that each man trod
Is dim, or will be dim, with weeds,”

to the resulting question,

“ What fame is left for human deeds
In endless age?”

the poet answers that “It rests with God.”

Changes in Scotland .

Dr. Clouston’s retirement from the Royal Edinburgh Asylum
is one among several changes in Scotland which we cannot
but regret. Dr. Rutherford had no sooner resigned from the
Crichton Royal Institution at Dumfries, and our colleagues had
no sooner settled down to their respective duties, than the
Morningside vacancy was declared. We sincerely wish both
physicians many and happy days and a green old age, promising
useful results of learned leisure in retirement.

We cannot well conceive Dr. Clouston on the shelf, dusty
with years; and somehow Morningside will not be quite
the same to his older friends. When we remember what he
has done to develop that important institution, how he has
enhanced its reputation, how he has so lightly borne the burden
of responsibility and laboured so constantly in the pressure of
consultations, of medico-legal work, of journalistic and literary
en £ a gements, how he has lectured and taught, given time
and careful attention to our affairs and the business of the
oyal College of Physicians—when we thus briefly recite his
ac levements we refrain from rash prophecy as to the nature oi
is uture development. We expect with certainty the “last
ruit off an old tree ” before the curfew:

* Not bed-time yet! The full-blown flower
Of all the year—this evening hour
With friendship's flame is bright”

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In accepting Dr. Clouston’s resignation, the Managers of the
Royal Edinburgh Asylum were moved to place on record their
high privilege to express their deep sense of the services con¬
ferred by him on the institution since 1873, by the remodelling
of the West House and the erection of the stately edifice of
New Craig House. Passing beyond domestic details they go
on to state that few men in his department have enjoyed so
fully the confidence of the medical profession at large. The
Hundredth Anniversary of the Royal Charter of the Asylum was
celebrated last year, and Dr. Clouston, in summing up his
experience of thirty-five years in Morningside, refers all too
briefly to the changes which those years have brought. He
notes that it is his forty-seventh annual report, and that it has
been written with greater difficulty than any one which has
gone before, in view of the fact that it was quite impossible
to indicate the feelings with which he leaves his patients
and his work:

“ Eheu fugaces, Postume, Postume
Labuntur anni.”

When we turn to the Report of the Crichton Royal Institu¬
tion, we find the Directors recording the event of the year, which
will long cause it to be remembered with regret. This refers to
the retirement of Dr. Rutherford, the distinguished physician
and able administrator during twenty-five years of service,
in which he heightened the reputation of the Crichton
and multiplied its resources in a marvellous degree. Dr.
Rutherford contributes a very short resume of those noteworthy
achievements, but, short as it is, too long to find place here. The
generous superannuation allowances made to Dr. Rutherford
and Dr. Clouston, the appropriate expression of regard conveyed
to them, cannot but soften the regret with which these energetic
and distinguished physicians pass from their official labours.
They have joined the veteran Dr. Yellowlees, and will not fail
us in wise and kindly counsel—Nestors all.

“ Ubi tres medici, tres amici.”

Dr. Maudsley and the Metropolitan Hospital for Mental

Diseases .

The offer of thirty thousand pounds by Dr. Maudsley to the
London County Council in aid of the erection of a metropolitan

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hospital for the insane, is a striking evidence of the sympathy
for suffering that is begotten of life-long efforts in its relief.
A highly distinguished career is more truly ennobled by such
an act than by the distinction conferred by any public honour.
If Dr. Maudsley’s name is associated with the institution, as it
should be, it would be a worthy perpetuation of the memory
both of the munificence and the man.

The necessity for such an institution is beyond all doubt
The general hospitals have so unanimously neglected their duty
of providing wards for incipient mental disease that these have
been relegated to the workhouse infirmaries, or the police cells,
when their malady had developed sufficiently to render them
unbearable in their families or intolerable by the public. The
police cell is certainly not a desirable place for the treatment
of disease, and although some of the workhouse infirmaries
have done excellent work in late years, they cannot furnish the
means of treatment which should be forthcoming in the specially
equipped wards of a general or special hospital. These maladies
offer more possibilities of arrest in their incipient and prodro-
matous stage than most other forms of disease, and this neglect
is therefore all the more deeply culpable.

The proposed hospital, it may be hoped, will be closely
allied to one of the general hospitals, where it would have the
advantages of having at all hours the assistance of specialists
of every kind and the apparatus for inquiry and treatment
which each specialty demands. To provide all this skilled
knowledge with the necessary appliances at all times available
in an isolated hospital of the special type would necessitate
great expenditure and involve an immense amount of extra
work.

The association of the mental with a general hospital, as in
the case of the out-patient departments, would go far to help
on recognition in the popular mind that insanity is disease, and
to destroy at once the prejudice against mad-houses, which might
to some extent attach itself to a hospital devoted to such
diseases.

Such an alliance need not necessarily be a drawback to the
general instruction to the medical students of the Metropolis,
and might be of real advantage to those who were devoting
themselves to this branch of medicine.

The clinical study of mental diseases would certainly be

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391

advantaged by such close association with those engaged in
other special and general work ; the isolated special hospital,
on the contrary, would suffer from the loss of the criticism and
suggestion which would arise from close connection with
general medical workers.

The pathological work of such a hospital should be of great
importance, the early stages of disorder being so commonly
associated with one or more conditions of bodily disease, that
the study of these states should throw more light on their
development than is to be obtained from the pathological
terminals, often very remote from causation, furnished by the
asylum. Here, also, the special would be greatly advantaged
by association with general pathology.

The cost of such a hospital will, in any case, be very large ;
and this would be very much greater if started as an indepen¬
dent institution. In a community so heavily involved in debt
as London, with such gloomy financial prospects, the question
of undertaking such a large initial outlay and so great an
annual expenditure must ultimately depend on the extent of
these.

The London County Council has always shown a great
desire to help the insane, and will certainly carry out the
object so practically and generously supported if it can possibly
do so, and we trust, therefore, that future generations may have
reason to remember with thankfulness the originator of the
institution that might appropriately be named the “ Maudsley
Mental Hospital.”

Mental Therapeutics .

The treatment of mental disease, although based on the
relief of the physical conditions accompanying it, is also
dependent to a very great extent on the mental environment,
and this environment is entirely dependent on the knowledge,
experience, and skill of those who have to deal with the daily
life of the individual.

The importance of this aspect of treatment cannot be over¬
estimated, and cannot be too frequently or too emphatically
dwelt on. The alienist physician, fully recognising this and
practising it in every hour of his professional life, is but too apt

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to forget that what to him is an intuition, an almost uncon¬
scious reflex, is an unknown quantity to the vast majority of
his professional brethren. The daily round of the true alienist
physician is, or should be, to the understanding observer a
profound study in psychic medicine.

Furnished with boundless sympathy, unfailing hopefulness,
unlimited forgivingness, armed with fullest knowledge of the
general working of the disordered mind, and of the idiosyn¬
crasy of his individual cases, the true physician’s visit is a
marvellous dispensation of psychic medicine, every form of
emotional appeal and intellectual stimulus being administered
with the minutest adaptation to the needs of the special case.

In text-books and in the general literature of insanity, little
is to be found descriptive of this important element of treat¬
ment, except from inference, although in the older writers it
was much more largely dwelt on.

The silence on this most important therapeutic element has
led the profession and the public to conclude that there is
really nothing special in the treatment of insanity; that any
doctor, and particularly those who had nothing to do with
insanity, could prescribe the necessary rigime and administer
the necessary drugs ; that any lay person, especially those who
had no experience in lunacy, could undertake the care of an
insane person. The results of this woeful error can be testified
to by the experience of many asylum physicians, and to it
the chronic lunacy of hundreds of human beings may be
traced.

The treatment of insanity by inexperienced caretakers, often
under unsuitable conditions, that has resulted from this
ignorance of the most important and essential element of suc¬
cessful cure, has developed to such an extent that some more
definite expression should be given to our knowledge of this
subject.

The importance of mental influences in the treatment of
disease is seen in the empiric cures effected by faith curers, by
Christian Scientists, by innumerable systems, shrines, etc., and
it is fully time that these mental influences should be reduced
to scientific accuracy. Several Continental workers are already
doing so, and it is equally important that the mental influences
employed in asylums should not only be practised but be
brought before the profession from a scientific point of view.

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The After-care Association .

The annual meeting of the After-care Association for the aid
of persons discharged recovered from asylums for the insane
was held on January 29th at 48, Wimpole Street, by the kind
permission of Dr. Blandford.

The chair was taken by Mr. Anthony Hope Hawkins, who
made a very interesting opening speech, in which he alluded to
his relationship to the late Mr. Hawkins, the Chaplain of Colney
Hatch, to whose initiative the founding of the Society was due.

Dr. Savage also read a short paper on “ The Convalescence
from Mental Disorders and its Difficulties,” which greatly
interested the unusually large meeting.

The Report shows that the usefulness of the Association is
steadily increasing, the numbers aided being larger in each
year. The income of the Society from subscriptions is well
maintained, and there is a substantial reserve from legacies, life
subscriptions, etc., to meet any contingencies that may arise.

During the year a “ guild ” has been formed which promises
to be of much importance, not only in supplying clothing, but
also in spreading the knowledge of the aims and objects of the
Association.

The prevention of relapse, which after-care assists very con¬
siderably, is alone sufficient to justify the support which so
many asylum superintendents give to its work, and to commend
it to those who have not hitherto availed themselves of its
services.

Prevention of relapse, however, is only secondary and
incidental to the main purpose of sheltering, helping, and com¬
forting many who, on leaving asylums, would practically be
homeless and friendless but for this Association.

Part II.—Reviews.

A Text-book of Mental and Sick Nursing\ adapted for Medical Officers
and Nurses in Private and Public Asylums. By Robert Jones,
M.D., with an introduction by Sir W. J. Collins. London : The
Scientific Press, Ltd., 1907. 8vo. Price 3s. 6 d.

Dr. Jones has dedicated his book to the Princess Christian, whose
encouragement has done so much for nurses; and Sir William Collins,

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whose long administrative experience gives him right to authoritative
utterance, in commending the work, says that the inherent difficulties
of treatment of the insane justify every effort towards instruction. That
is an approval of the labours of the army of asylum physicians, who
give so much of their time and attention to the training of attendants
and nurses throughout the country. Dr. Jones begins by saying that
the proper training of asylum nurses (male and female) was only
seriously begun within the last twenty years; but the fact is that
twenty-four years have now elapsed since the methods were formulated
and the first edition of the hand-book of the Association was prepared.
Dr. W. A. F. Browne, early in the forties, directed attention to the
subject, and gave lectures in the Montrose and Dumfries Royal
Asylums; but it was not until Dr. Clouston revived the question, and
until Dr. Campbell Clarke took it up, that general consent was attained.
We could have wished that Dr. Jones, in conclusion, had said that
mental nursing is pre-eminently suitable to able and conscientious men
as well as women. The conscientious and devoted work done by
attendants deserves equal recognition, and Dr. Jones addresses his
book to both sexes.

We may regard the work as an expansion of, and a commentary on,
the official hand-book, which is now undergoing revision. It has the
merit of the personal note, instruction given by a physician of long and
wide experience, devoted to the improvement of the condition of the
insane and all that familiar phrase means. The first part of the book
constitutes the anatomical and physiological groundwork upon which
the professional knowledge of the nursing staff must be based. It
labours under the common disadvantage of having to convey highly
technical facts and inferences in words which must present difficulties
in due appreciation, but it is apparent that Dr. Jones has constantly
kept these difficulties in mind and has performed his task effectively.
Three chapters are devoted to the psychological analysis of normal and
abnormal individuals, and conclude with a simple classification of
insanity which will enable the nurse to arrange her ideas in a practical
way. We believe that the preliminary information leads up to the
special work of nursing clearly, and that nurses will value the book on
that account. It is strange that examiners so seldom require of nurses
an intelligible account of their observations on certain well-marked
cases of mental disorder. Nothing is better calculated to arrange their
ideas than practice in the reporting of cases as they have come under
personal knowledge.

The remaining fifteen chapters constitute the larger part of the
work, dealing with the management of the insane, therapeutical
measures, complications of maladies, emergencies, etc.

We heartily commend Dr. Jones* Mental and Sick Nursing as suit¬
able for teachers and taught.

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395

Manual for Nurses in Hospitals for Mental Diseases [Manuel des
Gardes-Malades dans les Hopitaux pour Maladies Mentales\ By
Dr. Jules Morel, Medical Director of the State Lunatic Asylum,
Mons. Bruges: Houdmont Boivin et Fils 1907. Price 2 s.

In an interesting preface Dr. Morel directs attention to the progress
of mental nursing during thirty years. He notes the unanimity of
alienists in regard to the increasing worth and quality of those who
devote themselves to this work. The value of the asylum nursing staff
has not only been increased by organised lectures of a practical and
theoretical nature, but the better quality of the nursing staff is reflected
in the greater tranquility and happiness of the patients. Dr. Morel is
hopeful that the example of foreign countries and the attention that
they devote to mental nursing may result in the Belgian asylum
authorities rivalling their zeal. It is to this end that he has responded
to repeated requests and issued his most practical manual.

While mainly concerned with nursing, the manual appeals to a wider
circle, in that it contains many practical hints on the construction and
furnishing of asylums, and the treatment of the insane. The several
subjects are dealt with in a concise and lively manner. The one
chapter in the book that may be taken exception to is that on the
anatomy and physiology of the body. These important subjects are,
perhaps, treated in a somewhat elementary manner. A useful chapter
on the primary principles of hygiene to some extent supplies the
deficiency complained of, as it includes the wide range of ventilation,
lighting, heating, food, and clothing. The instructions under the head¬
ing, “Care to be given to the Sick,” are full and to the point. In this
chapter Dr. Morel has no objection to light-smelling plants or bouquets
in the sick-room, but objects to the presence of cage-birds, dogs and
cats. Dr. Morel is very happy in his treatment and care of the insane.
Many useful and valuable points are dealt with, and no subject of
importance has escaped his attention. The manual is well printed. It
is written in a charming and lucid manner, and may be confidently
recommended as a book of value to all interested in the nursing of the
insane.

[We regret to hear that the Church has issued an order that no
attendant shall read such a book, and in consequence Dr. Morel has
involved himself in very considerable expense. We have searched in
vain for any ostensible reason for this unwarrantable obscurantism, but
the clerical mind works in its own grooves now as ever. Our sympathy
is entirely with our distinguished colleague, and we hope that our
readers will hasten to acquire copies of the manual and thus relieve
Dr. Morel of some part of his pressing obligations.]

The History of the Bethel Hospital at Norwich, built by Mrs. Mary
Chapmanin 1713. Commenced by Sir Frederick Bateman and
completed by Walter Rye. Norwich, 1906. Fo. Illustrated.

By degrees the older asylums are finding historians to gather up the
records and set them forth in readable monographs. This handsome
LIV. 28

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volume, beautifully illustrated, is, in some measure, a memento of that
beloved physician, the late Sir Frederick Bateman. His scanty leisure
and his lamented decease did not permit him to complete the labour of
love which he had undertaken; and it is well that Mr. Rye was found
willing to continue and conclude the work of preparation and publication.

The History is prefaced by an account of the site, the foundress, and
her family. The lives of the Trustees and Governors, among which are
many notable names, and details of interest regarding the property
follow; and an appendix concerning the riot of 1648 is of special interest

Mrs. Mary Chapman, whose father was Sheriff and Mayor of
Norwich, was moved to build the hospital in 1712, at a cost of ^314.
The purpose she had in mind was to relieve the poorer class of insane
persons, because some of her nearest kindred were so afflicted, and she
clearly restricted the operations of the charity to those who, not being
idiots, were such as had local claims. It is to be noted that Mrs. Chapman
instructed that it should remain a private trust, and that the Court of
Chancery decided that the hospital was for cure, not for care. This early
recognition of the vital purpose of a hospital is somewhat extraordinary,
for under the Rules of 1728 a certificate must be granted by the
physician that each insane person is fit for admission.

The hospital has received many benefactions, the first dating from
1729, and by the generosity of many supporters it was enlarged in
1763. Since then the minutes show various improvements, and the
photographs with which the book is adorned show the present condition
of the institution. Certain entries are of interest, e.g., in 1756 the
master retired on a pension of £20 a year; in 1832 the Board was
impressed with the necessity of more effective nursing at night; and
increased attention was given to sanitary requirements in 1851.

The Building Agreement of 1712 is reproduced in its quaint and
exact phraseology—a happy thought! We are glad to note that a grate¬
ful patient, who received much Christian kindness from the officials
and nurses, suggested that the tomb of the foundress should be
renovated. This was carried out at the Governors* expense.

Degeneration in Families: Observations in a Lunatic Asylum . By
Fr. Lange, M.D., Middelfart, Denmark. Trans, by C. Chr.
Sonne. London: Kimpton, 1907. 8vo. Price 35. 6 d. net.

This is a book of many repetitions and strange psychological ideas.
The translation is marked by an uneasy style and irritating solecisms.
The very title, insisting on lunacy , repels the reader, and the main
thesis of the work is unnecessarily depressing. These asylum records
constitute a part only of the question of degeneration; they are culled
from the wreckage of humanity, and they do not show the opposite side
of the shield—the regeneration of families by the introduction of pre¬
potent fresh blood. No adequate deductions can be drawn from the
exclusive study of the insane, of the tubercular, of the cancerous. We
require the records of families taken at random from the general popu¬
lation, with special reference to the normal persons as well as the
abnormal. No doubt a failure of the nervous system repeated genera-

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1908.]

tion after generation issues in decay and obliteration of the unhealthy
stock, but there are also sporadic cases of insanity in a renascent stock.
What would be the condition of the civilised world if the author should,
unhappily, prove to be correct in his idea that a family only needs four
generations from its flourishing climax to dissolve, collapse, and die
out ? The integrity of the great middle-class of this country would be
menaced, the House of Lords would be promptly disbanded, and the
constant recruiting of the haves from the ranks of the have-nots
would come to an untimely end.

Nature, too, as usual in writings of this class, comes in for reproba¬
tion—“ Indeed, no mercy is to be hoped for from Nature.” Are the
reparative powers of nature on the wane because of these morbid
psychological studies ? Even in asylums we can discern these repara¬
tive attempts by methods familiar to the physician, and our hope lies
in so guiding those attempts that we may attain to a greater success in
psychiatry.

Dr. Lange recognises the frequency of lues, scrofula, phthisis, and
cancer among insane families, but fails to see any light in the relation¬
ship. Can it be that the clinical work and the laboratory records
referring to toxines have been overlooked ? He discusses groups of
cases relative to epilepsy, apart from its pathology; to “ potationary
inheritance” (yet another polite equivoque for drunkenness), and to
the “ aristocracy of mental diseases—the great families ”—which would
seem to be the dreary remainder. This remainder is marked by
“ uratic degeneration.” It does not seem worth while to pursue the
study of these oddly selected groups, even to elucidate what is meant
by rectilinear brainwork, and the solid and reliable working of the
brain. If our readers desire to follow Dr. Lange through his indis¬
putable facts, his “psychiatric radicals,” he may search further to
recognise (1) the restriction which is the cause of melancholy, (2) the
flight of mania, (3) the debilitation of confusion, (4) the erroneous
conceit as the centre of insanity, and (5) the coercive conceit which is
final. But he will not find these conceits without stringent labour, for,
of course, there is no index and no schematic system of chapters.

JDc rAbsolut Nicessiti de PAssistance des Enfants anormaux et de ses
Risultals au Point de Vue social . Par Maurice Royer. Paris,
1907. Octavo, pp. 150.

This little treatise is introduced by a preface by Dr. Bourneville, who
is now retired from his service at the Bicetre, though he still continues
to be physician of the Fondation Valine. After a short description of
the degrees of mental weakness from birth, Dr. Royer bestows a well-
deserved tribute to the philanthropic labours of Edward Seguin in the
education of idiots, which he began in 1837 and carried on for a year
at the Bic&tre (1842). In 1851 he transferred his activity and great
teaching powers to America; he died at New York in 1880.

While Seguin was premier des premiers in the education of abnormal
children, the second place in France is assigned to Bourneville. This
distinguished physician and journalist, by his unrivalled energy has

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restored and upheld the school for idiots at the Bicgtre, and given to
the world a long series of researches made by himself and his internes,
which have thrown so much light upon the pathology and treatment of
idiocy, epilepsy, and other nervous disorders of children. Bourneville
has published twenty-five tomes on these subjects, besides numerous
reports to different councils and contributions to medical journals.

Dr. Royer explains the methods of training pursued by Bourneville
and the results obtained. This chapter is illustrated by forty-one wood-
cuts, which show the ingenious apparatus for the instruction of imbecile
children and the gymnastic exercises used at the Bicfctre.

In the next chapter the author pleads with force and eloquence on
the duty of the State to take the charge of abnormal children who require
to be educated at special establishments. Dr. Royer details the present
state of the assistance of these unfortunates in France and other countries.
It appears that Dr. Royer is no student of foreign literature; in the
bibliography which he gives, filling five pages, only one work in English
is mentioned; but, indeed, France has done so much in this department
that she has little need to seek aid from foreign countries. The author
gives a report of fourteen cases to illustrate the improvement which
sometimes attends careful medical and educative training. Some of
these are unusually favourable. The story of Henriette Vel might almost
do for a magazine. Deserted by her mother when fifteen months old,
this child was sent to the Fondation Valine when eight years old, reported
to be affected with pronounced imbecility accompanied by epilepsy.

She was treated with hydrotherapy and bromide of camphor, under
which the attacks of epileptic vertigo disappeared. At the age of eigh¬
teen she went to work in a shop where there was a restaurant, and, as we
are told, a young labourer, who took his meals there, was attracted by
her appearance and did not hesitate to ask her in marriage, and persisted
in his project although warned by the girl of her situation and former
complaint. We are then told in feeling language how she worked and
saved that their little house might be furnished ; she quitted the Fonda¬
tion the day of her marriage, went alone to the maire of Montreuil where
her fianck and the witnesses awaited her. The Sunday after the marriage
Henriette came with her husband to thank the good women of the
Fondation who had been so kind to her. She continued to be regular
and industrious, and the pair are said to be quite happy. In several of
the other cases reported we are told that the matter ends with marriage
and maternity.

Dr. Royer’s book is written with a pleasing enthusiasm and that clear¬
ness and preciseness of expression which generally characterises the
writings of French scientific writers. William W. Ireland.

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Part III.—Epitome.

Progress of Psychiatry in 1907.

AMERICA.

By Dr. William McDonald, Jun.

During the year which has recently come to a close, much his
happened which might well receive mention in a resume of the
psychiatric work in America, and many events would bear close scrutiny
and study as sign-posts of the trend of this modern branch of medicine.
The space, however, is too limited to permit even a complete catalogu¬
ing of important occurrences, much less a satisfactory analysis. We
are permitted to touch only here and there upon the more obtrusive
points in the year’s history.

Recent reports indicate that Christian Science, spiritualism, and other
pseudo-sciences have gained a foothold in Germany, in France, and
other countries. Americans are accustomed to regard their more
conservative English brethren as immune from the ravages of any such
fanatical epidemic as has emanated from the teachings of Mother Eddy.
We admire the Englishman’s stability and his resistance against the
attacks of such energetic propagandists. With great interest, however,
are we awaiting his response to the subtle and insidious advances of
certain theories which, though on an infinitely higher plane than
Christian Science teachings, have awakened in America a powerful
movement toward the mental treatment of mental disorder, a movement
which has been stigmatised somewhat hastily and unjustly as the
u Mother-Eddyism of medicine.”

Boston, jocularly known as the “ hub of the universe,” has long been
notorious for its uncritical acceptance of, and wild enthusiam over, the
so-called cults. To one bom and bred under another influence than
that of the blue stocking, in an atmosphere unsoftened by the effluence
of Browning and unenriched by the savory emanations of the baked
bean pot, there is no way of comprehending the animus which builds,
almost over-night, to “ Mother Eddy , Christ, and John the Baptist,”
that beautiful million-dollar “Church of Christ - Scientist,” or its
predecessor, the old “ Mother Church ” with its stained glass window
entitled “The Woman God Crowned,” representing the woman of
the apocalypse clothed in the sun and crowned with twelve stars. The
uninitiated, wending his infidel way among the streets of Boston’s con¬
servative Back Bay, views with amazement the multitude of prosperous-
appearing establishments flaunting in highly polished brazen letters
such proclamations as, Christian Science Reading Rooms , Library of
Spiritualistic Literature , Clairvoyant Parlors; Bombasti y Hindu
Astrologer; Dr. Squeezer , Osteopathist; A. Skinner , Professor of
Palmistry; Madame Faker , Cheirographer; Madame Dreamer , Spiri¬
tualistic Medium. What may be the portent of the existence of this

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EPITOME.

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thriving colony of pseudo-science pushing its way into the very heart of
a highly cultured city, and, apparently wholly unconscious of any in¬
congruity, seating itself on the very hearthstone of learning, next to one
of the greatest medical schools in the world, under the very doors of a
magnificient public library, among beautiful churches, and between the
doors of world-renowned physicians, scholars, musicians and artists?
Is there to be found any causative relation between the impudent
assurance of such proselytism and the present enthusiasm among
Boston’s physicians, clergymen, and laymen over the principles of
psycho-therapy ? Unquestionably the last query must be answered in
the affirmative, though the analysis of the relationship is difficult, since
the connection is not by one bond but by many.

It would be unfair to hold Boston alone responsible for all that to
which the names psycho-analysis and psycho-therapy have been applied,
since many other communities have taken up the movement and the
whole country has exhibited deep interest. It was merely for Boston
to take the initiative, and Boston did so simply because Boston is Boston,
and because there is something in its inhabitants—perhaps inherited
from fanatic Puritan forefathers—which prompts them, in the eager
search for truth, self-cultivation, and self-betterment, to seize upon any
newer doctrine so long only as it extends at least a promise of the fulfil¬
ment of yearnings for higher things. Thus Christian Science and other
pseudo-sciences naturally found a rich soil in common with these later
doctrines of mental therapy, which it is to be hoped are but the begin¬
nings of a real science of mental healing.

But there is even a closer relation between the pseudo mental science
and this new alleged legitimate offspring of psychiatry. If we are just
in our estimate of Christian Science as it is to-day, we must admit that,
despite the blasphemous pretensions of Mrs. Eddy, her church has won
a large number of adherents, many of whom seem to be sober and
rather reasonable beings, who lay stress, not so much upon the body¬
healing powers of the “ science,” as upon those elements of the teach¬
ings which tend to develop and encourage cheerfulness, contentment,
and healthfulness of mind. Indeed, there is universal testimony to the
effect that the followers have, as a rule, an appearance of quiet happi¬
ness, while their meetings and religious services are characterised by a
minimum of that sombreness and morbid melancholy which too often
rests like a pall over religious congregations. Other churches observing
the alarming falling-off in religious attendance, viewing sadly their own
empty pews, while the neighbouring Christian Scientist teachers address
full houses, are prompted to ask if, after all, these may not have found
something new, appealing forcibly to the heart and mind of weary,
discontented man. At any rate the instinct of self-preservation forces
them to look to their guns lest prompt annihilation be their fate.
Herein may be found one of the factors responsible for the present
activity of the clergy in “ mental therapeutics,” and, indeed, it has been
suggested that the medical profession itself is not entirely unselfish in
its suddenly aroused interest on this subject. As expressed by a
speaker at a recent psychiatric meeting, “ there can be no question of
the influence of conscious thought upon bodily health, or vice-versd; the
physician has been so busy with his drugs, the surgeon so much occu-

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1908.]

pied with his knife, that the importance of correct thinking, on the part
of the patient, has been neglected by the profession. Others, however,
have recognised the value of developing healthy mental control, and
we to-day are faced with the question, ‘ Shall we, as physicians, claim
the field of mental therapeutics, or shall we abandon it to the church,
to the charlatan, and the quack ?’ ” In other words, it is a question
concerning the daily bread and butter of the physician.

That the church, with a beginning realisation of the loss of its hold
upon men, is showing a desire once more to get in touch with them,
and is seeking to supply something for which humanity is crying aloud,
is revealed by the activity of Emmanuel Church, Boston. Surely you
across the sea have heard of this work. Even so you may be impelled
to ask, as was one of the foremost of New York’s practical neurologists,
in attendance at a recent joint meeting of New York, Philadelphia,
Baltimore, and Washington neurologists and psychiatrists, with the
Boston Society of Psychiatry and Neurology : “Tell us exactly what you
do at the Emmanuel Church, for we cannot pick up a scientific
periodical but has some reference to the work in Emmanuel
Church, while the lay journals—at least those printed east of the
Hudson River—Heaven knows they contain little else but reference to
psycho-therapeutics in Emmanuel Church, Boston.” A similar interro¬
gation was put by Dr. John K. Mitchell, of Philadelphia, who said:
“ Are you sure you have not given a new name to an old practice ?
The word psycho-therapeutics may not appear in the Index Medicus ,
but we have all used the principles for years, and our fathers used
them before us. In fact, psycho-therapeutics has been practised, to
be conservative, since the time of the Pharaohs. What is there that
is new in your treatment of patients ? What do you do at Emmanuel
Church ? ”

Whether they have heard of Emmanual Church or not, your readers
may find, if interested, in the Century Magazine for March, 1908, a
concise and well-written account under the title Christianity and Healthy
an Experiment in Practical Religion , by the Rev. Samuel McComb , D.D.,
who also bears the title Associate Director of Class for the Moral Treat¬
ment of Nervous Disorders, Emmanuel Church , Boston.

Those who are familiar with the commendable work of Pierre Janet,
Morton Prince, and the psycho-analytic method of Jung and others,
may guess correctly as to the character of the work at Emmanuel
Church after reading the headings of the chapters of the above-
mentioned article, which are: Suggestion , Subconsciousness , Faith ,
Prayer. To convey some notion of the work done it is only necessary
to add that there is a church clinic , to give a single testimonial as to the
experience of a patient, and to quote a few sentences from Dr.
McComb’s article. The quotation is as follows: “Along the lines
above indicated an interesting and, it is believed, fruitful experiment
has been going on in connection with Emmanuel Church, Boston.
The Church is Protestant Episcopal, but the work it is seeking to do
is human and universal, knowing no distinction of creed or social
station. This effort may be described as an attempt to weld into
friendly alliance the most progressive neurological knowledge of the
schools and a primitive New Testament Christianity as scholarship has

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[April,

disclosed it, with a view to the relief of human suffering and the trans~
formation of human character.”

The testimonial is : “ F. is a woman who had suffered a long
period from neurasthenia and melancholia. For nine months she
knew no sleep without drugs. Much against her will she was induced
to attend one of our meetings for nervous patients. She was greatly
interested and impressed; that night she took no narcotic, and slept
seven hours. In three weeks or so she obtained normal sleep, and
though since then she has been exposed to great mental stress, she
has gained thirty pounds in weight, and feels, as she expresses it y
* Ten years younger/ ”

In the February Outlook is an article by Richard C. Cabot, M.D.,
of Boston, giving a more detailed account of the work at Emmanuel v
Church. It appears that Dr. Worcester, Director, has studied
psychology under Wundt, in Germany, and taught it for six years at
Lehigh University. Dr. McComb, his associate, has also studied
psychology at Oxford, and has had special opportunities for acquaint*
ing himself with abnormal psychology. Evidently, then, the patients
treated at Emmanuel Church have unusual opportunities to obtain
intelligent advice. It is questionable if the amount of good, which Dr.
Cabot believes has been accomplished in the clinics of Dr. Worcester
and Dr. McComb, would be accomplished in other churches, of which
the majority of pastors have no special knowledge of either normal or
morbid psychology. Nevertheless, Dr. Cabot’s belief in the import¬
ance of religion—using the term as he has qualified it—in the cure of
disease, is based upon sound reasoning, and the success of the work at
Emmanuel Church is explained by the employment of a rare combina¬
tion of religious spirit with scientific knowledge and skill under the
direction of Dr. Worcester. In order to demonstrate the rationality of
Dr. Cabot’s contentions a paragraph or two from his article are worth
quoting in full:

“ Because I believe, then, that all explanation, all encouragement, all
education which ignores religion is, for that reason, slipshod and
slovenly, I believe that patients whose physical ills can be mitigated
through explanation, encouragement, and education need the help of
someone to whom religion is a working reality.

“ Using the word religion, as I have done in the inclusive sense, not
as one activity or one interest among others, but as the foundation and
motive power of all interests and activities, I should say that the most
religious persons, in my acquaintance, are the educators and the social
workers. Were they free to take up the work of psycho-therapeutics r
I believe they would be better fitted for it than either the ministers or
the doctors, but since this is impracticable, and since the great majority
of the medical profession still incline to behave as if religion were a
special more or less harmless interest like a taste for old china, the help
of the right kind of minister should be welcomed by all physicians who
have at heart the bettering of the conditions of mental and nervous
health in the community at large.”

It is difficult to convey in a few words any adequate conception of
the enthusiasm which has been aroused in this country over the subject
of psycho-therapeutics. Not only have medical societies busied them-

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PROGRESS OF PSYCHIATRY.

403

selves quite universally with the topic, but many churches and societies*
the daily papers, and miscellaneous periodicals have taken up the cry.
An attempt has been made to establish clinics in New York and other
cities. The press is full of reports of the work, and many neurologists
and psychiatrists have expressed themselves in lay and scientific journals
as being entirely in sympathy with the effort. Moreover, a number of
prominent physicians have been writing in the lay magazines articles
intended to instruct the public concerning the nature of obsession*
phobia, and other morbid mental phenomena.

With full recognition of the good which unquestionably has already
been, and is still to be, accomplished by such labours, one must also be
cognisant of possible harm which, through ignorance or carelessness,
may follow this well-meant expenditure of energy. One result of all
this activity in psycho-therapeutics in the medical profession, with the
clergy and among laymen, has been the production of a perfect whirlwind
of carelessly-used terminology. Such words as auto-suggestion , hetero-
suggestion, synthesis , dys-synthesis, sub-consciousness , mental automatism>
multiple personality , and similar high-sounding terms from the mouths
of the untutored at times amuse, but more olten distress the students
who realise their uncertain significance. They who have in times past
thrown themselves with all the energy and tact at their disposal into the
mysteries of psycho-therapeutics, occasionally, it is true, with success in
the treatment of the patient, though often experiencing chagrin at the
futility of their efforts, are standing dumbly, almost benumbed, with
eyes anxiously strained toward the future, watching for the outcome of
all this indiscriminate education of the populace concerning unhealthy
states of mind, the nature, cause, and cure of which are, for even the
leaders in psychiatric thought, as yet debated and uncertain quantities.
We wonder especially and with fearsome misgivings, concerning the
effect of such suggestion and hetero-suggestion upon minds heretofore
healthy and unburdened.

Last year your correspondent had much to say concerning the Thaw
case, which then occupied the centre of the stage here and had aroused
some attention in foreign lands. Personal letters have shown that
British psychiatrists were especially interested. The first trial ended in
a disagreement, an outcome which had been quite generally prophesied
as the inevitable consequence of the vast amount of confusing and con¬
tradictory so-called expert medical opinion presented to the jury. The
cost to the State and the accused was enormous, and the whole trial
was a disgrace to legal procedure and a shame to medicine. The
second trial, lately finished, formed a pleasing contrast with the first.
It was conducted with dignity, and there was little prostitution of expert
medical testimony to the disgusting solicitations of Mammon. The
jury brought in a verdict of “ not guilty by reason of insanity,” and the
patient was promptly committed to the State Hospital at Matteawan,
where, it is to be hoped, he may remain so long as he is in need of care
and restraint, and until public opinion would no longer be outraged by
his release.

A significant, almost startling, phenomenon in connection with the
second Thaw trial was the facile introduction of foreign witnesses.
English and French testimony was imported for the occasion, and

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EPITOME.

[April,

stepped from the steamer into the court-house with a timeliness and
punctuality really marvellous. Truly the oceans are daily growing
smaller ; the inhabitants of the world are becoming citizens of one great
community, neighbours on one side or the other of a narrow street.
And we, whose everyday business is psychiatry, are we touching elbows
on terms of sufficient intimacy? When our respective bodies politic
and bodies social shall have fully established their bonds of common
sympathy and fellowship, let us not be found with discordant psychiatric
theories or dissimilar practice. In the interests of universal peace and
harmony, as well as for the dissemination of news of common interest,
the publication yearly in the Journal of Mental Science of an epitome
of foreign psychiatric progress is a step in the right direction. But
there should be more frequent correspondence; there should be
a greater number of corresponding members to respective national
societies ; delegates to national conferences should be more regular in
attendance, and international convocation should be of more frequent
occurrence.

That perhaps after all some good may result even from such an
unfortunate affair as the Thaw trial is suggested by the sudden accession
of interest which medical jurisprudence has received as an apparent
direct outcome of discussion concerning the state of Thaw’s mind
before, during, and after the homicide, and as to his responsibility for
the crime.

For a year or two preceding the trial there had already been an
awakening of interest in affairs medico-legal, but during the last year
not only have the old-established psychiatric and neurological societies
devoted more of their programmes to debate upon criminal responsi¬
bility, but in addition new societies, composed of both jurists and
physicians, have been formed in many cities, and the proceedings of
these bodies, reported in both lay and professional journals, have
aroused widespread interest and attention. Not only is the public
thereby receiving much-needed education, but, better still, judges and
lawyers are waking from the lethargy of self-satisfaction and self-
sufficiency which has long characterised their attitude toward the
medical aspects of crime. They are realising more fully that the law
has not spoken the last word concerning the criteria of responsibility,
or as to the most just and wise disposition to be made of those whose
misdeeds are partly or entirely the result of inherited and acquired
abnormal mentality. While there is a growing distrust of those pro¬
fessional witnesses whose methods have so often smacked of char¬
latanism, or at least of questionable morality, there is on the other hand
strong evidence of a longing for competent and reliable medical advice.
The indications are that the near future will see in America a re¬
organisation of the law and of court procedure in relation to medical
evidence, with a resulting gain in both the cleanness and utility of the
testimony.

But however great may be the import of recent attention to the relations
of insanity and crime, still more significant is the earnest consideration
of crime itself, apart from its purely medical aspects. Whoever has
followed the trend of events must have noted the evidences of an
increasing solicitude for matters penological, a concern which, though

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PROGRESS OF PSYCHIATRY.

405

it, strictly speaking, belongs outside of the realm of medicine, has
received its momentum through channels leading directly from
psychiatric study. More and more is society becoming cognisant of
the sinful waste of human energy going on behind our prison walls.
Methods of correction, and especially the probation of first offenders,
have given results so brilliant as to command instant notice and a
prompt withdrawal of endeavour from the punishment of crime to its
cure.

During the year we have been startled by the appearance in the
daily papers of certain wonderful, complete, and permanent cures of
dementia praecox following extirpation of the thyroid gland. On
inquiry, however, it was found that these reports emanated from an
over-enthusiastic and somewhat misguided assistant at a hospital in Balti¬
more where experiments had been conducted in the hope of finding
some relief for this distressing condition. The physician-in-chief of
that hospital states that the reports are greatly exaggerated, and that
his assistants had all been pledged to secrecy until trustworthy data
could be announced. The April number of the American Journal of
Insanity will contain a letter giving the real facts.

We note with regret the retirement of Dr. Clouston from active
service. No British alienist enjoys a higher esteem in the United
States; none has done more for British psychiatry, It is to be hoped
that he may have before him many years of scientific usefulness, and
that his retiring pension will be commensurate with his distinction and
the quality of the service that he has rendered the cause of mental
medicine, and, indeed, humanity itself. It is always gratifying to
American alienists to hear that their British brethren, better off in this
respect than themselves, since the system of pensioning is not in vogue
in the United States, have been rewarded in this manner. The only
institution in this country to adopt an age limit and prescribe a pension
scheme for its medical officers is the MacLean Hospital at Waverley,
Mass., which is the department for mental diseases of the Massachusetts
General Hospital. Our distinguished colleague, Dr. Cowles, an
honorary member of your society, is the first beneficiary of this new
departure.

BELGIUM.

By Dr. Jules Morel.

The year 1907 will be remembered in the psychiatric annals of
Belgium.

The struggle undertaken by the Society of Mental Medicine in 1893
for the organisation of professional education for asylums was absolutely
sterile. While I was asking for methodical teaching in the barrack
asylums in order to have more rational observation and examination of the
patients, Dr. Peeters, who was more independent by reason of his posi¬
tion, commenced professional instruction among the attendants at the
Gheel colony. I^ter, he was ably assisted by Dr. Meens, attached also to
the colony at Gheel. A certain number of the members of the Society o

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EPITOME.

[April,

Mental Medicine maintained that individual instruction of the nurses by
the physician was more profitable ; they feared that professional know¬
ledge would result in a state of semi-education, which would soon be for¬
gotten and not be to the credit of the teacher. Asylum physicians were
certainly ignorant of the manuals of instruction published in England,
Germany, Italy, France, and the United States, otherwise they would have
known at once that professional knowledge makes the attendants more
intelligent, more capable of understanding their proper place as regards
treatment, and more capable of appreciating medical care.

However, in 1895 Society of Mental Medicine decided to make
a trial, and MM. Peeters and Morel were directed to study the question
more fully. Finally, the Society expressed the desire that such special
instruction should be established everywhere.

Notwithstanding this happy decision, and in spite of the recommen¬
dation made to follow the plan laid down in the Manual of the Medico-
Psychological Association of Great Britain, we felt that the new Belgian
manual would not meet with that recognition hoped for by those who
placed themselves at the disposal of the Society of Mental Medicine for
its compilation. A circular was sent round to all the directors and
physicians of the asylums asking them to subscribe to the projected
work. The answers were not long in coming, and only a total of forty-
three books were asked for. As a result the manual was not published.

Since then there has been a great change. Holland, Germany,
Austria, Italy, England, and the United States of America have seen
the birth of numerous manuals and publications devoted to the treat¬
ment of the insane.

At the International Congress on the Care of the Insane, held at Anvers
in 1902, Dr. Van Deventer proposed that—“ It is important that the staff
to which is confided the care of the insane should receive professional
instruction, both practical and theoretical. This instruction ought to
be given by the medical staff of the asylum upon whom falls the super¬
vision and control of treatment.” This recommendation was adopted
unanimously. Following this event two excellent works appeared, one by
Dr. Meens, of Gheel, on The Professional Education of Nurses, and one
by Dr. Van Deventer on The Education of the Nursing Staff in the
Netherland Asylums. It is a curious fact to note that not one of those
who had formerly opposed the professional instruction of asylum
attendants have now a word to say against it. We should be able
to reply that the success obtained in other countries has been such that
not only, for example, in Holland, have 800 nursing diplomas been
already given, and in Great Britain 8,900, but also that in many countries
the results were such that the duration of study has been extended to
three years. A point worthy of our attention and which we suppose ta
be the motive of those who have for so long opposed us on this question
is found in a passage from Dr. Van Deventer's book, which is: “ Dr.
Robberten, Physician to the Asylum of Rosmalen (Condesvater), where
the nursing is in the hands of a religious (Roman Catholic) corpora¬
tion, made it known that the nuns of the Asylums of Bois-le-Duc, Yuckt,
and of Rosmalen could not take part in the examinations organised by
the Society of Psychiatry, the Bishop of Gams not having given his
consent/’

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PROGRESS OF PSYCHIATRY.

407

f908.]

In the meantime, ideas have progressed, convictions have become
facts, and the advantages of professional instruction have found favour
in the eyes of the authorities. Impelled by conscious need, schools for
the training of nurses and attendants have been raised at the three
comers of Belgium, and finally the religious authorities have given
them their high protection. Concerning asylums two manuals are
published; one, in the Flemish language, for the special use of the
Freres de la Charitfe (we do not understand why it is limited to this
religious congregation, it is not to be bought in the open market); the
other by Dr. Morel, is entitled,^ Manual for Nurses in Mental Hospitals .
The author suppresses the word “ asylum ” and treats of “ lunatics ”
as hospital patients. In his introduction he says : “ Mental diseases are
diseases of the brain, which, again, are fused with other diseases, etc. 19

The medical service in a hospital for the insane ought to be organised
in such a manner that each nurse should be. able to intervene usefully
in case of need in giving help to the sick. It is necessary that the
probationers should first have some idea of common illnesses and
certain fundamental principles of hygiene before attempting to study
the treatment of the insane. But it is not sufficient to be acquainted
with the books indispensable to the instruction of nurses. It is necessary
also that theoretical and practical instruction should be given by the
asylum physicians, who ought to be in touch with each individual pro¬
bationer so as to acquire a knowledge of their physical and moral
suitability, and who should be consulted in order to draw attention to
such of them who do not possess those attributes essential to a good
nurse. Those who fail in these respects ought not to be presented to the
examiner and receive diplomas.

It is a matter of much doubt if, in Belgium, there will be accorded
to asylum physicians sufficient power to make a proper choice of those
anxious to become nurses or attendants. Their position is not equal
to that which obtains in the greater part of the world’s asylums.
Although professional teaching is to be given at some of the asylums,
we have not yet arrived at the point as to whether examinations will
be organised definitely, or what will be the authority charged with the
formation of examining boards.

FRANCE.

By Dr. Ren£ Semelaigne.

A new lunacy law .—A new law of lunacy has been recently voted by
the Chambre des Diputls t and is now being considered by a committee
of the Sinat .

One of its provisions is that of transferring the powers of detention
from the administrative to the judicial authority. At the present time
when a relative wishes a patient to be received into a public or private
asylum he has to present to the superintendent (1) a petition made and
signed by himself; (2) a medical certificate written on stamped paper;
(3) an official certificate of birth or any other paper identifying the
alleged insane patient. The superintendent must send, within twenty-

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EPITOME.

[April,

four hours of reception, a certificate to the Prlfet de Police in Paris, or
to the Prlfet du Dlpartement in other parts of France. That officer of
the Government directs a medical inspector to visit the alleged insane
person. A fortnight after the reception, the superintendent sends a new
certificate.

According to the new law, the procedure will be: (i) a petition of a
relative,which has to be countersigned by the Juge de Paix, the Maire f
or the Commissaire de Police \ in cases of urgency such visa is required
not more than forty-eight hours after reception; (2) a report to the
Procureur de la Ripublique , made and signed by a medical practitioner
and duly authenticated, containing all particulars and especially the date
of the last visit (not more than seven clear days before the reception,
instead of a fortnight as now), the symptoms and facts daily observed
which constitute evidence of insanity, and a statement that the patient
has to be placed under care and treatment in an asylum; (3) a paper
duly identifying the person.

Such reception being provisional, the alleged insane person is placed in
a special ward and remains subject to strict observation. The super¬
intendent has to send, within twenty-four hours, a report (1) to the
Prlfet of the Dipartement in which the asylum is situated; (2) to the
Procureur de la Ripublique of the Arrondissement where the patient
resides; (3) to the Procureur de la Ripublique of the Arrondissement
where the asylum is situated. Within the three days, the Prlfet directs
a medical inspector to visit the alleged lunatic. The medical
inspector immediately presents a report to the Prlfet and to the
Procureur de la Ripublique. The superintendent sends, a fortnight
after the reception, to the two above-mentioned agents of the Govern¬
ment, a report on the state of the patient.

Following these formalities, the Procureur de la Ripublique writes his
requisition, which he sends to the President of the Tribunal of the
Arrondissement wherein the establishment is situated, and he adds the
medical report on reception, the medical report of twenty-four hours
and of the fortnight, and the report of the medical inspector
directed by the Prlfet to visit. The President gives an order for
detention or for discharge, but if he has any doubt, if the patient,
or if a relative, or a friend, oppose the detention, in such case
the Tribunal has to be consulted, and there must take place an
immediate investigation in Chambre du Conseil\ or, if not satisfied,
order a further examination by two doctors, one of them being chosen
by the patient or his representative.

An innovation of the present law relates to Frenchmen received in
foreign asylums, or foreigners detained in French establishments. No
one can henceforth be taken abroad in order to be treated as insane
without a previous declaration to the Procureur de la Ripublique,
such declaration being accompanied by a medical report When a
Frenchman, being abroad, is obliged to take steps to place a fellow
countryman in an asylum, he must send, within a month from the
reception, a declaration to the Procureur de la Ripublique of the
residence of the patient in France. The provisions of the law with
respect to the management and administration of the estates of the
insane will be applied to estates situated abroad.

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PROGRESS OF PSYCHIATRY.

409

A foreigner sent to France in order to be placed in an establishment
for the insane may not be received without the presentation of a petition
and a medical certificate, both authenticated in his own country or by
a diplomatic agent of his nation in France. If such papers are not
written in French, a translation will be annexed and certified con¬
formable to the original. Within three days of the notification of the
reception, the Prefet will advise the Government, who will send a notice
of the fact to the diplomatic agent of the country to which the patient
belongs.

A similar notice will be given, within the same time, to the diplo¬
matic agent of the native country of any foreigner, living or travelling
in France, who, for his welfare or for the public safety, has been placed
under care and treatment in an asylum.

The placements £ office or orders of reception, directly given by public
authority ( Prlfet de Police in Paris, Prefet du Dlpartement in the other
parts of France), will be submitted to the approval of the judicial
authority.

According to the rules of the new law, anyone who becomes cog¬
nisant of his own mental disorder may claim to be received in an
asylum, for which purpose he must make and sign a petition, and pro¬
duce a paper testifying his identity, without any medical certificate, but
afterwards he is subjected to the usual proceedings.

Absence on trial, which is now allowed without being legally sanc¬
tioned, will hereafter be registered and granted by the superintendent;
if such absence has to be continued for more than a month, authority
from the Prlfet becomes necessary.

The law, which contains 71 Articles, makes provisions with respect
to the management and administration of the estates of the insane,
also for the detention of criminals and of prisoners becoming
insane, and for care, treatment, visitation, etc. The Sociltl Medico -
Psychologique and the Sociltl de Mldecine Ugale have elected special
committees in order to study the new provisions of the law, to gather
suitable advice, and to report to the committee of the Senat the results
of such inquiry.

Pellagra and Psychosis .—Professor Regis, of Bordeaux, has carefully
studied the actual conditions of pellagra in the Department des Landes ,
which has been for so long a time the principal seat of this disease in
France. During the past fifteen years, pellagra has seemed to disappear.
Professor Regis does not impute the fact to the disuse of maize as a food,
but he believes that it results from proper drainage of the country,
from better hygiene, and from the actual condition of the inhabitants,
who have been enriched by the traffic of resin and wood. The intermittent
fevers, which formerly were frequent, vanished at the same time.

But the families who had suffered remained subsequently more or
less impaired, and sometimes show various stigmata of degeneration,
particularly a bodily or mental weakness, and an especial tendency to
certain psychical disorders.

Professor Regis has recently observed two interesting hereditary cases.
A woman, aet. 25, showed consecutive to puerperal eclampsia a genuine
acute mental confusion ; afterwards a state of katatonic stupor, with all
the signs of early dementia, which finally became chronic. She came

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EPITOME.

[April,

from two families who had suffered from pellagra, and she showed some
peculiarities rather frequent in the offspring of such people, such as
constitutional defects of temper and fancy, a very bad dentition, and a
dull coloration of the skin.

The second case was a girl, set. 21, native of a place where pellagra
had been peculiarly severe. Charged with an infanticide, she was
submitted to a medical investigation, which showed that she was not
insane but had an heredity from pellagra. On her father’s side, her
grandfather had been insane, an aunt had been feeble-minded; another
aunt, equally feeble-minded but pellagrous, had exhibited, when she was
thirty years old, an acute attack of insanity, with a terrifying hallucina¬
tory delirium and a suicidal attempt, and had died of consumption.
Two other aunts had very feeble intellects and unbalanced minds; a
cousin committed suicide; her father was intelligent, but vicious. On
the mother’s side, her grandmother had suffered from pellagra, and had
shown mental symptoms; also suicidal attempt. Her mother was
hysterical.

Professor Regis had recently to attend a female patient suffering from
pellagra with a well-characterised pyschosis. She was a country woman,
aet. 44, who entered the clinical ward for pyschiatry at the Saint Andr£
Hospital at the end of 1906. She was a native of the D'epartemcnt its
Landes , but had left it twenty-eight years previously. She never made
any use of maize as a food. She had been employed in tilling the ground
in the sun for many years, and used to drink freely. She showed a
genuine mental confusion, and during the acute stage presented
repeatedly automatic fugues. Such leaning to fugues was recently
noticed in pellagra. Professor Regis readily supposed that the tendency
to suicide, in such psychosis, has been greatly exaggerated, and that, if
the bodies of many patients suffering from pellagra have been found
in the pools of the Landes , they were the result of accident and were
drowned during an hallucinatory or unconscious vagrancy.

On the disorders of the cerebellum in general paralysis .—Drs. Anglade
and Latreille, of Bordeaux, have examined the cerebellum in nearly all
the general paralytics who died in the asylum of that town for seven
years. Meningitis was usual, but a third of the cases did not present any
other change. The pia was generally thickened, and opalescent in the
middle line, on each side of which the inflammatory processes extend
posteriorly and inferiorly. In such meningitis might be found, not
only conjunctive inflammation, but also an inflammatory reaction
of neuroglia. Meninges and cortical neuroglia simultaneously react.
Only one disease, /. e . the idiocy from meningo-encephalitis, presents
similar changes in the cerebellum.

GERMANY.

By Dr. Johannes Breslxr.

The great difficulty in inducing young physicians to enter asylum
work has led the German Society of Psychiatry to form a committee
for the purpose of looking after the interests of medical officers as

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I908.] PROGRESS OF PSYCHIATRY. 4II

regards pay, promotion, etc. A meeting is to be held, and the papers
read will be published in the Psychiatrische Wochenschrift .

The annual meeting of the same Society was held at Frankfort-on-
Maine in April, 1907. The advisability of alienists being placed at the
head of all institutions for epileptic, feeble-minded and backward
children and reformatories was advocated. Dr. Scioli described the
observation ward which has been established at the asylum at Frank¬
fort for young people with mental trouble. The same alienist gave an
account of the new colony for inebriates, also at Frankfort. The homes
for inebriates used to be under private ownership and management, but
the city of Frankfort was the first to set the example of attaching these
to the asylum. A farm was acquired and put under the same direction
as the latter. From April 1st, 1901, to March 2nd, 1906, 154
inebriates were received, of whom 92 were discharged “ improved,” 44
“ not improved.” One died, and 18 remained. The example of the
city of Frankfort-on-Maine might very well be copied by other munici¬
palities.

The treatment of mental diseases by prolonged bathing has been
undertaken in the ward gardens at the asylum of Dosen, near Leipsig,
and at Gothingen (see reports by Lehmann and Dehiv in Psychia -
trische Wochenschrift , pp. 136 and 414, 1907). The result is said to be
favourable. The boarding out of patients makes good progress. The
city of Leipsig has adopted it by boarding cases from the asylum in the
city itself. The suitable occupation of patients continues to form an
interesting study as a method of treatment.

Starlinger ( loc . at ., p. 53) gives a full description of the “working-
therapy” at the asylum of Mauer-Pehling (Nieder-Oster-reich). There
he formed a clinical working party (three attendants and twelve patients)
for trial of uncertain cases prior to being distributed among the general
working groups.

The After-care Association continues to flourish. The Hiilfsverein
of the Rhine Province (President Dr. Peretti) has 10,685 members,
coming from 280 cities, towns and villages.

The epidemic of religious mania with glossolabie y which appeared
last August and September in Hessen, has probably been reported in
the English newspapers. The psychic phenomena were interpreted by
the more orthodox people and clergy as divine inspiration. Now that
public opinion has repudiated this suggestion another explanation
has been given, which is that the victims were deluded by the devil,
who imitated divine phenomena for the temptation of pious souls (vide
Dr. Fred Jansen in Zeits. for Religious Psychology , No. 8, 1907).

During 1907, we had to lament the death of Professor Mendel, of
Berlin, editor of the Neurologisches Centralblatt, and of Dr. P. F.
Mobius, of Leipsig, a well-known alienist, neurologist, and popular
writer. His numerous pathographic works (on Goethe, Schopenhauer,
Rousseau, Neitzschke, and others) are well known in England, and have
been the prototypes of many others. In his memory, there has been
founded a prize, to be given biennially for the best treatise dealing
with some branch of psychiatry or neurology.

LIV.

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EPITOME.

[April,

ITALY.

By Dr. G. C. Ferrari.

The new lunacy law, which prescribes public competition for all the
medical posts in asylums, has caused a new fervour of serious scientific
work amongst alienists. Such is not without danger, for it is quite pos¬
sible that if they all apply themselves to scientific research the patients
may be a little neglected, whilst they ought to remain the final aim of
alienistic work, but nobody should complain of that which will increase
the culture of the physicians.

A sufficiently good and vigorous sample of this culture has been
given by Italian medical men, above all by the younger ones at the
Congress of the Socidtfc Freniatrica Italiana, which met at Venice at the
end of September last. Different questions were debated and also the
result of the work done in the asylums and the many psychiatrical
clinics.

Amongst the general questions discussed, on the initiative of Drs.
Catola (Firenze) and Pighini (Reggio Emilia), was that of the “ altera¬
tions in the organic metabolism in the psychoses.” The general con¬
clusion was that as regards our actual knowledge of the biological
chemistry and our methods of investigation, we are ignorant as to the
manner our mental processes—normal and pathological—manifest
themselves in the formulas of the organic changes. The widespread
demolitions of the central nervous system induce without doubt a
bradytrophism; but we have not yet demonstrated the same effect in
the histological alterations which accompany the different mental dis¬
eases. It is more probable that these alterations of the metabolism,
which we have met with in the different mental disorders, may be in
consequence of the intoxications which determine also, it would appear,
the histological alterations and the corresponding mental disorder. The
future is probably with the study of the psychoses, due to disorders of
certain organs (thyroid gland for example), and of the cytotoxines and
anti-cytotoxines. But what is wanted above all is a revision of our
methods to render them more rational, true, and scientific.

Dr. Guidi has studied the question of “ the carbamic intoxication in
epilepsy.” It is a long time since this author began to demonstrate that
the epileptic phenomenology is due to the retention in the organism
of epileptics of carbamic acid; indeed, by the subministration of pro¬
gressive doses of this acid he was able to produce an aggravation of
the epileptic phenomena. Salemi (Verona) has tried to examine the
variations in the “elimination of methyl blue in the old people, normal
and insane,” but he has only met with a general relaxation of all the
changes. Muggia (Venice) is, on the contrary, very sceptical regarding
the study of the elimination of methyl blue as an indication of the
rapidity of organic metabolism, because the individual variations are
always very marked. The elimination of the blue and also of chro¬
mogen is not governed by any constant law, and the appearance of the
chromogen proves the existence of a process of reduction of which we
are ignorant of the place of production.

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1908 .] PROGRESS OF PSYCHIATRY. 413

Ziveri (Brescia) has studied “ the liver processes in dementia prsecox,”
and he believes that the hepatic weakness may be in relationship with
the general weakness in these cases.

Cerletti (Rome) showed microscopic preparations demonstrating
special corpuscles around the vessels of the human cerebral cortex and
the mammiferous differences both normal and pathological. The ques¬
tion is regarding little corpuscles which are half-moon, ovoid, and round
in shape, with a glossy or granular surface, and which present here and
there spherical condensations, but in which there is no trace of a nucleus;
whereas if the brain had been hardened in formol there sometimes can
be seen some short processes. These corpuscles are clearly differen¬
tiated from the cells proper to the blood-vessels, from nerve-cells, from
fat-cells and neuroglia-cells, but the author will not advance any hypo¬
thesis at present.

Forli (Rome) has studied the alterations in the brain and cranium
following upon circumscribed lesions of the former. He made a small
trephine in the skull of a kitten and destroyed a small area of the
meninges and brain substance on one side; on the other side he made
a similar trephine, which injured the meninges only, as a control.
Sixty kittens were thus operated upon, and at the autopsies there was
demonstrated an obvious diminution in the cerebral mass. Corres¬
ponding to the diminution of one side of the cerebrum was always found
imperfect development of the cerebral peduncle and of the corresponding
half of the pons, while the cerebellum showed no diminution. Corres¬
ponding to this hemiatrophyof the cerebrum was found a diminution of the
cranium on the same side, and a poor development of the body generally.
All this, according to the author, is the result of localised destruction of
the cerebrum after birth.

A burning question in these days is that of the nosography of
dementia prsecox of Kraepelin. and the communications on this subject
to the Congress were numerous. Brugia (Bologna) denies that a
psychological examination of precocious dements shows the characters
of true dementia. A great part of that which seems to be destroyed is
merely sleeping. The essential psychological character of dementia
praecox is the separation, the general and complete discontinuity, while
in true dementia there occurs the progressive meaning of the whole
psychic state. From this is derived the want of precision in the term
“ dementia praecox,” which state is not one of dementia, and which is
not necessarily precocious. Clinical experience goes to prove that
there exists an essential paradementia in the three forms described by
Kraepelin, and a form consecutive and symptomatic. Salerni (Venezia)
has endeavoured to see if there was not a difference between simple
neurasthenia and the prodromal neurasthenia in dementia praecox. He
believes that in dementia praecox, in the neurasthenic stage, states of
doubt, so characteristic of ordinary neurasthenia, are absent. This is
readily explained because it is the question of a symptom, the presence
of which supposes the integrity of critical judgment, which disappears
first in dementia praecox. Zanon (Udine) has studied “ the degenera¬
tive characters of dementia praecox.” Two only out of 182 cases
examined presented no degenerative stigmata; the average number
of stigmata does not vaty with the form of dementia, eighteen of

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EPITOME.

414

[Apri',

which appeared with marked frequency as in the constitutional
psychoses.

Another question much discussed at the Congress was the “ relation¬
ship of alcoholism to the neuro-psychopathies.” Different parts of
Italy give different results, because the quality of the drink is very variable,
also the percentage of alcohol present. Statistics on this subject are not to
be relied upon, because authors differ as regards diagnostic criterions from
time to time. Montesano (Roma) states that 79 per cent of the latter
come from alcoholic parents. P rom a practical point of view the Congress
decided to support the anti-alcoholic movement, and to abolish in
asylums the use of wine, substituting for it water. The asylum
physician has the right to prescribe wine as a medicine always con¬
sidering that alcohol is always dangerous to the nervous system
enfeebled by disease.

The last question which received treatment by the Congress was
that of the best type of asylum—a subject of first importance in Italy,
because the new lunacy law advises each provincial administration to
possess an asylum for their province. The Congress stated its preference
for the village plan after the type which exists at Mendrisio (Canton
Tessin en Suisse), which gives to the asylum the physiognomy of a true
hospital, and limits the unclimbable fence to the sections containing
the dangerous, criminal, and excited patients. Tamburini (Rome)
recommended the division of the hospitalisation of the insane into two
—a small asylum for treatment, as in a medical clinic for acute insane,
and an agricultural colony for chronic patients.

Finally the Congress expressed many views advocating the modifica¬
tion of certain articles in the lunacy law, articles which the practice of
three years has demonstrated as inefficient. Two points were of
real importance because upon them depends in part the ultimate
development of the asylums, and these are as follows: The lunacy
law obliges the provinces to maintain in their asylums criminals
pardoned by reason of their mental disease, or who have finished their
sentences in the prisons or in the “ Manicomi Giudiziari ” and are still
insane. This article of the law has carried disorder in the asylums
because the criminals, although insane, are different from the rest and
are dangerous to the other patients, above all when the desire is
to put hospital surroundings and influences around them. The Con¬
gress expressed the desire to have established inter-provincial asylums
for the criminals, in order to isolate them from the ordinary insane. The
other interesting point was that relating to the “backwards.” The
Congress declared that backward children are not insane in the sense
required by the law, and that the provincial administrations are not respon¬
sible for their maintenance. They ought to be supported by public bene¬
ficence. Above all the Congress maintained the view that the backward
ought to be protected from private speculation to which they are now
abandoned, and that their treatment should be controlled by the State.

The Congress at Venice ventilated freely the ideas at present
fermenting in Italy. We regret that we have not sufficient space to
mention scientific work going on in other centres of Italy, such as
Florence and Naples, for example, who did not take to the Congress all
they could have. Of this we shall speak later.

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PROGRESS OF PSYCHIATRY.

415

SPAIN.

By Dr. W. Caroleu.

Although the amount granted for public instruction in the budget
is increased, yet nothing is allowed for the teaching of psychiatry in the
universities. On the other hand, the omission of the teaching of
comparative psychology in the last curriculum of medical study remains
as a proof of the attitude of the State towards mental science.

The opening of the beautiful College of Medicine at Barcelona
without any provision for psychiatrical training is a sign of the times.
Some desultory lectures to medical students at the St. Bandilier’s
Asylum, and those given to pupils of forensic medicine at the same
asylum, complete all that is done to teach mental diseases at a great
Spanish university. Other universities are even worse provided.

As regards publications the year has been a fruitful one. Dr.
Morini, the well-known editor of the Phrenopathic Review, has written
a study of Dementia Praecox with statistical tables regarding his own
(St. Bandilier’s) asylum; Dr. Dalcerini has given us a monograph on
asylum structure in general; Dr. Victorie, an interesting booklet on
Insanity in the Spanish army; Dr. Barcia, a miscellaneous tract on
clinical observation; Dr. Rz Mendez, a Study of Psychiatric and
Neurological Treatment; and Dr. Contero, a text-book on Responsi¬
bility. In the Phrenopathic Review, the only one in Spain, since Dr.
Dalcerini’s Anna/s of Mental and Nervous Therapeutics deals with only
one side of the subject, there were published valuable articles on
Clinico-therapy, by Dr. Rins; on Cerebral Anatomy, by Drs. Saconella
and Victorie; on Military Psychiatry, by Dr. Yuarros. As a curiosity
to be found nowhere else in Spain there is an article on the English
and Scottish Commissioners’ blue books, and another dealing with the
increase of insanity in Ireland.

The Committee of Inquiry into the cause of insanity in Spain has
begun its work by sending round a series of interrogations to the asylums.
The labour is meritorious though unfruitful. The certificates which
come with patients show wretched confusion and scantiness of facts.
The widespread ignorance of mental science among medical men, and
the reluctance of families to reveal the truth, are great obstacles to the
Committee’s investigations. The cause of insanity is often not stated,
or grossly misrepresented. The diseases are badly known, general
paralytics described as alcoholics, etc., or vice-versd . The case-books
kept in asylums are only administrative records, and rarely is the form
of insanity indicated. In short, Franetti’s proposition in Spain is
Utopian.

The erection of a new asylum in Gerona is to be recorded as supply¬
ing a need where there was no provision for the insane, of a scientific
character, either rich or poor. The result of a meeting to elect a chief
physician was a pitiable failure, indicating the absolute want of efficient
medical men devoted to mental diseases. All branches of medical
science are studied but psychiatry, and although a great number of
young graduates proceed to Paris or Berlin to improve their knowledge
of obstetrics, surgery, dermatology, or ophthalmology, yet none ever

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416 epitome. [April,

seem to attend the psychiatrical clinics. Theses for the degree of
doctor never relate to mental disease.

Legislation regarding the insane has made no advance during the
year. The last Orders in Council are of a somewhat more lenient
nature, but, as usual, show a bitter feeling of animosity and hostility.
Spanish law gives sanction to the absurd pretension that family care is
better than asylum treatment. Cases of cruelty, unjust sequestration,
and other misconduct in private care are recorded. The want of
good nurses is an obstacle to good home treatment, and there is
a similar scarcity in hospitals. At present nuns are mostly employed.
Their state of ignorance is hardly credible. At Holy Cross Asylum,
the most ancient and richly endowed in Barcelona, the Sisters of
Charity during the past year only were taught reading and writing. It
is no use complaining of the total absence of medical principles in such
a staff, and there are no signs of improvement anywhere.

Legislation on these matters is urgently needed, but nobody seems
to care. As all, except the asylums, is in the hands of the nuns’
congregations the remedy is difficult, and little can be Hoped from a
campaign of reform on the part of superintendents and medical teachers.
Only a radical change in the Spanish manner of thinking on these
subjects will result in any progress or evolution.

Epitome of Current Literature.

i. /Etiology.

The Influence of Morbid Heredity in General Paralysis [SulP Influenza
del!Ereditarietct Morbosa Nella Paralisi Progressive *]. (Riv.

Speriment. di Freniat ., vol. xxxiii, fasc. ii, Hi, 1907.) Fomaca.

After a short review of the literature of the subject, the author states
the results of a personal inquiry into the family history of forty-two
general paralytics under his care in the Rome Asylum. In twenty-four
cases he found positive evidence in the parents, in the grandparents, or
in relatives in the collateral line, of insanity, or of organic or functional
nervous affections, or of vascular disease of the nervous system ; in ten
cases no reliable data on this point could be obtained, and in eight cases
such morbid heredity could be definitely excluded. In some of the
cases of the last group syphilis, acquired or inherited, was traced. The
cases with neuropathic heredity are recorded in detail, clinical notes
being given regarding each observation, and the family history being
further shown in diagrams referring to three generations.

The author concludes from his investigation that heredity is the most
important individual factor in the aetiology of general paralysis, occurring
in 70 per cent . of the cases studied by him ; and he maintains, further,
that the disease tends to develop at an earlier age in direct proportion to
the severity of the ancestral taint. He draws particular attention to the
frequency with which the disease appears in several members of the same

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CLINICAL PSYCHIATRY.

417

1908.]

family. Nine of his cases showed this condition, and he has collected
thirty similar observations recorded by others. So far as any inference
can be drawn from this limited number of cases, it appears that the
male line suffers more than the female, and that in both the most fre¬
quent mode of inheritance is the direct, the occurrence of the disease
in father and son being met with in 48 8 per cent, of the thirty-nine
family cases, and in mother and son in 25*6 per cent., while uncle and
nephew were affected in only 128 per cent., and grandfather and grand¬
son in 7*6 percent ; the cases of simultaneous occurrence in two or more
children of the same family came to 20*5 per cent.

As regards the other factors which have been supposed to play a part
in the genesis of general paralysis, Fornaca gives the following figures
for his own cases; syphilis (congenital or acquired, known or suspected)
in 60 per cent., vascular disease in 30 per cent., alcoholism in 25 per
cent., tuberculosis in 20 per cent. Suicide was noted in the ancestral
history in 15 per cent of the cases, and criminality in 25 per cent .

Particulars are also given regarding 44 children of general paralytics.
Of these 17 died in infancy; 6 of the survivors presented positive and
3 probable symptoms of inherited syphilis; 2 were epileptics and 2
were microcephalic idiots, and 7 others were mentally deficient.

W. C. Sullivan.

3. Clinical Psychiatry.

The Prodromal Medico-Legal Period of Dementia Prcecox [La Periode
Medico-legale prodromique de la Dime nee Pricoce\. (DEncephale,
Fev, 1907.) Antheaume, A., and Mignot, R.

Criminal and anti-social acts are frequent in cases of dementia
praecox under the influence of impulses, delusions and hallucinations,
that is to say, signs of intellectual weakness usually precede distur¬
bances of the moral sense. In a certain percentage of cases, however,
there is a prolonged prodromal period in which grave disorders of the
moral sense are exhibited with no evidence of any intellectual defect.
The authors recount illustrative cases, all of whom were predisposed to
insanity by heredity. One was that of a well-educated youth who, up
to the age of twenty, showed neither moral or intellectual defect. He
then commenced a career of alcoholic excess, contracted syphilis and
joined a band of hooligans. Pyromania, brawling, intemperance,
violence, vagabondage, and pederasty preceded symptoms of intellectual
weakness, which did not appear until after he had been sent to the
asylum at Charenton, the case then assuming the character of simple
dementia praecox. In another case quoted there was a prodromal
stage of six years in which the patient lived a similar anti-social life.
Following this period of moral insanity, stupor, delusions of grandeur,
hallucinations and stereotypies gradually developed, revealing the true
nature of the case. A prodromal period of this kind, analogous to that
observed in the early stages of general paralysis, is of obvious medico¬
legal importance. It may be that many cases in prisons are of this
type, and indicate the necessity for an organised inspection by expert
alienists, H. Devine.

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418 EPITOME. [April,

The Emotional Factor in Post-operative Insanity [Stato Emotivo Gaio
Post-operatorio Causa di Psichosi\ (Ann, di NevroL, anno xxiv,
fasc. v, vi, 1906.) Sanna Safaris,

This case has been recorded by the author as a contribution to the
study of post-operative psychoses. The patient was a woman, aet. 37,
who had shown no previous indications of mental disorder, but who
had a convergent psychopathic heredity. Thirteen days after under¬
going the trivial operation of canthopiasty for entropion due to old
trachoma, she developed an attack of acute mania. The operation was
performed under cocaine; the only antiseptic used was boracic
solution, and the bandages were removed after two days. Beyond the
fact that she was highly gratified by the good result of the operation,
there was nothing to note in the patient’s mental state during the days
immediately preceding the outbreak of the maniacal symptoms. The
attack tasted seven weeks, and was characterised throughout by a strik¬
ing predominance of affective exaltation. The author points out that,
in view of the trivial character of the operation, there can be no sugges¬
tion that either shock or intoxication by antiseptics or anaesthetics had
anything to do with producing the mental disorder. He is disposed,
therefore, to believe that the pleasurable emotion aroused by the
successful issue of the operation was the real exciting cause of the
psychosis, this exaggerated result being explained by the patient’s
neuropathic heredity. W. C. Sullivan.

3. Treatment of Insanity.

Trinitrine in Two Cases of Mental Disorder . (Le Prog, Med,, June 1 st t
1907.) MM, Rimond (of Metz), and Voivenel (of Toulouse,)
Without exception, say the writers, mental disorder has an ana¬
tomical basis. The ego is not an entity; disorder of the ego depends
upon disease of the brain, organic or functional, as the case may be.
In some instances the disease of the brain upon which the mental dis¬
order depends is a cerebral anaemia, due to constriction of the cortical
vessels; if we can modify the cerebral circulation we shall modify the
ego. In certain cases of this nature, it occurred to the writers to try
the effect of trinitrine, in view of the influence of this drug in producing
dilatation of the peripheral vessels—an effect manifested both objectively
and subjectively in various ways, among which may be mentioned a
notable congestion of the fundus oculi as seen by the ophthalmoscope.
The somatic disorders for which trinitrine is used, and in which it often
gives considerable relief, are, angina pectoris, cerebral anaemia, neuralgia,
dyspnoea in cases of chronic nephritis with contracted kidney, and
nervous asthma. The two cases of mental disorder in which the
writers administered this drug were, first, that of “ a hysterical woman,
set. 48, suffering from hysterical mania with auto-suggestion,” and
secondly, that of “a woman, set. 47, suffering from melancholia in con¬
nection with the menopause.” In the former case, the patient suffered
from intense facial neuralgia, with spasm of the facial muscles; she
had a fixed idea that the nerves of the face had been “ lacerated " or

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1908.]

TREATMENT OF INSANITY.

419

“ dislocated ” as the result of an accident, and was perpetually talking
of these nerves. She had actually received a blow on the right temple
from a stone, and two months later she began to suffer from right facial
neuralgia, which recurred daily, the attacks lasting about an hour.
Their recurrence was regarded as due to “auto-suggestion.” After the
illness had lasted for some years, it was treated by the administration
of 6 minims of 1 per cent . solution of trinitrine three times daily. Im¬
provement began immediately, and in ten days the patient no longer
experienced anything beyond trifling pains in the affected region of the
face, and the facial spasm had ceased; the fixed idea regarding the
“ dislocation of the nerves ” had also entirely disappeared. In the
other case, at the epoch of the menopause, the patient, apparently
as the result of the removal of her husband (a general paralytic) to an
asylum, had an acute melancholic paroxysm, associated with angina
[? pseudo-angina] pectoris. Four days after the onset of the melan¬
cholia, treatment with 6 minims of the 1 per cent . solution of trinitrine
was begun. After the third day, the violent sense of pectoral constric¬
tion gave place to a moderately painful sensation. In ten days, the
pain in the praecordial region had entirely disappeared and the mental
condition was notably improved.

It appears that the authors go too far in assuming that in either of
these cases the relief of a hypothetical “constriction of the cortical
vessels ” had anything to do with the improvement in mental condition
which followed the.administration of trinitrine. In both cases, it is at
least equally likely, that the symptoms of mental disorder—the fixed
idea regarding “dislocated nerves” in the first case and the melan¬
cholia in the second case—were merely secondary manifestations on
the part of a sensitive and unstable nervous organisation. Relief of
the primary somatic disorder by the trinitrine would naturally be
followed by an amelioration of the secondary symptoms of mental
disorder. Moreover, this explanation does not conflict, as does that of
the authors, with the law of parsimony. M. Eden Paul.

Annexes to Prisons , for the Sequestration of Criminal Lunatics. [Anexe

an Gefdnznissen fiir geisteskranke Verbrecher ]. ( Psych.-Neuro .

Wochenschr ., August 3rd, 1907.) Nacke P.

The proper treatment of criminal lunatics is still an open question.
The principal alternatives are: (1) special institutions (like Broadmoor),
(2) annexes to prisons, (3) ordinary asylums. Transference of criminal
lunatics to ordinary asylums is now rarely undertaken ; one of the two
former alternatives is commonly chosen. It seems doubtful if it is
possible to lay down general principles. What is suitable for one
country, or for one part of a country, is unsuitable for another. Each
system has its disadvantages. For large countries special institutions
may be the best; for small countries they do not come into the
question. Nacke refers to a paper by Colin, “ Deux Quartiers de
Stiret£ pour Alidn£s Criminels,” Revue de Psychiatries 1907, p. 177, in
which the latter writes in favour of special institutions, and criticises
annexes to prisons. Colin quotes the opinion of Scottish alienists, as
having said: “ Whatever plan you adopt, avoid trying annexes to

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420

EPITOME.

[April,

prisons, and, above all, avoid anything like the annexe to the prison at
Perth ! ” Colin formed unfavourable opinions also with regard to such
annexes to prisons on the Continent, and considers the only suitable
way of dealing with criminal lunatics is in special institutions, like
Broadmoor. “ In such an asylum ” (for criminal lunatics), he writes,
“is it alone possible to effect the necessary classification of cases;
there alone can the patients be treated humanely, and in accordance
with their special requirements ; there only can the work be properly
organised; from such an institution the harmless patients can be
weeded out and sent to ordinary asylums, or, in suitable cases, set pro¬
visionally at liberty (liberation conditionelle).” Nacke, however, is of
opinion that the advantages claimed by Colin for the special institu¬
tions for criminal lunatics can be realised also in the annexes to prisons,
and for this reason the system deserves a further trial, not only in
Germany, but elsewhere. Still, he admits that such places as Broad¬
moor, Matteawan, and Dannemora arc really ideal for the treatment of
criminal lunatics—“ of the similar Italian institutions I prefer to say
nothing at all.” But where small numbers of criminal lunatics have to
be dealt with, annexes to prisons remain necessary, and for these the
following conditions must be fulfilled : (i) The inmates must be kept
under restraint in the annexe as long as they are-dangerous—if
necessary for the whole of their life; the harmless patients can be
transferred to ordinary asylums. (2) The annexe must be large enough
to permit of some classification of the patients. (3) There must be pro¬
vision for various kinds of work, and more particularly for garden and
field work. In small towns this is easy; in large towns it will be diffi¬
cult. (4) The Medical Superintendent must of course have had special
experience in the treatment of mental disorders, and must be in supreme
control. The objection may be made that the provision of such an
annexe to every considerable prison will prove more expensive than the
provision of two or three special institutions for criminal lunatics.
There is some truth in this, but the advantages outweigh the objections,
the advantages being the easy transfer of mentally disordered criminals
from the prison to the annexe, whereby heavy expenses of transport will
be saved, and also the possibility of transferring all the dangerous cases
from the ordinary asylums to the prison annexes, so that it will be
no longer necessary to make special provision for the management of
these cases in the ordinary asylums. M. Eden Paul.

4. Pathology of Insanity.

Contribution to the Nosology and Histology of Paralytic Amaurotic
Idiocy [Beitrage zttr Nosographie und Histopathologie der Amaurth
tisch - paralytischen Idioticformcn\ (Arch . fur PsychiatH. i%

Bd. xlii .) Schaffer.

The case described at great length by Professor Karl Schaffer, of
Buda-Pest, was an idiot of low grade, who reached the age of twenty-
four years. The family history was not known. She was utterly help-

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1908.] PATHOLOGY OK INSANITY. 421

less, the legs drawn up in a state of spastic rigidity. She suffered
from frequent epileptic attacks, during which she bit her tongue. She
was almost blind. She spoke a few words to which she attached a
meaning.

The abnormalities observed in the brain are illustrated by two
pages of lithographic plates. These indicated arrest of development.
No anomalies were noted in the convolutions, but, on examining the
inner structure of the brain, it was found that the nerve-fibres were
deficient in the temporo-occipital regions, so that neither the primary
nor the secondary radiations of Flechsig could be seen. The central
white substance was deficient in quantity, especially in the frontal and
temporal lobes. Schaffer explains the amaurosis by the failure of the
optic radiations, and the idiocy by the defective apparatus of associa¬
tion in the centrum ovale. The fibres in the cortex, when compared
with another brain, were found neither to be wanting in number nor
to be abnormal in structure.

Dr. Schaffer observes that his case differs from the interesting forms
of genetous idiocy which have been described by Sachs and others.
Schaffer gives a clear summary of the knowledge already gained about
this rare type, which he himself has also studied at first hand. Vogt
considers the characteristic symptoms to be: (1) Weakness of the
extremities to complete paralysis, generally diplegic, rarely paraplegic.
The paralysis is sometimes spastic, sometimes not. (2) Loss of vision
up to complete blindness. Through the ophthalmoscope this has been
found to be owing to atrophy of the optic nerves, which in the cases
described by Sachs was accompanied by the characteristic white patch
in the retina at the macula lutea with a cherry-red spot in the middle.
{3) Mental deficiency passing into total amentia. (4) Arrest of bodily
growth, impairment of digestive functions, marasmus, and death through
exhaustion. (5) The malady progresses steadily, and is accompanied by
loss of smell and hearing, symptoms of disordered function of the medulla,
And loss of co-ordinating power. (6) The disease follows families; by
far the most of the patients described by Sachs were children of Jews.

Vogt divides this form of idiocy into two groups. In the first, the
malady comes on during nursing or in the first or second year of life,
and is accompanied by the patch in the macula. In the second group,
the affection does not appear till from the fourth to the sixteenth year.
There is an increasing dementia and blindness owing to atrophy of the
optic nerves, but the spot is wanting. Vogt does not regard the absence
of this patch as a reason for differentiation. He has thus an infantile
and a juvenile form. Those under the last group are generally affected
about school-age with loss of sight, diminution of intelligence, and
motor weakness. The symptoms are slower in their progress, and the
subject may remain in a moribund state for months, even for a year.
These juvenile cases are not so closely confined to the race of Israel.
Schaffer remarks that in eighty-six instances of the infantile type the
spot in the macula was only absent in five, and in some of these instances
tbe absence was doubtful Schaffer tells us that in the infantile type
of amaurotic idiocy there has been found a degeneration of the nerve-
cells of the brain, such that has not been observed in any other disease of
the central nervous system. This cystic degeneration consists in an

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422

NOTES AND NEWS.

[April,

increase of the inter-febrile substance, and a swelling of the body of the
nerve-cells and the dendrites in the whole central nervous system,
which, with NissFs staining process, gives an intense chromolysis, so
that the whole preparation encrusted with NissFs corpuscles makes
CajaFs spongioplasnia conspicuous. The swelling of the cells and
their processes is very decided, but it does not involve the axis
cylinders, which thus appear like separate bodies.

Congenital microscopic deformities play no part in Sachs* amaurotic
idiocy, of which the sub-stratum is a microscopic degeneration of the
nervous tissue.

In opposition to Vogr, Schaffer considers the spot on the macula to
be distinctive of Sachs* amaurotic idiocy. In conjunction with Dr.
Julius Grosz and Dr. M. Mohr he ascertained that the spot on the
macula persisted to the end in all the cases of this affection which they
examined, and sometimes this was not accompanied by atrophy of the
optic nerves.

There are other cases of idiocy complicated with blindness and
paralysis which cannot be included in this form ; for example, Spielmayer
has described four children in one family who, up to the sixth year, were
sound in body and mind; then commenced a mental degeneration
passing into idiocy, accompanied by a progressive atrophy of the retina
(retinitis pigmentosa). Three of these children died in the first year of
puberty. The father had become infected with syphilis before the con¬
ception of these four. Another child conceived before this remained
healthy. William W. Ireland.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

Minutes of the Quarterly Meeting held (by the courtesy of Dr. Miller) at
Hatton Asylum, Warwick, on Thursday, February 20th, 1908, under the presi¬
dency of Dr. P. W. Macdonald.

There were present—Drs. S. Agar, M. A. Archdale, H. T. S. Aveline, J. S.
Bolton, D. Bower, Cunyngham Brown, C. Caldecott, J. Chambers, T. Drapes,
J. A. Ewan, J. W. Geddes, H. E. Haynes, C. Hopkins, P. T. Hughes, A. M.
Jackson, Robert Jones, W. S. Kay, H. C. MacBryan, P. W. MacDonald, G. R.
Macphail, Ch. lVfercier, Alf. Miller, J. H. Morton, H. H. Newington, B. Pierce,
D. Rambaut, W. Rawes, H. Rayner, W. F. Samuels, E. H. O. San key, H. W.
Smith, J. J. Soutar, J. B. Spence, Helen G. Stewart, T. S. Tuke, H. R. Turnbull,
J. Turner, W. Vincent, E. B. Whitcombe, H. W. Wilcox, and Outterson Wood.

The minutes of the last quarterly meeting having been previously printed in the
Journal, were taken as read and were confirmed.

The following new members were unanimously elected:

Marc Antony, L.R.C.S.&P.Irel., Assistant Medical Officer, County Asylum,
Mickleover, Derby. Proposed by Richard Legge, Bedford Pierce, and Marriott L.
Rowan.

Robert Cunyngham Brown, M.D.Durh., Deputy Medical Officer, H.M. Prison,
Parkhurst, I.W. Proposed by O. F. Naylor Treadwell, P. W. MacDonald, and
C. Hubert Bond.

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NOTES AND NEWS.

423

1908.]

Ralf Brown, M.R.C.S., L.R.C.P.Lond., Resident Assistant Physician, “ Moor-
croft," Hillingdon. Proposed by Theo. B. Hyslop, R. H. Cole, and Reginald J.
Stillwell.

Henry Cooke Martin, B.A., M.B., Ch.B.Edin., Assistant Medical Officer, Newport
Borough Asylum, Caerleon. Proposed by Wm. F. Nelis, C. Hubert Bond, and
J. Glendenning.

Macdonald Munro, M.B., B.Ch.Glasg., Assistant Medical Officer, Earlswood
Asylum, Redhill. Proposed by Charles Caldecott, H. Hayes Newington, and
C. Hubert Bond.

Andrew Banks Raffle, M.D., B.S.Durh., Assistant Medical Officer, Northampton
County Asylum, Berry wood. Proposed by Wm. Harding, H. Hayes Newington,
and C Hubert Bond.

William Frederick Samuels, Lic.Med.&Surg.Dublin, 1905, Assistant Medical
Officer, Warwick County Asylum, Hatton, near Warwick. Proposed by Alfred
Miller, Conolly Norman, and Daniel F. Rambaut.

Harry Victor Walker, L.R.C.P.I., L.M., L.S.A., Ticehurst House, Ticehurst.
Proposed by H. Hayes Newington, A. S. L. Newington, and C. Hubert Bond.

Factories and Workshops Act of 1907.—The President stated that before pro¬
ceeding to the other business on the agenda there was a matter which had been
before the Parliamentary Committee and the Council, and that the latter had
decided it should be brought before the meeting. He stated that he believed it was
known to all that a circular letter, under date January 27th, had been sent out
from the Lunacy Commissioners’ Office with regard to the Factories and Work¬
shops Act, 1907. This matter had been before our Parliamentary Committee
that day, and it had been before the Council, who had resolved that it should come
before the general meeting. The position of things, he went on to say, was this :
The Home Secretary, under Section 6 of the new Act, may, if he thinks fit, appoint
an inspector to inspect laundries and workshops in public asylums. It was felt by
many that this would not be to the advantage or for the good of public asylums,
seeing that we have already one official body to inspect them—namely, the Com¬
missioners in Lunacy. While there are those who hold strong views both ways, the
President invited anyone who wished to express an opinion on the matter to do so.

Dr. Soutar gave a retrospect of a previous endeavour that had been made to
bring asylums within all the purposes of the Act of 1901. That, he said, had been
resisted. He strongly deprecated subjecting asylums to the inspection by another
Government Department. Where there might be any doubt about a particular
detail, it could readily be suggested to the Visiting Committee that the latter
should obtain an expert opinion, but that would be a totally different thing to the
intrusion of Factory Inspectors. He thought that this view should be expressed
to the Commissioners in Lunacy.

Dr. Whitcombe stated that his own Committee were of opinion that the new
Act could not refer to institutions which were used solely for the care of people
who were insane. He thought that the Association should express this view to the
Commissioners in strong terms; and that any supervision beyond that of the
Commissioners was unnecessary.

Dr. Robert Jones thought that the Association should be very cautious how
they sent such a resolution up until they were asked for one and until they knew
the views of the Commissioners.

Dr. Mercier said that while expressing his respect for the Birmingham City
Council he would point out that no such body was necessarily qualified to be able
to inteipret a dubious clause in an Act of Parliament.

Dr. Rayner thought that the discussion should centre round the question
whether the change would be for the good or the harm of the institutions, and
that the Association’s view, whichever direction it took, could very properly be
communicated to the Commissioners.

Dr. Whitcombe moved that this meeting of the Medico-Psychological Associa¬
tion is of opinion that no such additional inspection is desirable.

Dr. McDowall seconded.

Dr. Spence expressed himself in harmony with what had been said, and he
would vote for the resolution if he could be sure that the meeting really repre¬
sented the opinion of the majority of superintendents, and he pointed out that it
had not been on the agenda.

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424

NOTES AND NEWS.

[April,

Dr. Bedford Pierce hoped the matter might be deferred.

Dr. Hayes Newington pointed out that the Commissioners conld not be
expected to wait three months before taking action, and that now was the only
chance to express an opinion. He thought that to-day’s meeting was a very
representative body.

Dr. Turnbull moved the following amendment:

“ That in view of the way in which laundry and other machine work has to be
conducted in asylums, it is in the opinion of the Medico-Psychological
Association undesirable that asylums should be brought under the pro*
visions of the Factory Acts.”

The amendment was seconded by Dr. Aveline.

Dr. Caldecott was of the opinion that the Commissioners interpreted the Act
as including asylums.

Dr. Bower feared that the amendment disagreed with what the Legislature had
decided.

Dr. Turnbull : No, it is left to the Home Secretary to decide.

The amendment was carried by a large majority.

Dr. Bedford Pierce suggested a further amendment, seconded by Dr. Bower:

11 That this meeting believes dual authority in respect of the supervision of
asylums is undesirable; but if it be thought desirable to inspect asylum
workshops in a different manner than at present, this inspection should be
subordinated to the existing authority.”

The second amendment was defeated, and Dr. Turnbull’s amendment was
adopted as a substantive resolution. The General Secretary was instructed to
forward a copy of it to the Commissioners in Lunacy.

Dr. John Turner then gave a lantern demonstration, and read a paper upon
“ Some Further Observations bearing on the Supposed Thrombotic Origin of
Epileptic Fits.” In the discussion that followed Drs. Robert Jones, Bolton, and
Mercier took part. Dr. Turner replied.

Dr. Cunyngham Brown then read a paper entitled, “ The Boarding-out of the
Insane in Private Dwellings,” which he illustrated by lantern views. Owing to
the lateness of the hour no discussion was possible. It was felt, however, that the
points raised were so practical and interesting that the value of a debate upon
them at an early date would be great.

In the evening about thirty members dined together at the Regent Hotel,
Leamington, the company including several guests from the neighbourhood.

At the Council Meeting held at Hatton Asylum in the morning, on February
20th, there were present:—Drs. Aveline, Bolton, Bond, Chambers, Drapes, Ewan,
Robert Jones, P. W. Macdonald, McDowall, Mercier, Hayes Newington, Bedford
Pierce, Rayner, Turner, and Turnbull.

SCOTTISH DIVISION.

The Half-Yearly Meeting of the Scottish Division of the Medico-Psycho¬
logical Association of Great Britain and Ireland was held in the Eastern District
Hospital, Duke Street, Glasgow, on Thursday, March 19th, 1908.

Present: Drs. P. W. Macdonald, Baugh, Bruce, R. B. Campbell, Carswell,
Clouston, Easterbrook, Graham, Hotchkis, Ireland, Carlyle Johnstone, Keay,
J. H. Macdonald, T. C. Mackenzie, G. D. McRae, Oswald, Parker, Richard, Shaw,
Sturrock, Turnbull, Urquhart, Yellowlees, and Hamilton Marr (Divisional
Secretary). Dr. P. W. Macdonald, President of the Association, occupied the
Chair.

The question of celebrating the jubilee of the present legislative system of
lunacy administration in Scotland was carefully considered, and it was unanimously
resolved that the following paragraph be inserted in the minutes, and that an
excerpt thereof be transmitted to the General Board of Lunacy, the chairman of
each of the various royal asylums and district lunacy boards, and the Secretary of
State for Scotland.

“ In view of the fact that it is now fifty years since the Act 20 and 21 Victoria,

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Chapter 71, came into operation, the Scottish Division of the Medico-
Psychological Association resolve to record in their minutes this expression of
their recognition of the great advances which have been made in Scotland during
the last half century in tne treatment of the insane and the scientific investigation
of insanity; their acknowledgment of the humane, enlightened and generous
manner in which the asylum boards of the country have provided for this most
unhappy class of the community; and their appreciation of the broad and sympa¬
thetic policy consistently pursued by the Commissioners of the General Board of
Lunacy in their control of Scottish lunacy administration—a policy which has not
only been fruitful in the protection and promotion of the best interests of the
insane, but has also done much to encourage and assist those who are more
immediately engaged in carrying out their care and treatment."

Dr. Macdonald drew attention to the resignation of Dr. Clouston from the
post of Medical Superintendent of the Royal Edinburgh Asylum, and paid a high
eulogium to the work Dr. Clouston had done, to his intense enthusiasm, and to
the encouragement he had given to many who occupy important posts in the asylum
service in the Kingdom.

The Chairman made suitable reference to the great loss which the Association
has sustained through the deaths of two most notable members of the profession,
via. Dr. Wilson and Dr. Conolly Norman. Having dwelt on the respective merits
of those gentlemen and on the great amount of good which has resulted from
their labours, he moved that it be recorded in the minutes that the members
learned with deep regret of the sudden deaths of two such valued friends and
colleagues, and that the secretary be instructed to transmit an excerpt of the
minute to the relatives of Dr. Wilson and Dr. Conolly Norman, and to convey
the sympathy of the members with them in their bereavement.

Dr. John Carswell, Certifying Physician to the Glasgow Parish Council, and
Physician-in-Charge of the Insane Wards in Duke Street Hospital, gave an
interesting account of the functions these wards fulfil. Dr. Carswell also
demonstrated some cases of clinical interest.

The meeting was adjourned sine die .

OBITUARY.

Dr. Macleod.

We regret to record the death of Dr. Murdoch Donald Macleod, at Westwood
Road, Beverley, on March 3rd.

Dr. Macleod belonged to the Morven Macleods, and was a thorough High¬
lander, both parents and three grandparents being Macleods. His father was the
Rev. Norman Macleod, Free Church minister of North Uist, and his mother a
daughter of Dr. Alexander Macleod.

He received his education at the Edinburgh High School and University, and
obtained the degree of M.B. and the licence of the College of Surgeons in 1873.
After being house-surgeon to Mr. Joseph Bell in the Edinburgh Royal Infirmary,
he early entered the specialty of psychiatry, and went as assistant medical officer
to the Cumberland Asylum at Garlands. In 1882 he was appointed medical
superintendent of the East Riding of Yorkshire Asylum at Beverley, which has,
under his able direction, been very greatly extended and improved. He was presi¬
dent of the East Yorkshire and North Lincolnshire Branch of the British Medical
Association in x8S6, taking as the subject of his presidential address “ Puerperal
Insanity," and vice-president of the Psychological Section of the British Medical
Association at the annual meeting at Carlisle in 1896. He had been a member of
the Medico-Psychological Association since 1873. He was a member of the Cale¬
donian Medical Society, was elected president in 1899, and was keenly interested
in Gaelic literature and romance.

Dr. Macleod was an enthusiastic volunteer and golfer ; was well known in the
East Riding for his geniality and his very keen interest in all sports and open-air
pursuits. He was for some time captain of the Beverley Company of the Second
Volunteer Battalion East Yorkshire Regiment.

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426 NOTES AND NEWS. [April,

His health had been failing since 1899, when he felt symptoms of cardiac weak¬
ness and retired from the Volunteers. In 1903 he had a paralytic stroke, but he
recovered from this and was again able to undertake his duties at the asylum. In
June, 1906, however, owing to increasing infirmity, he resigned his post of medical
superintendent, the County Council granting him a retiring allowance of £600
a year.

He bore his physical weakness with wonderful spirits, and was seen outside in
his bath-chair only a few days before he died. He appears at the last to have
caught an attack of influenza, from which he sank and died within twenty-four
hours of the onset.

He was buried at Walkington on March 6th, the medical profession, the asylum
staff, and the Volunteers being well represented at the funeral.

Dr. Macleod was in his fifty-seventh year, and leaves a widow and three sons
and two daughters.

Dr. G. R. Wilson.

We record the premature death of Dr. G. R. Wilson with deep regret. A
sudden attack of pneumonia carried him off in the prime of life, and bereaved his
widow and two children of a singularly gifted parent. After he gained his degree
(1889) in the University of Edinburgh and worked in the Queen Square Hospital,
he served as Assistant Medical Officer in the Royal Asylums of Dumfries and
Edinburgh. In the latter he was promoted to the rank of senior, and in course of
time became Physician to the Mavisbank Asylum. In 1905 he left Mavisbank to
devote himself to consulting work in Edinburgh and to open a sanatorium for
nervous maladies at Newmains. This institution soon proved successful, and it
was hoped that Dr. Wilson would have had a useful and prosperous career in the
further practice of his profession. He was a man of many parts, and enthusiastic
in his work, indeed he was engrossed in the specialised interests to which he succes¬
sively devoted his attention. He was well-known to the leading neurologists of
London and held in esteem by them.

He published two works on Drunkenness and on Clinical Studies in Vice and in
Insanity, which gained him repute among those who are interested from the
psychological and the sociological standpoints. So long ago as 1896, he produced
an important paper on Weismann's Theories in Insanity, and he gained a medal
on receiving his degree of M.D. in Edinburgh. Dr. Wilson was also a member of
the College of Physicians, a man eminent in his profession, possessed of many friends,
many of whom will remember him as an International Rugby player, and always
the most genial of companions.

THE SECOND INTERNATIONAL CONGRESS ON SCHOOL
HYGIENE.

Contributed by Robert Jones, M.D.

The Second International Congress on School Hygiene was held in London,
from August 5th to 10th, under the Presidency of Sir Lauder Brunton ; the first
Congress having been held in Nuremburg three years before, and the next to be in
Paris in 1910.

The object of these congresses is to educate public opinion as to the economic
gain of recognising the prior claim of the public welfare; that the work done by
efficient wage-earners of sound physique is a great asset to the State when
compared with the inefficiency of the underfed and ill-developed as industrial
agents. The Congress recognises that children’s eyes, ears, teeth, their hours of
relaxation and of sleep, their food, and their varying degrees of mental power all
demand public attention.

The London Congress was opened by Lord Crewe, as Lord President of the
Council, and Sir Lauder Brunton then delivered the inaugural address. The
Congress was attended by numerous delegates from most countries.

The subject matter before the Congress was divided into eleven different
sections, each with its own president and secretaries. As one of the secretaries of

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1908.]

Section I, dealing with the Physiology and Psychology of Educational methods
and work, of which Sir Tames Crichton-Browne was President. I spent most of
my time in this section, but I was also able to attend several of the others. This
section and Section VIII, dealing with special schools for feeble-minded and
exceptional children, are the two which possess most interest to members of the
Medico-Psychological Association. In dealing with feeble-minded children the
connection between mental retardation and imperfect physical development was
especially discussed. Bad home conditions, overwork out of school hours,
adenoids, ear trouble and deafness were fully entered into and discussed in one or
other of these two sections, and it was pointed out by several speakers that the
fuller education of mothers and proper attention to the teeth, eyes, and ears would
greatly lessen the evils from which children suffered in after life.

The two great objects of the Congress were (1) to urge the necessity for
medical inspection of school children as recommended by the Departmental Com¬
mittee upon Physical Deterioration, it being pointed out that to neglect curable
conditions in childhood was to treat the sufferers later in asylums, reformatories,
hospitals, and prisons, and Dr. Leslie Mackenzie took a very active part in this
discussion; and (2) to draw the attention of the Board of Education to the need
for teaching hygiene in elementary schools, the Provincial Committee in Scotland
being announced as having alreaay resolved to begin this in their institutions for
the training of teachers.

In many countries of Europe, including Russia, and even in Chili and the
Argentine, the medical inspection of school children is already compulsory; more
especially is this the case in Sweden and Denmark, where the doctor confers with
the headmaster and the drill instructor. Moreover, the children of the poor are
attended free, and all schools are under inspection, both elementary and secondary.

The successful results which have attended the work of the Congress are already
very marked, for Parliament has since enacted that medical inspection of school
children shall come into force on January 1st, 1908, and it will be the task of the
local education authorities throughout the country to carry this out under the
control of a central medical authority in a special medical department recently
established under Dr. Newman in the Board of Education for England and Wales.
It is hoped that a special memorandum embodying the main principles for the
guidance of the local authorities may soon be issued by the Board, and that the
collated reports may be prepared for general information. It was also suggested
at the Congress by Dr. Dyke Acland that the secondary schools should not be left
without compulsory medical and hygienic supervision.

The Board of Education has now recognised that instruction in hygiene must
in future be given in training colleges and the prefatory memorandum in the
regulations for the training of teachers, and also for the examination of students
in training colleges, states that the Board has under careful consideration the need
for requiring the special instruction of all students in the principles of hygiene, so
that they may themselves be able to give practical instruction to the scholars in
this most important subject. As is known, teachers at a training college carry
out a two years' course, and hygiene is included as a compulsory subject under
Elementary Science, and the inspector must himself be satisfied of the competency
and fitness of the teachers. But for students who take a University course, how¬
ever, compulsion is not laid down, and the attention of the President of the Board
of Education is to be drawn to this anomaly.

In Scotland, as stated, a course of hygiene which includes the personal hygiene
of children as well as the hygiene of the schoolroom is now made compulsory
upon all students training to be teachers, and it is specially laid down that there
should be at least seventy hours of theoretical and practical instruction in personal
and school hygiene. A lead in this direction is shown by King's College, and for
the first time in London special hygiene classes for teachers have been inaugu¬
rated, and the Education Committee of the London County Council has looked
favourably upon the scheme. It is not too much to expect that in future the
principles and practice of hygiene should now form part of the education of every
citizen.

An interesting paper was read by Mr. John Gray, Treasurer of the Anthropolo¬
gical Society, upon 11 The Importance of School Anthropometries in the Study
and Control of National Evolution." Two methods of improving the efficiency of

LIV. 30

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428

NOTES AND NEWS.

[April,

a people were—(i) the Eutrophic one, which includes good up-bringing ; and (2)
the Eugenic, which improves the stock by selection. It was suggested that upon
collected data of physical and mental characteristics, correlation between man and
his environment could be calculated, and insidious processes of natural deteriora¬
tion detected. He urged that the first step should be the measurement of school
children.

A paper read by Dr. Francis Evans gave statistics as to deafness among
1000 children in the schools of London. One-third had some degree of deaf¬
ness mainly due to throat conditions. The mental capacity of children with
deficient hearing was, as a consequence of the deafness, below that of normal
children, and much of this could be avided by breathing exercises and the proper
use of the handkerchief.

The experience of Dr. Janet Campbell in the London County Council
Secondary Schools was given. Most of the scholars there are intended for pupil
teachers, and it is necessary to eliminate those likely to be unfit, and systematic
inspection is carried out to maintain the standard of health at the highest level.
The parents are notified as to defects, of which the most common being anaemia,
lateral curvature, and round shoulders. Detail relating to the teeth, vision,
hearing, the heart, lungs, and the general physique are recorded, and the co¬
operation of the drill mistress is considered to be necessary.

Mrs. Coghill Hawkes supported this by similar experience in the polytechnics
and secondary schools for girls.

The Warden of Bradfield College, the Rev. Dr. H. B. Gray, presented a paper
on the teaching of hygiene in secondary schools, and emphasised the necessity for
the teaching of natural laws to boys, to ensure orderliness of conduct, both mental
and physical.

Canon Lyttleton, of Eton, originated a prolonged discussion upon the com¬
parative value of the classics, when compared with modern languages, as mental
gymnastics.

Play, games, and out-of-door recreation also received attention by the Congress.

Dr. H. Kenwood, Professor of Hygiene at University College, urged that for
orderliness, method, and “ morale,” the home and the parent could often be
reached through the school and the child.

Dr. Louis de Bourdineau read a paper, showing that baths attached to the
schools were provided in certain districts of Paris, and forty children per boor
could be bathed therein.

The subject of tuberculosis in schools was discussed at some length, and the
danger of teacher to child infection was pointed out.

The problem of “ Fatigue ” was discussed by Dr. Myers, and “ Sleep ” by Miss
Ravenhill, in full, practically, and highly interesting papers.

In the eleven Sections so many papers were read, and so much discussion
elicited from English, French, German, Russian, and other foreign authorities,
that from this standpoint at least the Congress was a complete success. It has
been impossible to do more than refer briefly to salient points. A valuable
exhibition of school appliances formed a striking feature of the Congress.

NURSING EXAMINATION IN NEW ZEALAND.

The following questions set for the examination of candidates for the State
qualification in mental nursing have reached us from Dr. Alexander. We referred
to this new development in the last number of the Journal. It is evident that
the examination is at once searching and suitable m scope. The questions are
justly fitted to the end in view, viz. the test of adequate knowledge in nursing.

Examination for Registration of Mental Nurses.

20 th December , 1907. Time allowed , three hours .

I. (1) What useful purposes do the bones serve P

(2) (a) What is the difference between simple and compound fractures ?

(A) Why is one more serious than the other ?

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1908.] NOTES AND NEWS. 429

(3) In what classes of patients are the bones brittle and therefore more liable

to fracture P

(4) The patients are crowding in to dinner when one of their number falls in

the middle of the passage, where he is in danger of being trampled
upon: (a) What signs would lead you to suspect that his right femur
had been fractured ?

(b) What would you do with the patient until the arrival of the medical
officer ?

II. (1) Describe the heart under the following headings:—(a) Size, ( b) shape,
(c) position, (< d ) tissue of which it is mainly composed, (e) its divisions,
(/) the openings leading out from and into any of these divisions,
adding which of these openings are guarded by valves, and the object
of the valves in each case.

(2) When a person is walking the muscles press upon the bloodvessels, and

you are told that this assists the flow of blood towards the heart:
Why does it not have the opposite effect ?

(3) What would you do until the arrival of the medical officer under the

following circumstances:

(a) A patient has put his fist through a window pane and severed the
radial artery at the wrist.

(1 b ) A patient has very bad varicose veins of the lower limbs, the pressure
of which has thinned the skin, say near the calf. The patient scratches
the limb in this position and ruptures a vein.

11 (1) Mention the different classes of food essential for the welfare of the body.

(2) Classify each of the following articles of diet according to the class or

classes to which it belongs:— (a) Bread, (b) butter, (c) eggs, ( d ) fish,
( e ) potatoes, (/) milk.

(3) Describe briefly the digestive processes to which a mixed meal is sub¬

jected (a) in the mouth, ( b ) in the stomach.

(4) What would you do if a patient showed symptoms of choking during a

meal P

(5) Mention the classes of patients in which you have to specially guard

against this accident.

IV. (1) Mention the rules and regulations referring to bathrooms and the bathing
of patients therein, stating after each what you deem the reason there¬
for.

(2) N ame the three commonest and possibly fatal disasters for which a breach
of such rules and regulations may be directly responsible, and state in
detail how you would act in each emergency.

V. (1) Mention anything you have been told or observed that would give you
warning that certain epileptic patients were going to have fits.

(2) Describe in order what takes place during a severe epileptic fit.

(3) What is your duty towards the patient during the fit ?

(4) State the characteristic symptoms of epileptic insanity.

NOTICES BY THE REGISTRAR.

Examination for the Nursing Cf.rtificate.

List of the successful candidates at the examination for the Nursing Certificate
held in November, 1907.

Lancaster County ( Whittingham). —Females: Bridget Daly, Lily Francis
Johnson, Alice Dixon, Emily Swift, Maud Hassall, Annie Gibson, Annie Starkey,
Nellie Young, Hannah Callaghan, Mary Dixon, Cicely Hannah Woodcock.

Lancaster County (Rain hill). —Males: John William Mylehreest, Philip Whiteley,
Albert Mears, William Hollingworth, Arthur Hilton, Samuel Briggs. Females :
Helena A. W. Oldrieve, Florence Hallmann, Alice Mary Jones, Agnes Mary Tate,
Annie Maud Busfield, Amy Maria Chase, Daisy K. Longman.

Somerset and Bath (Cotford). —Male: Frank James Burrows. Female: Mary
Jane Jefferies,

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430

NOTES AND NEWS.

[April,

Staffs County (Cheddleton). —Female: Florence E. Evans.

Staffs County (Burnt wood ).—Female : Mabel Scott.

Warwick County. —Males: William Sabin, Fred. W. Salenger. Females:
May Sheldon, Hannah Heeley.

West Riding•, Yorks. —Males: William John North, Harry Robertshaw, Fred.
Brigg, Joe Pearson, Joseph Collins, Herbert Kempton, Joe Thornton, 'Arthur
Weightman, Robert Hawkes, Arthur Fearnside, Arthur Kellett.

Notts City. —Male: Harry Bradley.

Bethlem Hospital. —Males: Herbert Humphreys, Thomas Pook, George Henry
Woolford.

Bet hnall House , London. —Male: Francis O’Reilly. Females: Alice Chapman,
Emma Austin.

Caterham. —Males: Harry Howes, Charles Hy. James Cook, Thomas Prout,
Charles T. Kendall, Hubert Woodward, Harry James Sumner. Females: Bessie
Louisa Farrow, Constance Piper, Alice Piper, Nellie Lynds, Fanny Raggatt, Ethel
May Golding.

Holloway Sanatorium .—Males : Robert Walmsley, William R.*Walmsley.

Wye House, Buxton. —Male: Edward Strutt. Females: Mary Ann Oakden,
Elizabeth J. B. Lockerbie, Sarah Jane Blood, Rose Pilkington.

St. Patrick's Hospital, Dublin .—Females : Annie Clyde, Kathleen Foster.

Stewart Institute, Dublin .—Female : Mary Dames.

Argyle and Bute District. —Male: Alexander Beadie. Females : Henrietta C.
Munn, Elizabeth M. Fulton.

Gartloch .—Females : Margaret MacMillan, Mary MacKinnon.

Inverness .—Males : Angus Macauley, Donald Monk.

Montrose .— Male: Robert Ritchie. Females: Laura Meston Macdonald, Mary
Helen Buchan.

Roxburgh District .—Females : Annie McCloskey, Alicia M. B. Keaghey.

Riccartsbar .—Female : Jessie Ann Towler.

Stirling District. —Male: Charles M. Ritchie, James Forde. Females: Kate
Ley, Jessie McGavin Aitken.

Murray*s Asylum, Perth .—Male : John Robertson. Female : Grace Sangster.

Morningside. —Females: Christina Ann MacLennan, Mary Anderson, Katie
McDonald.

Bangour Village .—Females : Marguerite Chiney, Sarah Reynolds.

Valkenberg, S. Africa .—Males : Patrick Com mins, Cornelius Fogarty, William
Drysdale Gordon, Michael McKeviot.

The following is a list of the questions which appeared on the paper:

1. Describe the “ insane ear.”

2. What precaution should be taken in dealing with infectious disease ?

3. Describe from case* in your own experience examples of—

(a) exalted,

($) persecutory, and
(c) depressive delusion.

4. To what class of joints does the hip-joint belong ? What bones enter its
formation ? Of what movements does it allow ?

5. Describe in detail the methods which a trained mental nurse will adopt in
dealing with a patient of uncleanly habits.

6. What points require attention in feeding paralytic patients ?

7. How is butter digested ? How do the products of its digestion reach the
blood stream ?

8. How would you prepare a soft rubber catheter for immediate use ? Why is
it needful to take special care in its preparation ?

9. Describe an epileptic fit ? What is petit mal ? How would you distinguish
the former from apoplexy and the latter from syncope?

10. A patient in the harvest field is wounded in the ankle by a scythe and there
is much loss of blood. What would you do until medical assistance arrives, when
the nearest doctor is fully five miles distant ?

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431

X908.]

APPOINTMENTS.

Eager, Richard, M.B.Aberd., Senior Assistant Medical Officer to the Devon
County Asylum, Exminster.

Fairies, John Stothart, L.R.C.P., L.R.C.SEdin., etc., appointed Medical
Superintendent of the Sandwell Hall Asylum for the Feeble-minded, Hands worth,
Staffs.

Mathieson, J. M., M.B., Ch.B., Fifth Assistant Medical Officer to the West
Riding Asylum, Wadsley.

Riggall, Robert Marmaduke, L.R.C.P., etc., Second Assistant Medical Officer
to the Devon County Asylum, Exminster.

Robertson, George M., M.B., C.M.Edin., appointed Physician Superintendent,
Morningside Asylum, Edinburgh, vice T. S. Clouston, M.D., F.R.C.P.Edin.,
retired.

Wood, G. E. Cartwright, M.D., B.Sc.Edin., Bacteriologist to the Metropolitan
Asylums Board’s establishment at Belmont.

MEETING.

The next Quarterly Meeting will be held at 11, Chandos Street, on Tuesday,
May 19th, 1908.

LIV.

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 226 [ m, n W o"^.“] JULY, 1908. VOL. LIV.

Part I.—Original Articles.

Amentia and Dementia: a Clinico-Pathological Study.
By Joseph Shaw Bolton, M.D., M.R.C.P., Fellow of
University College, London; Senior Assistant Medical
Officer, Lancaster County Asylum, Rainhill.

PAGE

[Introduction and summary of contents. li. 270]

PART I.

[Morbid anatomy of mental disease. li.

[Degeneration of the cerebral vessels in mental disease . . li.

[Influence of tuberculosis on the symptomatology and morbid anatomy
of mental disease .li.

PART II.—AMENTIA.

[Introduction.

[Group I.—Idiocy and imbecility
[Group II.—Excited and “moral” cases
[Group III.—Recurrent cases ....

[Group IV.—Hysteria.

[Group V.—Epileptic insanity ....

[Group VI.—Paranoia (primary and developmental)

PART III.—DEMENTIA.

PAGE

[Introduction . Lll. 221]

[The general pathology of mental disease and the functional regions of

the cerebrum .......... lii. 224]

[Mental confusion and dementia . Lll. 428]

[Varieties of dementia . , .lii. 711 ]

LIV. 3 2

. LI.

508]

. LI.

s»s]

. LI.

523]

. LI.

659]

. LII.

>4]

284]

333]

336 ]

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434

AMENTIA AND DEMENTIA,

[July.

[Group I—Primarily neuronic dementia

[(a) Senile or “ worn out " dementia
[(b) Presenile or “climacteric ” dementia
[(c) Mature or “adult" dementia .

[(d) Premature dementia
\_Group II—Progressive and secondary dementia
[(a) Progressive senile dementia
[(b) Dementia paralytica
Croup III—Special varieties of dementia

[(a) Dementia following sense deprivation

(b) Dementia following epilepsy .

page
. lii . 716]

• 7*73

. LI1I. 84]
. LIU. IO7]
. LIII. 423]
. LIV. i]
. LIV. 10]
. LIV. 22 ]
. LIV. 265]
. LIV. 269]

• LIV. 434
. LIV. 444

• LIV. 445

Special Varieties of Dementia.

(b) Dementia following Epilepsy .

The present group contains 20 cases of " Dementia follow¬
ing Epilepsy,” of which 12 are of the male and 8 are of the
female sex.

As has already been indicated both in the introduction to
this section (Journal of Mental Science , 1908, pp. 267—8), and
also in the section on “Epileptic Insanity” (ibid., 1906, pp.
5—14), epilepsy occurs most frequently in association with
mental disease in those types of the latter in which cerebral
degeneracy is most marked. This remark is illustrated by
the following table, which shows the percentage of epilepsy in
certain divisions of the 728 cases under consideration :

Low-grade amentia

Number of
cases.

Percentage of
epilepsy.

(idiocy and imbecility)

• 94

37 ' 2

High-grade amentia

. 189

127

Dementia

445

4‘5

Total

728

io ‘9

The writer regards both epilepsy and amentia as degenera¬
cies, and considers the general effect of coexisting epilepsy to
be harmful in all types of the latter. The epileptic idiot or
imbecile is more spiteful and degraded, the epileptic high-
grade ament is more vicious and impulsive, the epileptic

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1908.] BY JOSEPH SHAW BOLTON, M.D. 435

maniac is more treacherous and dangerous, and the epileptic
dement becomes progressively more demented, than occurs in
the cases of the corresponding types of mental disease when
this complicating factor is absent.

The writer has produced evidence in this paper that epilepsy
may occur in association with any grade and even with any type
of amentia. Though for convenience cases of amentia asso¬
ciated with epilepsy have been grouped separately under low-
grade amentia (ibid., 1905, pp. 515-523), and as a special
group of “ epileptic insanity,” it would have been possible to
have scattered them throughout the various types of amentia
which have been described. Certain cases of insanity with
epilepsy might be included in the group of “excited and
‘moral’ cases,” large numbers of cases of insanity with epilepsy
are “ recurrent,” the alternation of typical hysterical attacks
with true epileptic fits has been referred to under “ high-grade
amentia with epileptic mania,” and, finally, certain cases which,
in the absence of fits, would be classed under “ paranoia,” are
illustrated by Case 237 under “higher grade amentia with
epileptic mania.” The coexistence of epilepsy and mental
disease, however, so profoundly influences the course of the
latter, and so modifies its symptomatology in the case of the
higher grades of amentia, as to necessitate the inclusion of
“ epileptic insanity ” as one of the types of amentia, unless as
an alternative “ amentia with epilepsy ” and “ amentia without
epilepsy ” were considered quite separately. This, though a
possible, is not a desirable clinical classification, because the
majority of the examples of the higher grades of amentia,
when associated with epilepsy, exhibit a sufficiently character¬
istic symptomatology to enable them to be classed under the
term “ epileptic insanity.”

The facts above cited may, in other words, be regarded
rather as evidence of the unity of mental disease than as
indicating the desirability of regarding amentia with epilepsy
and amentia without epilepsy as separate divisions of a general
group of amentia.

A similar line of argument may be applied to the subject of
dementia. The writer is of the opinion that dementia follow¬
ing epilepsy is not a consequence of epilepsy per se, but that it
occurs in such epileptics as possess higher cortical neurones of
deficient durability. Owing to the existence of certain general

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436 AMENTIA AND DEMENTIA, [July,

and local extra-neuronic but intra-encephalic morbid states, which
result in the development of a progressive dementia, in some
cases closely resembling that of dementia paralytica, examples
of dementia following epilepsy form a fairly definite clinico-
pathological group. As in the case of “ amentia with
epilepsy,” so in that of “dementia following epilepsy,” the
epilepsy, however, merely accentuates the mental state and
does not evolve anything new. The majority of the cases of
“ dementia following epilepsy ” are examples of “ primarily
neuronic dementia” of the “senile,” “presenile,” “mature” or
“ premature ” forms, in which epilepsy is a concurrent phenomenon.
A few are examples of “ progressive and secondary dementia” of
either the senile or the paralytic form. In the case of the
latter of these, owing to its syphilitic aetiology and consequent
individual course, the epileptic cases are included (in the
intention of the writer though not in fact, as the small number
of cases of dementia paralytica does not happen to contain an
example of the epileptic form), as are all the other (and non¬
epileptic) types from the imbecile to the “ normal.” In the
case of the former of these, on the other hand, this course has
not been adopted, since there is nothing especially characteristic
in progressive senile dementia beyond the inevitably
progressive nature of this type, and the senility of the cerebra
and of the cortical arteries of the sufferers. Cases of
“ Dementia following Epilepsy ” are thus conveniently grouped
together under a special heading.

Few remarks are needed with regard to the cases included in
this group.

The 12 cases of the male sex commenced at the respective
ages of 12, 15, 16, 17, 18, 25, 27, 28, 31, 32-, 38, and 39-.
The first of these was an imbecile (slight low-grade amentia),
and the others in italics were high-grade aments. Of the 12
cases, 9 were single and 3 were married, the latter being those
commencing at the ages of 18, 27, and 28 respectively.

The 8 cases of the female sex commenced at the respective
ages of 14, 24, 24 , j/-, 31, 42 , 46 and 48. Those in italics
were high-grade aments. Of the 8 cases 6 were single and 2 were
married, the latter being those commencing at the ages of 31
and 48 respectively.

With regard to the symptomatology of “ Dementia following
Epilepsy,” the writer has again and again been impressed by

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BY JOSEPH SHAW BOLTON, M.D.

437

the difficulty of distinguishing between cases of ordinary
primarily neuronic dementia and cases of epileptic dementia, in
the absence of a history of epilepsy. This remark especially
applies to cases of premature dementia, as the maj'ority of
examples of epileptic dementia occur before maturity. The
chief distinguishing feature, when a series of cases is analysed,
is the profound grade of the dementia which occurs in cases
suffering from epilepsy. Such cases, in fact, had they not
suffered from epilepsy, would probably have become ordinary
examples of primarily neuronic dementia. Under the influence
of epilepsy, however, the dementia, instead of remaining
stationary when at the most it has advanced to the moderate
stage, progresses until it becomes gross. Whilst alcoholic
cases frequently exhibit a well-marked degree of dementia with
extreme mental hebetude and great loss of memory, they differ
from cases of epileptic dementia in being, as a rule, useful
mechanical workers, who suffer from a more or less general
maiming of the cerebrum, instead of an extensive dissolution of
the centre of higher association with less marked affection of
the regions concerned with the processes of lower association.

As a rough criterion of the severity of the grade of dementia
which exists in epileptic cases which have developed dementia,
it may be remarked that of the 12 males, g were unable to
work, 2 were ordinary workers, and I could do a little work; and
that the whole of the 8 females were incapable of employment.

The following table, which for convenience is inserted here,
very roughly but graphically illustrates the relative severity of
the grade of dementia in the several types of cerebral dissolu¬
tion described in this part of the paper :

Type. Workers.

Refuse
to work.

Unable
to work.

Total.

Primarily neuronic dementia :

Premature

e 4

• 15 •

33 •

112

Mature ....

.11

7 •

Presenile ....

• 13 •

1 7 •

Senile ...

. 10

56 .

123

Progressive and secondary dementia :

Dementia senilis

. - .

Dementia Paralytica .

• 4 •

9 •

Dementia following sense deprivation

. — .

7 •

Dementia following epilepsy

. — .

Dementia following cerebral lesions

‘ ~ *

6 .

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438

AMENTIA AND DEMENTIA,

[July.

It will be noted that the proportion of non-workers is about
the same in the groups of progressive senile dementia and
of dementia following epilepsy.

The following ten cases of “ Dementia following Epilepsy w
are inserted as illustrative examples of the group under con¬
sideration :—

Imbecility with Epilepsy; Premature Dementia; Afale, at 22;
duration of retrogressive symptoms ten years .

Case 701.—A. T—, male, single, of no occupation, set. 22. Certi¬
fied two years. An illegitimate child. Epileptic since the age of two
years, and showed mental symptoms at the age of twelve years. Notes
taken four days after admission.

A very dull and phlegmatic man who appears to be about sixteen or
seventeen years of age. When the attendant is asked if the patient has
had any fits the latter replies : “ I ain’t got nothing in here,” and smiles
fatuously, adding, “ No more fits, never take them things.” He gives
his name and states that his age is twenty-one. When asked to write his
name he does this in the slow and careful manner referred to in the
section on “Premature Dementia,” and also writes the surname first and
then the Christian name afterwards on the next line. When asked whether
he has been to school he replies, “ Got put in H— Asylum and had to
do school along with ’em.” He says that he has done nothing since he
left school. When he is then asked about his fits he says, “ I don’t take
’em now,” and adds, “ I took fits for years ; none for eight years ; had
’em right on my life till then.” He remarks that his mother wanted to
kill him, but didn’t dare to do it, and that his father also wanted to kill
him with a poker. “ I didn’t want that thing; he ain’t what I call a
father; he’s only a step-father to me.” He does not know where he is.
He came “when them men come ; last week I think.” He states that
the day is “ Thursday or else Friday ” (Monday). He was at his
previous asylum four or five months, “That’s all I was down there”
(nearly two years).

Whilst under observation the patient was unable to occupy himself,
but was clean in his habits.

High-grade Amentia with Epilepsy ; Premature Dementia ; Male , at
27 ; duration ten years .

Case 703.—C. J—, male, single, of no occupation, aet. 27. Certified
ten years, and showed symptoms for some months previously. Notes
taken four days after admission.

A dull-looking man, with a narrow peaked forehead and a rough
skin. Convergent strabismus. He has a habit of performing washing
movements with his hands as he sits. He gives his name in a slow
drawl, and when asked his age replies, “ I ain’t sure of the age.” He
writes his name in the slow and careful manner already referred to as
characteristic of premature dementia. He knows neither where he is

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439

1908 .]

nor where he has come from. He apparently has no recollection of
the name of the asylum from which he has been transferred: at any
rate, he states that he has not heard the name before when it is re¬
peated to him. He knows neither the day nor the date. When asked
about fits he replies, “ I hev had ’em,” and states that he does not
know when.

He feeds himself, and can partly dress himself. He knows the way
to the lavatory, and at times walks about the ward. He is entirely
unemployed. He is occasionally shaky on his legs.

Whilst under observation this patient remained quite unchanged.

Epilepsy; Premature Dementia; Male, at. 24; duration seven years.

Case 704. —A. E—, male, single, of no occupation, set. 24. Certi¬
fied some months. He first showed symptoms at the age of seven¬
teen, about which age his fits began. Notes taken five days after
admission.

A dull man of childish appearance. Several old scars on the fore¬
head. Pupils large and react normally. Left slightly larger than
right. He gives his name, adding a second Christian name, and states
that his age is twenty-four on his next birthday. When asked when he
came here he replies, “We all came together between a week and a
fortnight.” He, however, knows the present day and the day on which
he came. He calculates the interval from Thursday to Tuesday to be
seven days. When asked about his fits he indicates that they are mild,
as follows: “ There’s nothing to say of ’em, if I was to have one.” He
states that he was only a fortnight at his previous asylum. He says
that before he went there he hawked fruit, but has no idea when that
was. He says that he intends to continue this occupation when he
leaves this asylum. He went to school when he was “ a little nipper,”
and got into the “ highest standard.” He says (incorrectly) that he can
read and write well. His attempts at arithmetic are as follows:
12 x 11 = 24, 7x9=64, 8x5 = 40, 7 x 6=42, 12 x 11 = 64, 5x9 = 64,
8x11 = 56, 4x3=12, 9x2 = 24, 4x2 = 8. It is, therefore, quite
clear that he has at one time learned, but has forgotten, the multiplica¬
tion table. He says that he did no work at his previous asylum, but
he thinks that “ If I were asked to do it I should hev to do it, I dare
say.”

Whilst under observation this patient looked after himself. He
never did, or attempted to do, any work. He occasionally used to
pick up a newspaper, but did not seem to be at all interested in its
contents.

High-grade Amentia with Epilepsy; (? Presenile) Dementia; Male,
at. 45/ certified seven years; showed symptoms for twenty-seven
years.

Case 705. —W. E—, male, married, farm hand, set. 45. Certified 7
years, but had shown symptoms since the age of eighteen. Mother
insane, and maternal aunt deaf and dumb and “ silly.” Notes taken
four days after admission.

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440

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A man of anthropoid appearance. Ears simple, pear-shaped, and
without lobules. Smile happy and fatuous. He at once begins to talk
in a practically incoherent manner. Name? “Yes, E—; I be the
youngest one.” Age ? “Yes, I bin middling hearty, I ain’t bin ailing
like.” AGE ? “ Pretty nigh 40.” Married ? “ Yes, been married, wife’s
dead and gone, and young uns, too; I think more on ’em so I ain’t
troubled myself about ’em.” He has had fits for several years, but “not
for two years I don’t think I have.” What day is it? “I used to take
a little physic, I did, just to keep a cold wave on me.” Age ? “ I was
bom in five and twenty in February.” Where are you? “At R. B—"
(name unknown). Have you ever heard of H—? (the asylum from
which he has come) “No I’ve never touched her, some says she’s been
about here, but I ain’t seen her and I don’t know her.”

This patient remained unchanged whilst under observation. He was
dull and quiet and uninterested in his surroundings. He at first
required coaxing even to dress himself and made no attempt to employ
himself, but later on became a worker of average type.

Epilepsy ; Dementia; Male , cet. 66; certified twenty-seven years .

Case 707.—A. G—, male, married, occupation unknown, aet 66.
Certified thirty-nine years. Notes taken four days after admission.

A dull, heavy and depressed-looking man. His forehead is covered
with vertical and horizontal wrinkes. He appears to take no interest in
his surroundings, and sits down without looking at me. Whilst being
examined he incessantly turns his hat round and round. He gives his
name as “ J. W—, from L — ” (both these names are unknown). His
age is “very near 60.” Where are you ? “ Three corners off Old Road”
(name unknown). When the name of the asylum from which he has
come is mentioned to him he does not recognise it, and adds “ I heard
some talk of such a party . . . and three more besides.” What time

of year is it ?“ 12 o’clock ” (3 p.m.) He says that he has not yet had his
dinner to-day. He recognises one of the attendants as the man who
“keeps the stores.” When he is asked who another is he replies,
“ B—r if I do.”

As a rule the patient looks stolidly forwards or downwards, but at
times he looks up in a dull and sleepy way. Whilst he is apparently
deeply absorbed he at once looks up if he is gently touched on the
hand. He replies fairly readily to questions, and, as has been indicated
above, he has a habit, when he is doing such a thing as putting on his
trousers, hat, etc., of passing the article from hand to hand, from the
left to the right round the front, before he puts it on. He feeds
himself. He never makes a move to the lavatory.

Whilst under observation he remained quite unchanged.

High-grade Amentia with Epilepsy; Premature Dementia ; Female^
2 4 > cer lifted seven years , and previously at the age of fourteen

Case 713. F. C,— female, single, of no occupation, aet. 24 ; certi-

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1908.] BY JOSEPH SHAW BOLTON, M.D. 44 1

fied seven years, and previously at the age of fourteen years. Notes
taken, on the day after admission.

A dull, vacuous girl, with an open mouth and a vacant expression.
Pupils dilated. Palate very high and V-shaped. Ears lobuleless. She
gives her name and states that her age was twenty-two years last
December. She speaks with a certain amount of hesitation. She does
not know when she came to this asylum. She recognises the name of her
previous asylum when it is repeated to her, and says that they have a
home built there, that she has come from it, and that she was there “ a
good long time now.” She informs me that previously she lived
with her “ gwanmother.” She does not know when she began to have
fits. “ It makes my head so funny. I couldn’t hardly tell you.” When
she is going to have a fit her “ bosoms hurt me and my head goes.”
She here makes jerky movements with her hands over her forehead,
and adds, “ Makes my head so funny that I don’t know where I am the
same day I have ’em.” . . . “ My head is funny for two or three

days afterwards.” Patient is very childish and simple, very dull and
listless, and quite unable to employ herself, although she can dress
herself with assistance.

Whilst under observation this patient remained unchanged.

High-grade Amentia with Epilepsy; Premature Dementia ; Female ,
cet, 27 years ; duration three years.

Case 715.—M. W—, female, single, of no occupation, set. 27. Was
previously in an asylum at the age of twenty-four years, and the
present is a continuation of that attack. Notes taken two days after
admission.

Patient is a dull-looking girl, who at first resisted when she was
brought forward for her case to be taken. She gives her name, but
does not know her age. She knows that she has been here two days.
She writes her name slowly, painfully, and carefully. Her attempts at
arithmetic are as follow: 2 x 2 = 3, 4x2 = 8, 5x3 = 9, 6x2 = ?
She spells cat “ tac.” She cannot spell “ horse,” and she says that she
does not know what a horse is. She spells “cow” and “man” cor¬
rectly. During this examination she stands up as if saying a lesson.
Her articulation is normal, and the above replies, as does her hand¬
writing, present the various indications which have already been described
as characteristic of ordinary premature dementia. She is dull and slow
and appears to know nothing about anything when she is questioned.
When I have done with her she walks off and imagines that she is
going home.

After five months her condition was as follows : She is on the whole
quiet, and she is entirely unemployed. She dresses herself somehow
and washes herself, and then requires to have her hair done for her.
For from ten to thirty minutes before a fit she is excited, violent, and
impulsive, strikes the nurses, and throws the furniture about. After a
fit she is for at least twenty-four hours very dull, drowsy, and con¬
fused. She thinks that people deprive her of her food. She sometimes
stands or wanders about the whole day, but takes no notice of anyone.
When asked to do anything, e.g. t to play the piano, she says, “ No, I’m

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442

AMENTIA AND DEMENTIA,

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not going to; I don’t want to,” but soon afterwards will get up and
do it She never either reads or writes. She is invariably clean in
her habits.

Whilst under observation this patient remained unchanged.

High-grade Amentia with Epilepsy; Dementia; Female , cet. 32;
certified one year and previously in an asylum.

Case 716.—E. F—, female, single, of no occupation, aet 32. Cer¬
tified one year and had previously been in an asylum. Notes taken on
the day after admission.

A vacant-looking girl with a pale face and staring eyes; pupils
mobile : palate narrow and very high ; ears lobuleless. She gives her
name “same as you’ve got written there,” pointing to my book. Age?
“ I don’t justly know how old I am, but I had a birthday on October
3rd.” She knows the day and has been living here “ some time now.”
She went to H— (her previous asylum) in a fly yesterday when the fly
went there, and she was in the train yesterday. She thinks that she
went to H— (her previous asylum) yesterday, “ same as the rest of ’em
did.” She thinks that the month is September (October), and repeats
that her birthday will be on October 3rd. She came here because she
had fits. She suffered from them for some time before coming here.
“ I never hardly knows when I have ’em. I’m taken so suddenly and
knocked down on the floor.” After a fit “I feel all right.” After her
examination was concluded and she was going away she suddenly fell
down on the floor exactly like a case of hysteria.

Whilst under observation this patient was dull, listless, and un¬
occupied. She did very little for herself and took little or no interest
in her surrounding.

High-grade Amentia with Epilepsy; (? Premature) Dementia ; Ftmak,
at. 43 ; certified otie year.

Case 718.—L. G—, female, of no occupation, aet. 43. Certified one
year. Notes taken on the day after admission.

A dull, apathetic, and sleepy-looking woman. The angles of her
mouth droop, and her hands are narrow and atrophous, and show signs
of prolonged disuse. She is very dull and slow in speech and movement,
and pays little attention to questions. She gives her name and states
that her age is 38 years. She, after repeated requests, slowly and
laboriously writes her name as an almost unintelligible scrawl. When
she reaches the edge of the paper she endeavours to squeeze in the last
three letters, and, failing to do this, leaves out the last two. She is
very slow at imitating simple movements, and especially so when both
hands are needed. When her limbs are thus placed in some position
they often remain so for as long as a minute before she slowly allows
them to fall to her lap. Were it not known that the patient frequently
suffers from epileptic fits—for example, she had five during the night
following her admission—the case would, without hesitation, be diagnosed
as one of long-standing premature dementia with motor symptoms (cata*
tonic form).

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BY JOSEPH SHAW BOLTON, M.D.

443

Whilst under observation the patient remained dull and apathetic,
uninterested in her surroundings, and quite unoccupied. She was
unable to do anything for herself and was defective in her habits.

Epileptic Mania ; Progressive Presenile Dementia ; Female , cet. 54 ;

certified six years .

Case 720.—E. V—, female, married, housewife, set. 54. Certified
six years. Mother suffered from fits. Notes taken two days after
admission.

A garrulous woman with a very scarred face. She gives her name,
and states that her age is fifty-two years. She has come from “Worth
Rectory. That was my home and I’ve always found it so.” She
points out one of the patients and says that she is her niece. She then
informs me that Queen Alexandra has four or five daughters here, and
that the nurse is her sister-in-law and Mr. J. N—’s wife. She does not
know me, but asks if I took lodgings at her place when she first came
away. She knows the day, and says that she could soon tell me the
date if she had an almanac. She owns “this whole place. My
brothers have bought the ground in front of my house here and your
brother took the butcher’s shop on the schools.” She then begins to
tell me about her family. When asked about fits she tells me that she
has had two in about twenty years. She has been married sixteen or
eighteen years, and has had twelve or fifteen children. “ They came
by anyhows. I once had three and my sister that is Queen Alexandra
now helped me through with ’em, but they all died as soon as they
were born. Mr. B— (name unknown) didn’t like to see ’em lying
about, and he used to make boxes and bury ’em. They were only tiny
children and lived only ten hours, and I had three alive working under
the Queen at R— Church, my own daughter, a nephew of mine, and
my own son.” Ten years ago she had her tongue taken out and cut
off and splintered, and her husband, her brother, and herself have all
been mutilated.

Five months after admission the following notes were taken : She
looks a dull, miserable object. She says that she has been murdered
by inches and inches for 127 years and worse for 119 years. She has
a clock to prove it, the clock of her grandmother, which stood for
over 1,000 years in a church. The ward clock is a church clock, and
no one can claim it but herself. To-day is “ Tuesday, hot-cross-bun day ”
(Monday, February 1st). “I will give you a clean apron on Valentine’s
day. I am not saucy, and give no one sauce,” etc. She is very
abusive, and at times uses foul language. She is violent and impul¬
sive and a “ terror.” Nearly every day she swears about her food,
and if she cannot at once get what she wants she throws the plates,
chairs, etc., about. She is not destructive, but she is untidy in her
appearance and cannot dress herself properly She never does any
work. She sometimes asks for a prayer-book and then swears at it.
She has very severe fits, and for two or three hours after them she is
confused and violent.

Whilst under observation this patient visibly deteriorated in her mental
condition, though she remained as violent and impulsive as before.

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444

AMENTIA AND DEMENTIA,

[July,

The present and final group contains eight cases of cerebral

lesion of various kinds. They are as follows :—

M. F. T.

(1) Cerebral syphilis - . .2 - 2

(2) Other lesions (gross) :

(a) Old standing (embolism, etc.) 123

(b) Gross vascular degeneration . — 3 3

Total . .3 5 8

This group calls for no especial remark beyond the reference
contained in the introduction to the section ( Joum . Ment. Sci .,
1908, pp. 268-9).

Of the cases of cerebral syphilis, No. 721 is an example of
organic dementia in a man of originally defective intelligence
who was aged 42, had been certified nine years, had been pre¬
viously under asylum treatment between the ages of fourteen and
twenty-four, and showed evidence of congenital syphilis ; and No.
722 is an example of progressive dementia, who was aged 46,had
been certified one year, and showed evidence of former syphilis,
gross vascular degeneration, and paralysis of the left side of the
face. The father of the latter case was insane.

Of the cases of gross lesion, the male patient (No. 723) was
aged 41, had been certified four years and suffered from bi¬
lateral palsy secondary to trauma. Of the five females, No.

724 was aged 45, had been certified since the age of twenty-eight,
and suffered from a right-sided palsy following childbirth; No.

725 was aged 48, had been certified one year, and also suffered
from a right-sided palsy ; and Nos. 726—728 are examples
of progressive dementia, with cerebral lesions following vas¬
cular degeneration, and were aged respectively 67 (certified
three months), 75 (certified twenty-nine years), and 53 years
(certified twenty-two years).

None of the cases contained in this group are appended, as,
apart from dementia, their symptomatology is individual and
accidental, and their inclusion would, therefore, serve no useful
purpose.

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BY JOSEPH SHAW BOLTON, M.D.

445

General Review and Summary^).

The present paper contains the final results of an investi¬
gation into the functions of the cerebrum and the physical
basis of mental disease which has occupied the writer during a
period of more than twelve years. The general review and
summary, which follows, therefore affords him an opportunity
of generally summarising the results of his researches and of
indicating on the one hand in what degree they confirm and
elaborate the conclusions of other workers, and on the other in
what respects they differ from these.

The first paper of the series was published in the year 1900,
and dealt with the exact histological localisation of the visual
area of the human cortex cerebri. In this communication the
cortex of the occipital region of the cerebrum was minutely in¬
vestigated, and the writer histologically mapped out a definite
area surrounding the calcarine fissure. This region, which he
termed the “ visuo-sensory area,” he proved to be the visual
projection sphere by a systematic micrometric examination of
the whole of this and of the neighbouring cortex in normal
persons, and in cases of long-standing and of congenital blind¬
ness. In the cortex surrounding the visuo-sensory area, to
which he applied the term, since adopted by Campbell, Mott,
etc., of “ visuo-psychic,” he found by the micrometric method
that old-standing optic atrophy and congenital blindness caused
no modification of the lamination. In this paper the writer intro¬
duced a classification of the cortical layers of the visuo-sensory
area and of the visuo-psychic region (based on the existence of
three primary cell and two primary fibre laminae), which has
since been largely adopted, notably by Mott and by Watson. It
may further be noted that in this paper the results of the
writer's later study of the mode of development of the cortical
laminae were foreshadowed in the statement, “ The majority of
the layers of the cortex do not vary appreciably in thickness as
the result of age or chronic insanity, but there is an almost
exact correspondence between the thickness of the conjoined
first and second layers of the cortex (outer layer of nerve-fibres
and pyramidal layer) and the degree of amentia or dementia
existing in the patients.” Amongst other facts which were
elicited was one of primary importance with regard to the

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446 AMENTIA AND DEMENTIA, [July,

functions of the cell-layers of the cortex, namely, that the
pyramidal layer of the visuo-sensory area develops earlier than
that of the visuo-psychic region, and reaches its adult depth at
the age of one month : whereas in the latter region it is less
than three-quarters of the adult depth at the age of one month,
and but five-sixths at the age of three months.

With regard to the delimitation of the visuo-sensory area,
the writer indicated that his research confirmed the opinion
held by Henschen and supported by the embryological
researches of Flechsig and the clinico-pathological observations
of Seguin, Vialet, etc.

In introducing his classification of the cortical layers he
critically examined those of Meynert (1872), Krause (1876),
Betz (1881), Leonova (1893), Hammarberg (1895), Schlapp
(1898), and Cajal (1900).

Since the publication of this paper, which was the first of
the kind since the important research of Bevan Lewis and
Henry Clarke (1878) on the cortical localisation of the motor
area of the brain, whose belated recognition has followed the
experimental work of Sherrington and Griinbaum, and the
histological researches of Campbell and of Brodmann, many
papers dealing with cortical localisation by the histological
method have appeared. Of these the chief are by Brodmann
(1902-1907), Campbell (1905), W. Kolmer (1901), Hermanides
and Koppen (1903), Koppen and Lowenstein (1905), Elliot
Smith (1904-1907), O. Vogt (1906), Mott (1907), and G. A.
Watson (1907). In these papers the whole cortex in many
orders of mammals has been mapped out into various histo¬
logically different regions, but, except in the case of the visuo-
sensory and motor areas, experimental or histological proof of
the function of these areas is not yet complete. Two only of
these researches call for remark here, namely those of Brodmann
and of Campbell. These authors have independently mapped
out into histologically different areas the whole human cortex
cerebri. In only two regions, however, are their maps in com¬
plete accord, namely in the motor or Betz-cell area and the
visuo-sensory area. The former of these is the area mapped
out by Lewis and Clarke (1878), and the latter is that mapped
out by the writer (1900). The extent of the visuo-psychic
region, which was described by the writer as surrounding the
visuo-sensory area, but was not more closely defined owing to

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BY JOSEPH SHAW BOLTON, M.D.

447

its somewhat indefinite limits, is given so differently by
Brodmann and by Campbell that it might appear that no
advance had been made on his original description. A careful
study of the maps of Brodmann and of Campbell in the light of
the writer’s special knowledge of the histological characters of
several portions of the cortex cerebri has, however, convinced
him that the more elaborately detailed map of the former of
these investigators is the more correct. In support of this
statement he would refer to the recent paper of Gordon
Holmes on the histology of the post-central gyrus, in which
the findings of Brodmann are confirmed. The writer is, how¬
ever, of the opinion that whilst further histological research will
undoubtedly enable certain other (projection) areas to be as
precisely defined as have been those of the motor and visuo-
sensory areas (even if Brodmann’s findings in these respects
should not be confirmed in their entirety), the differentiation of
the remainder and greater portion of the grey mantle into
equally precise areas will be attended with great difficulty
owing to the probability that considerable differences exist in
the case of different individuals. He nevertheless regards such
precise differentiation as possible, and considers that light will
in the future be thrown on the histo-pathology of amentia or
cerebral sub-evolution by this means.

It may, therefore, be stated that the exact limits of the
motor or Betz-cell area, and of the visuo-sensory area, are
known beyond doubt, and that their functions have been
proved by experimental or histo-pathological methods. As
regards the less certainly defined visuo-psychic region, the
associational, in contra-distinction to receptive, function of this
region has been developmentally proved by the writer in the
paper under present reference, and he here, from a different
aspect, confirms the doctrine of Flechsig with regard to centres
of association and of projection.

The next paper to which reference will be made was pub¬
lished in 1903, and dealt, by the method of micrometric
measurement, with the histological basis of amentia and
dementia. The first part of this research consisted in an
attempt, which was successful, to determine whether any con¬
stant relationship existed between the macroscopic morbid
appearances, which are well known to exist in many cases of
mental disease, and the clinical types of insanity manifested

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AMENTIA AND DEMENTIA,

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by the patients. It was shown that these morbid appearances
vary in degree with the amount of dementia existing in the
patients, and are otherwise independent of the duration of the
disease ; and the following regions of wasting of the cerebrum
in dementia were determined :

(1) The greatest amount occurs in the prefrontal region
(anterior two-thirds or so of the first and second frontal con¬
volutions, including the neighbouring mesial surface, and the
anterior one-third or so of the third frontal convolution).

(2) It is next most marked in the remainder of the first
and second frontal convolutions. (In dementia paralytica
Broca’s gyrus should, as a rule, be included here, and 2 and 3
should follow 4.)

(3) It is, perhaps, next most marked in the ascending
frontal and Broca’s convolutions, though this, in many cases at
least, should follow 4.

(4) It is next most marked in the superior and inferior
parietal lobules and in the first temporal convolution.

(5) It is least marked in the remainder of the cerebrum.

With regard to cases of insanity without dementia, it was

indicated that no morbid appearances were present, but that
small and simply convoluted cerebra were frequent. It was
further shown by micrometric measurement that in certain such
brains as appeared normal on macroscopic examination the
cortex was markedly deficient in depth.

The second and histological part of the paper dealt with the
micrometric examination of a specially selected area lying in
the centre of the chief focus of wasting (1), in foetuses, infants,
normal individuals, idiots, imbeciles, cases of chronic and re¬
current insanity without dementia, and cases exhibiting various
grades of dementia. The writer was able to demonstrate
several facts, of which the following are the most important :

The normal prefrontal cortex .—In the three normal cases
examined, not one of which is likely to be developed above the
average, and any one or all of which may be below this, the
general average measurements of the first case are almost the
counterpart of the average of the three. The difference between
the several cases exists in the pyramidal layer of cells, which of
all the layers is the easiest to measure accurately, and the other
layers are practically of the same depth.

The development of the prefrontal cerebral cortex .—The pre-

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1908.] BY JOSEPH SHAW BOLTON, M.D. 449

frontal cortex begins to laminate about the sixth month of
foetal life by the separation off of the polymorphic layer (5),
and the inner line of Baillarger (4), both of which layers are
very little below (three-fourths of) the normal depth almost
from the first. The layer of granules (3) next develops, and
at the period referred to is only about half the normal depth.
At this time the pyramidal layer (2) is only one-fourth of the
normal depth. At birth the pyramidal layer is still little more
than half the normal depth; the granule layer (3) has now
become three-fourths of the normal, and the fourth and fifth
layers are as before (rather more than three-fourths of the
normal depth).

The prefrontal cortex of congenital amentia .—Degrees of
under-development, general and local (f.e. y with regard to position
in convolution, not to position in cerebrum), exist, which vary
inversely with the mental power of the individual concerned.

The prefrontal cortex of chronic insanity without dementia .—
In these cases under-development of the pyramidal layer of
nerve-cells exists, the other layers being approximately normal.

The prefrontal cortex in dementia and dementia paralytica .—
Degrees of wasting exist which vary directly with the amount
of dementia present. When the mental power of the patient is
as that of the new-born child, all the cortical layers are approxi¬
mately in the same condition as in the latter.

Amentia and dementia. —In many cases amentia undoubtedly
co-exists with dementia, but as a whole the greater the amentia
the less is the dementia co-existing, and vice~versA y as the less
highly developed the neurones the greater is their relative
durability, and the less is the injury produced by the slight
“ stress ” which is necessary to affect them, whilst, on the con¬
trary, highly developed but deficiently durable neurones, to be
subjected to a breaking strain by “ stress,” require it in their
case to be so great that rapid degeneration results. This de¬
generation only becomes extreme in those cases in which severe
vascular affection is present.

As a consequence of these results the writer was, therefore,
enabled to formulate the following conclusions with regard to
the functions of the cortical cell-layers :—

The layer of polymorphic cells (5) is the first to be differen¬
tiated during the process of lamination, and it is the last to
fail in the retrogression of dementia. A decrease in this layer

Liv. 33

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AMENTIA AND DEMENTIA,

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exists in extreme aments (normal or otherwise), and in dements
who are unable to carry on the ordinary animal functions, such
as attending to their own wants, etc. This layer , therefore ,
probably subserves these lower voluntary functions of the animal
economy .

The granule layer (3) is developed after the polymorphic
layer. In the visuo-sensory area the optic radiations end in
the midst of the hypertrophied and duplicated granule layer.
This layer , therefore , probably , reasoning by analogy, subserves
the reception or immediate transformation of afferent impressions ,
whether from the sense organs or from other parts of the
cerebrum.

The pyramidal layer (2) is the last layer of the cortex
cerebri to develop, and it is also the first to undergo retro¬
gression in dementia. It is the only layer which appreciably
varies in depth in normal brains ; the degree of its development
in normal infants and in congenital aments varies directly with
the mental power of the individual, and the degree of its retro¬
gression in demented patients varies directly with the amount
of dementia existing in the patient. This layer y therefore ,
subserves the “psychic ” or associational functions of the cerebrum.

The first and fourth layers of the cortex cerebri, being
primarily cell-process layers, do not need further reference in
this connection, although it is not denied that the relatively
small number of cells which, in the adult state of the cortex
especially, are contained in these layers, may and probably do
possess important though minor functions in the process of
cerebration. In the psycho-motor area, for example, the Betz
cells, which really belong in the opinion of the writer, to the
fourth layer or “ inner line of Baillarger,” and are therefore not
“ pyramidal ” cells at all, constitute the origin of the important
efferent tract for skilled voluntary movement. Probably the
“ solitary cells ” of Meynert in the occipital cortex possess a
somewhat analogous function, and perhaps the same may be
said concerning the more or less pyramidal-shaped cells which
lie in layer 4, or the “ inner line of Baillarger,” in other regions
of the cerebrum. One is probably hardly justified in assigning
a function to the few cells which lie in the first or superficial
layer of the cortex cerebri, but perhaps, reasoning on general
grounds, it is not unfair to suggest that they possess associa¬
tional functions similar to those of the pyramidal layer above

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1908.] BY JOSEPH SHAW BOLTON, M.D. 45 I

which they lie, and with which, in order of time, they appear
to be developed.

In a further communication, also published in 1903, the
writer applied his results to the question of the functions of the
frontal lobes. He remarked : “ The anterior centre of associa¬
tion of Flechsig is the region concerned with attention, and
the general orderly co-ordination of psychic processes ; and the
cellular elements throughout the cortex, which are especially
concerned in the performance of associational functions, are
those of the pyramidal layer of nerve cells ” ; and, “ The
pyramidal layer, therefore, subserves the * psychic’ or associa¬
tional functions of the cerebrum. This is pre-eminently the
case in the prefrontal region, less so in the visuo-psychic region,
and least of all in the visuo-sensory region. These three
regions are , therefore , of different grades in the hierarchy of
cerebral function .”

The writer is thus in agreement with Flechsig with regard
to the existence of centres of association and of centres of pro¬
jection, but, as the result of his researches, he defines three
grades in the hierarchy of cerebral function, namely : (1) centres
of projection, of which the visuo-sensory area is a type ;
(2) regions of lower association, of which the visuo-psychic
region is a type ; and (3) the centre of higher association, co¬
ordination, and control, which is situated in the prefrontal region.

The writer thus differs from both Flechsig and Bianchi in
recognising three grades of cerebral function, in place of the
projection and association areas of the former, and the percep¬
tive and conceptive centres of the latter.

He will now refer to the important paper by Watson (1907)
on the mammalian cerebral cortex, which, from the phylogenetic
aspect, forms the complement of the ontogenetic conclusions
which the writer published in 1903 with regard to the mode
of development and functions of the primary cell-laminae of the
cortex cerebri. In this paper Watson has mapped out the
cortex cerebri of certain insectivores into histologically different
regions, and he has confirmed the work of the writer on the
order of development of the primary cell-laminae of the cerebral
cortex, and as regards the functional significance of these.
Watson’s conclusions, in brief, are as follows:

“ The foregoing data support the following conclusions, which
apply only to mammals , and which form, from the point of

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452 AMENTIA AND DEMENTIA, [July,

view of the Insectivora, and of the lower mammals belonging
to various other natural orders so far examined, a complement
to those arrived at by Bolton, as the result of his studies of the
development of the human cerebral cortical layers, and of their
depth in the adult normal individual as well as in various degrees
of amentia and dementia,

“(i) The infra-granular portion of the cortex (4 and 5)
(omitting the constituent cells which possess motor or analogous
functions) is concerned especially with the associations neces¬
sary for the performance of the instinctive activities, that is, all
those which are innate and require for their fulfilment no experi¬
ence or education. These form the basis of many complex
actions necessary for the preservation of the individual and the
species, such as the seeking appropriate shelter and protection,
the hunting for food—each after his own kind—and the quest
of the opposite sex. . . .

“ (2) The supra-granular (pyramidal) layer—which is, rela¬
tively to the infra-granular cortex, so poorly developed at birth
—is slow in reaching maturity, and is, even at its best, in certain
lower mammals, such as the Insectivora, only of an insignificant
absolute depth, subserves the higher associations, the capacity
for which is shown by the educability of the animal. It has,
therefore, to do with all those activities which it is obvious that the
animal has acquired (or perfected) by individual experience, and
with all the possible modifications of behaviour which may arise
in relation to some novel situation, hence with what is usually
described as indicating intelligence as apart from instinctive
acts, the former being not merely accompanied but controlled
by consciousness (Lloyd Morgan).

“In practical animal behaviour the two sets of processes are
probably more or less constantly interwoven, the higher activities
(supra-granular layer) coming to the aid of the lower as far as
the capability of the animal allows. In the case of the lower
mammals (eg, Insectivora), the limits of this capability are
comparatively soon reached, and correspondingly these mammals
possess a relatively poor supra-granular layer. . . .

“ The infra-granular layers thus constitute the earlier de¬
veloped and more fundamental associational system of the cerebral
cortex; the supra-granular layer, a higher and accessory system
super-added, and of any considerable functional importance only
in certain regions in lower mammals, such as the Insectivora."

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BY JOSEPH SHAW BOLTON, M.D.

453

The writer will now generally review his present paper,
which, whilst it summarises, and in places provides further data
with regard to, his previous researches, is mainly devoted to
the application of these to the subject of mental disease.

The paper consists of three parts, of which the first (April,
1905) is devoted to the verification and amplification of his
conclusions with regard to the correlation of the various clinical
types of mental disease with the morbid appearances found in
such cases after death. For this purpose the earlier 200 cases
have been increased to 433 with substantially identical results.

As the result of his clinico-pathological and histological
studies the writer enunciated a provisional classification of
mental diseases, in which he used the term amentia to, in the
widest sense, connote the mental condition of patients suffering
from deficient neuronic development , and the term dementia to
similarly connote the mental condition of patients who suffer
from a permanent psychic disability due to neuronic degeneration
following insufficient durability .

The term amentia as thus defined covers a much larger
group than that indicated by the terms idiocy and imbecility,
and includes all cases possessing a general or special develop¬
mental deficiency which may become evident either with the
dawn of psychic life, or at such critical periods as early
childhood and school-life, puberty, adolescence, marriage,
maturity, childbirth, the climacteric, etc., at any one of which
the degenerate may fail to respond normally to his environ¬
ment and may show his or her inherited deficiency.

The class may be grossly divided into two subdivisions,
namely low-grade aments , or idiots and imbeciles, and high-
grade aments , in whom the developmental deficiency becomes
evident at or after puberty. In the case of the latter group,
apparently complete recovery of a permanent or a temporary
nature may occur, a stationary condition of insanity without
appreciable dementia may follow, or at once or later a varying
degree of dementia may ensue. These patients usually show
more or less marked stigmata of degeneracy, and, in the case
of the first two sequelae referred to, post-mortem examination
of the cranium shows no abnormality of the intra-cranial fluid
or membranes, apart from those associated with the local or
systemic diseases which are the cause of the fatal issue.

The term dementia , as defined by the writer, is also applied

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454 AMENTIA AND DEMENTIA, [July,

in a somewhat different manner from that sanctioned by
common usage, in that it refers to a permanent psychic
disability due to neuronic degeneration, and not to a loss of
mental power, which may be temporary or permanent He
employs the term mental confusion to connote the symptom-
complex, which occurs in many acute cases of insanity, and
which is not peculiar to what is commonly described as
Korsakow’s disease or “ polyneuritic psychosis,” but occurs to
some degree not only in many cases which recover, but in all
cases which are developing dementia.

Onset of mental confusion .—As in the highest grades of pure
amentia, so in all cases associated with mental confusion, the
time of onset of the attack (*>., when the potential lunatic
becomes an actual one) depends on “stress” in the very
widest sense, and including the specific causes of mental con¬
fusion which are enumerated in the section under remark.
The “ stress ” required may be slight, as when the hereditary
disability is marked, in which case the patient rapidly enters
an asylum and either recovers, often only to relapse, or remains
a permanent inmate ; or it may be extremely great, as in the
highest psychopaths, where syphilis, alcoholic excess, a
generally irregular life, and the severest business strain and
worry may be needed, in which case an extremely rapid case
of dementia paralytica is likely to ensue ; or any intermediate
degree may be necessary to determine the breakdown.

Development of dementia, .—In the more lowly aments the
neurones are relatively stable, as their functional power is so
slight that “stress” cannot intervene to any dangerous extent,
and consequently these cases do not, as a rule, develop
dementia, especially as they frequently die before (premature)
senile involution of the cortical neurones occurs. On the other
hand, in higher degenerates of any grade whose neurones
suffer from deficient durability, it may almost be considered a
general law that the higher the development of the neurones,
the greater is the degree, or at any rate the more rapid is the
progress, of the dementia which results when “stress” has
determined the time of onset of the insanity. Until senility
occurs, or apart from vascular changes due to whatever cause,
the dementia is never severe, the ordinary chronic lunatic with
moderate dementia being the common result. It is, however,
probably correct as a general average statement (excluding

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1908.]

BY JOSEPH SHAW BOLTON, M.D.

4 SS

dementias ensuing on mental confusion following the indirect
action of toxines) to remark that the dementia of puberty and
adolescence is severer on the whole than the dementia of
maturity, and this, again, than the dementia of presenility (eg.,
climacteric melancholia, etc.). The primary cause of the
development of dementia is thus a deficient durability of the
cortical neurones. If this decrease in durability is slight,
neuronic degeneration ensues in old age; if it is more marked,
it occurs at the climacteric; if it is still more marked, it will
appear at maturity; and if it is very marked, it will appear at
adolescence or even puberty. On the other hand, in amentia
the deficiency is developmental, though in many aments
deficient durability also exists, and the mental condition thus
often becomes a mixed one owing to the development of
dementia in a high-grade ament or in one of the milder types
of low-grade amentia.

The second and third parts of the present paper deal,
chiefly from the clinical aspect, with “Amentia” and “Dementia”
respectively. The data employed, apart from occasional
special illustrative cases, are derived from a study of 728
chronic or recurrent lunatics admitted into the East Sussex
County Asylum, Hellingly,during the first seven months after the
opening of the institution. Practically all the cases were transfers
and all were chargeable to the different unions of East Sussex.

These cases were grouped as is shown in the following
summary:

Amentia.

(I) Low grade (idiocy and imbecility,
primary and secondary, with or
without epilepsy) .

(II) Excited and “moral” cases .

(III) Recurrent cases

(IV) Hysteria .....

(V) Epileptic insanity

(VI) Paranoia (primary and develop¬
mental) .....

Total amentia ,

I 7

—

106

1 77

283

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456

AMENTIA AND DEMENTIA,

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Dementia.

(I) Primarily neuronic (age, “stress”
or both):

(a) Senile or “worn-out” dementia

0 b ) Presenile or “climacteric” de¬

123

mentia ....

syphilis, childbirth, etc.)

(d) Premature dementia (approxi¬

mately “dementia pnecox”) .
(II) Progressive and secondary :

I 12

(a) Dementia senilis

(b) Dementia paralytica
(III) Special varieties :

(a) Dementia following sense-depri¬

vation .....

(b) Dementia following epilepsy

lesions ....

Total dementia .

198

247

445

Grand total .

304

424

728

The second part of the paper deals with the subject of
amentia. The section on low-grade amentia (idiocy and
imbecility) calls for no remark here. Those on “ excited and
‘ moral * ” and on “ recurrent ” cases, however, deserve considera¬
tion owing to the fact that they include, as part of their
contents, the whole “ maniacal-depressive ” group of Kraepelin,
which has of late attracted so much attention.

In the former of these groups are contained the following
general types : (a) “ moral ” cases ; (£) simple “ emotional ”
chronic mania; ( c ) chronic mania with incoherence and
delusions ; and ( d) “ cranks and asylum curiosities.” About
three-quarters of the cases are of the female sex, the proportion
varying from 8 : I in class ( b ) to about 3 : 2 in classes (a)
and (d).

The cases in these clinical classes respectively show the
following prominent characteristics :

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BY JOSEPH SHAW BOLTON, M.D.

457

(a) Alteration of moral sense , with a tendency to do desperate
things, e.g. } to commit suicide or even homicide, to perform
acts of self-injury or self-mutilation, to strike, smash or destroy,
to intensely irritate those around them, to be sexually inclined
in a normal or abnormal manner, etc.

(£) Alteration of emotional and intellectual control\ e.g.,
exuberance, instability, vanity, garrulity, childishness, and
often violence, treachery and destructiveness. The younger
and adult types usually display a more or less marked loss
of control over the emotions and instincts. The older types
differ from these in the fact that the loss of control affects
chiefly the intellectual functions. Their association of ideas is
normal, except for its extreme rapidity and complexity. They
talk continuously whenever a listener can be found, and they
are frequently inconsequent, and show a marked tendency to
parenthesis during their descriptions.

(c) Rapid and uncontrolled association of ideas , with delusions
of grandeur, which may or may not co-exist with or follow
delusions of persecution. These cases form a half-way house
between classes ( b ) and ( d) y and shade gradually into each of
these. They differ from the former in being on the whole less
troublesome, and in showing an apparently complete
incoherence in their association of ideas, and from the latter in
the fact that their ideation is simply rapid and uncontrolled,
rather than grotesque or symbolical, and resulting in erratic
and eccentric conduct.

(d) Stereotyped , symbolical , or grotesque association of ideas,
which leads to weird actions and eccentric general behaviour.
These cases are extremely conceited, vain, and grandiose.
They are of many types, and may be simply asylum “ show-
birds,” or may possess considerable artistic or intellectual
talent. As a class, these cases only differ from certain “sane ”
individuals in the absurd and grotesque extremes to which they
carry their ideas, and their resulting behaviour and actions ;
and their stereotypism, which often suggests dementia, also
only differs in degree from the stereotypism and prejudice
which are often seen in the “ cranks ” of the outside world.

In the latter of these two groups are included all types of
“ recurrent ” case, whether these are still capable of “ recovery,”
or have become permanently insane asylum inmates. About
two-thirds of these cases are of the female sex.

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458 AMENTIA AND DEMENTIA, [July,

The writer would remark in this connection that he is unable
to regard mania and melancholia as simple and opposite emotive
states (the view of the supporters of the “ maniacal-depressive ”
generalisation [Deny and Camus]), though mere excitement and
depression may be such. Mania, whilst at times outwardly
indicative of general exaltation of cerebral function, is more
often a sign of decreased activity of the higher controlling and
latest evolved portion of the cerebrum. Melancholia, on the
other hand, whilst it is indicative at times of recuperative general
depression of cerebral function, or of impending loss of higher
cerebral control, is more often a sign of the onset of permanent
general depression of cerebral function, and is thus the objective
evidence of impending or developing (presenile) involution of
the cortical neurones. With regard to “ mania,” he would
remark that the possessor of one of the finest intellects he has
met with was insane, and in a condition of permanent and
uncontrolled exaltation of cerebral function. He had earlier
in life been a university professor, and a near relative had
attained to eminence. This individual might be regarded as
the owner of a cerebrum which was too elaborately developed
to be properly controlled in its existing stage of evolution.
Such brains, working under proper control, may be common in
the far distant future. From the normal aspect, it is well
known that fine pieces of work have been rapidly done whilst
their authors were so intensely absorbed as to be practically in
a condition of general cerebral exaltation or mild “ sane ” mania,
for which, however, the subjects had afterwards to suffer in
recuperative depression of the cerebral functions. The higher
types of recurrent insanity thus grade upwards towards the
cerebral hyperactivity of genius, whilst the lower types grade
downwards into the analogous cases who are never really
sane, although they may legally pass as such. In conformity
with these opinions it may be remarked that, cases which
develop dementia being excluded, the experience of the writer
has convinced him that the greater the degree of cerebral
degeneracy the less evident is depression as a symptom or
a phase of symptomatology, and vice-versd . Melancholia is,
therefore, pre-eminently a characteristic of the latter (recurrent)
group, and is of subordinate importance, and often entirely
absent, in the case of the former (permanent) group. The
writer has, in fact, often noted that cases which at one time

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BY JOSEPH SHAW BOLTON, M.D.

459

were “ circular ” have later on partially or entirely lost the phase
of depression, and he is disposed to regard this phase, when
post-maniacal, as to some extent indicative of a still possible
return to the “ normal.”

It may be remarked that in the “ excited and ‘ moral * ” and
the “ recurrent ” types of amentia, the functional disturbance of
the cerebrum is of a relatively low order, and, considered from
the general aspect, involves ( 1 ) decreased action of the higher
and latest evolved cerebral functions of control and co-ordina¬
tion, which results in abnormalities of immediate cerebral activity,
and in consequent emotional and psycho-motor disturbances of
various kinds, and ( 2 ) in addition, in the more degenerate types,
generally aberrant and subnormal cerebral activity. In other
words, the cerebrum, as a machine, is working in a defective
manner, and all the “ functions of mind,” and not merely the
emotions, are involved. This abnormal form of cerebral activity
is, however, of an immediate type, and does not to any extent
involve the revivication of complex and time-related portions of
the subconscious content of mind.

In the case, however, of hysteria and epilepsy, which subjects
are dealt with in the succeeding sections, whilst at times the
sufferer may be insane owing to loss of higher cerebral control,
the symptoms are frequently due to an alteration of personality.
This may be conveniently defined as a mental state in which
the higher cerebral functions are exercised, not over psychic
processes founded on such recently acquired time-related por¬
tions of the content of mind as constitute the normal person¬
ality, but over psychic processes founded on complex and time-
related portions of the subconscious content of mind, which
exhibit such abnormal prominence as to entirely replace for the
time those recent experiences on which normal cerebral activity
depends. In such cases not only one, but several such time-
related portions of former experience may separately acquire
abnormal prominence and thereby give rise to the phenomena
of multiple personality. In the normal individual, on the other
hand, the recent time-related personality cannot be voluntarily
subordinated, and all that is possible in this direction is the
occurrence of some degree of associational elaboration of former
sensori-memorial images, which is always imperfect and often
incorrect.

In the case of paranoia, which constitutes the last type of

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460 AMENTIA AND DEMENTIA, [July,

amentia, the mental condition is somewhat different. The
personality is altered, but this alteration is due, in the deve¬
loped state, to the permanently abnormal prominence of
certain time-related portions of what should be part of the
subconscious content of mind. These particular time-related
experiences serve as a basis on which develops a continually
increasing aggregation of abnormal psychic units. In other
words, in place of the normal gradually changing personality, a
certain former personality remains as a permanent basis on
which is built up a continually increasing abnormal psychic
edifice. In such cases, when they have become “chronic,” it is
probable that the greater part of the available psychic content
consists of symbolic verbal groupings which have become
relatively stable through frequent repetition, and that the
processes of cerebral association required for the re-integration
of the former concepts and percepts which these verbal group¬
ings symbolise, and for the revival of the old sensori-memorial
images, are markedly reduced (see remarks on the significance
and functions of language, pp. 467-469). These symbolic
verbal groupings continue throughout the life of the sufferer to
entirely dominate what would otherwise be relatively normal
processes of immediate cerebral activity, and in this, in effect
though greater in degree, resemble the “ opinions ” of many of
the one-idea-ed “ cranks ” in the outside world.

The writer has here limited himself to expressing his views
as to the type of deviation from normal cerebral function which
exists in hysteria, epilepsy and paranoia, as he considers that a
mere summary of the contents of the respective sections would
not serve a useful purpose. He therefore refers the reader to
the actual sections for specific details regarding his views on
these types of amentia.

He would, however, remark that though all the above
types of high-grade amentia can for convenience be separately
described, the normal mind is nevertheless one and not several
“ functions of the brain,” and amentia is also one and not several
kinds of subnormal or subnormally aberrant mental function,
which in different cases merely varies in degree and not in
kind. In consequence, whilst all the types of amentia which
he has described may be recognised as types , cases of an inter¬
mediate nature exist between each of these. For example, in
many epileptic high-grade aments hysterical attacks may

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BY JOSEPH SHAW BOLTON, M.D.

461

occur during the day and typical epileptic fits during the night.
In conformity with this view, the writer has indicated, through¬
out the description of high-grade amentia, that amongst
“ normal ” individuals sane homologues of all the types of
high-grade amentia are common.

In the third and most lengthy portion of the paper is con¬
sidered the subject of dementia.

The first section, which deals with the general pathology of
mental disease and the functional regions of the cerebrum, need
not here be referred to, as it merely generally summarises and
in places elaborates the conclusions of the writer which have
been already dealt with.

The next section is concerned with mental confusion and its
relationship to dementia. The term “ mental confusion ” is
employed to connote, in the broadest sense, the mental symptoms
which occur in association with certain pathological states of the
cortical neurones which may be followed by the recovery or by
a more or less extensive dissolution of these elements. The
writer indicates his opinion that dementia never develops
except in such cases as have suffered front a more or less severe
grade of the mental confusion which is its necessary precursor .
After a reference to the causation of mental confusion, the
symptomatology is described and critically discussed, and it is
pointed out that all the various types of mental confusion (whether
occurring in recoverable cases, in any of the classes of primarily
neuronic dementia, in progressive senile dementia, in dementia
paralytica, etc.), conform in reality to a standard description, a 7 id
in their essential characteristics are one and the same morbid
mental state . The slighter cases, when due to the direct action
of toxines (eg., the less severe types of “ polyneuritic psychosis,”
“ puerperal confusion,” etc.), recover : the more severe develop
dementia, as do all cases due to permanent causes, or occur¬
ring in consequence of mere deficient durability of the cortical
neurones. Whilst clinical observation may not necessarily
enable a definite prognosis to be made as to whether any
particular case is presumably recoverable or not, certain sym-
ptomatological indications of the likelihood of the development
of, or of the actual existence of, dementia, are frequently present.
This question is fully discussed in the section under reference.

The writer desires to draw especial attention to the above
generalisation with regard to mental confusion and dementia,

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462 AMENTIA AND DEMENTIA, [July,

owing to its fundamental importance in relation to the unity
of mental disease, as on the one hand a condition of Amentia
from cerebral sub-evolution and on the other one of Dementia
from cerebral involution or dissolution.

The remaining portion of this part of the paper is devoted
to a classification of the varieties of dementia. The first group
of “ primarily neuronic dementia ” is divided into the several
classes of “ senile or ‘ worn-out * dementia,” “ presenile or 1 clim¬
acteric * dementia,” “ mature or ‘ adult ’ dementia,” and “ pre¬
mature dementia.” These different classes are fully discussed
in the several sections, and, except in the case of premature
dementia, need little reference here. The senile class naturally
includes many types of high-grade amentia who are suffering
from cerebral involution. Such maniacal presenile cases as
have developed dementia, and which Kraepelin would class
under “ maniacal-depressive insanity,” are necessarily included in
the presenile class, as are the cases of presenile melancholia with
dementia, which, after Dreyfus, would also be included under
“maniacal-depressive insanity.” It may finally be remarked
that the cases of mature dementia for obvious reasons, since
maturity is the period of maximum cerebral activity, are largely
induced by intemperance, syphilis (mild dementia only), child¬
birth, etc.

The “ premature dementia,” which is discussed and illustrated
at considerable length, is not synonymous with the “ dementia
praecox ” of Kahlbaum, of Pick, and of Kraepelin, but includes
premature dements only. Though the conventional clinical
subdivision into types is followed, the writer endeavours to
explain on general grounds the characteristic phenomena which
form the basis of this. He considers in brief that the cause of
these phenomena is to be found in an immature condition of
the centres of association of the cerebrum.

In cases belonging to the previous classes of “senile,”
“ presenile,” and “ mature ” dementia, whatever be the respective
degrees of involution or dissolution which later on result, the
centres of association, both lower and higher, have by frequent
repetition necessarily acquired a capacity for relatively stable
neuronic groupings as the physical basis of the psychic pro¬
cesses performed by the respective patients ; and this statement
especially applies to the neuronic groupings in the psycho¬
motor area, which serve as the physical basis for the perform-

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BY JOSEPH SHAW BOLTON, M.D.

463

ance of “ skilled ” voluntary accomplishments. In other words,
in these classes, considered for the moment from the purely
physical aspect, the cerebra are completely built and thoroughly
tested machines in full running order at the time when the break¬
down is precipitated by too rapid running or by “ wearing out.”

In the case of the class of premature dementia under con¬
sideration the state of affairs is very different. Here there is,
in the first place, a highly deficient durability of the cortical
neurones ; or, to continue the simile, imperfectly tempered
material has been employed for the construction of the parts,
and the neurones, or the parts themselves, are in many instances
imperfectly constructed. Further, though most of, or all, the
individual parts are placed in preparatory juxtaposition, even
the simpler complexes of construction have only recently and
experimentally been grouped into series. This is, in fact, the
case even in the more highly endowed patients, in whom the
higher complexes of neuronic association have already been
tentatively produced.

It is thus only to be expected that, when such a machine is
set running at high speed, all kinds of local breakdown will
ensue. In the human cerebrum, owing to a structure which in
its complexity of construction overshadows any machine of
human manufacture, and to the numerous sources of motive
power which exist through the medium of the different varieties
of sensorial stimulation, complete breakdown is relatively rare,
though local stoppages, local anomalous groupings of the
simpler complexes, and particularly local repetitions or irregu¬
larities of action, are of common occurrence. This is especially
obvious, though not peculiar to these, in the case of the more
fundamental motor exhibitions, the patient either performing,
or not performing, or often repeating, certain actions, and
exhibiting, as the essential characteristics of these motor
performances, on the one hand a tendency to uncertainty, and
on the other a tendency to repetition, of action*

In the case of premature dementia, therefore, it is possible
to make a subdivision of the cases into those which do and
those which do not exhibit phenomena which originate in
sub-evolutional and dissolutive conditions of the psycho-motor
area of the cerebral cortex. These are the “approximately
‘katatonic’” and “approximately ‘hebephrenic’” sub-classes
which the writer has employed.

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AMENTIA AND DEMENTIA,

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His views as to the position occupied by the “ paranoid”
type of premature dementia are difficult to summarise. The
writer limits the term “paranoia” to cases of developmental
origin in which the centre of higher association is the primary
region at fault, in that it is unable to exercise its normal
functions of co-ordination of, and of corrective and selective
control over, the centres of lower association. He thus includes
“paranoia” under the heading of “amentia.” In this course he
is in accordance, in fact if not in terminology, with Bianchi
and certain other authors.

In the delusional cases which he excludes from the group
of true paranoia, and which are discussed in the section on
“Mental Confusion,” various local disabilities exist in one or
more of the centres of lower association, and these lead either
to unharmonious action of these centres in relation to one
another, or to more generally aberrant psychic processes,
involving also the centre of higher association. This condition
is evidence of local cerebral dissolution which slowly becomes
widespread ; and, for the sake of clearness, it may be spoken
of as dissolutive in contra-distinction to developmental paranoia.

The cases contained in the “paranoid” sub-class of prema¬
ture dementia are of a similar type to the former, and may be
termed, solely for the sake of clearness, examples of premaiure
dissolutive paranoia . Such cases occur at all ages and might
conveniently be classed as examples of “paranoid dementia.”
The writer, however, prefers, owing to the fact that all grades
of delusion exist in cases of dementia, from the unsystematised
to the semi-systematised, or even the systematised, not to
make use of any such general symptomatological division,
although during the description of premature dementia he has
found a sub-class of the kind convenient. His excuse for
making an exception in the present instance lies in the fact
that, of all the classes of primarily neuronic dementia, the
amount of dementia is the greatest in the premature variety,
in which, therefore, such a symptomatological division is both
possible and convenient for descriptive purposes, although,
from the general psychiatric aspect, it is undesirable. In other
words—to render his position quite clear—whilst in premature
dementia the few “ paranoid ” cases stand out sharply from the
(usually more demented) “hebephrenic” and “katatonic”types,
in the other varieties of primarily neuronic dementia no such

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1908.] BY JOSEPH SHAW BOLTON, M.D. 465

“paranoid” group is evident unless all cases exhibiting
systematised, semi-systematised, or even unsystematised
delusions were included in this, to the exclusion of every other
symptomatological characteristic. Under such circumstances,
as so many further possible sources of delusion exist, owing to
the more extensive mental content of the adult individual, a
reductio ad absurdum would necessarily result.

The writer thus considers that the peculiar symptomatology
exhibited by cases of premature dementia is susceptible of a
rational explanation, and that this type of dementia is not
a special form of mental disease, but merely exhibits unusual
features in consequence of the occurrence of neuronic disso¬
lution in a cerebrum which is still immature.

The second group of “ progressive and secondary dementia ”
is divided into classes of u progressive senile dementia ” and
“ dementia paralytica.”

With regard to the former class, the evidence that there is
a direct relationship between the presence of degeneration of
the cerebral vessels and the development of severe dementia is
indicated. This subject is discussed in Part I of the present,
and in greater detail in a previous paper.

The subject of dementia paralytica is on the other hand
considered here at length. The summarised conclusions of the
writer are as follows :

He considers that dementia paralytica is a branch of mental
disease, and that the subjects of this form of mental disease
would, if they had not been syphilised, have suffered from one
or other of the types of primarily neuronic dementia. He is
further of the opinion that former syphilis is a necessary
antecedent to dementia paralytica.

With regard to the first question, he has shown, by a study
of the death-rates in mental disease at different ages, and by a
comparison of these death-rates with the homologous death-
rates in the corresponding general population, that the
exclusion of the general paralytic population of an asylum leads
to the result that lunatics (particularly those of the male sex)
have an extraordinarily low death-rate between the ages of
thirty-five and fifty-four. If, on the other hand, the general
paralytic population is included in the total lunatic population,
this result is not apparent.

He has also pointed out that the morbid anatomy and the
Liv. 34

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466 AMENTIA AND DEMENTIA, [July,

pathology of dementia paralytica do not differ in their essential
features from those of progressive senile dementia. He has
further shown, by a classification of the types of dementia
paralytica and a comparison of these with the varieties of
primarily neuronic dementia, that the two series are homologous.

On these various grounds he has based his contention that
dementia paralytica is a branch of mental disease. As con¬
firmatory evidence he has pointed out the high percentage of
heredity of insanity and of parental and family degeneracy
which can be obtained in cases of dementia paralytica, and he
has shown that cerebral under-development occurs in certain
types of this form of mental disease.

With regard to the second question, he has indicated his
reasons for considering that former syphilis is a necessary
antecedent to dementia paralytica. He is of the opinion that
the ordinary sane individual and the ordinary psychopath or
potential lunatic, if possessed of cortical neurones of average
durability, may suffer from syphilis with impunity as regards
the later onset of dementia paralytica, and he considers that the
same statement may be made with regard to the syphilised
lunatics with little or no dementia, who are fairly common in
asylums. On the other hand, he holds that a psychopath who
possesses cortical neurones of subnormal durability, and who,
apart from an attack of syphilis, would develop a moderate grade
of dementia, would, after an attack of that disease, sooner or later
suffer from one or other of the types of dementia paralytica.

He thinks that the important feature in which dementia
paralytica differs from progressive senile dementia consists in
the possession, by the subjects of former syphilis, of a perma¬
nently enhanced capacity of reparative reaction on the part of
the non-neuronic elements of the encephalon. In both cases
neuronic dissolution and non-neuronic reparative reaction occur
pari passu . In the case of dementia paralytica, non-neuronic
reparative reaction is more or less intense, and vascular degenera¬
tion is relatively slight; in the case of progressive senile dementia
non-neuronic reparative reaction is relatively feeble and vascular
degeneration is relatively severe. He would illustrate this point
by a coarse analogy, comparing dementia paralytica to certain
types of progressive renal cirrhosis and progressive senile
dementia to senile renal cirrhosis.

On these grounds he includes dementia paralytica and pro-

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1908.] BY JOSEPH SHAW BOLTON, M.D. 467

gressive senile dementia under the common group of “ Progres¬
sive and Secondary Dementia.”

This part of the paper finally contains groups of “ Dementia
following Sense-Deprivation,” “ Dementia following Epilepsy,”
and “ Dementia following Cerebral Lesions.”

The subject of “ Dementia following Sense-Deprivation ” is
considered at greater length than the frequency of the condition
might appear to demand. This course is adopted for the
following reason. In the case of the preceding groups the
dissolution or involution of the centre of higher association is
either primarily neuronic or is also due to extra-neuronic but
intra-encephalic morbid states. In the case of dementia follow¬
ing sense-deprivation, however, dissolution of the centre of
higher association occurs in cerebra which are permanently
maimed, in the neuronic sense, in their functionally lowest and
most stable portions, namely, one or more of the centres of pro¬
jection ; and the exciting cause of the dissolution of the centre
of higher association in such cerebra is the stress induced by
the necessarily abnormal modes of lower cerebral association
which result from this maiming. The consideration of the sub¬
ject is therefore necessarily preceded by a discussion of the
processes of lower cerebral association and of the relationship
of language to these.

As has already been indicated, the writer recognises three
grades in the hierarchy of cerebral function, namely : (1) centres
of projection for the reception of sensations ; (2) centres of
lower association for the recording of sensori-memorial images
and the association of these into complex psychic units which
differ, not fundamentally but in detail, on every occasion on
which they are evolved or employed ; and (3) a centre of higher
association which is concerned with the general control and
co-ordination of psychic processes and the grouping of the
complex psychic units evolved by processes of lower association
into harmonious series of concepts by means of voluntary atten¬
tion and selection. He thus regards perception and conception
as processes , and does not predicate the existence of centres for
percepts and concepts, terms which in his view are psychological
generalisations for psychic products that require integration
from sensori-memorial images on each occasion on which they
are evolved. This integration occurs by the aid of the cerebral
mechanism of language.

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468 AMENTIA AND DEMENTIA, [July,

Words may be described, without serious error, as mental
algebraic symbols which, without interpretation into their con-
ceptive, their perceptive, and finally their sensori-memorial
equivalents, are meaningless. Language, in other words, may
be compared to the symbolic system employed by mathema¬
ticians, and the ever-varying sensori-memorial complexes which
words symbolise may be likened to the numerals of arithmetic.

A word, per se> represents merely an auditory or visual
sensation, or a cheirographic or articulatory kinaesthetic
impression, unless it is employed as a symbol on which to
integrate the percept or concept which it signifies, and for such
integration the cerebral mechanisms or associational systems
connecting the different projection and sensori-memorial regions
of the cortex are needed.

Words may arise into consciousness through any one of the
four language-spheres. When, however, they are voluntarily
and silently reproduced, i>., thought of, words are invariably
awakened through the articulatory word-centre under normal
conditions. They cannot be voluntarily repeated in thought
by means of the cheirographic centre if the hand is not
actually moved, though such hand-movements may be replaced
by slight movements of the head, or even of the lower jaw or
the eyes, through the agency of their respective motor spheres.
If words should spontaneously arise in the visual or the
auditory word-centre, the condition is so abnormal as to
constitute a hallucination, which the subject may or may not
be able to distinguish from a true visual or auditory sensation.

However they may arise into consciousness, words naturally
possess very different symbolic values. Illustrations need not
be given here, as the subject is dealt with in the section under
present reference. Since this section was written a recent
paper by E. H. Rowland has come under the notice of the
writer. In it the author discusses “The Psychological Ex¬
periences connected with the Different Parts of Speech.” The
conclusions of the author with regard to the symbolic values of
the different parts of speech, and those expressed by the writer
in the section referred to, are in accord.

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BY JOSEPH SHAW BOLTON, M.D.

469

The auditory, visual, cheirographic, and articulatory word-
centres thus merely signify the cortical regions in which lie the
physical bases of mental algebraic symbols. These, unless
they serve as inciting agents from which spread, in different
directions throughout the cerebrum, complex impulses of
association, signify no more than unmeaning sounds, shapes,
and musculo-kinaesthetic sensations.

Language is produced by the suitable co-ordination of the
verbal content of the auditory and articulatory word-centres.
It is originally acquired by imitation under the influence of
auditory sensations, and in educated persons language is more
highly evolved owing to education of the visual and cheiro¬
graphic spheres. When once it has been acquired, however,
language (*>., functional activity of the several word-centres
with their commissural systems) is not necessarily employed as
the instrument of thought, although it has been primarily
evolved for this purpose. Examples are common in which the
mechanism of language is employed in a purely mechanical
manner; and in the text of the paper several illustrative
examples are given.

This summary would become of inordinate length were the
above remarks critically compared with the views of the
numerous authors who have written on the subject. Those,
however, of Bianchi, who has recently elaborately discussed the
functions of the cerebrum from the psychological standpoint,
require a passing mention. This author, whilst fully recognis¬
ing the necessity of language for the reproduction of thought,
considers that, apart from words, there exist in the cerebrum a
centre for concepts in the frontal lobes and centres for percepts
in the post- and infra-Rolandic regions of the cerebral mantle.
He recognises two grades only of cerebral function, (1) a region
of government in the frontal lobes, and (2) a mantellar parlia¬
ment existing in the various perceptive zones ; and he regards
language simply as a mechanism for the reproduction of
thought. He considers that even abstract conceptions exist
apart from words. “The coalescence of the word with the
abstract conception, and the impossibility of separating them,
do not warrant us in denying that they are formed in different
areas ” (p. 131). This quotation is inserted out of fairness to
the author, though the writer has not misinterpreted his opinions,
as he devotes several pages to the endeavour to prove that per-

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470

AMENTIA AND DEMENTIA,

[M%

cepts and concepts can exist in the absence of words . What
Bianchi, however, really clearly indicates is that words and
language can exist in the absence of percepts and concepts,
which is a very different matter.

In connection with this question, the recently published views
of Pierre Marie are of importance. This author considers that
in all types of aphasia (with the exception of anarthria, which he
considers not to be aphasia at all) diminution of intelligence is
present. “Cest qu’il y a chez les aphasiques quelque chose de
bien plus important et de bien plus grave que la perte du sens
des mots ; il y a une diminution trcs marquee dans la capacity
intellectuelle en general ” (p. 241). The elaborately detailed
observations of Marie do not give support to the views of
Bianchi, but are readily explicable if, as is the opinion of the
writer, language be regarded as a necessary symbolic instru¬
ment for the carrying on of psychic processes, and not merely as
an instrument for the expression of separately elaborated
psychic products which already exist in certain cerebral
centres.

During the description of “ Dementia following Sense-De¬
privation;” the writer separates congenital from acquired cases,
and indicates how deafness is a more serious deprivation than
blindness. The examples of deaf-mutism which are cited, all
of whom are high-grade aments, exhibit not only dementia, but
originally defective intellectual powers and an imperfect visual
and cheirographic substitution of the auditory and articulatory
language spheres. Further, these cases differ from those suffer¬
ing from acquired sense-deprivation in presenting no signs of
irritability, excitability, and stubbornness.

In the section on “Dementia following Epilepsy” is repeated
the observation that epilepsy occurs most frequently in associ¬
ation with mental disease in those types of the latter in which
cerebral degeneration is most marked. For example, 37*2 per
cent, of low-grade aments (idiots and imbeciles), I2'7 per cent\
of high-grade aments, and only 4*5 per cent . of cases of
dementia suffer from epilepsy. It is remarked that the
general effect of co-existing epilepsy is harmful in all types of
mental disease and accentuates the special symptomatology.
With regard to “ Dementia following Epilepsy,” the writer in¬
dicates the marked grade of dementia which ensues, and also
the impossibility, in the absence of a history or evidence of

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1908.] BY JOSEPH SHAW BOLTON, M.D. 47 I

epilepsy, of distinguishing between cases of primarily neuronic
dementia and of epileptic dementia.

The third part of the paper concludes with a reference to
“ Denjentia following Cerebral Lesions,” which calls for no
remark, as, apart from dementia, the symptomatology presented
by such cases is individual and accidental.

In concluding this general review and summary the writer
would remark that, ap^irt from the clinico-pathological evidence
which he has adduced in favour of the thesis he advocates,
recent research in psychiatry tends more and more to decrease
the number of “ mental diseases,” and to make for the unity of
insanity as on the one hand the symptomatological expression
of cerebral sub-evolution, and on the other that of cerebral dis¬
solution and involution. The generalisation of “dementia
praecox” groups together many types of the insanity of
adolescence. The discovery of the two j’uvenile, the tabetic,
the chronic degenerate, and the senile forms of dementia
paralytica has widened the original conception of general
paralysis as a peculiar acute mental disease of adult life. The
generalisation of “ maniacal-depressive insanity,” recently still
further extended (Dreyfus) by the inclusion of presenile melan¬
cholia, has classed together many types of cerebral degeneracy.
Finally, even the generalisation of “ polyneuritic psychosis ” has
recently been extended by Knapp, who recognises numerous
aberrent types of symptomatology.

These few illustrations of the direction in which recent
research in psychiatry is advancing, serve collectively and in¬
dividually as evidence in favour of the broad generalisation of
amentia and dementia advocated by the writer in this paper.
Whilst he does not presume to imagine that he has done more
than add a further example to the numerous classifications of
mental disease which have been published, he is nevertheless
convinced of the general correctness of the clinico-pathological
basis on which his generalisation of amentia and dementia is
founded, and of the approximate accuracy of the classification
of mental disease which he advocates.

Though his attempt to indicate the physical basis of mental
disease may for the present be doomed to failure, he is satisfied
that future histo-pathological research will confirm the general
correctness of his observations, and by extending our know¬
ledge of the functions of the cerebrum will eventually demon-

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472

AMENTIA AND DEMENTIA.

[July,

strate not only the general physical basis of mental disease
which he claims to have proved, but also a special physical
basis for many of the clinical types of symptomatology which
are commonly regarded as individual mental diseases.

The writer desires, in conclusion, to express his grateful
thanks to Doctors Jones and Mott, Taylor, and Wiglesworth, for
the use of the clinico-pathological material which he has had
the privilege of collecting at the Claybury, Hellingly, and Rain-
hill Asylums respectively. He also wishes to express his
indebtedness to Dr. G. A. Watson for the loan of histological
specimens, and to Mr. F. J. Abram, who has kindly drawn certain
of the diagrams and has rendered valuable assistance in the pre¬
paration of the photographs with which the paper is illustrated.

(*) The writer does not wish this “General Review and Summary” to be
regarded either as an abstract of the paper or as a summary of conclusions.

References.

(The following list of references includes only certain publications
which are specifically mentioned in the General Review and Summary.)

Bevan Lewis and Henry Clarke. —“The Cortical Localisation
of the Motor Area of the Brain,” Proc. Roy. Soc., No. 185, 1878.

Bianchi. — Text-book of Psychiatry, authorised translation by J. H.
Macdonald, 1906.

Bolton. —“ The Exact Histological Localisation of the Visual Area
of the Human Cerebral Cortex,” Phil. Trans., vol. cxciii, 1900. “The
Histological Basis of Amentia and Dementia,” Arch . of Neurol., vol ii,
1903. “The Functions of the Frontal Lobes,” Brain, part cii, 1903.

Brodmann. —“ Beitrage zur histologischen Lokalisation der Gross-
hirnrind z,” Journ. fur Psychol, und Neurol., Bd. x, 1907 ; also Bd. ii,
1902--3 ; Bd. iv, 1905 ; and Bd. vi, 1906.

Campbell. —Histological Studies on the Localisation of Cerebral
Function , 1905.

Deny and Camus. — La Psychose maniaque-dipressive, pp. 86-90,1907.

Dreyfus. — Die Melancholic ein Zustansbild des manisch-dcpressiven
Irreseins, 1907.

Gordon Holmes. — “ A Note on the Condition of the Post-Central
Cortex in Tabes Dorsalis,” Rev. of Neurol, and Psychiat., vol. vi,
No. 1, 1908.

Knapp. — Diepolyneuritschen Psychosen, 1906.

Marie. —“Revision de la question de TAphasie,” La Semairu
Medicale, p. 241, 23 Mai, 1906.

Rowland, Eleanor H.—“The Psychological Experiences con¬
nected with the Different Parts of Speech,” The Psychological Review,
Monograph Supplement, January, 1907.

Watson— “The Mammalian Cerebral Cortex, with Especial Re¬
ference to its Comparative Histology—I, Order Insectivora,” Arch, of
Neurol., vol. iii, 1907

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A PHILOSOPHY OF PSYCHIATRY.

473

A Philosophy of Psychiatry. By Bernard Hart, M.B.,
M.R.C.S., Assistant Medical Officer, Long Grove Asylum,
Epsom.

“What we gain from speculative philosophy is not so much answers to ques¬
tions which common sense universally asks, as the knowledge that these questions
themselves, since they are based on untrue concepts, must vanish away.”— Paul
M6ller.

Psychiatry has the unenviable characteristic of containing
within its borders more diverse and conflicting opinions than
any other branch of science. These disputes relate not only to
the conclusions reached by different authors as regards matters
of theory or fact, but also to the method of research, and even
to the material with which the subject deals. This is so
obvious, that if the numerous existing text-books are carefully
compared it is hardly possible to realise that they profess to
deal with one and the same subject. Metaphysicians and
materialists, psychologists and clinicians ride their particular
hobby horses, and produce a number of diverse schools whose
parallel is only to be found in the history of philosophy.

In modern times the goods and evils of specialism have made
themselves ipuch felt, and psychiatry is advancing along
numerous very distinct paths. Unfortunately, those who are
engaged in a particular line of research are too often afflicted
with panaceaism, and regard with open or only partially-veiled
contempt the efforts of other workers along other lines.
Psychologists and pathologists proceed in happy ignorance of
each others' work, or at any rate with wonderfully naive ideas
concerning the inter-connection of their various spheres. While
Professor Janet in Paris is publishing psychological master¬
pieces which give one the impression that a powerful search¬
light is being thrown into the dark places of insanity, an anony¬
mous writer in the Times condescendingly informs the lay
public that he “ cannot help regarding psychology as an ignis
fatuus .”

By certain pathologists the view that mental diseases are
really brain diseases, and that anatomy and physiology are the
only routes by which they can be properly attacked, is regarded
as a self-evident truth. The brain constitutes a part of reality,
something which^eally exists and is causally effective, whereas
psychological research deals with flimsy unrealities. Advance

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474 A PHILOSOPHY OF PSYCHIATRY, [July,

except by way of the microscope and test-tube is a fraud and
delusion.

The psychologists, on the other hand, take refuge in Plato,
Bishop Berkeley, and Tyndall's much-quoted Belfast address.
They insist that mind is the immediate and therefore the only
real fact, and they tend to ultimately lapse into a view even
more one-sided than that of their opponents. These divergent
opinions are really the result of a more or less conscious endea¬
vour on the part of men skilled in the conceptions of a parti¬
cular branch of science to apply those conceptions to a far
wider sphere of being. In other words, we have dogmatism in
the sense in which it was originally defined by Kant ( x ).

Now, in this country, and to a large extent in Europe also,
the preponderating dogmatism is undoubtedly the physiological,
and the pathological laboratory is the hub of the asylum
universe. The growth of this conception forms an important
chapter in the history of psychiatry, and some profit is to be
gained by a consideration of the various factors which have
contributed to its popularity. Historically the physiological
conception arose as a reaction against the theological and meta¬
physical explanations of the middle ages. Its progress was
materially assisted by the rapid growth of the physical sciences
and the endeavour to bring all experience into line with them.
In an age when psychology was confounded with metaphysics
and regarded as a subject essentially opposed to the methods
of science, it is easy to understand the strenuous attempts to
bring insanity within the pale and make it conformable to the
laws of physiology. Psychology was then in its armchair stage
—the student was expected to sit down and evolve the subject
from the depths of his own mind by a process of introspection.
Observation and experiment, the methods of the natural
sciences, were not considered to be applicable, and it was obvious
that any attempt to understand dementia praecox by a process
of introspection would be singularly unsuccessful. An attack
upon insanity from the psychological point of view has only
become possible with the development in modern times of an
objective psychology working along the lines of the other
sciences.

If we endeavour to trace to its essential basis the narrow con¬
ception that anatomy and physiology are th% only routes by
which insanity may be properly approached, and that the brain

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BY BERNARD HART, M.B.

475

is the reality underlying it, we find the naYve idea of reality as
something extended, tangible, and visible, and the assumption
that science is essentially concerned with measurement, and
therefore only applicable to the material world. These two
propositions, whether they be expressed or implied, form the
kernel of what we may call the doctrine of physiological dog¬
matism. If, therefore, we would determine the relation of the
latter to modern thought, it is necessary to inquire what
measure of validity is to be ascribed to the two conceptions in
question.

Now the view that science is concerned with an external
“ real ” world of “ things-in-themselves ” composed of extended
objects arranged in an infinite space, was at one epoch very
generally accepted. It may be said to have reached its reductio
ad absurdutn in the materialistic writings of Buchner (*) and
Moleschott ( 8 ) in the middle of the nineteenth century, and it
is now discredited by modern thinkers. It was the prevalence
of doctrines of this nature which aroused Mach’s gibe, that ‘Every
philosopher has his private natural science, and every natural
scientist has his private philosophy. The majority of natural
scientists, however, tend to embrace a materialism some hundred
and fifty years old, whose insufficiency has long been obvious,
not only to the philosophers proper, but to all those accustomed
to think philosophically ” ( 4 ). Scientists, fully occupied in con¬
structing the magnificent edifice of empirical knowledge, had
paid but little attention to the foundations upon which they
were building. The practical value of their work was so
evident that objectors could be silenced by the retort that the
proof of the pudding lay in the eating. The primary assump¬
tions of science were left to take care of themselves, until
physicists suddenly aw r oke to the fact that they had been guilty
of the grossest metaphysics, and were in danger of becoming
even more metaphysical than the philosophers. Obscurantist
attacks, which had formerly been vainly directed against the
results of science, were now turned against its postulates, and
the evidently vulnerable character of the latter made the need
for some refurbishing acutely felt. Hence there arose a school
of critical philosophy which, though its roots may be traced
back to I£ant, has attained its main development during the
latter part of the nineteenth century. It is unique amongst
philosophical creeds in the fact that its chief exponents have

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476

A PHILOSOPHY OF PSYCHIATRY,

[July,

been men eminent in the scientific world—Clerk Maxwell
( 6 ), Ostwald ( 6 ), Mach ( 7 ), Karl Pearson ( 8 ). Pearson's
Grammar of Science remains the finest vindication in the
English language of the principles, methods, and aims of
modern science. The short exposition which follows is an
endeavour to cull the essential points from its pages. But
limitations of space prevent more than a short summary of the
principal conclusions being given, and for the demonstration
of their validity the reader must be referred to the original
work.

Science is characterised, not by its content, but by its
I method of investigation—it embraces the whole field of
knowledge, and is as applicable to history as it is to chemistry.
It deals, not with a fabulous entity called “ matter,'” but with
the content of the human mind, and acknowledges its inca¬
pacity to deal with anything which forms no part of that
content. The material of science is therefore human
experience, what James calls “ the flux of sensible reality.”
In other words phenomena, of whatever sort or kind they may
happen to be, constitute the material, while science is simply
our method of treating this material. Now it is found that
human experience does not take place in an entirely hap¬
hazard and chaotic manner, but that the events follow one
another with more or less regularity and order. This is the
principle of the uniformity of nature. The aim of science
is to find a means of proceeding from one point of experience
to another with the least exertion of mental energy, in other
words to achieve an “economy of thought” Its method is
firstly to take some portion of human experience and to
classify the facts found therein into sequences ; secondly to
find some simple statement which will resume an indefinite
number of these sequences in a single formula. Such a
formula constitutes a scientific law. The law is the more
fundamental the wider the range of facts which it resumes.
It is not a mythological entity; it is merely a construction of
the human mind to enable it to deal better with its experience.
If we examine any scientific law in order to determine its
essential nature, we find that it has no immediate reference to
sense-impressions, or in other words to phenomenal reality,
but is purely ideational or conceptual in character. The
meaning of this statement will be made clearer by taking an

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1908 .]

BY BERNARD HART, M.B.

477

example, e.g. t Newton's law that “ Every particle attracts every
other particle.” Now a particle is not a sense-impression ; it
is defined as an infinitely small portion of matter, that is to
say, a pure idea, formed by carrying what is given in sense-
impressions to a conceptual limit in the mind. “ Newton is
here dealing with conceptual notions, for he never saw, nor has
any physicist since his time ever seen, individual particles, or
been able to examine how the motion of two such particles is
related to their position ” (®). Similarly geometry, with its
points, straight lines, and surfaces, is dealing with entities
which are frankly acknowledged to be conceptual in character,
and to have no real existence in the world of sense-
impressions. The physical conceptions of the atom and
the ether are precisely analogous in their nature. We find,
therefore, that science does not profess to mirror some
hypothetical universe lying altogether outside the human
mind, but simply to provide a conceptual model, a “conceptual
shorthand,” by aid of which we can resume our sense-impres¬
sions and predict future occurrences. “ The physicist forms
a conceptual model of the universe by aid of corpuscles.
These corpuscles are only symbols for the component parts of
perceptual bodies, and are not to be considered as resembling
definite perceptual equivalents. ... We conceive them
to move in the manner which enables us most accurately to
describe the sequences of our sense-impressions. This manner
of motion is summed up in the so-called law of motion.”
We therefore reach the conclusion that science is simply a
mode of conceiving things. The justification of science lies
precisely in the fact that it does enable us to resume our
sense-impressions and predict future occurrences ; its value as
truth lies in its value as a working hypothesis by which we
may become the masters of phenomena.

Now there may be more than one mode of conceiving the
same things, and which mode we adopt may depend on the
practical necessities of the moment. Thus the mathematician
insists on regarding bodies as bounded by continuous surfaces,
whereas the physicist is compelled to regard them as bounded
by discontinuous atoms. Neither of these modes is more true
than the other; the question is merely which one has the
greatest practical value in the particular sphere of thought in
question. The old absolute conception of truth has no

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478 A PHILOSOPHY OF PSYCHIATRY, [July,

meaning for modern science; truth is regarded as relative; it is
no longer a static but a dynamic concept ( 10 ).

Armed with these conceptions let us now direct our
attention to those fields which more particularly concern us,
and firstly let us consider the problem of the physical and the
mental. What, in fact, is the difference between physics and
psychology? We are usually told that there are two orders of
phenomena, the physical and the mental, two series which are
so qualitatively different that the passage from one to the
other is unthinkable. Concerning the relation between these
two series innumerable philosophical battles have been waged,
and science must approach the question with a due regard for
the metaphysical quicksands which await her on every side.
It was pointed out by Bishop Berkeley that sense-impressions
are the only things of which we have any immediate knowledge,
and modern science, having with some difficulty duly digested
this fact, has discarded the pretence that it is engaged in a
research into “things in themselves,” and has relegated the
latter to the limbo of useless figments. Being entirely prag¬
matic in its ideals, and having a criterion of validity measured
solely by utility, it recognises that its field is the content of
the human mind, neither more nor less. The modern scientist
cannot therefore be accused of sharing the vulgar conception
that “reality” consists of “material substance,” which by means
of “energy and force” acts on “spiritual substance,” giving rise
in the latter to “sensations” which mirror the external reality.
What then does he mean when he distinguishes between the
mental and the material? The answer is that he means two
different modes of conceiving human experience. On the phe¬
nomenal plane the physicist and the psychologist are dealing
with precisely the same entities, sense-impressions ; the
distinction between them lies in their different conceptual
methods of resuming these sense-impressions so as to express
them in simple formulae. The physicist resumes his sense-
impressions by means of a conceptual model involving space
and time, whereas the psychologist regards them as actual or
potential constituents of a consciousness. As Mach ( n ) puts
it, there is a “change of direction” in their methods of research.
The ultimate goal of the physicist is a complete description of
the universe in terms of motion or mechanism, the ultimate
goal of the psychologist is “personality.” Neither method is

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1908.]

BY BERNARD HART, M.B.

479

in itself better, more perfect, or more real than the other; a
comparison between them can only be made on the grounds
of utility. We are only entitled to ask by which method we
are better enabled to resume our experience of the past and to
predict our experience of the future. And the only answer to
this question which it is possible to give in the present state
of knowledge is that both methods are of value, and that
neither can be abandoned in favour of the other. Whether
mechanism or consciousness will be ultimately found to provide
a better description of phenomena is a problem which the
future alone can decide. It may at least be conjectured,
however, that the perfect conceptual description of the universe
will be of a type essentially different from both, an all-
embracing concept from which mechanism and personality
may be deduced as particular examples.

For the present the physiologist and the psychologist must
be allowed to proceed along their respective roads. But there
must be no jumping from one mode of conception to the other.
The physiologist must not introduce a psychological conception
into his chain of cause and effect, nor must the psychologist
fill up the gaps in his reasoning with cells and nerve-currents.
The former error is comparatively rarely met with, the latter is
unfortunately only too common. No physiologist would con¬
sent to admit “ ideas ” as active elements in the sequence of
changes which take place in the nervous system. He simply
points out that he has no use for such a conception, and that,
so far from helping him in his explanation of phenomena, it
vitiates his reasoning, and destroys the validity of all his
former concepts. The psychologist, on the other hand, is a
weaker vessel; he less commonly belongs to what James has
termed the “ tough-minded ” school of philosophy. He is
usually prepared to humbly admit that the phenomena of
memory are adequately explained by the potential physical
energy of a brain cell, and does not venture to suggest that the
potential psychical energy of an idea is a conception just as
valid, and with precisely the same claim or lack of claim to
real existence.

Now, if psychology and physiology are two different modes /
of conceptually describing the continuum of human experience, 1
we see at once that there is room for another body of know¬
ledge, a description of the correlation existing between the two

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480 a philosophy of psychiatry, [July,

conceptual series. Such a science actually came into being
with G. T. Fechner ( 12 ), and under the name of psycho-physics
has attained a considerable development during the past fifty
years. From its very nature it is obviously dependent upon
the perfection of the psychological and physiological conceptual
systems which form its material—and for the insufficiencies of
psycho-physics the insufficiency of psychology is largely to
blame. The amount of importance to be assigned to psycho¬
physics is a question of peculiar interest to the alienist, for the
validity of the “clinical method” is to a large extent dependent
upon its solution. This point will be subsequently discussed.

We must now consider what meaning we are to ascribe to
the term “ insanity.” Amongst the laity there is an almost
universal belief that insanity is a definite morbid entity
analogous to typhoid fever. We smile at the fond wife who
pathetically insists that her husband is not insane, but is only
suffering from “ nervousness.” Nevertheless the profession is
by no means exempt from reproach in this respect, and grave
consultations are held to determine whether a patient is suffering
from hysteria or insanity. Now if we carefully examine what
is meant by insanity we find that its connotation is so shadowy
and indefinite as to be almost meaningless, and that it denotes
a group of individuals who have hardly anything in common.
Perhaps the best possible definition of insanity is expressed in
the motto of a certain asylum magazine : “ We do not all think
alike.” An individual is said to be insane if his mode of
thought differs in quantity or quality from the normal. Nor¬
mal, however, is here a very elastic conception, and means
little more than the vague limits between which the majority
of men do think. The little more which it does mean is prac¬
tically deducible from this definition. On the principle of
natural selection the mode of thinking adopted by the majority
of men will be one more or less in relation with reality, that is
to say, a mode which will enable the thinker to appropriately
dip into the continuum of sensory experience, in other words a
mode which will enable him to adapt himself to his environ¬
ment. The mental processes of the insane, which differ from
those of their fellow men, are therefore usually less efficient in
their relation to reality. A genius, of course, thinks differently
from the vulgar herd, but differs essentially from the insane in
the relation of his thoughts to reality. Nevertheless, the

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BY BERNARD HART, M.B.

1908.]

481

distinction frequently does not save him from being regarded
as insane by the less plastic among his contemporaries.

We have seen that the concept “ normal thinking ” is re¬
markably elastic. As a matter of fact, it is to a great extent
a function of the environment. Thinking which is normal and
adequate in one environment is abnormal and inadequate in
another, and there are numerous individuals who betray no
mental abnormality so long as they are not subjected to any
unusual stress. A man may therefore be considered sane in
one environment, insane in another, according to the less or
greater amount of adaptation required from him.

Insanity is, in fact, a legal and sociological term; it denotes
individuals belonging to the anti-social group. It is impossible
to find any reasonable line of demarcation between insane,
criminal, and immoral. Formerly the insane were treated as
criminals ; we are now slowly but surely approximating to the
point of view which regards criminals as insane.

If the meaning of insanity is so vague and ill-defined we
must be content to assign an equally vague and ill-defined
province to psychiatry. The territory with which it professes
to deal is so vast that the futility of drawing conclusions with
regard to insanity as a single entity is obvious. The psychiatry
of the future will form an essential basis for history, sociology,
and politics—but that it is destined to be subdivided and
specialised to an enormous extent is beyond question. Now,
with this fascinating vista opening before us, what are the
available methods by which we may hope to further our know¬
ledge ? First and foremost we must guard against the wiles
of the panacea-monger, against every attempt to enclose our
science within the narrow limits of dogmatism. And here we,
run at once against the most cherished dogma of the alienist,
the opening statement of almost every text-book : “ Insanity
is a disease of the brain.” It cannot, of course, be denied that
this formula has been of enormous utility in the past. As a
weapon of reform against the theological and metaphysical
conceptions of the middle ages it led to the most notable
advances which psychiatry has yet made. It still remains the
basis of some of the best scientific work of the present day.
But to regard this conception as a unique and ultimate end, to
argue from it that the field of psychiatry must be reduced to a
single path, is totally unjustifiable. The statement that

Liv. 35

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482 A PHILOSOPHY OF PSYCHIATRY, [July,

insanity is a disease of the brain is a physiological conception;
whether it is adequate to describe the phenomena observed
is a question for physiologists to decide, and whether it can be
ultimately brought under the wider conception of mechanism
and treated as a particular example of the laws of motion is
a question which physiologists and physicists must decide
between them. But we have seen above that physiology is
only one method of conceptually describing the sequences of
human experience; the claims of the psychological method
must also be allowed, and it is mainly to emphasise the import¬
ance of this other aspect of things that the present paper has
been written. Nevertheless, it is necessary to avoid exaggera¬
tion, and we need only show that physiology is a limited
method of describing actual phenomena, that it must not be
regarded as the only talisman with which we may approach the
study of insanity, and that its claim to a unique appropriation
of the real is based on crude and naive conceptions totally
foreign to the spirit of modern science. As Janet remarks:
“ S’il faut toujours penser anatomiquement, il faut se rdsigner
k ne pas penser du tout quand il s’agit de psychiatric” To
deny, however, that physiology is a genuine and potent method
of research would be merely foolish. The only test of scientific
truth is utility, and judged by this standard the accomplish¬
ments of physiology are amazing. It has so many champions
that there is no need here to discuss its use as a method in
psychiatry. But it is necessary to emphasise the point that
the physiology of insanity must proceed by means of physio¬
logical conceptions, and must not juggle with the psychological.
No useful purpose is served by constructing a diagrammatic
representation of a psychological conception, and then pro¬
ceeding to translate its points into brain-cells and its lines into
nerve-fibres. Yet this mode of dealing with the problems of
insanity is extraordinarily common, and, curiously enough, its
perpetrators regard it as a genuine scientific advance. It would
be as reasonable to suppose that a French riddle is solved by
translating it into English. In order to achieve any solid con¬
tribution to knowledge, pathologists must practically neglect
mental symptoms altogether. What can be done in this way
is illustrated by Dr. Bruce’s Studies in Clinical Psychiatry.
Physiological sequences are studied by means of physiological
conceptions, and lead to physiological therapeutics—aimless

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1908.]

BY BERNARD HART, M.B.

483

psychology is rigidly excluded, and the result is a book which
gives an impression of solidarity and coherence totally different
from that produced by the ordinary hotch-potch.

A similar rule must be observed when dealing with the
psychological conception of insanity. To remark in the
middle of a psychological discussion that a certain phenomenon
is due to a toxin acting on the cerebral cortex is no explana¬
tion at all. It is merely a lapse into a language which, for the
purpose in hand, is entirely meaningless. Yet an irrelevant
use of physiology is characteristic of a large number of psycho¬
logical writers. The conception of the “ subconscious ” has
been a most potent weapon in enabling us to comprehend
abnormal mental phenomena, and is now established on the
most solid grounds. But there is a school of thought which, j
while admitting that the concept must be used in a purely /
psychological manner, insist on regarding it as a brain fact and
not as a mind fact. This is an example of confusion between
the two conceptual methods.

Certain statements in the last paragraph require some quali¬
fication. It will be at once objected that the clinical method,
which the alienist rightly regards as his most efficient weapon,
is compelled to introduce both physical and psychological con¬
ceptions into the same train of thought. Thus we observe that
an excessive dose of alcohol is followed by the mental symptoms
of intoxication, and that a patient with typhoid fever is liable to
develop that affection of consciousness which we term “ delirium.”
If we accept the general principles enunciated above, are we
justified in thus mixing the physical and the mental ? The
answer to be given to this question depends entirely upon our
point of view at the moment. We are fully justified in saying
that certain toxins cause mental confusion if we clearly realise
that we are merely recording the succession of certain events in
time, and not insinuating the existence of a causal relation. In
order to make this statement clearer we must consider for a
moment the philosophical meaning to be ascribed to the word
“ causation.”

Let us first note that clinical observations of the kind men¬
tioned are possible, because all human experience takes place
in time, and the temporal character also adheres to both the
physical and mental concepts by which we resume this experi¬
ence. Hence it is possible to resume one portion of experience

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484 A PHILOSOPHY OF PSYCHIATRY, [July,

by a physical concept, another portion by a mental concept, and
to record the fact that the one precedes the other in time. This
is precisely what we do when we say that a toxin causes mental
confusion.

Now, Hoffding ( 13 ) states that “ The causal concept appears
under two aspects : under a provisional, elementary form, with
which we are often compelled to be content; and under an
ideal aspect which all research and all theories strive after. The
elementary causal concept presents only an unconditional succes¬
sion : if the phenomenon A appears, then B inevitably follows,
and B only appears when A has preceded it. It is not asserted
that the causal relation holds between A and B themselves. It
is possible that they are both the successively emerging con¬
sequences of a previous cause. The ideal causal concept goes a
step further and sees in the phenomenon, which we call the
consequence, the continuation of that phenomenon which we
call the cause, or its equivalent in a new form.”

It is in this latter sense that causation is taken in all exact
scientific work. Now if we say that a toxin causes mental
confusion we are using the concept of causality in its first or
empirical, and not in its second or ideal form. It is impossible
to conceive of a mental state as the continuation of the collec¬
tion of atoms termed a toxin. If, therefore, we are proposing to
do exact scientific work, we must endeavour to work out the
mental state as the resultant of the preceding mental state, the
bodily conditions as the result of the preceding bodily con¬
ditions. We are accustomed, for instance, in every-day life to
say that the idea of a meal makes the mouth water. But for
the physiologist this statement has no meaning. He is ready
to show how a certain impression on the retina by means of
neural connections causes an increased secretion of saliva. But
if you insist on introducing an “ idea ” into his causal series you
destroy the fundamental postulates on which his science is
built. Similarly, psychology cannot form itself into a science
by endeavouring to weld into a causal series the totally dis¬
parate conceptions of toxins and mental states. Causal rela¬
tion, in its scientific sense, can only be asserted of the different
parts of one and the same conceptual series, whether it be
physical or mental. But these considerations do not alter the
fact that clinical observations of the type described above have
a certain value of their own, and in the present imperfect state

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1908.]

BY BERNARD HART, M.B.

485

of our knowledge a very great value. For one thing they form
data for that science of psycho-physics which we have previously
mentioned, for another they are of the nature of first approxima¬
tions, and constitute a basis for subsequent and more exact
work. But this more exact work must take the form of a
causal series composed of mental states, and a second causal
series composed of physical states.

The first essential in the study of insanity is, then, that the
pathologist and the psychologist must pitoceed along distinct
lines, each employing a coherent system of concepts, and each
refraining from interpolating any concept belonging to the
other. But there are certain methods which, as they depend
upon the very nature of thought, may be properly made use of
by both. Here belong the much-mooted questions of classifica¬
tions and disease entities. Now the first point to be made is
that, as the aim of science is to resume our past experience in
order that we may predict future experience, classifications and
disease entities cannot be the end of psychiatry, but only one
of its means. Any classification, therefore, which enables us to
handle our material in a convenient manner, and which enables
us to predict the future to any extent, has to that extent
validity and utility. It will be the more valid and the more
useful the more it fulfils these conditions. On the principles
expounded above it is obvious that diseases are simply con¬
venient labels for grouping together more or less similar
sequences of phenomena, and it is hardly necessary to point out
to medical men that their borders are indefinite and to a certain
extent arbitrary. Yet in the numerous discussions which have
raged on the subject of terminology in psychiatry, many writers
have evidently regarded diseases as ready-made articles which
only require to be found, so that any particular classification
must necessarily be right or wrong. Strictly speaking, in
classifications of this kind the words right and wrong have no
meaning. The whole question is one of practical utility. The
Linnaean classification of plants was not wrong ; it was simply
less useful as a weapon of research than that now adopted.
Similarly, the question at issue as regards Kraepelin’s theories
is not whether the diseases he describes really exist or not,
but whether his classification enables one to proceed more
efficiently in the departments of prognosis and therapeutics. If
this is so, then his classification is valid and an advance on that

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486 A PHILOSOPHY OF PSYCHIATRY, [July,

which it replaces. Kraepelin will then occupy a position in the
history of psychiatry analogous to that of Kepler in astronomy.
Great generalisations, such as Newton made, are more likely to
proceed from the strictly psychological researches of Janet, or
those of Jung and the Zurich school.

The function of a classification, then, is to serve as a weapon
of research. It must be clearly recognised that classification
exists for psychiatry, and that psychiatry does not exist for
the purpose of forming classifications. In the melancholy and
despairing chapter on classification which prefaces most modem
text-books it is usually stated that the ideal, ultimate, and
perfect classification is the anatomo-pathological. If the
conception of the principles of science explained above is
correct, it is obvious that some exception must be taken to
this statement. The anatomo-pathological is, of course, an
ideal classification—it is the perfectly legitimate ideal of the
physiological method. But there is no more reason for
ascribing perfection to the physiological ideal than to the
psychological. The relative merits of each must be ultimately
determined according to their practical utility, and it is very
certain that, in the present state of knowledge, the data for
such a determination are absolutely lacking.

If we apply our criterion of value, that is to say, the
possibility of practical deductions, to the various classifications
which have held their sway in psychiatry, it is true that we
find imperfections everywhere. But it is no less true that we
find evidence of a steady advance. If we open a text-book of
fifty years ago under the heading “Mania,” we are totally
unable to construct a coherent mental picture of the cases
described under it. If, on the other hand, we are told that a
patient is suffering from katatonia we are enabled to form a
pretty accurate idea of what we may expect to see. If
katatonia be taken here in its wider sense as a symptom-
complex and not as the narrower conception employed by
Kraepelin, then the advance here indicated is to be regarded
as an advance in the symptomatological classification. We
have been provided with more definite labels. This type of
improvement is the ideal of the symptomatological method,
and certain authors maintain that it is the only type which
can be entertained in the present state of knowledge. That it
has a certain utility as an economiser of thought is obvious,

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but its imperfections are denied by no one. Probably its
greatest defect is that it tends to direct attention away from
the ultimate aim of all science, the resuming of past and the
predicting of future experience. It was as an endeavour to
obviate this objection that Kraepelin conceived his disease
entities and the longitudinal method of treatment. The
essential advantage of this move was the importance assigned
to prognosis and therapeutics. The essential disadvantage
has been the more or less unconscious tendency to make the
patient fit the disease. Much valuable mental energy has
been wasted in arid discussions as to the precise disease entity
to which a certain case was to be assigned. The most modern
method of research combines the advantages of the sympto-
matological and disease-entity classifications, while it is to a
great extent free from their imperfections. This is the method
which Farrar ( 14 ) refers to as the “biological,” and is in fact
simply a recognition of the truth that psychiatry must proceed
along the lines that have led to success in all other branches
of science. It might also be called the evolutionary method,
for it is an endeavour to trace the development of a mental
state from that which preceded it, each constituent thread
being conceived as related in a definite manner to its antece¬
dents. By this means it is hoped that laws completely
describing these relations will ultimately be formulated, and
that the reproach of scrappiness and incoherence so frequently
levelled at psychiatry will be removed. Thus a delusion will
no longer be regarded as suddenly coming into existence
without rhyme or reason, but its origin from the preceding
mental state will be definitely traced out.

There is no reason to call the attention of the physiologist
to the method just described ; he is perfectly acquainted with
it, and employs it continually in all his researches. Dr. Bruce’s
recent work, to which we have already referred in a similar
connection, is an excellent example of the systematic observa¬
tion of pathological sequences, and the endeavour to describe
them by simple pathological laws. But the application of this
method to the psychological conception of insanity is com¬
paratively rarely attempted, more especially in this country. A
good deal has been done on the continent and in America by
Janet, Freud, Jung, Morton Prince, and others. Janet’s great
work on “ Psychasthenia ” ( 15 ) is a splendid example of what may

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488

A PHILOSOPHY OF PSYCHIATRY,

Duly,

be accomplished by the psychological method, and its perusal
may be confidently recommended to the anonymous gentleman
in the Times who “ cannot help regarding psychology as an
ignis fatuus .” If any progress is to be made, this is the
type of work which must be substituted for that method of
case-description so much in vogue, in which delusions, halluci¬
nations, and bad tempers are aimlessly catalogued without
reference to each other or to the patient.

The ultimate aim of science is the predicting and influencing
of future experience. Translating this into the language of
medicine we reach the all-important question of therapeutics.
Here, again, the dogmatists and panacea-mongers are much in
evidence. There is a school of thought which will have nothing
to do with any therapeutics that is not physiological and which
contemptuously dismisses the question of psycho-therapy as
clap-trap and nonsense. This view is not only dogmatic, it is
irrational, and it contradicts common-sense. The statement
that magnesium sulphate is an efficient form of treatment, while
the effect of a kind word is an unscientific delusion, is one which
any nursery governess would have sufficient common-sense to
laugh to scorn. Yet this statement, expressed in less bald
language, is so widely held to be a self-evident truth that its
origin and basis merit some investigation. It arises from those
naive conceptions which we have already criticised—the idea of
the physical as something objective and real , of the mental as
merely a flimsy, subjective, shadowy mirror image of the same
reality. Hence, by the law of the conservation of energy,
which is regarded by these thinkers in the light of a categorical
imperative, if we would alter the reality we must do so by the
employment of “ real ” alias physical causes. If insanity is an
alteration of the brain then it can only be affected by physical
agents, which alone have the power of acting upon the brain
substance.

Now, as this doctrine contradicts common-sense, there is con¬
siderable d priori justification for regarding it with suspicion;
and, as a matter of fact, we have already seen that it is based
upon entirely erroneous premises.

The reality with which science deals is not a hypothetical
world of “ things-in-themselves,” but the phenomenal reality of
human experience. This reality is no more physical than it is
mental, it simply is. The distinction between the physical

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489

and the mental comes into being on the next plane ; it is a
difference in the method of conceptually regarding this
phenomenal reality. When this distinction becomes more
evolved and systematised, it becomes the distinction between
physics and psychology. The physical and the psychological
are two methods of conceptually describing one and the
same content, the content of the human mind. Now both
these methods make use of the concept of causality, and it is
perfectly obvious that where we can speak of cause and
effect we can also speak of therapeutics. For therapeutics is
simply an endeavour to interpolate an element into a chain of
causes with the object of producing a given effect.
Physiological therapeutics is, then, to be regarded as the
ultimate aim of the physiological method of conceiving in¬
sanity, psycho-therapeutics as the ultimate aim of the
psychological method. We saw above that there was no
reason for ascribing peculiar perfection to the physiological
rather than to the psychological, so we must conclude that
physiological therapeutics have no a priori claim over
psycho-therapeutics. Their relative merits must be deter¬
mined by their practical utility. As a science physiology has
progressed very much further than psychology, with the
result that physiological methods of treatment are at present
more systematised and rationalised than psychological.
Psycho-therapy is still in a nebulous stage, yet under the names
of tact, intuition, sympathy, etc., it forms a considerable part
of the stock-in-trade of every successful physician. Suggestion,
which constitutes one of its methods, is now generally
acknowledged to play an important r6le in the action of drugs.
This is the factor which explains the popularity and occasional
efficacy of quacks and patent medicines, and buried in
irrelevant details it forms the modicum of truth contained in
the doctrines of Christian Science. In the hands of men like
Janet, Freud, and Jung, psycho-therapy has been rationalised
to a certain extent and systematically employed with the most
striking results. The classification of cases adopted in the
best English asylums, the endeavour to segregate the curable
from the incurable, and to provide the patients with a cheer¬
ful and stimulating environment, is another example of this
same method. As a science it is still in its infancy, but f
that a vast field of potent therapeutics is now opening before

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490 MENTAL RECREATIONS OF THE MENTAL NURSE, [July,

us in this direction cannot be doubted by any impartial
observer.

(') Hoff ding, History of Philosophy , vol. i, p. 375.—( s ) Buchner, Kraft und
Staff. —( 3 ) Moleschott, Der Kreislauf des Lebens. —( 4 ) Ernst Mach, Erkenntniss und
Irrtum , Leipzig, 1905, p. 4.—(*) Maxwell, Scientific Papers , Cambridge, 1890.—
( 6 ) Oswald, Naturphilosophic, Leipzig, 1902; Die Uberwinding des wissenschafU
lichen Materialismus, 1905.—(') Mach, Die Mechanik in ihrer Entwicklung ,
Leipzig, 1883; Die Analyse der Empfindung, Jena, 1902.—( 8 ) Karl Pearson,
Grammar of Science, 1892.—( 9 ) Ibid., 2nd edition, 1900, p. 281.—-( I0 ) The doctrines
described in the text have ii^ recent years become the basis of “ Pragmatism/' a
system which has already obtained a firm hold upon the philosophical world. For
an exposition of its principles the reader may be referred to Dewey, Studies in
Logical Theory , Schiller, Studies in Humanism, Milhaud, Le Rationnel, 1898,
William James, Pragmatism, 1907. Pragmatism, however, is really an ontological
theory, and goes very much farther than the scientific idealism of Pearson, which
is really a working hypothesis. The validity of the latter, therefore, is by no means
dependent upon that of the former.—( n ) Mach, “ De la Physique et de la Psycho¬
logic,” VAnnie Psychologique, 1906.—( l2 ) Fechner, Elemente der Psycho-physik,
Leipzig, i860.—( 1S ) Hoffding, The Problems of Philosophy , New York, 1905.—< M )
C. B. Farrar, “Types of the Devolutional Psychoses,” Brit.Med. Journ., September
29th, 1906.—( 15 ) Janet, Les Obsessions et la Psychasthenie, Paris, 1903.

The Mental Recreations of the Mental NurseJf) By
Robert Jones, M.D., F.R.C.P.Lond.

Our distinguished President, Sir William Collins, in his
admirable oration delivered to us last year, expressed apprecia¬
tive sympathy with the main objects of the Asylum Workers*
Association. These are, firstly, to raise in the public esteem
the calling we have chosen, and secondly, to succour those
members of our body who have suffered in the service.

Our President’s very eloquent and appealing address, clothed
with the literary grace and expressed with the philosophic
charm so peculiarly his own, was in matter and manner such
that we all fervently hoped for an anniversary of the pleasure
experienced last May. The claims made in his speech from the
ethical side, viz., upon character and conduct, rather than from
the purely intellectual aspect of the nurse’s duties, are applic¬
able to all those who minister to the mentally afflicted, and our
President’s invocation that we, as asylum workers, should not
let go our sympathy nor neglect the qualities of the heart out
of homage to those of the head, will long be cherished as among
his wisest aphorisms.

We regret that Sir William Collins—who was recently

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BY ROBERT JONES, M.D.

491

described by a cabinet minister in the House of Commons
as one of the ablest members of the Legislature—is not again
to address us this year, but we are proud that our leader and
the figure-head of our Association is one whose success in so
many departments of human activity has been phenomenal,
and that whether by the sick-bed, or in the professorial chair,
or administering the affairs of the greatest city in the world, or
acting as Vice- to the noble Chancellor, of our Imperial Uni¬
versity, or furthermore, in directing inquiries into the great
affairs of State, our President is one who always kindles interest
and rouses enthusiasm, and we rejoice that with his multitudinous
engagements he still consents to direct our counsels and to
extend his sympathetic and practical interest in our very special
work. I, as one of his Vice-Presidents called upon to address
you, feel the disappointment as much as any of you do, and I
crave the kind indulgence and sympathy of my audience as a
most inadequate representative of our distinguished President.
My only claim—and it is a proud one—is that I am one of
yourselves, an asylum worker, and one who for nearly thirty
years has taken a continuous interest as well as a sincere
pleasure in the work we have selected to do with the best of
our ability.

The two-fold object of our confraternity or guild, viz ., our
advancement and our benefaction, are fully set forth in the
Annual Report which has just been read to us, but the roll of
membership, 3,000 out of a possible 18,000 asylum workers,
can hardly be considered satisfactory, and it is earnestly hoped
that before the close of another year a substantial increase will
be made in our roll, so that the leaven of our active membership
may give such an impetus to the objects of our Association
that not only may solidarity and coherence be imparted to it,
but that also greater influence, sympathy and vigour may be
extended to our work, which, on account of its exceptional
claims to humanitarian considerations, should inspire interest
beyond all others.

Our medium of inter-communication—and every organisa¬
tion has its literature of propagandism—the Asylum News , has
been for many years under the Editorship of our wise and
tactful friend, Dr. Shuttleworth, who has done much to cement
friendship, to uphold the asylum nurse, to advance his and her
status, and to sustain his and her position before the public

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492 MENTAL RECREATIONS OF THE MENTAL NURSE, [July,

gaze ; and it is hoped, now that other arrangements are being
made for its continuance, the secret of his successful piloting
may be imparted to his successor, Dr. Nicoll, whom we sincerely
congratulate upon his honourable selection and distinction.
The pages of the Asylum News demonstrate only too clearly
the need there is for help to those of our numbers who have
fallen by the way, and as a plea for these benefactions it
may be urged there is no one, unless he has lived in actual
touch with the insane, who can in the smallest degree appre¬
ciate the relief of change and rest from the peculiarly trying
conditions, the arduous stress and the overwhelming strangeness
of the work of nursing the insane. Such a rest as our funds
permit, insures for our workers a complete change of thought,
not only from the objective but from the subjective world in
which we live—a world full of phantom voices, visionary sights
and unexpected realisations, which cannot be ignored and which
not infrequently become dire catastrophes. The constant
watchfulness necessary to secure safety, to preserve and en¬
courage order and method in such a world, the need always to
exercise tact, sympathy, and forbearance, under the most adverse
and trying conditions : the necessity for bringing gentleness,
serenity, and kindness into the lives of these “ waifs and strays
of intellect ” must and does tell upon any ordinary individual, and
the Home of Rest or a pension at the close of a long pilgrimage
cannot but be a well-merited recognition for trying duties well
performed.

There is absolutely no parallel to asylum work in any voca¬
tion, and I am certain that the services of the staff in many of
our asylums who assist so faithfully to keep down the sum total
of human suffering are not justly, adequately, nor fully recog¬
nised.

Our report indicates a greater demand than at any previous
time upon the Home of Rest Fund, and although there has
been an inordinate call upon it during the year, yet there is
still—through the careful oversight of our Treasurer, Mrs.
Chapman—a small balance left to the good. It is probably
not too much to say that the special work of benefaction
organised by this fund is a most deserving charity, and needs
to be brought prominently—as we know only our President can
do—before a sympathetic public, which only requires to be
convinced of merit in order to assist its due reward.

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493

It is true that in some instances public authorities refuse
pensions to their well-worn employees ; still, the London
County Council, happily, has always shown a readiness to con¬
sider services faithfully rendered in their asylums, services
rendered in isolation from family life, and which are not unat¬
tended with serious risks and danger to life and limb, which
are constant on week-days and Sundays, night and day alike,
and which must never be allowed to pall, or the object of our
service is unattained. In the asylums of the London County
Council the leave of the staff has been extended to a full day
and a half per week for the male attendants, and to three
weeks annual leave for nurses, and every evening from eight to
ten o’clock is free to nurses of both sexes to go out of the
asylum. Furthermore an increase in wages and emoluments
has recently been made, all of which tend to show that the
greatest municipal authority in the world pays a due regard to
the nature of these duties, to the need for rest, and also for home
life and the comfort of those engaged in their services—a con¬
sideration which, in the presence of members of this authority,
I beg to state, is keenly recognised and appreciated.

Within the last few years nursing the sick in mind and body
has become much more exacting, and greater stress has been
laid upon the requirements of the asylum staff, confronted, as it
is, with the risks, difficulties, troubles, and anxieties inseparably
associated with the care of the insane. The Medico-Psycho¬
logical Association of Great Britain and Ireland, which grants
a certificate for proficiency in mental nursing, has recently
extended the minimum period during which the necessary
training and experience can be obtained to three years, but
probably few nurses will be enabled to complete their full
course of studies within this period, so that a high state of
efficiency is expected from them, and the acquisition of the
certificate may be taken to imply qualifications and attainments
of no mean order.

Text-books are published upon mental nursing, and the
duties of the mental nurse are therein precisely defined and
fully described, and I myself am guilty of publishing a treatise,
may I venture to hope, for the further delectation of the asylum
nurse ? All these facts suggest that those who have selected
the vocation of nursing the insane are under an obligation to
extend the usefulness of their talents by applying their minds

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494 mental recreations of the mental nurse, [July,

diligently to reading, studying, and observing ; to attendance
at lectures and demonstrations, and by presenting themselves
for examination. As the elevation of the mind is the principal
end of all studies, so it should be our pleasure and purpose to
work with zeal and enthusiasm, for work done with thorough¬
ness leads to success, and in no department of medicine is a
good nurse of such incalculable value as in a case of insanity,
where the essence of treatment is that alluring, baffling, and
even mysterious influence of one mind upon another, and it is
remarkable what power can be exercised over an insane
person—his habits of attention and trains of thought—by a
well-disciplined mind. Attacks of mental disorder may be cut
short, infinite anxiety and risks saved to both patients and
relatives, accidents avoided, suicides averted, and valuable
lives restored to reason through the efforts of a good mental
nurse.

It is essential therefore that we should obtain as high a class
of applicants for asylum work as possible, persons of good
character, and those who will make the welfare of the patients
their personal interest, and who will persevere by example and
precept to promote their recovery and well-being. It is only
by providing surroundings suitable to their responsibilities that
the best type of nurse—refined and cultivated women—can be
encouraged to join asylum service.

With this preamble, which I admit has been at rather undue
length, I would like to point out more especially that the duty
cast upon the mental nurse of either sex to cultivate and
improve their art—which in most instances is the re-education
of the reason—psychic pedagogy as it is called—has furthermore
another aspect, viz., that the nurse owes also a duty to herself
Every person is bound to make his life worthy, and for this
the nurse must have proper leisure, adequate rest, and
opportunities afforded for mental and physical recreation. It
is only by means of proper leisure that self-culture can be
possible, and the best self-culture helps to enthrone the sense
of duty within us. Sir James Crichton-Browne, in his Presi¬
dential Address of 1902, referred to the nurse’s recreation, and
that he might see nurses mounted upon suitable motor cars,
after having shown competence in golf and bridge ! Although
these are probably figurative and hyperbolic attainments, yet
there is no question but that the asylum nurse should receive

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ample opportunity for bodily, and more especially for mental,
improvement.

In the life of Darwin we are told how his father, Dr.
Darwin, declared that he had “often seen the paramount
importance, for the sake of the patient, of keeping up the hope
and with it the strength of the nurse in charge.”

In my few remarks, I have chosen more especially to dwell
upon the mental aspect, in order to advance the claims for
mental diversion, which, in my opinion, are equally as, even if
not more, essential to health than are the purely physical
claims. The mind must have occupation, for lack of interest
and idleness lead to irregularities, and if the mind is kept busy
and well disciplined the person is true to the best of himself.

The mind of each one of us is probably endowed with a
vast number of gifts of totally different variety, and, like the
limbs of the body, if they are not exercised they waste and we
are crippled.

It is of supreme interest therefore for the mental nurse to
possess a well-arranged mind, for she has to be buoyant
when hope can scarcely be entertained, and if her own mind
is right it helps to correct what is wrong in others and to
mollify what is hard in her special surroundings. She has to
dignify labour of whatever kind in order to educate and
encourage those around her. She has to realise the maxim
that sowing corn or writing epics is work which can be equally
elevating, that the faculty of effort is necessary for both, and
that to master things is to insist on oneself, and thus to be
true to the best of our individual self.

Of the pleasures intermediate in tone between the bodily
and mental are those afforded by gardening. Our men know
the mental value of this diversion, for it teaches patience,
quickens curiosity, it induces hope and tender ways, it affords
pleasure to others, and it has the charm that something has
been accomplished by oneself which is beautiful and varied,
and thus is twice blessed. I have seen effects which delight
the eye and scent the air from a few seeds sown in window-
boxes or flower-pots, and the delicate appreciation of colour
together with its artistic arrangement, and for which ladies are
famous, prove that women are par excellence adapted for
gardening effects. Of the two cults which in recent years have
received more attention than any other, viz., the care of

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496 MENTAL RECREATIONS OF THE MENTAL NURSE, [July,

children and of gardens, I believe their advancement to be due
to the fact that they have been the objects of serious study on
the part of capable women. Even one species, such as the
Linum or the Geum or the Salvias, or Saxifrages, in its many
varieties, can be made a study of by any ordinary person, and
even where there is no full scope for gardening, Nature herself,
in her own time and way, profusely scatters plants which can
become the museum of the collector ; the name, date and
habitat of the collected specimen reminding the nurse of many
happy associations, at the same time giving point and object
for her rambles, and cultivating her powers of observation and
her aptitude for describing and reporting. Probably, of all the
pleasures which can refresh the mind, there is none more
invigorating and strengthening than reading, which to the mind
is what physical exercise is to the body, viz ., the best preserva¬
tive of its strength and efficiency. It is the most soothing
remedy for many of the ills of the body, and the position of
librarian to a mental hospital or an asylum is one of the most
pleasure-yielding posts, *>., if there is adequate literature to
circulate, as there should be. I think that reading aloud
should be cultivated by nurses, and their usefulness and value
might be further enhanced if they were to take lessons in
elocution from competent teachers. I believe that many mental
patients would be soothed by good and clear reading aloud to
them. I know its value with children.

It is chiefly through books that most of us have enjoyed
intercourse with great minds, by whose intellectual companion¬
ship we are at the same time entertained and elevated. It
is consoling to know that no matter how poor a person may
be, there is the knowledge that the best characters never
refuse to cross his threshold. In this way some of the most
charming lives that have adorned literature are drawn into our
own circle, in which we find ideals to love and idols to
worship. I think that good reading, which may equally be
the diversion of young and old, rich and poor, ill and well,
forms the best counteracting agency to unworthy temptation.

With the number of foreigners in our great cities and their
asylums many of our nurses have the opportunity for learning
a foreign language, and such an interest may be the means of
kindling a sympathy between herself and the patient when
other means have failed. In these days of short cuts to attain-

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1908.] BY ROBERT JONES, M.D. 497

ments text-books are cheap, and a little progress every day
may mean much progress in a year !

There is a great consolation to the tired and too often
despondent mind of the mental nurse in the reading of poetry,
which is really musical thought, and it is curious that the great
Darwin expressed regret that he had not devoted more time to
poetry as an intellectual diversion, showing that he desired to
relax his logical attentions by an exercise of the imaginative
faculty, and in the words of our President, to familiarise
himself with “ the language of the heart rather than that of
the head.” It is gratifying for me personally to know that one
of my own staff, possessed of the true poetic spirit, delights
the readers of the Asylum News , and that he is no less
distinguished as a kind, orderly, and conscientious mental
nurse.

I am convinced that the Executive Committee acted most
judiciously when they introduced prizes for the study of
literature in our own reading circle among our nurses. My
own experience of introducing a circle of the Home Reading
Union convinced me not only that it was possible to obtain
pleasureable intellectual diversion from reading upon a definite
syllabus, but that a taste for wholesome reading could thereby
be initiated and cultivated. During one winter at Claybury we
read out of penny copies, John Bunyan’s Pilgrim's Progress , “The
Merchant of Venice,” “ Hamlet,” and Wordsworth’s poetry,
and on each occasion the discussion which followed showed
how much meditation and study had been given to this
diversion.

The influence of music was well exemplified by the Society
of St. Cecilia, which based its efforts upon the purifying influence
of music on our emotional nature. In the Berlin Charity
Hospital concerts are given on every Sunday afternoon from
5 to 6.30 for the benefit of the patients. Witness the
ethical results of music in the missions of Sankey and Moody,
ofTorrey and Alexander, of the Salvation Army, and of the
Church Army with Prebendary Carlile at its head. Music
charms away care and anger and terror ; it delights the ear,
soothes the tired nerves, composes the thoughts, dispels morbid
ideas and recreates the mind. It might be worth while apply¬
ing the experimental method for the determination of the
effects of music on the circulation and on the nervous system,

LIV. 36

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498 MENTAL RECREATIONS OF THE MENTAL NURSE, [July,

and thus indirectly on other functions of the body, ip a more
serious and systematic way than has hitherto been done. Some
of my hearers may not be aware that Elgar, now numbered
among the Immortals, was formerly interested in the band
of the Worcester Asylum, and at one time conducted it.
However, it is not often that we get an Elgar to guide our
musical staff, but the services of those who are talented always
command a ready appreciation, and one of our own nurses at
Claybury was afforded such facilities for the cultivation of her
talents that she entered the lists of competition and success¬
fully carried away some of the best prizes in our immediate
neighbourhood. The pleasure she afforded to others has left
happy reminiscences of her devotion to an art which can be the
handmaiden to duty, and which she now exercises in a higher
and a wider sphere at another place.

The great philosopher, Carlyle, described music as “ the in¬
articulate speech which lets us for a moment gaze into the
Infinite.”

Painting and pictures are also well known as branches of
aesthetic art, and they have their due place in the relief of
mental fatigue and as antidotes to the monotony of routine,
which cannot but be the inevitable lot of the asylum nurse.
Sir Joshua Reynolds said that a room hung with pictures was a
room hung with thoughts, and we as mental physicians practise
this precept, for do we not make a great point of decorating the
walls of our mental hospitals with these consolers to the lonely
and the brain-weary ? How often do we see the sick in mind
gaze into illustrations in books, or prints upon the walls,
and in this way obtain representations of healthy ideas which
help to direct their thoughts once more into normal channels ?
In this connection, the value of pictures cannot but find a ready
response in our President’s heart, for some of my own earliest
appreciation of pictures was due in a great measure to the
influence of the artistic mind of our President’s father, whose
academy pictures from his own brush will always be to me a
happy recollection.

I may be permitted to state that our President himself has
not neglected this side of his versatile genius, and I expect
that he still appreciates the pleasure afforded by this diversion
in a busy life.

How many of us have put in a spare half-hour at the National

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499

Gallery and refreshed our thoughts with the inspiring genius of
some great painter until we think we understand and love him
—for a great picture is also a great moral lesson ? Art is a
sweet consoler, and, unlike a book, pictures can be gazed at
without sustained effort, for when the eye is fatigued the mind
can then relax its attention. At the Claybury Asylum some
of our nurses* private rooms demonstrate how much interest can
be taken in, and how many happy recollections can be preserved
through the love of art. The days of the “ kodak ” are so
obstrusive that I will pass over its ubiquitous transports, merely
remarking that I possess many volumes of its productions, and
I confess to a lingering attachment for its more or less libellous
—often more—representations of men and things, and I would
also add of women and children !

There is one other aspect upon which I should like to dwell.
It received a dignified allusion from our President in his address
last May, and that is the religious influence in the life and work
of the mental nurse. Much has been said upon this aspect, and
there are those present before whom any remarks of mine may
possibly appear to be a presumption, but from the psychological
aspect alone there is a consolation in spiritual belief which no
other emotion affords.

Religion is a part of man’s nature which cannot be banished
or repressed, and there is in every breast a longing and a
yearning for its comforts. That hopeful look into the future,
from which no one has yet lifted the veil, is the foundation of
much of our faith and belief. History has preserved many
instances of the repression of our hope and faith and creed, but
these have emerged from the struggle, and in spite of opposition
and conflict are to-day as dominant in the minds of many of
our workers as they were in the days when the mediaeval Church
was the sole custodian of our knowledge and of our ideals.

Religion implies a sacrifice and a service to others, and it
tends to subordinate man’s will to higher ideals. The self-
denial it rouses yields a gratification which can compare with no
other. It implies the ordering and the submission of our nature
to that of something transcendent, some great Power immanent
in Nature itself, and yet which lies behind and directs Nature.
I will not dwell upon this aspect further than to state that its
influence is to mould character, to place a higher value upon
duty, and to stimulate that highest attribute of man’s mind, viz,,

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MENTAL DISORDER IN ADVANCED LIFE, [July,

the spirit of love and reverence. Spiritual agencies kindle
emotions of fervour, sympathy, and right-mindedness even among
our roughest characters and in the most crowded areas of our
large cities, and opportunities for cultivating this side of our
nature should be placed before every one of our workers. It is
through influences of this kind that what is best and noblest
can be elicited and developed.

In conclusion, I may be permitted to state that into what¬
ever sphere a well-trained and sympathetic mental nurse enters,
there the standard of life is raised, for she brings enlightenment
and encouragement to her patients upon such subjects as cleanli¬
ness, self-discipline and self-control ; thrift, the'home, and the
care of the young.

I should be wanting in my duty, as the head of a large
institution in which so much of its success depends upon the
nurse, if I did not advocate her claims for mental diversion as
well as for physical recreation, and plead her cause for a liberal
support of the Home of Rest Fund which endeavours to meet
both these claims.

(*) Address delivered before the Asylum Workers’ Association, May, 1908.

Observations on the Less Severe Forms , Pathology and
Treatment of Mental Disorder in Advanced Life .
By Alexander Robertson, M.D., F.F.P.S.G., Con¬
sulting Physician Glasgow District Lunacy Board; Visiting
Physician, Old Men and Women’s Home, Glasgow.

This communication is based on a study of cases in
Glasgow’s Aged People’s Home. The Home is for those in
reduced circumstances, but above the pauper grade. It has
accommodation for 140 men and 86 women. Reference is
made to this point to enable a general inference to be drawn as
to the proportion and frequency of cases of the more acute
though brief forms of mental disturbance among the old; for
with one exception they all occurred within a period of two
months since the beginning of the present year. However,
looking back over the last twenty years, my impression is that
the number of cases here recorded is above the average of our
previous experience.

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1908.]

BY ALEXANDER ROBERTSON, M.D.

SOI

It will be understood from the nature of the establishment
that the more pronounced and continuous forms of mental
disease are not retained. When they occur, as happens now
and again, they are removed to an asylum for the insane.

The Walls of the External Blood-vessels as an index of the Con¬
dition of those within the Cranium.

Many years since (*) I directed attention to the relations of the
temporal arteries to the branches of the internal carotid dis¬
tributed to the brain. Having the same parent stock, the
common carotid, it was pointed out that there was considerable
correspondence in the condition of their respective walls in
states of degeneration. If, it was stated, the temporal arteries
were indurated, those within, supplying the fore and mid-brain,
would, in all probability, be found so also.

Further experience of my own supported this conclusion. It
was also corroborated some years later by Dr. McRorie, then
Assistant Pathologist, Glasgow Royal Infirmary, who published
a valuable paper entitled, “ Atheromatous Disease of Arteries,”
in which he treated the subject more widely O.

In the summary of his conclusions he states in regard to the
point under consideration, “ A tortuous or rigid temporal does
not necessarily mean that the cerebral vessels are atheromatous,
but it is well to presume that they are so.”

It would, however, as I pointed out in my paper, be a
mistake to infer from such remarks that the absence of rigidity
in the temporal arteries is suggestive of a sound state of the
cerebral vessels. On the contrary, it is not rare to find the
latter diseased, while the walls of the former are soft and appa¬
rently in other respects normal.

The practical corollary to be drawn from these statements is,
that when symptoms point to the presence of disease within the
skull, particularly in patients past middle life, the state of the
temporal arteries should be ascertained. This is easily done by
running the finger along their walls in their course in front of
and above the ear.

Brief Maniacal Attacks .

Excitement of short duration, accompanied by a varying
amount of intellectual disorder in different cases, is probably

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MENTAL DISORDER IN ADVANCED LIFE, [July,

the most common, as it is the most disturbing variety of mental
derangement met with in the Home. Two groups of cases
occur—one apart from obvious organic disease of the brain,
the other associated with it.

The three following cases illustrate the first of those groups,
and may be classified with the so-called functional mental
disorders:

T. H—, aet. 75, shipwright, teetotaler for forty years, has
been a much respected man ; is somewhat deaf, but says, “ as
is usual in my trade,” sight good for age. Heart and lungs are
free from obvious disease; radial and temporal arteries hard
and tortuous, especially the radial.

Prior to the onset of his mental disorder on January 17th
he was a little peculiar in his manner of speaking. On that
date he became much excited in one of the halls of the Home.
He was then removed to the sick room and put to bed. There
he was violent and could be controlled with difficulty, took off
his night-shirt and messed the bed-clothes.

The maniacal condition passed off in about three days. He
then became rational, but was depressed and physically some¬
what exhausted, also complained of headache. When asked as
to the cause of his illness, he said that his son-in-law had not
sent money to pay his board in the Home. This was scarcely
correct, though there had been a little delay in forwarding the
usual remittance.

Since then he has remained well, except that on February
10th and nth he complained of headache and was a little con¬
fused mentally, so that he had difficulty in finding the way to
his dormitory. This condition, however, quickly passed off,
and within a week he was able to transact business correctly
at a bank.

Mrs. W—, aet. 82 ; is in fairly good bodily health and condi¬
tion. Heart and kidneys apparently normal. Both radial and
temporal arteries are thickened, the right temporal more than
the left.

On admission to the Home on February’ 4th she was a little
excited and restless. Within three days excitement increased
considerably, so much so that it was feared it might be neces¬
sary to have her removed to an asylum. It was most marked
at night; she was restless, noisy’, would not stay in bed,

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1908.]

BY ALEXANDER ROBERTSON, M.D.

503

and persisted in walking about the bed-room. There was,
however, little mental confusion. No delirious ideas were
expressed and her answers to simple questions were correct.
As indicating her general intelligence while yet excited the
nurse’s remarks are worth quoting. On my asking her what
she thought of patient’s mental state she replied : “No one in
the Home knows her belongings better than she does.” Under
treatment the mental excitement subsided in a few days, and
she settled down into what has become her ordinary state of
mind. She is somewhat childish both in conversation and
manner—a condition that is not rare in old age.

T. H—, aet. 81, ploughman, four and a half years in Home.
He suffers from cardiac disease, mitral regurgitation; pulse
drops every sixth or seventh beat; both radial and temporal
arteries are markedly hardened; sight pretty good; urine
normal.

When in the ordinary wards of the Home he was said to be
rather irritable, but no indication of mental unsoundness was
apparent. He has been in the sick room for about three months
and nearly always in bed through general frailty. About
the end of January, without any apparent special cause, he
became excited and confused, both day and night. This mental
disorder continued about three days, when it subsided abruptly,
and he was restored to his usual calm, composed habit of mind.
He has remained so since then, except that on four occasions
he has had brief attacks of rambling and mental confusion.
These did not last above two hours, and occurred at varying
times of the day ; there was no accompanying excitement. In
the intervening hours of these days his mind was clear and
correct.

Remarks on these Three Cases .

They are fairly typical of the most common form of mental
disorder met with in the Home. The most distinctive feature
is their short duration—three or four days, and even two hours.
The character of the disease did not differ materially from
what is seen in asylums. In Case 2 the condition was one of
simple mania—excitement without much intellectual derange¬
ment ; in Cases 1 and 3 the mind generally was involved.

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504

MENTAL DISORDER IN ADVANCED LIFE, [July,

Their treatment will now be considered. In Cases i and 3
it was thought that there was probably hyperaemia of the
cerebral vessels, in the latter case passive rather than active.
Accordingly depletion of these vessels seemed to be indi¬
cated ; 2 or 3 gr. of calomel, followed in six hours by haustus
niger or a Seidlitz powder was given. This, besides exert¬
ing a derivant action on the vessels of the brain, would clear
away bowel toxines should any be present. Another part
of treatment was the application of a poultice of equal parts
of linseed and mustard to the nape of the neck for half an hour.
A sleeping draught of paraldehyde, 2 drachms or 1 drachm,
was also given—the safest of medicinal hypnotics for old people
—but its influence was not great till the paroxysm had begun to
subside. In Case 1, where the headache returned and was
persistent, blistering liquid was painted on the nape of the neck.
How far these simple and ordinary measures were effective in
removing the morbid condition of the brain can only be sur¬
mised. That they were of use seemed very clear. However,
only a temporary condition, such as a stasis in the blood-supply,
especially of the frontal area of the cortex, could account for
the speedy clearing of the intellect being possible.

Case 3 differed from the others in that there was well-
marked cardiac disease present, along with equally well-pro¬
nounced disease of the blood-vessels. It is not easy to say
how far, if at all, the condition of the heart was responsible for
the mental disturbance. I speak thus doubtfully as it is
remarkable how seldom the mind is disturbed in severe disease
of the heart of any kind, unless there be accompanying con¬
gestion of the lungs and imperfect oxidation of the blood, with
the presence of toxines. No doubt the mechanical arrangements
within the skull, through which the required supply of blood
for the maintenance of the functions of the brain is preserved,
largely explain this comparative immunity from mental disorder
in well-marked diseases of the heart. Still there are cases,
such as the one referred to (3), where/when associated with
disease of the cerebral blood-vessels, as in all probability exists
in it, this element can scarcely fail to be an important con¬
tributing factor in the causation. Accordingly digitalis and
nux vomica formed an integral part of the treatment, and were
steadily given with, it was considered, beneficial effect on the
cardiac action.

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1908 .] BY ALEXANDER ROBERTSON, M.D. SO5

Group II, where clear organic disease is present, is illustrated
by the following case :

T. S—, aet. 81, ploughman, in Home two and a half years;
took much whisky when young, not later; temporal and radial
arteries only slightly hardened; heart and kidneys free from
obvious disease.

About fifteen months ago he had an apoplectic seizure, with
right hemiplegia, and was for several weeks confined to bed
through the palsy of his limbs. He recovered to a great extent
and has been walking about the wards during recent months,
but with considerable drag of the leg and a little impairment
of speech.

The special feature to which it is wished to direct attention
is the maniacal attacks from which he suffers. On three
occasions during the last year he has become suddenly excited,
noisy, and incoherent in speech. He has not been convulsed
during these attacks. They do not last above four or five days.
During their continuance his speech is thicker and articulation
less distinct than usual. At their close he gets up and walks
about as previously.

In the intervals the prominent defect in the mental condition
is emotional weakness. His replies to simple questions, though
correct and intelligent, are often interrupted by an outburst of
sobbing. Less frequently he laughs without cause, but the
laughter generally ends with a sob.

Delusional Disorders .

Where definite and persistent illusions, hallucinations, or
delusions proper are present, the condition amounts to the
ordinary insanity of asylums, always presuming that the patient
fails to admit the fallacy of the imaginary impressions. Here
also the cases may be arranged in two classes, namely those
in which obvious organic disease is absent, and those where it
is clearly present.

(1) Without organic disease .—Mrs. M—, aet. 91, in home
about six years; bodily health has been good during her
residence; heart and kidneys are free from obvious disease;
right temporal and radial arteries are hard and tortuous, left
ones less so.

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MENTAL DISORDER IN ADVANCED LIFE, [July,

S06

Her general intelligence is good, and she is of a cheerful,
happy disposition. No mental disturbance was noticed till
about eighteen months ago when she said that some of the
other ladies were wearing her clothes. This delusive idea soon
passed away and she remained apparently well till a year since,
when she declared she saw trees and shrubs growing in the
lobbies of the Home. She sought the help of others in walking
from room to room to enable her to avoid the fancied obstacles,
so vivid were they in her imagination. These also seem to
have passed away in a week or two ; at all events she ceased
to speak about them to the nurses or other inmates.

Towards the end of 1907 she was admitted into the sick¬
room on account of general frailty. This room commanded a
view of a neighbouring chapel. After two or three weeks while
she lay in bed she began to say that she saw on the ridge of
the chapel-roof a young man and a young woman standing
together. She said that they came there in the morning about
8 o’clock and stayed all day. When reasoned with on the
impossibility of her impression being in accordance with fact,
she replied, “ I must believe my own eyes; seeing is believing.”
No other delusive idea was manifested and her general con¬
versation and conduct were correct during the time—about a
month—she remained in this room. She was then changed to
another one where the outlook from her bed was different.
There was still a building in view, but of another kind from the
one seen from her former apartment. Here I was much
interested to find that the usual hallucinations were no longer
present. But their absence was not for longer than a fortnight.
Then one morning she told me that the young woman had
returned but was alone. Two or three days later she said that
her companion was once more with her on the roof. Since
then, in her view, they have continued to occupy their elevated
seat, but not so uniformly; sometimes they would be absent,
and at other times, though present, they would be under
the cover of an umbrella or within a fancied small house
perched on the highest part of the roof. Still later, along with
these false impressions, delusive ideas like those that first
troubled her were again revived, namely, that various people
have been appropriating her money and her clothing. Apart
from these morbid ideas, to which she seldom refers spon¬
taneously, she talks and acts quite sensibly.

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BY ALEXANDER ROBERTSON, M.D.

507

1908.]

G. S—, aet. 80, weaver; in home for three years. Is a
healthy man, and has not been addicted to alcohol. Temporal
arteries are moderately hard; radial scarcely affected; no
undue tension of arterial walls. Sight and hearing good.

About a year ago through a fall he broke the neck of his
thigh-bone, and has since then been confined to bed in the
sick-room. Though rather odd in his ways and talk, no
definite indication of mental disorder was noticed till four or
five months since, when he complained to myself that numerous
vermin were on his shirt and bed-clothes. Careful examina¬
tion failed to show the slightest foundation for the complaint.
After two or three days this morbid fancy disappeared, but
within a week later he became sleepless and noisy at night.
He said that someone, and he specially blamed a young man
by name, whom he knew outside, got under his bed and thrust
needles and other sharp instruments through the mattress into
his skin. He made repeated and vigorous efforts to get hold of
his imaginary assailant, and in this way disturbed the other
inmates considerably.

Under the action of potassium bromide during the day, with
paraldehyde or trional at bed time and careful attention to
the bowels, the excitement quickly subsided. The last delusive
idea, however, though sometimes apparently almost in abey¬
ance, does not seem to leave him entirely. Now and again it
becomes pronounced, usually at night, and is then accompanied
by a little excitement.

It will be observed that the hallucinations in this case are
tactual: sight, hearing, taste, and smell have not been affected.
At the same time there is an almost constantly continuous
delusive idea present in his mind that his stinging pains are
due to the persistent malevolence of one now at a distance, but
with whom he was acquainted in the past.

(2) With organic disease .—I. S. H—, aet. 81, farm servant;
in home three and a half years; took much whisky when
young, little latterly. His heart and kidneys are free from
obvious disease; right radial and temporal arteries are
moderately firm ; left ones less so.

About eighteen months ago he had a severe apoplectic
attack, with right hemiplegia; speech was greatly impaired,
along with almost complete loss of power of the affected limbs
at the time, but after three or four weeks all the symptoms

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508 mental disorder in advanced LIFE, [July,

began to improve, and a month or so later he was walking
about, though with an obvious drag of the leg. Articula¬
tion was defective, but there seemed little, if any, loss of
language.

About a year ago, while in this improved condition, he had
a sudden attack of unconsciousness. He remained so for
nearly two days, when he gradually emerged from it, but
became restless and excited, and spoke, or rather mumbled,
incoherently. After nearly a week he recovered from this state,
and his mind was then apparently as clear as prior to the on¬
set of the seizure. At intervals of some months he has had
two other attacks of a similar kind. His recovery from them
has been remarkably good.

Reference will now be made to his general mental state.
Since the apoplectic seizure, and in the interval of the attacks
above described, the most striking feature of his conduct has
been the expression of emotional weakness. After answering
a few questions correctly he usually breaks down into a fit of
loud sobbing, which soon subsides if he is not further spoken to.
His intellect, as stated, is clear and correct, but this remark
only applies to ordinary simple matters, otherwise it is probably
much impaired in strength.

Remarks on the Delusional Disorders.

Hallucinations and delusions proper are more stable than
the maniacal conditions in the old. Yet both Cases i and 2
show greater variability than is usual in the paranoias of
asylums. In Case 1 delusions about being robbed were pre¬
sent only for a few days on two occasions at long intervals.
Again the visual hallucinations about trees and shrubs grow¬
ing in the lobbies of the Home were seen during less than a
week a year ago. On the other hand, the remarkable halluci¬
nation about the couple whose seat was on the ridge of the
roof of the building opposite has persisted for about two
months with a short interval, concurrent with her removal
from one apartment to another. But it, too, is subject to a
degree of variability. Thus yesterday, as I write, she said to
me at my visit about the dinner hour: “ Look,” her eyes
being directed to the roof opposite, “they’re no there now;
they’ll have gone for their dinner, they’ll be back again soon.”

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1908.] BY ALEXANDER ROBERTSON, M.D. 509

The hallucination had then disappeared, but the delusive
conviction of its genuineness was as firm as before.

In Case 2 the delusive idea proper and the tactual hallu¬
cinations have been nearly uniform in their character, but
the latter on three or four occasions during the last two and a
half months have seemingly been in complete abeyance, at all
events the patient has not made any allusion to them, and he
has been calm and rational in the intervals of their occurrence.

In the case associated with cerebral lesion consequent on
apoplexy, no derangement can be properly said to be present.
The permanent condition is one of mental, especially emotional
weakness. I did not see him at the outset of the attacks of
unconsciousness described. I do not regard them as epileptic
in their character. They seem to be more allied to certain of
the attacks to which many general paralytics are subject.
These usually leave the sufferers mentally worse, more or less,
than before their occurrence. On the contrary my patient
is not appreciably worse either in mind or body since his
seizure.

General Observations.

Leaving out of consideration the organic lesion of the
apoplectic seizures, with the resulting mental enfeeblement, too
serious a view need not be taken of the maniacal attacks in old
people. They are usually comparatively short in their duration
and mild in their character. This is shown by the fact that
the cases narrated were treated in the wards with patients
suffering from ordinary bodily troubles, under the care of
female nurses. They were, however, kept as far as practicable
apart from those who would be readily disturbed. Further, the
attacks themselves, as illustrated by the cases, are very amenable
to treatment.

It is otherwise with the delusional disorders. The intellectual
derangement rarely disappears altogether, though, unless
revived by reference to the subject of it, the delusion appfears
to fall out of consciousness occasionally for considerable periods.
With respect to the sensorial disorders, the visual hallucinations,
at least, sometimes change their forms readily. This is illus¬
trated by the experience of the nonagenarian lady, who as
narrated, at one time saw imaginary trees and shrubs, at

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5io

MENTAL DISORDER IN ADVANCED LIFE. [July,

another figures of a man and woman together—the most con¬
stant—and, at a third, the dwelling only of these ideal forms.
They may, however, be much more constant in their character,
as in the case of the tactual hallucinations, which latterly have
been always the same on each recurrence.

As a rule, temporary subsidence or even apparent disappear¬
ance of delusive ideas and their recurrence are more striking
features of mental disorders in the old than in the previous
periods of life. When the alterations in the blood-vessels
referred to in the earlier part of this paper, together with the
well-known degenerations in cells and cell-processes in senility
are considered, one cannot fail to realise the probability of
partial or even complete blocks in the circulation of short dura¬
tion occurring in small or even large areas of the cerebral cortex,
with consequent and proportionate interference with normal
mental action.

In drawing to a close, though outside the range of my subject,
I shall refer very briefly to the statements of various writers to
the effect that melancholia and hypochondriasis are common
forms of the mental derangements of old age.

This is not my experience in the Glasgow Home. On the
contrary, though I have met them both, they must be con¬
sidered rare in view of the large number of inmates and the not
infrequent changes from various causes that occur amongst
them. The immunity from these troubles depends largely, I
doubt not, on the careful attention to such common-place
details as the provision of an abundant supply of good food,
well cooked; warm clothes ; comfortable beds; and the main¬
tenance of a warm temperature, adequate for old people, both
in parlours and sleeping apartments. Along with these essen¬
tial conditions, kindness, tact and forbearance are shown to the
inmates by a superior class of nurses who attend to them.
Provided the conditions and arrangements are such as promote
bodily comfort, and are otherwise favourable to a tranquil state
of mind, the advent of melancholia and hypochondriasis need
not be feared.

(*) Glasgow Med. Journ., vol. i, 1866, p. 140.—( 3 ) Ibid., vol. xxxviii, 1898.

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1908.] DEMENTIA PR.ECOX AND MENTAL DEGENERACY. 5 I I

Dementia Prcecox and Mental Degeneracy in Syria .

By H. Thwaites, M.R.C.S., L.R.C.P., late Medical

Superintendent, Lebanon Hospital for the Insane.

In the realm of mental disease any finger-post which points
a way through the entanglements of aetiology is worthy of con¬
sideration. Present-day tendency is to magnify external at the
expense of internal causes, a cart-before-the-horse policy which
must bring confusion. Comparative lunacy endeavours at
least to reverse the position and to start straight by tracing
the affinity of form which exists between national brain types
and their insane corruptions, or by showing variations in the
relative incidence of disease forms and co-ordinating these
with dominant social or biological factors.

The chief point brought out by a three and a-half years* study
of insane conditions in Syria is the predominance of one form,
for which the great difficulty has been to find a sufficiently com¬
prehensive term ; the only one which has seemed at all adequate,
viz., “ dementia praecox ” as defined by Kraepelin in Johnston’s
valuable translation of his Lectures on Clinical Psychiatry
has been met with considerable opposing bias on account of
preformed ideas based on our somewhat insular conceptions,
but such prejudice has been scattered to the winds by the fact
becoming more and more clearly revealed that there is no term
which so faithfully represents the form in question.

In the following records of the Lebanon Hospital for the
Insane, for the three years ending September 13th, 1907, the
danger of treating the term with too much elasticity has
always been present. Symptoms readily overlap at the fruitful
period of adolescence; the outward similarity of dissimilar forms
is even more pronounced where language difficulties bar the
way of approach, and cases of congenital amentia, and particu¬
larly of maniaco-depressive insanity, where thought and volition
are much obstructed, have been liable of inclusion. Errors of
diagnosis are more likely to occur in dealing with men and
women of a foreign tongue, and correction for the personal
element is probably more necessary where statistics stand alone,
but in spite of possible discrepancies the broad truth which these
statistics convey may be insisted upon, and it may be inferred
that with successive years a greater degree of truth is reached,

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s I 2 DEMENTIA PRCECOX AND MENTAL DEGENERACY, [July,

and that the larger percentages of the last year are more correct
than the smaller ones of the first year.

These statistics may be thus tabulated:

Number of Admissions.

Year.

Men.

Women.

Total.

1904-5

1005-6

1906-7

• 85

Cases of Dementia Prcecox .

Year.

Men.

Women.

Total.

1904-5

1905-6

1906-7

Percentage of occurring Dementia Prcecox each Year .

Year.

1904- 5

1905- 6

1906- 7

Men.

Women.

27-4

. i6 - 6

377

•

13*6

3&’3

. 20

Average Yearly Percentage for the Three Years .

Men.33*5

Women.163

Year.

1904- 5

1905- 6

1906- 6

Variety of the Disease.

Approximately

hebephrenic.

katatonic.

paranoid.

Variety of Disease in the Difjerent Sexes .

Men

Approximately

hebephrenic.

Approximately

katatonic.

Approximately

paranoid.

. 4

Women . 7 . . 10 . . 0

It will be seen that more than one-fourth of the admissions to

the asylum, viz., 27 per cent ., are sufferers from dementia prsecox,
a fact which is confirmed by a study of the chronic and often

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1908.]

BY H. THWAITES, M.R.C.S.

513

grossly demented inmates, who, even in their advanced stage,
still present symptoms revealing the nature of their malady (of
66 chronic and confirmed cases, 33 or 50 per cent., were cases of
dementia praecox).

Further, of all the occurring cases, half are of the hebephrenic
variety, about half are katatonic, and a very small proportion
consists of the paranoid class. The disease is twice as common
in men as in women, whilst male cases incline towards hebe¬
phrenia, female cases to katatonia.

The difficulty of locating many of the cases was great. In the
hebephrenics particularly there was a tendency to relapse into

stuporous condition, bearing a superficial resemblance to the
milder phases of katatonia, and the fact has been clearly dis¬
played that the above classical grouping is purely arbitrary and
of convenience only for descriptive purposes, and that the
motor phenomena of the katatonic, the delusions of the para¬
noiac, and all the outre manifestations which appear in such
profusion have seemed accidental, the underlying and funda¬
mental element in all cases having been clarity of perceptive
power, with want of psychical feeling ; so much indeed has this
been the case that the varieties might well have been classified
in accordance with the degree of involvement in this latter
essential feature, which has presented itself at one extreme as
indifference and at the other as profound stupor. Following
Bolton’s ideas, the pathology would seem to be a question of
the degree of evolution of the psycho-motor area of the brain,
and the extent of accompanying neuronic dissolution.

To enumerate the points about the disease which have
asserted themselves most prominently, these are:

(1) Dementia praecox is an independent disease entity.

(2) Though it may assume a variety of form the disease is
one.

(3) The unifying factor is the presence of the comprehensive
faculty with want of feeling.

(4) Other symptoms, though abundant, are not essential.

(5) In order of frequency, the most prominent of the other
symptoms are—stupor, negativism, stereotypism in speech,
attitude and conduct, forced actions, automatic obedience.

To account for the undue prevalence of this disease in Syria
is more difficult than the mere enunciation of its existence, but
the purport here is to suggest that dementia praecox is the

uv. 37

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514 DEMENTIA PR/ECOX AND MENTAL DEGENERACY, [July,

exaggerated expression of a mental degeneracy, the roots of
which are to be traced outside asylums in the average mental
constitution; the strong resemblance which exists between it
in its essential feature and the mental type common in the
country points strongly to an inner connection, and leads to
the proposition that the condition is one.

All who have had to do with the care of the insane will have
experienced great difficulty in answering the question of causes
so painfully imminent in the minds of friends, the reason for
such evidently lying in the fact that to answer correctly, an
adequate explanation of developmental psychology is necessary,
and unless it be in the case of trauma or in the somewhat
doubtful case of toxic insanity, no single cause can be stated as
efficient. A closer study of insane conditions from the develop¬
mental side would seem the best way to obviate such difficulty,
and it seems not unreasonable to suppose, in this connection,
that the whole question is a dispositional one, that certain dis¬
positions commonly met with are the immature counterparts of
the morbid mental states which fill our asylums, the diseased
state being merely an evolution of the so-called healthy one.
Thus is the germ of maniaco-depressive insanity found in persons
regarded as insane, in their impeded thought and volition; the
confirmed hypochondriac was not always certifiable ; the para¬
noiac was known in his youth to be subject to extravagant, self-
opinionated, plaintive conduct; and thus is dementia praecox
to be found in an immature form in the supineness, apathy, and
phlegm of the Syrian youth who seems to have but a half hold
of consciousness.

The physiological characters of a race are mirrored in its
conventional and idiomatic use of the language, and there are
no expressions in Arabic more frequently or variously rendered
than such as in English would be translated, “ What matter!”
Such expressions of indifference reflect a national failing, and
are born of the spirit of fatalism so ingrained in the Oriental’s
conception of life, but in Syria also as a part consequence of
centuries of national dependence and subjection to foreign rule,
and they depict the normal attitude towards life’s affairs, grave
or gay. The Syrian servant girl, for instance, who, whilst
washing dishes, drops one, will proceed with the rest without
any show of concern, and without even stooping to pick up the
pieces. Such a state is a congenital one and may be included

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1908.] BY H. THWAITES, M.R.C.S. 5 IS

amongst those examples of morbid personality which are the
product of mental degeneracy.

From introspective analysis, the safest form of psychological
inquiry, this particular form of degeneracy is found to be
dependent upon diminished psychical feeling, that subtle sense
of which we are well aware, which forms the incentive to all
acquisition, but which is strongly resistant to faithful
description; and upon such hypothesis it shares the same
foundations as dementia praecox, the diagnostic symptom of
which Kraepelin states to be “ the peculiar and fundamental
want of any strong feeling of life’s impressions.” Diminution
of feeling, therefore, is the first step of a decadent process, the
final stages of which only are so pronounced that asylum care
becomes necessary, but which throughout its course may be
regarded as dementia praecox. Whether such feeling be an
independent brain function having its physical substratum, or
whether an integral suspension of the intellectual faculty
without separate material basis has never been satisfactorily
determined, but we can assume that it is vitally associated with
thought and ideation, and is essential for production in this
sphere, whilst our present inquiry leads us to the conclusion
that with its degradation there is an associated, possibly a
consequent change in the higher cerebral levels, leading to
apathy and indifference to current events, to retrogression of all
the higher attainments, and finally to their substitution by
stuporous and subconscious states. Such backward extension
in the process of degradation, from function to structure, is
simply the operation of a natural law than which none is more
certain, and which is illustrated beyond any manner of doubt
in the wasting of muscle from disease.

The structural development of the brain depends upon its
environment, the latter being to it what soil is to the implanted
seed. If this now fail to produce the constant traffic in
impressions which results in ideation and life to the growing
organ, convolutional starvation will be its lot, and this result
will be the same for a healthy and a constitutionally defective
brain, the only difference between them from the point of view
of environment being, that in the former it is of primary, in
the latter of a secondary importance.

Now, such dwarfing effect will appear first in the most con¬
spicuous life-function of the organ, viz., consciousness, and it

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5 I 6 DEMENTIA PR.ECOX AND MENTAL DEGENERACY, [July,

certainly seems that in the inroads made in this direction, in
disintegrations of consciousness we have the key to the posi¬
tion in dementia praecox. Pierre Janet has thus attacked
hysteria from the mental side, and in his theory of double per¬
sonality we have a more adequate explanation than has yet
appeared of many of the strange manifestations of that disease.
From the fact that many dementia praecox cases grow upon
an hysterical basis, and from the hysterical colouring of many of
the phenomena which occur in this disease, e.g. t the cataleptic
attitudes, it may well be that the two mental states are closely
allied. Psychical feeling would thus be a term synonymous, or
at least coextensive, with consciousness, and if it may not be
defined as the grip on life, it is at least that upon which such
grip depends, and lying at the threshold of an almost illimit¬
able sphere of functional activity, it carries in itself the vital
principle upon which acquisition in every department owes its
origin. Evolution fails of its purpose if it does not implant
this psychical feeling firmly and strongly in the individual as
the basis for all cerebral development; its absence is the open
door for disease and the dominance of subconscious states.
Wordsworth, that great psychologist, in “ The Excursion,”
thus depicts the vital principle pervading the human mind:

“ The food of hope
Is meditated action, robbed of this
Her sole support, she languishes and dies ;

We perish also, for we live by hope
And by desire; we see by the glad light
And breathe the sweet air of futurity ;

And so we live, or else we have no life.”

The youth suffering from dementia praecox is one congenitally
deficient, he enters upon his life struggle badly equipped
because devoid of, or with diminished, psychical feeling, he
cannot sustain the life of the brain at his own level of civilisa¬
tion, far less so at the relatively high level which he may have
to face, and the flickering flame dies out. This latter fact is
well illustrated in returned Syrian emigrants from America. In
the past year 20 per cent . of the admissions to the Lebanon
Hospital belonged to this class, and their form of disease was
a precocious dementia.

Is it, then, possible to trace any cause for so serious a lack in
the mental constitution of the average Syrian? In the indivi¬
dual we may read the history of his race ; his mental condition

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1908 .]

BY H. THWAITES, M.R.C.S.

517

is the accumulated result of past influences brought to bear
upon his germ plasm, and it is to these influences which have
constituted the environment to which we should turn for the
primary and efficient factor in the production of diseased states.
Unfortunately it is impossible to individualise cause and effect
and to know the actual share of each in the complex result,
for this reason, that these causes, mostly of a social or moral
nature, are themselves so complex and incapable of reduction.

But looked at in perspective, the history of Syria reveals
certain influences always at work which make us infer an
underlying connection between cause and effect in the result¬
ing mental type now under consideration.

The annals of the country show almost continuous subjection
to foreign rule; yet there was a time when Syria was to the
Syrian, and we may conclude from Bible records that at that
time the standard of civilisation was high, and the prevailing
mental type in no way inferior. The Phoenicians, at least, their
closely related neighbours, for many centuries we know were
one of the foremost peoples in the world, and particularly in
the realm of action ; but from the time that the Syrians became
servants of the Hebrew King David to the present day, they
have been a dependent race and have been forced to put up
with conditions imposed upon them by their rulers, with the
result that independence of spirit has been stifled, and acquisi¬
tion checked or suppressed in every department of mental
activity. It is true that the Arabs for a time infused new life
into the people, but such influence was short-lived and lost
itself amid the supineness of the Turkish regime ; and now art
is almost unknown, science has few ardent followers, philosophy
makes no progress, remaining content with past achievements,
and religion amongst the Mohammedans is of anon-productive
type, and among Christains, in the place of the birth of
Christianity, is mostly a system of fetishism without the intelli¬
gent application of inner principles. The mental life of the
masses is of a hand-to-mouth order consisting mostly of simple
sense impressions, and with so little traffic between higher and
lower centres that badly formed association tracts are inevit¬
able, and limited mental capacity with paucity of ideas the rule.
But the worst feature is that psychical feeling, or consciousness,
or the vis a tergo , or whatever you may prefer to call it, is
bound to suffer, and in extreme cases ceases to exist.

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5 I 8 OBSERVATIONS ON INSANE EPILEPTICS, [July,

It is inefficiency of environment then which has been the
responsible factor in producing the type of brain wanting in a
fundamental principle, and the lack persisting has become
focussed in posterity as endemic degeneracy. Whole neighbour¬
hoods, villages, and districts suffer rather than individuals here
and there, and a vicious circle has become established which
time and radical social reforms alone can alter. The individual
born with a constitutionally defective brain enters an environ¬
ment which tends to foster and increase his defect; without
psychical feeling he ceases to be aggressive, the higher attain¬
ments are lost, and soon he retrogrades still further, and suffer¬
ing from encroachments upon consciousness itself he permits
himself to be governed by subconscious states, and shows it by
his automatic, stereotyped, or negativistic conduct; he would
revert to a purely animal existence were it not that past
achievements cannot be completely obliterated. The wreckage
of a once conscious organism must perforce include the debris
of consciousness, and so we find the curious medley of intelli¬
gent and automatic phenomena which go to the make-up of
the full clinical picture of dementia praecox.

Observations on Insane Epileptics Treated under
Hospital Principles . By Leonard D. H. Baugh,
M.B., Ch.B.Edin., Senior Assistant Medical Officer, Gart-
loch Mental Hospital, Glasgow.

In this paper the writer aims at bringing into prominence
some advantages derived from the application of the principles
of hospital treatment to the care and management of insane
epileptics. Much of the clinico-pathological work recently done
on epilepsy tends to support the view that such treatment is
correct; and, further, it is now generally accepted that treat¬
ment of the so-called “ Acute Insanities ” (mania, melancholia,
etc.) on hospital lines gives the best results.

The cases studied are the epileptic admissions into the Gart*
loch Mental Hospital since its opening for the reception of
patients on December 8th, 1896. Up till May 15th, 1907, the
close of the last statistical year, inclusive of 36 epileptic imbe-

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BY LEONARD D. H. BAUGII, M.B.

519

1908.]

ciles, the admissions numbered 162 ; of these 84 remained resi¬
dent on May 15th, and formed n‘2 per cent . of our inmates.
All came from, or belonged to, Glasgow, and were certified
insane before they were sent here.

Age (on admission) ranged from fifteen to seventy-five.

The mental calibre .—In both sexes it is varied, and includes
all grades, from the imbecile with epilepsy who becomes un¬
manageable at puberty to (a) the wage-earning artisan at the
time of a mental breakdown closely associated with his epilepsy,
or ( b ) the latent epileptic, if I may term her so, who only
shows clinical manifestations of her epilepsy after having
passed through the stresses of pregnancy and parturition.

To detail principles of hospital treatment is not necessary ;
it will suffice to merely outline the methods of procedure. That
bed is the best place for a person when ill, and that, when ill,
attention is appreciated, are two axioms accepted “ communi
consensu .” In this institution it is recognised that admissions
are ill; they are therefore put to bed. The individual atten¬
tion bestowed on the cases has always been an outstanding
feature; to the beneficial results therefrom must be ascribed
much of the good derived from treatment.

Admitted, and put to bed under constant observation, the
epileptic is subjected to a thorough mental and physical exami¬
nation. The patient is kept in bed in the admission ward for
a variable period, for the amelioration of physical and mental
symptoms, further study, and to receive individual attention.
Diet is carefully arranged ; milk is the usual start, as, almost
invariably, the functions of the alimentary tract are found to
be deranged. No bromides or drugs, except simple purgatives,
are exhibited. Should the patient be taking fits a big enema,
and a purgative by the mouth are as a rule sufficient to check
the seizures. Marked improvement occurs under the regimen
indicated, often within a few days. It then depends on the
state of the patient, and the history obtained, whether the case
is sent to another ward for further bed-treatment (largely out of
doors), or to the observation ward for acute cases, for exercise,
etc., or, direct to the epileptic ward. Many undergo both the
outdoor bed-treatment, and the observation with employment
and exercise, before reaching the division for epileptics.

For those in the epileptic sections, principles of hospital and
colony management are combined. Useful employment, out-

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520 OBSERVATIONS ON INSANE EPILEPTICS, [July,

door and indoor, is provided; this, as far as possible, is devised
to suit the cases individually. The food is specially prepared
in the kitchen, and is largely carbohydrate. Apart from tea,
which is allowed daily, the diet on four days of the week is
purin free; on two days, to make it more palatable, a vegetable
mince contains a small amount of fresh meat; on Sunday a
moderate helping of corned beef is given each patient at
dinner time. The meals are served in the wards; this not only
makes for safety by facilitating observation, but prevents them
being reminded daily that they are debarred from participation
in the ordinary diets partaken of in the dining-hall. An
atmosphere of calm is aimed at; a patient who becomes
markedly excited or quarrelsome is put to bed and isolated
from the rest while unsettled. Isolation in bed, which is a
totally different thing from seclusion or restraint, appears to
have almost as favourable an effect in some of the chronic
insane as it has on neurasthenics undergoing Weir-Mitchell
treatment. Absorption of toxines from the bowel is guarded
against by the judicious use of aperients and purgatives.

We now pass to the advantages of the system followed. To
illustrate these, summaries of observations are brought to your
notice, and are placed under separate heads. The investiga¬
tions, as far as they went, were carefully made; the facts and
figures can therefore be accepted as accurate ; the deductions
that accompany them are the writer’s, and are submitted as
personal opinions and suggestions.

The turnover .—The following table shows the changes among
our epileptic patients during the period of ten years and five
months from December, 1896, to May, 1907. It is placed here,
as the figures given have some bearing on points advanced in
the paper :

Table I.

M. F. Total. M. F. Total.

Admitted . ioo . 62 . 162 Discharged recovered . 9 • 7 • ^

„ relieved . 19 . 5 • 2 **

Died . . . 26 . 12 • 38

Remaining . . 46 38 . *4

Totals, ioo . 62 . 162 Totals . 100 . 62 . & 2

Recovery (mental recoveries). —It is advisable to state clearly
that, in this paper, by recovery is meant, a return to soundness

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1908.] BY LEONARD D. H. BAUGH, M.B. 521

of mind normal to the patient before the onset of the insanity;
the term does not refer to a cure of the epilepsy. In insanity,
the result of epilepsy, a high recovery rate is not expected, but
in this institution, investigation reveals a ratio higher than
anticipated. In our cases the insanity resulted from, or was
closely associated with, the epilepsy. That the phrases
“ resulted from ” and “ closely associated with ” are judiciously
used, and that cases in which epilepsy may be regarded as
incidental are not included, the following illustration will show:
A woman, J. B—, aet. 30, melancholic and hysterical, came to
us as the result of alcoholic indulgences; these perhaps
aggravated her epilepsy, but did not appear to be in any way
the result of the epilepsy; therefore, neither on admission nor
on recovery was she classed among the epileptic insanities,
but was considered as a mania-melancholia, and the cause
ascribed to alcohol and hereditary predisposition.

This point has been emphasised, as such cases, although
not common, are met with; were they regarded as recoveries
from epileptic insanity our percentage would be higher. Of
the 162 admitted and considered, 36 were epileptic imbeciles
who had never developed mental soundness ; according to the
definition of recovery accepted, none of the 36 could recover.
We have, therefore, 126 that became insane from their
epilepsy after attaining mental development. Sixteen (9
males and 7 females) of these recovered, which is a percen¬
tage of 12*6. It is worthy of note that only 3 of the 16
have relapsed into our care. The majority of the cases that
recovered were in the bed-treatment and observation sections
during the whole period of their sojourn. It is beneficial for
recently-admitted patients, on regaining their acumen, to find
themselves surrounded by hospital environment; they receive
the impression that they have been ill and are being cared
for; this inspires confidence, and is a valuable agent in the
acquiring of patience and calmness. On rest in bed, the
cessation of bromide, the elimination of toxines present, we
depend to accelerate mentation and enable them to appreciate
their surroundings. Calmness, after it is acquired, is
strengthened by the continuation of the environment.

The three factors mentioned, namely—confidence in the
staff, mental alertness, and calmness, are of use in promoting
recovery; it appears essential to restore them if full benefit

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522 OBSERVATIONS ON INSANE EPILEPTICS, [July,

is to be derived from after-treatment, and without doubt it
can be said that too much care and attention cannot be
expended on attempts to establish them. To teach self-
control, attention to personal hygiene, dependence on self
instead of on bromides, a healthier, broader general outlook,
are all points of importance in the gradual education towards
recovery; but none of this teaching can be carried out without
the establishment of confidence in the staff, calmness, and a
moderate degree of mentation. Success, judged by recovery,
is by no means always attained, indeed, only in 12*6 per cent.,
but there is always a compensation (and a very appreciable
one) that the after-care of the case in the institution is ren¬
dered easier, as no case fails to derive some benefit from treat¬
ment such as is carried out with a view to promote recovery.

Relieved .—These may be regarded as examples of the partial
success of treatment, improvement being short of recovery. On
no longer needing care in an institution like this, 24 were
handed over to the custody of relatives or paid guardians. The
above brief statement must suffice, as the field opened up for
discussion of the stage, or stages, at which improvement is
arrested is too large to be gone into here.

Deaths .—There have been 38 deaths among the epileptics.
In 24, or 63*1 per cent., epilepsy has been an important factor;
in only 4, or 10*5 per cent., has death occurred in, or closely
subsequent to, the status epilepticus.

Status epilepticus. —This condition is defined in the Dictionary
of Psychological Medicine 1 as “ a rapid succession of epileptic
fits without intervening consciousness ”; it has since been
aptly termed by Clark and Prout, 3 “the maximum develop¬
ment of epilepsy.” The gravity of the condition, and the
interesting clinical phenomena associated with it, have prompted
many observations.

The prognosis has improved with clearer appreciation, but
the opinion is held by many that there is room for further
progress in combating this phase of the disease. Here an
attempt is made to enter into partial consideration of the
subject under sub-headings. It is hoped that the observations
recorded will serve as an argument in favour of individual
treatment on hospital lines, and that they may shed fresh
light on a few points.

Status sub-headings : (a) Percentages. —Of our 162 cases, 9, or

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1908.]

BY LEONARD D. II. BAUGH, M.B.

523

5*5 per cent., developed at some time status epilepticus, a close
approach to Dr. Turner’s 5 per cent? The attacks exhibited
numbered 29 ; of these 4 terminated fatally, a mortality of 137
per cent . This falls short of Dr. Aldren Turner’s 107 per cent .;
but compares favourably with the 50 per cent . of Burney Yeo,
Nothnagel, and Buisanger, the 45 of Lorenz, and the 33 per
cent . of Clark and Prout, as stated by Dr. Raffle; and is
rather less than half the mortality percentage of the series
tabulated by Dr. Raffle 4 himself, as his figures from 27 of the
insane at Exeter, if calculated in this way, give 34*2 per cent .

(b) A nalysis of 29 periods of status and the 4 resultant deaths .—
In accordance with the statements of others, the tendency
to recurrence was found to be marked in the majority; 6
cases were responsible for 25 attacks, and 3 of the 6 accounted
for 16, vide Table II appended. In this table, devised to
summarise the analysis, for purposes of grouping, Dr. Aldren
Turner’s 8 4 classes of status is the classification adopted. In
the cases no signs of increased severity were detected on recur¬
rence, notwithstanding that such signs were carefully looked for.
Except in one man, the type of recurrent periods observed
was mild compared with the classical description of Bourne-
ville. 6 In Class I is the exceptional man ; he exhibited
four periods of status within four years. All were grave ; three
left him temporarily paretic, and he died in the fourth. In
the intervals between, when free from paresis, he was often
irritable, suspicious, violent, and dangerous to others; he also
took, from 'time to time, fits. Classes II and III are grouped
together, as the cases appeared at one time to answer to the
definition “ occasional acute development in cases of severe
combined type,” at another, to “ single fits developing into
short series, which increase into a status period.” Here are
placed cases showing mild recurrent periods of status. The
term “mild” refers, as used here, more to the degree of
pyrexia and the after-state of the patient than to the severity
of the convulsions. To our institutional treatment, with all
which that means, must be attributed the mildness noted, and
to' the same factor the credit appears due for what, if not an
arrest of the recurrences, is at least an appreciable lengthening
of the intervals between the attacks. In Class IV the condition
usually arises as an unexpected development. Turner ascribes
it to “ accidental circumstances during the course of the dis-

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524 OBSERVATIONS ON INSANE EPILEPTICS, [July,

ease.” On the abrupt cessation of bromide, or other sedative,
being the cause of these periods of status with a sudden onset,
both Gowers 6 and Clark 3 have laid stress. The cases
studied belonging to this group were definitely epileptic, all
had had major fits. In the three illness of an acute inflamma¬
tory nature preceded the development of status; in Nos. 8 and
g there was also sudden discontinuation of bromide. All, after
a short series of fits, passed into the status. No history of
previous serial fits, or status, could be elicited, and the fact
that the two under observation here for years—four and eight
respectively—had never developed during their residence the
gravest manifestations (serial fits, or status epilipticus) strongly
supports the accuracy of the histories. On the other hand,
they had, from time to time, shown marked psychic equivalents.
The equivalents referred to were unaccompanied by convulsive
phenomena, or loss of consciousness. The prognosis in this
fourth class is regarded as unfavourable; practically all
succumbed during the first status period. The case credited
with two periods, under active treatment, only emerged from
the first for a few hours before passing into the second, which
proved fatal. If it be recalled that some authorities regard
serial fits and status epilepticus as the evidence of toxzemia,
probably auto-toxic in origin, and that the cases in this class,
subsequent to the onset of acute illnesses, such as pneumonia
and influenza, exhibited, but not until then, serial attacks
which developed into periods of status, a point of some impor¬
tance would seem to have been raised. From a limited expe¬
rience of such cases, the tentative opinion is formed that these
resulted from the action of definite toxines acting more or less
directly on unstable nerve-cells, and that there is thus a line
of demarcation between them and the cases in the other three
classes.

(c) Infrequency of status .—No epileptic has been in a status
period since November, 1905. The probable explanation will
be referred to when serial seizures come under consideration.

(1 d) Treatment of status is directed to (1) the free evacuation
of the bowel contents, (2) the administration of sedative, and
(3) the giving of nourishment. With regard to No. 1, it is so
prophylactic that with us it has been invariably acted upon
before the patient has developed status; therefore, reference
to such treatment should be with the explanation of the infre-

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1908.]

BY LEONARD D. H. BAUGH, M.B.

S2S

Table II.— A Summary of Analysis .

j Class.

No. of case.

Sex.

No. of
periods.

Type of
periods.

Residence.

Remarks.

1. G. D—

Male

Grave

4 years

Died in status.

attacks

1 death

in status.

2. M. N—

Female

Mild

years

No status for

years before death.

1 11

3 H. S-

Male

8 years

No status 8 months

before death.

■*-> and

4. A. S—

Male

6 years

No status 3 years,

alive.

ii hi.

5. A. Me—

Female

2^ years

No status 1} years,

alive.

6. J. H—

Male

2\ years

No status ij years,

alive.

attacks

no deaths

in status.

7. H. F—

Male

Average

4 years

Died status (influ¬

enza).

“ IV.

8. J. N—

Female

8 years

Died status (pneu¬

monia).

9. C. F—

Female

Grave

23 days

Died status

(ovarian).

attacks

3 deaths

in status.

quency of status. In the rare instances where status develops
in spite of our eliminative prophylactic treatment, we have re¬
course to sedatives to combat the convulsions, and feeding to
maintain the strength of the patient. Many drugs have been
recommended strongly, and in many instances as strongly
condemned. We have found a full dose of chloral hydrate (60
grains) given in milk by rectum reliable treatment, and have
not experienced the injurious results dreaded by some. Should
the chloral have been given while the patient was in the serial
stage, and the status develop before it could act, or, if the con¬
vulsions are severe, the employment of chloroform to produce
anaesthesia is useful; it checks the convulsions and conserves
energy. To keep the patient under chloroform for ten to
fifteen minutes is usually a sufficient time to enable the chloral
to act; should not much improvement be shown a second full
dose, or a half dose of chloral can be given, and the admini¬
stration of chloroform resumed for another fifteen minutes.
The cessation of convulsions may be regarded as the depth of

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526 OBSERVATIONS ON INSANE EPILEPTICS, [July,

anaesthesia to be maintained. Nourishment (eggs and milk) is
given per rectum if the period is likely to be prolonged. Nor¬
mal saline, one pint subcutaneously, counterbalances the
deficiency in the supply of liquids ; cardiac stimulant hypoder¬
mically should accompany the saline. The mode of adminis¬
tering nourishment, etc., detailed, is preferable to using the
stomach-tube, if there is the possibility that chloroform may be
resorted to.

Serial epilepsy .—Reference has already been made to the
opinion of certain authorities that serial manifestations result
from auto-intoxication. Our observations, as far as they have
gone, tend mainly to support this view, but are, as yet, too
incomplete to warrant putting into print. The cases here are
remarkably free from serial fits; this, along with the infre¬
quency of status, is ascribed to the portions of treatment
regarded as prophylactic and eliminative. It may be con¬
tended and, granted, against the use of one of the terms, that
much of treatment is prophylactic, e.g., all diet, as carried out
with us, is, and appears to have, a decided influence; but
in using the terms conjointly, with special bearing on mini¬
mising tendencies to serial fits and status periods, the procedure
referred to is as follows: Stated briefly, any patient who takes
four fits within twelve hours is given an enema (patients who
habitually take several fits a day are of course excepted), and if
a fifth seizure occurs, the fact is reported to the medical
officer. Influenced by time relationships, etc., the doctor
decides whether purgative, liquids, chloral, or more than one
of these should be given, and, if ordered, how. In a great
many instances nothing is necessary after the enema.

Diet , mainly purin free .—This diet has been used for over four
years; the general findings are much in line with Dr. Aldren
Turner’s, namely, seizures are not altered as regards frequency,
but are less severe in character. Tendencies to serial fits, con¬
fused states, and dream states appear less marked.

Avoidattce of bromide .—No sedative is given regularly unless
under exceptional circumstances; the “ role of chloral for
emergencies,” to quote Bevan Lewis, 7 is accepted. In rare
instances hyoscine is requisitioned for marked excitation,
whether evinced as pre- or post-paroxysmal psychoses, or as
epileptic equivalents. To avoidance of daily sedative is
attributed much of the comparative mental clearness, and the

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1908.]

BY LEONARD D. H. BAUGH, M.B.

S 27

good general health of our epileptics. The following figures
for May, 1907, show that the absence of bromide, etc., does not
imply an excessive number of fits. The two on bromide got it
to control irritability, not the fits.

Table III.— May , 1907: Female Epileptic Ward .

Patients.

Day fits.

Night fits.

Total fits.

135

150

285

I took

2 „ .

. 0

3 M

. a few

2 „ .

a few

. a few

2 on bromide

I 1

Good general health .—Our epileptics are remarkably free from
the blueness of extremities and foetor of breath, etc., that so
many writers refer to as found amongst such patients. Much
of this freedom is attributed to the avoidance of bromide.
That too much is not claimed in this regard the following
illustrations will show : (1) Medical visitors have several times
commented on the alertness, freshness of complexion, and
obvious good health of our patients of this class. (2) We
from time to time give full doses of chloral (60 gr.) yet find
no bad results, despite absence of any precautionary atropine
or other stimulant. (3) The appended table of weight, which
might be compared with Table III, speaks for itself as a sign
of health.

Table IV.— May, 1907: Female Epileptic Ward.

25 patients gave average weight 8 st. n lb.

Only 1 patient „ weight over n „

„ 3 patients „ „ below 7 „

2 on bromide regularly, both below average weight.

In conclusion, first, I must express my indebtedness to Dr.
Parker, the Medical Superintendent, who not only allowed free
access to all the records of the Institution, but has been ever
ready to supply information about the past of certain of the
older patients, and to offer sound advice on points that were
being observed. Next, the paper has been longer than

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528 SOME OBSERVATIONS ON INSANITY IN JEWS, [July,

originally purposed, but it is to be hoped that it has shown
some of the advantages gained from the hospital methods used,
such as:

The benefits from individual attention.

The attainment of a nearer approach to a physiological
standard of health.

The preservation of alertness of mentation.

That the graver manifestations of the disease itself are
lessened.

That mental recovery, where possible, is promoted and
facilitated.

Lastly, although much has been done to improve the situa¬
tion for the unfortunate sufferer from epilepsy by the colony
system, much more should be, and, it is to be hoped, will be
done. It is the firm conviction of the writer, that, when more
is done, most good will be gained from the full incorporation of
the principles of hospital treatment with the best principles of
the colony system.

References.

(1) Dictionary of Psychological Medicine , Hack Tuke.

(2) American Journal of Insanity , October, 1903.

( 3 ) Epilepsy* W. A. Turner.

(4) Journal of Mental Science % January, 1908.

(5) Recherches sur TEpilepsie, Bourneville.

(6) Epilepsy , Gowers.

(7) Psychological Medicine^ Lewis.

Some Observations on Insanity in Jews.Q) By Harvey
Baird, M.D., Assistant Medical Officer, Colney Hatch
Asylum.

The great majority of the insane Jews chargeable to the
various London unions are cared for in this asylum. Special
arrangements are made in order that they may observe
the customs and rites which their religion demands of them.
A Jewish Rabbi visits them and holds religious services. A
Jewish interpretress is on duty daily. There is a Jewish
kitchen, where the food is prepared in the manner they are

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1908 .] BY HARVEY BAIRD, M.D. 529

accustomed to. At certain periods of the year they fast as
they would do in their own homes.

The number of Jewish patients shows a yearly increase,
especially marked in the last few years. In 1903 there were
282 Jews here, while last year the number was 421, an increase
of 50 per cent . At this rate in twenty-five years this asylum
will contain only Jewish patients.

This raises the question as to whether the Jewish Board of
Guardians and London County Council might not consider the
erection of an asylum for Jews only. It is possible, however,
that the deportation of recent arrivals in this country under
the Aliens Act may diminish the rate of increase.

One has, consequently, a good opportunity to make a com¬
parative study of their insanity and that of their non-Jewish
fellow-inmates. All the cases admitted here from January 1st,
1903, to December 31st, 1907, inclusive, have been analysed,
and several striking differences will be observed.

The average admission age is much below that of the non-
Jew. In the five-yearly period previously mentioned, 288 male
and 299 female Jews were admitted; 35*3 and 34*9 were their
average ages. In all the London asylums 41*6 and 41*8 were
the average admission ages for males and females respectively
in 1906. Thus it will be noted that the London Jew becomes
insane some six and a half years earlier than his fellow citizens.
The cause of this may be due to their more neurotic tempera¬
ment, to greater stress and strain, to earlier marriage, with
possibly sexual excess, and to the peculiar liability of the
females to puerperal and allied insanities.

The histories of all the admissions here during the quin¬
quennial period chosen have been examined with a view to
giving some statistics as regards causation, and here again
some striking differences are observed. I may remark that the
histories have been taken with great care, a large proportion of
them by Dr. Beadles, late senior medical officer here. Although
believing that stress and strain may be a factor of some import¬
ance in the causation of insanity, I have not in comparing the
two classes taken into consideration those cases in which such
causes are alone given, nor have I done so where such condi¬
tions as fright, accident, masturbation, love affair, etc., are
mentioned. A considerable number of cases have no history,
and this is especially so in regard to the Jews, many of them

Liv. 38

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530 SOME OBSERVATIONS ON INSANITY IN JEWS, [July,

having no relatives in this country. Of the 2714 cases, 586
had no history. Excluding these, of the remainder 24*5 and 34
per cent . of the male and female Jews show heredity, and 33*4
and 36*8 of the non-Jews. It is questionable, however, if
heredity plays a less important part in the Jew, as information
on such a subject is probably more often concealed, and a
husband or wife is much more likely in the case of the Jew to
know little or nothing of the patient’s family. Probably
heredity is about equally common in both classes.

A history of alcoholic excess, as would be expected, is much
less common in the Jews. It was obtained in only 127 per
cent. of the men and 2*6 per cent. of the women, as compared
with 33*8 and 14*2 per cent . respectively in the other patients.
In both sections, however, alcohol alone was rarely a cause, and
I think it must be admitted that the majority of those who
drink to excess are of a somewhat defective mental standard
before they take to drink. At the same time the figures
undoubtedly show that inebriety is a rare vice in the Jewish
community.

A history of syphilitic infection was so rarely obtained in
females as to be valueless for comparative purposes. In the
men it was practically equally frequent in both sections, viz.,
5*5 and 57 per cent.

In regard to insanity associated with the puerperium,
pregnancy, and lactation, we find a remarkable disparity.
This is the difference that strikes one most forcibly when
examining these cases. For the Jews the figures are I2'i per
cent, puerperal, 3*9 per cent, pregnancy, and 3 per cent, lactation;
for non-Jews 5*4 per cent. *5 per cent., and 2'i percent ., or putting
all together 19 and 8 per cent, respectively. Dr. Beadles in
1900 found the figures to be 15 and 6’i8 respectively.

The causes of this increase in insanity associated with child¬
bearing may be several. The Jews usually marry earlier, about
twenty-four and twenty-two I am told are the usual ages.
Their fecundity is great, about five to eight being the usual
family. They are probably more moral and domesticated,
but after marriage sexual excess is probably common. Inter¬
marriage is more frequently to be expected than in the non-Jew.
The Jewess being of a more neurotic temperament, and becom¬
ing pregnant at an age when neuroses are likely to be prominent,
possibly also living in insanitary surroundings, and working at

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1908.] BY HARVEY BAIRD, M.D. S3 I

various trades during her pregnancy in many cases, it is not to
be wondered at that the strain of such an occurrence is too
much for her mental equilibrium.

General paralysis has been regarded as a disease to which
Jews are specially liable. Thus Beadles, in “ The Insane Jew,”
Journal of Mental Science, October, 1900, states that he found
21 per cent . of all male Jew admissions were paralytics, as com¬
pared with 13 per cent . for pauper admissions in all county and
borough asylums. I have, however, found a considerable
decrease in the frequency of general paralysis in the Jew
admissions. Indeed, there is a larger proportion in the non-
Jew admissions; 31 Jew and 147 non-Jew paralytics were
admitted, i.e., io*8 and 14*2 per cent, of the total admissions.
In regard to causation, heredity, syphilis, and alcoholic excess
were especially inquired into. The figures are 22*5, 22*5, and
16*1 per cent . for Jews, and for non-Jews 27*9, 15*6, and 32*7
per cent, respectively. Again, alcohol was usually associated
with some other cause.

Regarding the symptomatology of the cases, speaking gene¬
rally the alien insane Jew is a troublesome case. The propor¬
tion of Jews in the better wards in this asylum is small. Thus
of the Jew cases at present on the female side of this asylum,
162 are in wards the patients of which are not regarded as fit
to take meals in the dining-hall, and only 61 in such wards.
The proportion in the other patients is 552 to 503.

This shows a marked difference; in the one case the numbers
are nearly similar, in the other between twice and thrice as
many.

The proportion of workers is small, 25 per cent.

The relatives and friends exhibit an extraordinary pertinacity
in their endeavours to get the patients discharged. Con¬
sequently a large number are sent home as relieved. But as
regards recovery, according to the statistics of the last five
years, the outlook is considerably less favourable in the Jew.
This is surprising, considering the high percentage of puerperal
insanity. Thus only 22*2 per cent, of the male Jews admitted
recovered, and 30*8 of the females, or excluding transfers 25*8
and 34*2 per cent . respectively. Since the end of 1907 a small
number more have recovered, giving a slight increase. In 1906
the percentages of recoveries on admissions for all London
Asylums were 31*22 and 36*06. In regard to the Jews, my

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532 INSANE IN PRIVATE DWELLINGS, [Juty*

figures are less favourable than those of Dr. Beadles, who gave
26*1 for males and 42 per cent . for females.

Referring next to bodily diseases, my general impression
before investigating the subject was that the insane Jew
was usually of low vitality, especially prone to tuberculosis,
etc.

The statistics of this asylum, however, show that there is
practically no difference in regard to phthisis and dysentery in
the Jew and non-Jew ; 19 per cent . of the tubercular cases were
Jews, the same percentage as the average number of Jews resi¬
dent bore to the non-Jews; 20 per cent, of the dysentery cases
were Jews.

As regards epilepsy, there is practically the same proportion
of cases amongst the Jews as amongst the non-Jews.

Summarising, the following facts may be stated :

(1) The insane London Jewish population is doubling itself
every ten years.

(2) The average admission age of the Jew is six and a half
years less than that of the non-Jew.

(3) Alcoholic excess is three times as frequently an assigned
cause in the non-Jew as in the Jew.

(4) Insanity associated with child-bearing is relatively more
than twice as common in Jewesses.

(5) General paralysis is rather less common.

(6) The foreign Jewish inmate is relatively more trouble¬
some.

(7) The prognosis of the cases admitted is not so good in the
Jew.

(*) A paper read at the Spring Meeting of the South-Eastern Division.

The Boarding Out of the Insane in Private Dwellings .

By R. Cunyngham Brown, M.D.

Writing in the Nineteenth Century of 1889, in an article
entitled, u Lunatics as Patients, not Prisoners,” Sir John
Batty Tuke drew attention to the steadily increasing incubus
of pauper lunacy, and raised the whole question of lunacy
administration in England and Wales. In this paper he asked

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BY R. CUNYNGHAM BROWN, M.D.

533

1908.]

whether, commensurately with the increasing expenditure on
the care and treatment of lunatics, even at that time enormous,
there had been achieved an understanding of the hidden pro¬
cesses which underlie the insanities, and some means of arresting
their occurrence, such as the ratepaying citizen might reasonably
expect in return for the vast sums expended. These questions
Sir John Tuke answered by a decided negative, and he adduced
as his main reasons for this unsatisfactory state of affairs that,
in the first place, asylums were merely asylums in the classic
sense of the term, places of refuge, “ model lodging-houses for
the insane,” not great hospitals for the cure of disease; and,
in the second place, that the medical men who had the direction
of these establishments were occupied with administrative and
economic duties to the practical exclusion of scientific investiga¬
tion and their proper function of healers of the sick. He even
stated that it was quite an open question whether, in a certain
number of cases, asylum treatment did not tend to aggravate
the disease and render it chronic. That a certain number
recovered in consequence of it, that a certain number recovered
in spite of it, and that a certain number became demented
because of it, were, he believed, each and all equally true state¬
ments. “ A man merged in a crowd of irresponsible beings, all
under the influence of a common discipline, and under the
control of common keepers, must lose his individuality, and
cannot possibly receive that anxious care and attention at the
hands of one physician which is necessary from the nature of
the case. What every case of insanity demands as the primary
condition for recovery is, separate and individual treatment and
consideration.”

This necessity for the separate and individual treatment of
every case of insanity offering a chance of recovery is recog¬
nised by all, but since his words were written its possibility has
become more and more remote. Owing to a variety of causes,
viz., the accumulation of chronic and incurable dements
through declining death- and discharge-rates, the marked ten¬
dency amongst the proletariat to relieve themselves of aged
relatives who suffer from simple senile dementia, and an
increasing stringency of certification, the proportion of rate-
aided insane to general population, has risen since Sir John Tuke
wrote his article from 1 in every 376 to just under 1 in every
305 at the end of 1906, and the total pauper insane have

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534 INSANE IN PRIVATE DWELLINGS, [July,

increased from 75,000 odd to 113,000 odd, or have almost
doubled. What the proportion of the chronic and incurable
elements of the asylum population of England and Wales
may be it is impossible to tell, no collective statistics being
available. The last annual report of the London County Council
Asylums’ Committee, however, shows that of the 16,730 patients
remaining in their asylums—excluding the epileptic colony—at
the end of 1906,4,165, or 24*8 per cent., were secondary or senile
dements, 3,591 chronic maniacs, and 2,009 chronic melan¬
choliacs, giving a total proportion of such cases of 59*5 per cent .
These figures leave out of count entirely cases of congenital or
infantile defect, organic dementia, general paralysis, and chronic
delusional states, and though not admitting of general applica¬
tion, afford strong presumptive evidence that some three-
quarters of the patients resident in county and borough asylums
at any time are the subjects of chronic and wholly or partially
irrecoverable conditions. The deplorable results of this state
of affairs are well known. The overcrowding of asylums, largely
due to the accumulation of chronic, incurable, senile, and fre¬
quently bed-ridden patients, upon a large proportion of whom
the expensive equipment of a modem asylum is merely thrown
away, not only prejudices the recovery of acute and curable
cases and increases the death-rates from asylum dysentery
and tuberculosis, but it does much to impede the scientific
study of insanity.

One of the most urgent needs of to-day is the establishment
of special mental hospitals, or special departments for the treat¬
ment of acute and curable cases. Such hospitals, however, are
costly both in provision and up-keep, and it is evident that any
alteration of our existing administration which would affect a
considerable pecuniary saving without any loss of efficiency or
care in treatment, such as is to be found in the boarding-out
system, would thereby set free funds for the establishment of
special mental hospitals or special departments of asylums.
The fiscal policy of any department is of first importance, for
financial economy is inseparable from proper administration,
and the writer makes no apology for laying stress upon so
weighty a consideration. His visits to various centres of family-
care and an examination of their results have convinced him
that the family-care system is the means of saving very consi-
era le sums of money, is one which may be fearlessly adopted

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1908 .]

BY R. CUNYNGHAM BROWN, M.D.

535

by England and Wales, and that if adopted it will be of benefit
not only to the asylum and to the tax-paying public, but to the
patients to whom it may be safely applied. In advocating its
adoption by England and Wales the writer is well aware that
the subject is one not free from controversy, that whilst there is a
growing consensus of opinion that its adoption on a large
scale would undoubtedly be the means of a considerable
pecuniary benefit, there are many who regard the greater free¬
dom which it would confer upon the patients with apprehension,
and still more who consider its application in England and
Wales as impracticable; that is, that we have not in England
and Wales a suitable class of thrifty, intelligent, and trust¬
worthy peasantry in sufficient numbers to make the experiment
feasible, and further, that the treatment in private homes of
insane persons would be vehemently opposed by the general
public. This last objection is the only valid one, and, judging
from the experience of other countries, one which would be
very quickly overcome. Within recent years great numbers of
patients have been placed in cottage homes outside asylums in
the teeth of the fiercest local opposition, and not only has such
opposition been quickly withdrawn, but patients have been
applied for in greater numbers than the institutions deemed it
advisable to supply. Nevertheless, it is true that the public
mind during many years has become so thoroughly imbued
with the idea that all cases of insanity are, at any rate poten¬
tially, dangerous, that there is a prevailing conviction that the
asylum, and the asylum only, furnishes the sole means of the
treatment and disposal of lunatics. The public, in committing
their insane to these expensive institutions, whose luxury in
many cases justifies one in asking with the late Dr. Fere, of
the Bicfetre, whether the philanthropists who presided at their
installation have not been preoccupied with the eventuality of
their own sequestration rather than with the wellbeing of the
“ pauvres diables qui n’y peuvent rien comprendre,” are possessed
of a comfortable assurance that everything possible has been
done. The great overcrowding of many of these institutions,
however, their enormous death-rates, the fact that recovery-
rates show no tendency to improve, but, on the other hand, an
appreciable decline; that no sooner is one asylum completed
than plans must be submitted for another, and that nothing is
done to stem the influx of the indigent insane, are all forcing

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536 INSANE IN PRIVATE DWELLINGS, [July,

themselves into public recognition, and convincing many
besides physicians of the truth of what Roger du Loiret said so
far back as 1837, that “ en introduisant au milieu d'une troupe
d’ali6n6s incurables un malade atteint de folie r^cente en
passag&re, vous compremettaz la guSrison, vous la rendez a
jamais impossible, il n'y aura bient6t plus dans l’asile q’un
incurable de plus.”

The treatment of the insane in private dwellings, begun ages
ago at Gheel, in Belgium, as a place of miraculous healing,
entered its modern and rational phase only in the middle of the
nineteenth century, when the control and administration of the
colony at Gheel passed from the Commune into the hands of
the State. A few years later, following the Scottish Lunacy
Act of 1857, numbers of the insane were treated in private
dwellings in Scotland, and are successfully so treated
to-day. From Scotland the system passed to France, and from
France to Russia; and from Belgium to Austria, Italy, Holland
and Scandinavia. Perhaps its most remarkable development,
however, is to be found in Germany to-day, for, whereas in
that country there were in 1882 but two small family-colonies
for the insane with scarcely more than fifty patients, ten years
later there were thirty-two colonies with 1200 patients, and at
the end of 1906 there were fifty-one separate colonies with
2400 patients so treated. These different countries adopted
the system at the outset for diverse reasons—in Scotland for
want of asylum accommodation, in France to relieve their
asylums, in Holland entirely as the extension of the policy of
the open door, and in Germany from a combination of these
reasons; but wherever and however initiated it has been
invariably found to be not only a relief to congested asylums,
but in itself a valuable therapeutic aid.

As will appear from the short descriptions of the several
centres of the family-care treatment of the insane visited by the
writer, as a special commissioner of the British Medical
Journal , given hereunder, the following modes of disposal of
the patients, or combinations of these forms, have been
adopted.

Form A .—The patients may be placed within the homes and under
the care of married asylum or ex-asylum attendants in the close neigh¬
bourhood of the main asylums, and are visited by the asylum officials.
Veldwijk and Uchtspringe, Germany.

Form B .—The patients may be placed with guardians, not asylum

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BY R. CUNYNGHAM BROWN, M.D.

537

1908 .]

officials, in the close neighbourhood of the asylum. Visited by medical
officers under the direction of the medical superintendent of the asylum,
as at Gheel, Lierneux, and Rockwinkel. (Also Italy.)

Form C .—The patients may be placed within the homes of the
ordinary inhabitants of some district, remote from the main asylum,
generally a rural agricultural district, having, in the centre of the colony
thus formed, an asylum for the colony solely, and having smaller sub¬
colonies of groups in the surrounding region, each with its own small
hospital or lazarette. The patients are visited by the medical officers
of the colonial asylum under the direction of the medical superinten¬
dent of the colony, the whole forming an autonomous colony as at Ainay-
le-Chateau, Dun-sur-Auron, and Levet in France and Gardelegen and
jerichow in Germany.

Form D .—The patients may be scattered over villages and rural
districts throughout the country, disconnected from any asylum or
institution, visited not by asylum officials, but by local officials
(parochial medical officers and inspectors of the poor) yet visited by,
and under direct control of, the Lunacy Commissioners, as in Scotland.

Each of these systems is found to be good in that it permits to suit¬
able patients a degree of liberty, a diversity of natural interests and
healthy occupation, and an environment to which they are by nature
adapted, impossible within an asylum, combined with adequate inspec¬
tion and control. The choice of a system has been determined not so
much by the intrinsic merits of any one system as by the nature of the
country, the character of the inhabitants, and the form of administra¬
tion obtaining at the time, that system being chosen which most easily
fitted the existing machinery of care and control.

Form A. Holland.

The system in vogue in Holland, at the asylums of Veldwijk,
Bloemendal, and Dennenoord, is that in which the patients are boarded
out in the immediate vicinity of the asylum with ex-asylum attendants.
For many years there had been a considerable contingent of Dutch
patients at the colony in Gheel, but it was not till 1884 that this
system was inaugurated in Holland. At first it was only permitted
to board out cases with asylum attendants, but later this restriction was
removed, and to-day there are numbers of patients living with the
ordinary inhabitants. The work was initiated by the Christian Asso¬
ciation for the Treatment of Insanity and Nervous Diseases. This
Association is not a State institution, but is supported by voluntary
contributions and has the three asylums mentioned above, with a total
population of over 1,500 patients. These asylums were established for
paying patients, but patients of all classes are received, indigent patients
being accepted from the State asylums at fixed rates. The results have
been so favourable that the system has been applied since 1889 at the
State asylum of Medemblik, since 1900 at Grave, since 1892 at
Meerenberg, and at many other asylums. The law stipulates that in no
case must more than 10 percent, of the asylum population be disposed
of in this way, and that each patient must have been at least half a year

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538

INSANE IN PRIVATE DWELLINGS,

Duly,

resident in an asylum prior to being boarded out In Holland, unlike
most other countries, this method has not been adopted for pecuniary
reasons, or on account of over-crowding of asylums, but purely as a
therapeutic means of approved value. The writer was able only to
visit Veldwijk, but as this is the oldest family-colony in Holland and
the model on which the others have been planned, it may be accepted
as typical of the whole. The patients, to the number of ninety-three,
were of three classes, private patients of the first and second classes, and
state-aided or third class patients. The forms of disorder were varied,
being of the imbecile, demented, and quietly melancholic and delusional
states, and the patients for the most part lived in the homes of married
asylum attendants outside, but not distant from the asylum bounds. The
houses of the private patients need not be considered here in this con¬
nection, as they differ little from tne dwellings of the upper middle
classes in this country. The houses of the third class are detached or
semi-detached cottages of excellent construction, each with its own
garden, and in perfect order. The interiors were comfortably furnished
and scrupulously neat and clean. The patients of the third class,
numbering, as a rule, two in each house, must be of the same sex.
Each patient possesses a bedroom, whose cubic capacity, light space,
and number and quality of furnishings must conform to the regulations
laid down by the asylum authorities. The clothing of the patients is
supplied by the institution, but does not differ from that of the neighbour¬
hood, and is comfortable and sufficient. The patients were found to
be well nourished and contented, mingling well with the families with
whom they were placed, and obviously well cared for.

Inspection , etc.

Each patient is visited at least once a week by the medical director
or one of the three assistant medical officers ; also at frequent intervals
by a lay overseer or beamier , and twice yearly by the governmental
inspector of lunatics and lunatic asylums. The house of the guardian, or
huisvader , must also at all times be open to the inspection of the officer
of justice or his subordinates. Each patient also, as at other colonies,
has a book containing an inventory of the articles of clothing, etc,
supplied to him, extracts from the law of April 27th, 1884, setting forth
the conditions which must be fulfilled by the guardian, and spaces for
observations as to the patient’s bodily and mental state, and for the
signatures of the officials at each visit. The patients come also, once
weekly, to the asylum for bathing and examination by the medical
director, or to lay any complaints or requests before him.

Cost .

The connection between the asylum and the colony is of so intimate
a kind that the published financial statements do not contain figures
from which any comparison can be drawn between the asylum and the
colony in this respect. The director, Dr. Van Dale, however, stated
that the cost is slightly less in the colony than in the institution.

Digitized by L^ooQle

1908.]

BY R. CUNYNGHAM BROWN, M.D.

539

This same system (Form A) has been adopted at many asylums in
Germany, of which the small colony of Wilhelmseich, near Uchtspringe,
may be taken as a typical example.

Uchtspringe.

This, the sister asylum to the agricolous colony and asylum of Alt-
Scherbitz, was opened in 1894. Shortly after its opening the medical
director, Dr. Alt, erected in the neighbourhood of the asylum seven
double houses, for the occupancy of a married attendant in each, his
family, and three patients. The attendants pay fifty marks (£2 9 s.) a
year in rent, and are paid at the rate of 60 pf. (8 d.) a day per patient by
the institution, which also furnishes the patients’ rooms and provides
their clothing. The three patients in each house are, as a rule, com¬
posed of one adult able-bodied worker, one unable to work, and an
imbecile boy. The patients are visited at regular and frequent intervals
by one of the medical officers of the asylum, and go once a month to
the asylum for bathing and examination. The homes are clean and
comfortable, the patients cheerful and well behaved, and the food
wholesome and abundant.

Cost.

The total cost of maintenance of these patients amounts to one mark
a day as contrasted with the 1 m. 70 pf. of the asylum proper.

This system has not been further developed because Dr. Alt feared that
the interest in patients placed in families close to the asylum might be
submerged in that of so large an institution, and because it had already
served its founder’s aim by demonstrating the value of this form of
provision, and of enlisting public sympathy in this work. For these
reasons the next development was the formation (in 1898) of the auto¬
nomous colony at Gardelegen, in which the patients are boarded out
in the homes of the ordinary inhabitants, and later (in 1900) at Jerichow
(described later).

At this and at all the other German colonies each patient has a book
containing information relative to the patients, and a copy of the rules
for the guidance of the guardian.

This system of boarding out under attendant guardians in the close
vicinage of the asylum commends itself as a safe and simple way of
initiating family care in any country, of testing the fitness of a patient
for family life, and of accustoming the people of the neighbourhood to
this mode of provision. It is, in fact, only a slight extension of the
village asylums at Aberdeen and Bangour (Edinburgh). It is, however,
a more institutional form of government than is necessary or even
advisable for large numbers of the insane.

Form B. Gheel.

In which the patients are placed with the ordinary inhabitants
in the neighbourhood of the asylum, and are visited by the officers of
the asylum.

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540 INSANE IN PRIVATE DWELLINGS, [July.

The historical example of this mode is furnished by Gheel, but it is
also practised in the south of Belgium at Liemeux, and at Rockwinkel,
near Bremen, North Germany. The family colonies of Gheel and
Liemeux are identical in plan and mode of administration. There is a
central asylum capable of holding seventy inmates close to the village,
and surrounded by wide agricultural lands, populated by small farmers,
market gardeners, and the like. At the writer's visit Gheel had 1,834
patients, of whom 1,014 were men, and 820 women. The largest part
of these were either congenital idiots or imbeciles (35 per cent.), or cases
of chronic, secondary, organic, or senile dementia (37*5 per cent.).
About 10 per cent, were cases of epilepsy or hysteria, and a further
per cent, were melancholic or hypochondriacal. The patients are of
two classes, pauper patients and paying patients, usually about one
tenth of the whole number. Only two patients may be received in any
one home, and each patient must, according to the regulations of the
colony, have a bedroom to himself. The guardians are carefully
selected, the dwelling must conform to hygienic standards fixed by the
authorities, and the amount and quality of food are defined by law.
The government of the colony is placed nominally under the authority
of a Comite Permanent, composed of the burgomaster, one alderman
of the Commune, and three other members nominated by the minister
of justice, but for all practical purposes the medical director is the
responsible head. The colony is divided into four sections, for each
of which there is a sectional medical officer who acts under the medical
director. Each sectional medical officer is required to visit and report
upon each chronic incurable patient in his district at least once a month,
and each patient who seems to offer a chance of recovery, once a week.
There are also lay inspectors, gardes de section , numbering seven, who
visit each case twice monthly, and report on their condition, manage¬
ment, clothing, dwelling, etc. The medical director visits each case also
once a year. There are four bathing establishments, besides that at the
infirmary, for the use of the pauper patients, and another has been
erected for private patients.

Cost.

The patients are divided into three classes, the proprts, the semi’
gdteux , and the gdteux , and their guardians or nourriciers are paid
according to the class of patient—85 centimes a day for the propres,
99 for the semi-gdteux , and 125 for th t gdteux. From these sums the
guardians refund to the treasury of the colony about 20 centimes.
From this source and the payments of the pensionnaires or paying
patient?, the colony receives a yearly income of over 180,000 francs.
Apart altogether from the cost of erecting asylums or interest on outlay,
this system is found to be more economical than that of the ordinary
closed asylum. The writer visited every part of the colony and saw
several hundreds of the patients, inspected their homes, examined their
clothing and bedding and conversed whenever possible with both
patient and guardian. He found the patients pleased with their sur¬
roundings, and their guardians capable and intelligent. The patients
enjoy a degree of liberty unknown in our asylums, and are of great

Digitized by L^ooQle

BY R. CUNYNGHAM BROWN, M.D.

541

1908 .]

advantage by their labour, and the aid in money, to their guardians.
Formerly a barren heath, this portion of Belgium has been converted
into a fruitful garden.

Lierneux.

The formation of this colony is instructive in that it is not, like
Gheel, of ancient foundation, but was formed in 1885 as a means of
relief to the overcrowded asylums of South Belgium, in the face of con¬
siderable local resistance. The people of the neighbourhood, however,
finding that the patients were harmless and of profit to their guardians,
soon withdrew all opposition, and the demand for patients became
greater than the number the authorities deemed advisable to supply.
There has been a steady yearly increase in the number of patients
since the foundation, and on January 1st of this year the patients
numbered 537. As at Gheel, there is a central infirmary, close to
the village in which and in the surrounding country the patients are
boarded out with the people of the district. The mode of government
and the machinery of supervision are identical with those at Gheel, and
require no further mention.

Cost .

The following table gives the comparative figures of the daily cost per
patient in four neighbouring asylums and the colony at Lierneux.

Francs.

A Thopital des Anglais a Liege.277

A Thopital de Baviere k Li£ge . *279

A la sanatorium de Borgonmont.3*50

A Thopital de Venders .... 1-92

A la Colonie de Lierneux.1-50

Form C.

This form of family colony is represented by those of Dun-sur-Auron,
Levet, and Ainay-le-Chateau for the Seine Department, and in Germany
at Gardelegen and Jerichow and other places. They are all alike in that
the colonies are remote and entirely distinct from the asylum from
whence the patients are discharged. The patients are discharged
permanently from the asylum (in the case of France from the asylums
of the Seine Department at Paris, and in the case of Gardelegen and
Jerichow from the state asylums of the kingdom of Saxony) to the
colonies which have each their own directorate, staff, and budget.

The French Family-colonies.

Founded in 1892, the colony of Dun-sur-Auron was instituted expli¬
citly for the disencumbrance of the asylums of the Seine Department, and
the cases selected for transfer were, conformably to the ministerial instruc¬
tion of M. Loubet, “ aged people certified as insane, but in whom the con¬
dition of dementia, incurable but tranquil, and the senile enfeeblement of

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542 INSANE IN PRIVATE DWELLINGS, [July,

their faculties, hardly justified their detention in an asylum.” This class of
patient still preponderates in these colonies, but as experience gradually
disclosed the fact that the subjects of many other forms of mental affec¬
tion did well under family care, Dr. Marie, the founder and first medical
director of this colony, obtained a progressive extension of the categories
of cases likely to benefit by this form of assistance, and to-day there are
also many cases of delusional insanity, chronic mania and melancholia,
and adolescent dementia. The colony at Dun-sur-Auron gave such good
results that the numbers steadily increased; the dependent colony at
Levet was opened in 1896, the colony at Ainay-le-Chateau was opened
shortly after, and in 1900 converted into an independent colony, and
numerous small villages in the neighbourhood were made the foci of
sub-colonies, each with its little asylum, lazarette, or bathing establish¬
ment. At the time of the writer’s visit in 1905 there were 660 patients
at Dun, 86 at Levet, some 200 odd at the sub-colonies at Bussy, Osmery,
and Ourouer, 438 at Ainay-le-Chateau, and arrangements were being
made for future settlements at many other villages In the neighbour¬
hood.

At Dun and Ainay there are asylums each in charge of a medical
director, who is assisted at Dun by a medecin-adjoint y and another at
the colony at Levet. Most of the sub-colonies are connected by
telephone with the asylums at Dun or Ainay, and each sub-colony is in
charge of a lay overseer or surveillante des placements.

The patients are visited at regular and frequent intervals, and come
regularly to the asylum or the hospital of their sub-colony for bathing
and examination. The asylum is, further, the social centre of the colony,
where the patients meet in the salle-de-reunion for games and conversa¬
tion. During a house-to-house visitation to most of the 600 patients in
the village of Dun-sur-Auron, and also the hamlets of Bussy and Osmery,
many patients were seen in the streets, unmistakably demented, but
attracting no attention whatever from the ordinary inhabitants. They
were found occasionally at work, but as the majority are of advanced
years they were for the most part employing themselves in desultory
fashion, or at meals. The interiors of the houses were certainly above
the ordinary dwellings of the place in point of cleanliness and order,
and the patient’s clothing and bedding in excellent condition. Only
two patients, as a rule, are permitted in one house, as it has been found
there, as elsewhere, that when more than two are allowed, the proper
blending of the patients with the life of the family is impeded. The
rules stipulate that the food of the patients must be the same as that of
the family, and that at least three and a half kilogrammes of bread and one
litre of wine must be supplied to each patient per week, and four days a
week fresh meat, independently of vegetables and other foods. The
patients appeared thoroughly contented, and though, being for the most
part Parisians, many desired to return to Paris, not one wished, here or
elsewhere, to exchange the life of the colony for that of the asylum. At
Ainay-le-Chateau and the sub-colony of St. Bonney the same conditions
were met with, and the same favourable impression received. The only
points that seem open to question are, firstly, whether it is advisable
to transfer aged people, habituated town dwellers, to a distant colony
where they are out of reach of their friends or relatives, amongst a

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1908.]

BY R. CUNYNGHAM BROWN, M.D.

543

people who, however well disposed, have other ways than theirs; and
secondly, whether some binding restriction should not be inserted in
the rules of the colony as regards the supplying of alcohol to the
patients.

Cost .

The sum paid to the nourricier for each patient is 1 fr. 10 c. per day.
The personal clothing is supplied from the institution, and this, added
to the expenses of the infirmaries, medical and other service, etc., raises
the daily cost to 1 fr. 40 c. in the case of Ainay and to 1 fr. 60 c. in the
case of Dun, per patient. The average cost per patient per day in the
asylums of the Seine Department is 2 fr. 75 c. If to this saving be added
the avoidance of erection of fresh structures the resulting economy is
very considerable. Practically the same system (Form C) is in opera¬
tion at many of the family-colonies. The two the writer visited were
Gardelegen and Jerichow, and as the conditions obtaining amongst the
patients are the same at both places, Jerichow only need be described.

Jerichow.

Jerichow is a small country town between Schonhausen andGenthin,
of about 2,000 inhabitants, lying in the middle of wide and somewhat
sparsely populated agricultural lands. On account of its remoteness
from any large town, its dry and bracing climate, and the kindly and
honest character of its farming population, it was well fitted for the
formation of such a colony. A small provisional asylum was opened
in Jerichow in 1900, and in that year forty-five patients were placed with
families in the district. An asylum capable of holding 200 inmates was
completed in 1904. The asylum is built in separate blocks, each
capable of accommodating from forty to sixty patients, and stands in
fairly extensive grounds. It is complete in every way, has its chapel,
administrative bureau, laundry and other offices, but is much simpler
and cheaper in construction than the ordinary asylum, costing with the
internal furnishing 3,000 marks (between ^146-^147) a bed. The
whole has been built according to the plans of Dr. Alt, and resembles
the new village asylum at Kingseat, near Aberdeen, on a small scale,
and contained at the writer's visit 180 patients. Some of these were
permanent inmates, but the great majority were in the asylum either as
a temporary halting-place for observation on their way to the outside
colony or for treatment during transitory excitement or intercurrent
somatic illnesses.

The Homes.

The patients are scattered over a circular area of about twenty kilo¬
metres (twelve and a half miles) diameter. The houses are the small,
comfortable cottages of the neighbourhood. The patients* bedrooms
are as a rule superior to those of the family proper, owing to the
restrictions regarding air-space, etc., imposed by the directorate.

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544 INSANE IN PRIVATE DWELLINGS, [July,

The Patients .

The patients are entirely of the third or state-aided class, and are
discharged to Jerichow from the asylums of Uchtspringe, Alt-Scherbitz,
and Nietleben. No less than 45 per cent . are idiot or imbecile, mostly
young or adolescent imbeciles. About 5 per cent . are paralytic and
epileptic cases, and the remainder are composed of the subjects of
other forms of mental alienation. The selection of cases for family life
is made with the greatest care, only such being chosen as are able to
enter into the pursuits and interests of the family.

Inspection .

The whole colony is under the direction of a medical superintendent
assisted by two medical officers. Each patient is visited at least once
a week by one of the medical officers and twice a week by one of the
overseers, of whom, including the asylum attendants, there are thirty.
The care and supervision are extraordinarily thorough and have been
followed by the happiest results.

Cost .

The average cost per patient per day, inclusive of the sum paid to the
guardian, the cost of supervision, administration, and the expenditure
of the asylum, works out at 1 m. 30 pp which is a saving of 40 pf. per
patient per day on the ordinary asylum of the country. The saving
effected by this system of boarding out of the 563 patients in Saxony
was for 1904, 287,000 marks, not counting the saving on the avoidance
of new erections which would otherwise have been required. But it
has done much more than this. It has relieved the asylum of 14 per
cent . of their pauper population, it has been of material benefit to their
guardians, and it has been of great benefit to the patients themselves.

Form D. Scotland.

This form, in which the patients are boarded out with the ordinary
inhabitants of the country and are not in touch with any asylum, being
visited by parochial medical officers and lay inspectors, has on the face
of it less to recommend it than any of the other systems mentioned.
Nevertheless it has been in practice in Scotland for over forty-six years
with thoroughly satisfactory results, and is to-day applied to 19 percent
of her total insane poor. Prior to the enactment of the Lunacy Act
(Scotland) of 1857 the supervision and administration of the law
regarding both lunatic and ordinary poor were committed to a “ Board
of Supervision for Relief of the Poor,” now (since 1894) known as the
Local Government Board for Scotland. In 1857, however, a Lunacy
Act gave the control of all matters relating to the insane poor and the
supervision of all establishments for lunatics in Scotland—with the
exception of insane prisoners and those maintained in private dwellings
from private sources—to a General Board of Commissioners in Lunacy

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1908.]

BY R. CUNYNGHAM BROWN, M.D.

545

created by that Act. Under this law it became the duty of the Board
of Lunacy to see that every insane person in receipt of parochial relief
received adequate care and treatment. The immediate result of the
application of this law was the recognition of the necessity for much in¬
creased accommodation, asylum or other, for the indigent insane. Some
were placed in poor-houses, and the rest had to be kept in the homes
of relatives or boarded out with strangers. The experience gained
during this period, fortified by a study of the results obtained in other
countries, particularly those of Gheel, convinced the Board that under
efficiently organised supervision the boarding of a considerable number
of patients in private dwellings ought to form an integral part of any
complete system of providing for the insane. All matters, then, in
Scotland relating to the insane are in the hands of the General Board
of Lunacy. Scotland is divided into 874 parishes, in each of which the
administration of official assistance is entrusted to a popularly elected
Parish Council which is under the control of the Local Government
Board, and, in respect to the insane , under the control of the General
Board of Lunacy.

Scotland is also divided into lunacy districts, to each of which there
is a district lunacy board, which is responsible solely for insane persons
in asylums, having no responsibility whatever in regard to the insane,
pauper, or private, who are not in asylums. Both the parish councils
and the district lunacy boards, however, in regard to the insane, are
under the control of the General Board of Lunacy. Each parish council
has as its principal executive officer a paid official called the inspector
of poor, a post resembling, though of more importance than, that of
relieving officer in England. This official, or his assistants, investigate
all applications for relief, visit periodically all persons, including the
boarded-out insane, who are in receipt of parochial assistance, and
consider the applications of all who wish to become the guardians of
boarded-out cases. These guardians are selected with the greatest care
after personal investigation, and when a patient is placed in a private
dwelling the condition of the patient, the character of the guardian, the
persons forming the household, and the accommodation offered by the
home must be reported by the inspector to the General Board of Lunacy,
who in all doubtful cases withhold their sanction until they have been
satisfied by the inquiries of their own officers as to the fitness of the
arrangements. Each pauper lunatic under family care is visited and
reported upon to the Board by a deputy commissioner at least once,
but generally twice a year. The inspector of poor must visit and report
upon each case in his district at least once a year, but as there are con¬
tinually fresh applications being made for guardianship, involving a
personal investigation of the home of the applicant, the cases in the
neighbourhood are seen at the same time, and the total inspections
made are much in excess of the statutory requirements. The parochial
medical officer must also visit each case once a quarter, and also as
occasion may require.

The Patients.

On January 1st, 1907, there were 14,746 insane persons in receipt
of relief in Scotland. Of these 972, or 6*59 per cent ., were treated at

LIV. 39

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546

INSANE IN PRIVATE DWELLINGS,

[July,

home in their own dwellings, and 1802. or 12*22 percent ., were boarded
out in private dwellings with strangers. Thus 19 per cent, were under
family care, and these, whether living with relatives or strangers, are
subject in every case to the same official inspection and control. An
instructive fact regarding the relative numbers boarded out with strangers
and those treated in their own homes is the progressive increase of the
former class at the expense of the latter. Experience has shown, both
here and abroad, that the treatment of patients in their own homes is
much less satisfactory than when under the care of strangers, as natur¬
ally many parents do not possess the necessary qualifications for
guardianship, the ties of consanguinity also being often manifested in the
parents or other members of the family by feeble-mindedness, falling
short of certifiability, or defects in moral character. The treatment of
patients in their own homes is, in fact, only permitted in those cases
where, if it were not allowed, the case would escape official control by
the parents refusing parochial assistance. Another equally important
change relates to the channel by which these cases come on the official
roll. Formerly many were left in private dwellings on admission to
public relief, but during the last twenty years this number has under¬
gone a steady diminution, and now over two-thirds are composed of
cases discharged from asylums where they have undergone varying
periods of observation and treatment. The patients are not in Scot¬
land—except in a few instances as at Markinch, Kennoway, Balfron,
and Lanark—collected into considerable groups, but are dispersed over
the whole country. This dispersion was advised by the Commissioners
lest adverse public feeling should arise in the neighbourhood. No such
feeling, however, has arisen in any of the villages where such concentra¬
tion obtains, except in the case of a few individuals who have in no
instance been supported by the public sentiment of the locality. On
the contrary the aggregation of patients has been appreciated as a great
benefit to the people of the villages in which it has been tried, par¬
ticularly, as in Fifeshire, where these villages had been the seat of a
prosperous hand-loom weaving which had ceased on the introduction of
power-looms, and which has thus been saved from extinction. The
patients are boarded out to the number of two or three in each house.
Only rarely are these numbers exceeded, more than two never being
permitted except as the result of a special recommendation by the
Deputy-Commissioner. The cases, which are carefully selected, are
preponderatingly imbecile or demented. Imbecile women of child¬
bearing age are not boarded out, and are only permitted under family
care, when, if this were not allowed, the case would escape official
control. With regard to accommodation, diet, and clothing, the
Scottish system differs from that of the continental colonies in the
greater freedom which is permitted to the guardians in these particulars,
restrictions not being imposed which might result in a separation of the
patients from the other inmates of the house. The patients, however,
must always be of the same sex, and separate beds must be provided
for each patient, though in the case of women two patients may be
allowed to sleep together if they both desire to do so. No rule is laid
down as to cubic air-space, etc., and with all domestic matters it J$»
to quote Sir Arthur Mitchell, “ regarded as sufficient if a lunatic’s con-

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1908.]

BY R. CUNYNGHAM BROWN, M.D.

547

dition shows a reasonable approach as regards substantial comforts
to that of the poor but respectable portion of the general community.”

Cost.

There is no fixed rate of board in Scotland, and the sums paid to the
guardians vary from the 7 s. per week of large urban and burghal parishes
to 3 s. 9 \d. in the case of Shetland. The amount of attention and care
required and the accommodation offered are taken into consideration
in fixing the sums paid to the guardians. The clothing, of which each
patient must have two complete outfits, and, of course, medical neces¬
saries and comforts, are also supplied. Altogether the average weekly
cost per patient is about 8 s. 5 d. t as contrasted with the 9 s. nd. of the
establishments. The asylum rates, however, in Scotland do not include
the cost of land and buildings, which amounts to 6 s. 10 \d. per patient
per week. The cost of maintenance in private dwellings is thus just
one-half of that in asylums, resulting in an economy to Scotland of
between ^40,000 and ^£50,000 per annum. In 1904 the writer visited,
through the kindness ot the Commissioners, large numbers of these
cases in Scotland, and was very much struck by the good physical state
of the patients. In only two cases out of several hundreds were they
in poor bodily condition. They were found working cheerfully in the
fields and strawberry farms, engaged in various domestic offices or
sitting quietly at home. The accommodation, though varying within
wide limits, was found everywhere good, and their guardians were, as a
rule, intelligent and kindly folk clearly interested in their charge.
During 1903 only 1 *05 per cent, of the cases boarded out had to be
removed on account of bad or indifferent guardianship, and in nearly
every case where lax guardianship occurs, it is found to be when the
patient is under the care of parents or other relatives. The complete
separation of asylum from boarded-out insane, the infrequent visitation
of the patients in family-care, their wide dispersal over the country, and
their local medical supervision by parochial and not asylum officers,
and the further fact that about one-third of the whole number of
patients are resident with relatives, who, by experience, have been
proved to make the worst guardians of the insane—all sharply mark off
the Scottish system from any other. Notwithstanding these apparent,
and in the writer’s opinion actual, drawbacks, the Scottish system has
been in satisfactory operation for nearly half a century, and is applied
to-day to one-nineteenth of Scotland’s total pauper insane, the numbers
so treated being, on January 1st of this year, 2780.

In reviewing the whole family-care systems as outlined above
there are certain points deserving of note. In the first place
the patients are happier than in the closed asylums. Out of
the many hundreds of patients with whom the writer conversed
on the Continent and in Scotland in not one case did the
patient wish to re-enter the closed asylums. In many cases,
and particularly in French colonies, the patients, for the most

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54$ INSANE IN PRIVATE DWELLINGS, [July,

part Parisians, wished to return to their own city, but never to
the closed asylum. Also, at times, the patients wished for a
change of guardian, and this has been, where possible, acceded
to, as it is often only by a tentative experiment that the most
suitable guardian for any case can be found. A second striking
feature of the patients visited, with the exception of the French
colonies, in which a considerable proportion were aged people,
was their good physical condition. This is borne out by a
consideration of the death-rates of the boarded-out insane.
Notwithstanding that the classes selected for boarding-out—
imbeciles, dements, and chronic maniacs—have usually a high
death-rate and are notoriously prone to tuberculous disease, and
although the French colonies are composed preponderating^
of senile cases, the following tabular statement shows that the
death-rate in the boarded-out patients is just about one-half
that of the closed asylums.

Death-rates in 1906 in Boarded-out Insane and in Family Colonies .

Numbers.

Deaths.

Percentage

Scotland

2.774

113

4'°7

Gheel

1,844

103

5'°5

Lierneux

486

4*ii

Dun and Ainay

1,263

6 'g 6

In the above statement the writer has not included the
returns of the Dutch colonies, because, owing to the intimate
connection of the asylum and the colony, no separate statistics
are available. It may be stated, however, with regard to the
family-colonies of Saxony, that during the three years ending
December 31st, 1907, there have been only fourteen deaths with
an average yearly population of 448. Another feature is the
improved emotional tone of the patients. The patients are more
content than in the asylums ; the necessary restrictions of an
asylum, which at times undoubtedly re-enforce delusions of
persecution, are not felt, and the patient ceases to kick against
the pricks, and Professor Marie, who has frequently ventured
to discharge to the colony cases of melancholia with suicidal
tendencies, has affirmed that under domestic influences such
cases, as a rule, markedly improve, patients who had been
actively suicidal in the asylum ceasing to make any attempt on
their own lives. Doubtless it is in consequence of this im¬
proved emotional state that recoveries do occur in a class in

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1908.] BY R. CUNYNGHAM BROWN, M.D. 549

which recovery was not to be expected, in small though con¬
stant proportions.

The recoveries naturally vary with the classes boarded out,
and range from 1 per cent . of the total annual number of patients
in Scotland to 1*15 per cent . of the total number of patients, or
10*21 per cent . of the admissions in the case of Gheel.

The dangers which loom so prominently in the minds of
many are those of harsh or exigent guardianship, escapes,
suicide, casualties and assaults, and pregnancies in the female
patients. All of these are possible under any form of adminis¬
tration. Taking them seriatim, the danger of harsh coercive
measures by a guardian, in whose interest it is to make a
patient work well, has been found in practice to be a negligible
quantity. The satisfaction of the patients with their surround¬
ings is sufficient to dispel the fear, and given careful selection
of the guardians and efficient inspection and control this danger
is as little likely to occur as in closed asylums. Escapes from
the Continental family-colonies are exceedingly infrequent
occurrences, partly from their careful supervision but also
because of the manifest contentment of the patients with their
lot. In 1906, from the French and Belgian colonies there
were in all twelve escapes, and in the three years ending
December 31st, 1907, there were nine escapes from the Saxon
colonies, giving an annual number of nine escapes with an
annual number of patients of 4,079. As to fatalities and
suicides, there have been in the Belgian colonies, during the
years 1904-5-6, with an annual population of over 2,300
patients, three suicides and two accidental deaths; in the
Saxon colonies one suicide and two accidental deaths; and in
Scotland neither suicide nor fatal accident. In Scotland the
non-fatal casualties amount to almost one-fifth of those of the
asylums, this relative infrequency ensuing naturally upon the
carefully selected class boarded out. Pregnancies have occurred,
though very rarely, at Gheel, and at Lierneux the first and
only pregnancy in the history of the colony was recorded last
year. In Scotland these unfortunate events have been less
infrequent than elsewhere, there having been twenty-five in the
half-century during which family-care has existed in that
country. Nearly every one of these cases, however, has been
among the patients treated in their own families, and who, had
this arrangement not been consented to, would have refused

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550 THE TEACHING OF PSYCHIATRY, [July,

parochial assistance, and would thus have escaped official
recognition and inspection altogether. The risk of pregnancy
can, obviously, be most easily avoided by boarding out no
women of child-bearing age. On close inspection the risks and
dangers of boarding out suitable cases in private dwellings
prove to be, all of them, avoidable, and its advantages so great
that they far outweigh any of the considerations which
have been urged against its adoption in England and Wales.
It is a system which is applicable on a large scale only
to a certain proportion of asylum patients, that is, to inoffensive
patients who are the subjects of chronic mental disorders for
which no special treatment is required, and also to patients
convalescing from acute psychoses. To many of these latter
the family-care system offers the most satisfactory means of
testing their fitness for return to society, and if it be true that
the special mental hospital is the only proper entrance to the
asylum, it is equally true that the family-care system provides
the only proper exit.

The Teaching of Psychiatry . By D. G. Thomson, M.D.,

Medical Superintendent Norfolk County Asylum, Norwich.

I WISH that the advocacy of what I believe will be one of
the most important developments in the history of our specialty
had devolved on someone occupying a higher position in our
branch of medicine, someone whose opinions and views would
carry more weight and influence than mine can aspire to ; at the
same time thirty years* experience as a medical officer in
London and provincial asylums, public and private, perhaps
entitles me to open a discussion on a subject on which I have
spent some thought, and I am proud of the privilege of doing
so before this Association to-day.

I think we are all alive to the fact that new ideals and
possibilities are arising in our work among the insane. Half
a century or more has converted the ghastly chaos of the mad¬
house into the comfort, luxury even, of our present-day
asylums, and everlasting honour to the men who worked this
beneficent change. But we can no longer afford to rest on our

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551

oars and complacently gloat over the existing high-grade
administration of our asylums, and we who profess to be
specialists and leaders of opinion on matters connected with
the insane should now be considering if the time has not come
to take fresh stock of our position, to determine if our present
methods of dealing with the insane and of teaching and train¬
ing those who come after us are archaic or not.

I am afraid that some of us are satisfied to be efficient
administrators of institutions, to comply with the requirements
of the law applicable to the insane, to satisfy our committees of
visitors, the Lunacy Commissioners and other public bodies, and
all this—no light task in itself—to the peril of our proficiency
as physicians. I have no intention at present of referring to the
vexed question as to how far administrative and medical skill
can co-exist in the same individual, or be expected from him,
but I do postulate that in the treatment of recent or acute
cases—and they are the only ones that count—it is the highest
medical skill that is the essential factor of the two.

If any stimulus were required to bestir us and make us
reflect on these matters, surely it is coming from many
directions, notably in the recent work of Mott, Lewis Bruce,
Orr, Rows, Ford-Robertson, and others, and so recently as
Valentine's day, 1908, when Maudsley made his memorable
and munificent offer to the London County Council of ^30,000
“ for the establishment in London of a fitly equipped hospital
for mental diseases.”

It may be that our ultimate high function is the prevention
of disease, and I am afraid that the pessimism which is apt to
be the outcome of experience warrants a fear that therein lies
our only chance of being of much use to the race in the matter
of insanity, still, until we have succeeded in’preventing insanity
we will have to be contented with our less ideal function of
treating insanity as it arises.

I think I cannot give better introduction to the subject of
my paper than by taking the three main propositions given in Dr.
Maudsley's letter to the Chairman of the London County
Council.

“ As a physician,” he says, “who has been engaged in the study
and treatment of mental diseases for more than half a century
I have been deeply impressed with the necessity of a hospital
the main objects of which would be:

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552 THE TEACHING OF PSYCHIATRY, [July.

“(i) The early treatment of acute cases of mental disorder,
etc

“(2) To promote exact scientific research into the causes and
pathology of insanity, etc.

“(3) To serve as an educational institution in which medical
students might obtain good clinical instruction.^

It is the last or third proposition which will serve as text for
my remarks to-day, for after all it is the main proposition. Is
not the medical student of to-day the physician and investi¬
gator, referred to in the first and second propositions, of to¬
morrow ? And we will be beginning at the wrong end, so to
speak, unless we closely examine all that the third proposition
implies.

I think no one conversant with the existing state of affairs
will contend that the present mode of instruction of medical
students in psychiatry can do more than give them a smattering
of knowledge; indeed, except for those taking University
degrees even this modicum is not imparted. We all know the
kind of lectures given and the clinical exhibits, admirable in
their way, but which are sown on unprepared ground and which
are looked upon by the average medical student as of much
the same entertaining and bizarre character as the lectures on
poison murderers, Madeleine Smith, Pritchard and Co., in
medical jurisprudence^). Medical art is, however, long and
medical student life short, and after all, but a smattering or
merely the elements of any of the subjects taught in the medical
curriculum is attainable, so I must not labour this point I
am inclined to believe that Dr. Maudsley rather aims, in his
third proposition, not so much at the education in psychiatry of
the ordinary medical student as of the post-graduate medical
student who desires to take up mental diseases as a specialty or
as an adjunct to the practice of pure medicine or neurology.
Is it not a striking, nay, even an extraordinary, fact that mental
diseases among all specialities is the only one where no post¬
graduate training and special study are demanded ? If public
health work is pursued one has to study specially the subjects
therein included, and obtain a diploma in public health ; in
military and naval surgery special post-graduate study is
demanded, and after study in special military and naval hospi¬
tals a searching examination is undergone before obtaining the
diploma, or in this case commission as it is called.

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BY D. G. THOMSON, M.D.

553

Familiarity and custom blind us to anomalies, so I would ask
you to look at the matter afresh and see if our present method
of training the alienist is satisfactory. The majority of us
began our careers as assistant medical officers of asylums, with¬
out having had the opportunity of attending a post-graduate
course of instruction in mental diseases.

It may be answered that the actual service in the asylum is
the post-graduate course, and that the medical superintendent is
the instructor of the newly fledged doctor who is the assistant
medical officer, but we know that beyond imparting a measure
of his clinical and administrative experience to his juniors the
medical superintendent is in many instances unqualified, even
if he had the time, or were it his duty to do so, to give or
direct the necessary training and teaching.

The wonder is that under existing circumstances so much
good work has been done in the past, for let us picture to our¬
selves asylums dotted in more or less isolated positions all over
the country, the laboratories where any appreciable investiga¬
tion or original research is carried out numbering some 5 per
cent . of those asylums, the isolation and separation of those
asylums and laboratories from centres of medical thought and
intercourse, what wonder that there is this feeling of dissatis¬
faction, of unrest both in lay and medical circles, and a
clamouring for a more scientific method of dealing with the
ever-increasing burden of lunacy, and that especially at its source.

So much for destructive criticism of present arrangements ;
let us see shortly what are the various remedial changes which
have from time to time been proposed.

They may be classed under three heads, and virtually are
included in Dr. Maudsley's three propositions :

(1) The need for the provision of adequate early treatment.

(2) The promotion of more general and systematised investi¬
gation of insanity as a disease.

(3) The need of good clinical instruction for those who
desire to study mental disease.

As regards No. 1 I need say no more than that Dr. Clouston,
Dr. Carswell and others have strongly advocated the provision of
mental wards in general hospitals, the London County Council,
Dr. Maudsley and others the establishment of “receiving houses”
and special mental hospitals for early acute cases of mental
disorder, in the great cities at all events.

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554 THE TEACHING OF PSYCHIATRY, [July,

Now, I contend No. I is of little value and would be a gross
waste of money if propositions Nos. 2 and 3 are not considered
of prime importance ; they are practically complementary of one
another and may be considered together, and it is on those
two propositions that I have suggestions to submit for your
consideration.

I am absolutely convinced that the success of any scheme of
reform in the medical aspect of asylum or rather lunacy work
depends entirely upon the provision of definite post-graduate
training of our future alienists, and this post-graduate training
can only be organised and rendered effective if instituted by
the universities or other teaching bodies as suggested by Dr.
Maudsley and a diploma in mental medicine be granted, with¬
out which no one can aspire to lunacy work or appointments.
The Medico-Psychological Association has made a laudable
effort to stimulate the study of mental diseases by giving
prizes and by instituting a certificate of proficiency. Unhappily
the response has not been satisfactory.

As to the ways and means and the scope of this post¬
graduate training I can in this introductory paper merely
outline the latter, but one or two years* study of the following
subjects would be essential:

(1) The anatomy and physiology of the nervous system.

(2) Neuropathology.

(3) Experimental psychology, normal and morbid, such
work, for example, as that done by Dr. Sherrington, of
Liverpool, Dr. Rivers, of Cambridge, and one or two others.

(4) Psychiatry, systematic and clinical.

All those subjects could be taught in the wards and
laboratories of a mental hospital, such as Dr. Maudsley proposes
in London, and afterwards in similar institutions in the great
teaching centres, Edinburgh, Dublin, etc., and would provide
what he asks for, the “ good ’* instruction he refers to in his
letter. Dr. Maudsley does not write loose English ; he must
have had some comparative idea in his mind as between what
is in vogue in the way of psychiatric instruction at present, and
what that psychiatric instruction ought to be in his use of the
word “ good ** before the word “ instruction.**

I understand that the London County Council have
remitted the matter of the “ Maudsley Bequest ** to their
Asylums Committee for consideration and report. I am aware

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1908.]

BY D. G. THOMSON, M.D.

555

that that body comprises many eminent men, and some with
knowledge of asylum work, but I sincerely trust they won’t be
above appealing for expert advice in such an important
matter.

No one is more cognisant than myself of the difficulties
ahead in this matter of the proper training and teaching of our
future alienists, but in this introduction to a discussion
on the subject I won’t refer to these at present, but conclude
my remarks by moving “ that the Education Committee of
this Association be instructed to consider a scheme on the
lines I have suggested for post-graduate teaching in mental
diseases or psychiatry ” (which, as I have endeavoured to
show, is by far the most important and crying want at the
present time), “ so that we may approach the universities or
other teaching bodies on the subject.”

(') By the way, I read in the prospectus of a London post-graduate college that
a course of five demonstrations on mental diseases will be given by a medical
officer of one of the London County Asylums! Well, the only comment one can
make on this is “ better a small fish than an empty dish.’*

Discussion.

At the Quarterly Meeting on May 19th, 1908, in London.

Dr. Savage said that the subject was a most important one, and he felt strongly
with Dr. Thomson that the teaching of psychiatry must be reorganised. One
knew what would be best but one felt the extreme difficulty of obtaining it.
He said that in training men to become efficient in the treatment of those who
are of unsound mind there were certain points it would be essential to consider.
Firstly, in staffing their large institutions they must provide a medical superinten¬
dent. If the chief administrative officer were not a medical man they would soon
relapse into the sad state of affairs which once existed. Secondly, many persons
of unsound mind did not require what was ordinarily meant by the term “ medical
treatment.” Harm was done by keeping certain patients in bed, taking their
temperature, looking at their tongues and examining their stools and their urine,
and one was sure there were large numbers of patients whose disease could not be
demonstrated by any method unless the medical man were a resident in the asylum.
As regards the treatment of patients, some of the suggestions made recently
were anarchical in character; people were not satisfied with what existed and
therefore desired to do away with it all and start afresh. He feared, however, that
such a course would not lead to the desired goal in their branch of medicine. A
practical plan which had to some extent been adopted was to have hospital wards
in connection with the asylums, and the London University had set a good example
by providing that men might take their degree of Doctor of Medicine in Psychiatry.
His own feeling was that there was a slow development, and it was being
realised that more psychiatric teaching must be given, more use must be made of
hospital wards in asylums, and that it might be helpful to have wards for the insane
attached to the general hospitals.

Dr. Percy Smith agreed as to the incompleteness of the course of instruction
which medical students received in mental diseases, but quite realised that owing
to the many claims on their time it was impossible to extend this course. The
student was taught anatomy and physiology in the early part of his curriculum, and
neuro-pathology was included in the instruction given in the lectures and demon-

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556

THE TEACHING OF PSYCHIATRY,

Duly,

strations on pathology, but he certainly had not time to attend a course of experi¬
mental psychology. As to acquiring a knowledge of psychiatry, the members of
the Medico*Psychological Association knew that the only way to accomplish this
was by the daily observation of the insane and by living in the same institution
with them. He wished to ask whether Dr. Thomson thought no one should go as
a junior assistant medical officer to an asylum unless he had taken out special
courses of instruction in the various subjects which Dr. Thomson had indicated as
being suitable for post-graduate study. If that was Dr. Thomson’s view he held
that the market would be closed. Many men did not know whether they wished
to pursue the study of mental diseases until they had had actual experience in an
asylum. With regard to the Medico-Psychological Certificate, there was no doubt
that if it had been properly taken up by superintendents of asylums throughout the
country there would have been by the present date a larger number of men who had
specially worked at psychology and mental diseases and who would thus have been
well qualified to advance the treatment of the insane. He recognised with regret
the apathy displayed by some medical officers, but at the same time knew that there
existed a large body of highly-qualified men in their particular branch who,
though producing no epoch-making discovery, were doing their daily work
with thoroughness and interest. If Dr. Thomson looked through the list of
members of the Association he would see that their qualifications were as
good as those of men in any other branch of the profession. Dr. Smith
referred to the post-graduate courses of instruction which he had given at
Bethlem Hospital, and stated that his experience was that the men wanted clinical
teaching there.

Dr. David Orr said that ten years in an asylum was enough to open one’s eyes
to the good points in asylum work. There were many good points in asylum ad¬
ministration, and there had been for years. Dr. Thomson’s suggestion was that,
instead of sitting down self-satisfied, they should go a little further forward. With¬
out touching on the difficulties which had been mentioned, he thought that if the
present question were looked at squarely it resolved itself into one as to whether
they in the specialty should stay where they were now. Should English psychiatrists
be behind the whole world ? No one could follow the French, German, and Italian
literature without coming to the inevitable conclusion that most of the men en¬
gaged in asylums in those countries knew their clinical psychology, their psychiatry,
their pathology and neuro-pathology splendidly, and that they were thoroughly
trained men; that they had every opportunity of being trained and doing
thoroughly good work. The fact was undeniable that it was hopeless at present
to take our position with those men ; we could not do it. Therefore it was neces¬
sary to decide whether it was worth while to establish good post-graduate teaching.
As Dr. Thomson had said, that was the only way in which the specialty, as a
specialty, would rank with the specialty in other countries, and other specialties
in our own. As to the training of medical superintendents, he thought that
assistant medical officers would be able to devote as much time to science as to
the administrative part of their work ; and, having been thoroughly trained in the
first instance, having worked during their period of waiting for promotion, they
would be in a position to direct good scientific work on the part of their juniors.
This should be the position of the superintendent in England ultimately.

Dr. C. A. Mercier said he had greatly admired the dissertation of Dr. Thomson,
because he had put into words what he (Dr. Mercier) had been thinking for years.
He knew that Dr. Thomson’s opinions as expressed in the paper were held very widely,
much more widely outside their specialty than inside it. He had been delighted to
hear the breezy optimism of Dr. Orr, that they were not to be deterred from attempt¬
ing reform because it w'as difficult. He remembered formulating in that Association
years ago a saying for which he was grievously taken to task. He was asking
what men came into the world for, except to overcome difficulties, to make
impossible things possible. No doubt there were difficulties before them in con¬
nection with the present question, but those difficulties ought to be, and could be.
surmounted. The amount of education in psychiatry which was given to the
ordinary medical student could not, for the reasons Dr. Percy Smith had given,
very well be enlarged; the time of the student was already too much occupied.
What required to be given to the ordinary medical student who was going into
general practice was such a knowledge of insanity that he would be enabled to

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BY D. G. THOMSON, M.D.

557

recognise an insane person when he saw one, and so that he might know when it
was advisable to call in a second opinion. It was not for such a practitioner to
discuss the niceties of psychiatry, or to be able to treat a case right through. But
the subject which Dr. Thomson had just brought forward was a totally different
one; it referred not only to graduate, but post-graduate study; it concerned the
training of experts to take their places in our great asylums; not only the study
and treatment of the insane, but, still more important, the advance of our know¬
ledge of psychiatry. He did not at all agree with what Dr. Orr had said as to this
country being behind the rest of the world concerning psychiatry. He thought the
natural modesty of all Englishmen was apt to be very much exaggerated in that
direction. As an examiner he found that candidates gave him the opinions of
Germans and Italians and Americans, and that they read German, Italian and
American books quite unnecessarily, because the knowledge which they got from
them was, for the most part, second-hand knowledge derived from this country.
What the Germans, Americans, and Italians did for the most part was to give new
names to things which English alienists had known for a long time and present
them as new discoveries under the new names. He did not think the study of
psychiatry was at all backward in this country, but the teaching of it was. There
ought to be better organisation and better methods of teaching psychiatry and
training men to take their places in the extremely responsible positions of the
heads of the great public asylums of this country. It had been alleged—he did
not know with what truth—that candidates for the junior places in our public
asylums found the posts unattractive. But there was no branch of medicine so
well paid or which met with such a certain and large reward as that of psychiatry.
He agreed that every person who contemplated holding a responsible position
in an asylum should be a skilled psychiatrist. The actual scheme of training
was a matter of detail, which might be left to the committee which Dr.
Thomson suggested should sit upon the question. It should be comprehensive
and thorough, and include the preliminary subjects as well as the advanced
ones. Dr. Thomson recommended experimental psychology. He had no strong
opinion that experimental psychology should be excluded, but he had no
very sanguine hopes of it being 0? any great importance. But that normal
psychology should be studied he had no doubt at all. If insanity was, as it was
always called, a disease of the mind, or a disorder of the mind, if its synonym was
unsoundness of mind, surely persons who studied it and were constantly immersed
in the treatment of it ought to know something about the normal mind before
studying the abnormal mind. He felt very strongly that efforts for the promotion
of post-graduate study in insanity were very sorely needed; that the asylums in the
neighbourhood of our great cities and towns were the proper seats of that
instruction. The most important matter of all, perhaps, was to get the licensing
and examining bodies to grant diplomas and degrees in that most important sub¬
ject. Until recognition of that was secured he did not think the study would ever
be promoted successfully. If men had attained to a considerable degree of know¬
ledge of the subject, they would want to possess a diploma, some guinea stamp to
show that they had attained that knowledge. Unless that could be done, he very
much doubted whether the efforts of the Association would be attended with
success. He did not see why other universities should not do as London University
had done, and grant a degree in psychiatry, nor why the colleges should not be
giving some diploma in psychiatry, as was being done in the subject of public
health and in tropical medicine. It seemed to him to be such a natural develop¬
ment of the perpetual training and the increasing knowledge, for it was impossible for
any one man to know the whole of medicine ; and it was most desirable that every
man who took up any special branch of medicine should be thoroughly well
grounded not only in the more advanced, but in the more elementary and
preparatory studies, so that he should have a firm grasp of the whole. That
range of study, however, could not be secured except by the regulations of
examining bodies which required a thorough academical knowledge of the whole
subject from end to end. The study of the subject needed to be systematised.
The mere effort of persons working voluntarily must be backed up by the sanction
of the universities and other examining bodies, and he would like, with Dr.
Thomson’s permission, to add a suggestion that the subject should go before a
committee of the Association, which should be empowered to approach the

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558

[July,

examining bodies to ascertain what part they were willing to take in promoting the
post-graduate study of psychiatry.

Dr. Hubert Bond said he was sure that all present had listened with extreme
interest to Dr. Thomson's paper. it was a subject on which he had himself often
pondered and which he had at heart. There were sometimes two yolks in an egg,
and that was what he felt in regard to Dr. Thomson's contribution, namely the
desirability of inducing universities and qualifying bodies to establish and grant a
diploma in mental diseases, and the necessity to then persuade asylum authorities
to demand that candidates for their medical appointments should hold such. Was
the situation not comparable to the Public Health Department? All present
would remember the day when a public health diploma was not necessary for the
medical officer of health; and the moment it became necessary a great rush was
made to the portals of the universities and qualifying bodies to obtain those
diplomas. It would be just the same in their own field if a strong committee could
persuade the universities to grant such diplomas, and then asylum committees or
Parliament that such diploma should be necessary, at any rate in respect of medical
appointments in asylums of a certain size.

The Secretary read a letter which had been received from Dr. Clouston, in
which he said he regretted his inability to be present at the meeting, as he would
have liked to take part in the discussion on Dr. Thomson’s paper on the teaching
of psychiatry, and to express his opinion in favour of the author’s general
proposals. Dr. Clouston said he thought the subject a very important one for the
future of their department, and suggested that the question be brought up at the
annual meeting in July. It might be well, he thought, for the Educational Com¬
mittee to discuss it in the first instance.

The President thanked Dr. Thomson for coming forward and reading his
paper. He joined with Dr. Mercier in saying how pleased he had been to
hear Dr. Thomson have the courage of his opinions and call a spade a spade.
Then, how or where were all the necessary trained men to be got whom Dr.
Thomson wished to have in asylums ? Surely the proper places in which to
train them were institutions where they could get the necessary and full
experience, not only clinical, but pathological and other. That being so, he was
curious to know how Dr. Thomson would staff the asylums with trained men
unless they went through the asylums and trained, as at present. It was possible—
and he thought it would come—that the heads ot asylums should possess certain
definite diplomas. Much as Irishmen were accustomed to complain at the way
they were treated, he thought that in this respect they went one better than we in
this country, as he understood that no medical officer could be appointed super¬
intendent of an Irish asylum unless he had been qualified a certain number of
years, and had had a definite amount of experience. That was all in the right
direction. If they would only provide for a diploma in this special branch, they would
go a long way to meet Dr. Thomson's idea, which was an excellent one. While
there might be differences of opinion on details he was sure there was but one
opinion as to the desirability of everyone, especially those at the head of insti¬
tutions for the insane, possessing the requisite qualifications as to training and
experience, so that they might help and encourage those working under them.
He would join with Dr. Mercier in saying that Dr. Orr seemed to depreciate his
own work. So long as Dr. Orr and his colleagues were able to continue the
splendid work upon which they were engaged he did not think there was reason
to fear comparison with the work which might be done by Germans, or Italians,
or Americans.

Dr. Mercier said he understood Dr. Thomson to propose a resolution, and he
would be glad to second it.

The President said it would be more convenient to take that afterwards.

Dr. Thomson, in replying on the discussion, said he was grateful to Dr. Savage
for giving the meeting the benefit of his wide knowledge and experience ; but he
went more into detail, in regard to which he, Dr. Thomson, admitted there were
difficulties; and that stage had not yet been reached. All that he asked was that
that meeting should come to some agreement—or disagreement—about the
principle. He really referred to the future mental hospital for acute cases, or
even the hospital block for acute cases in connection with the large asylum. He
said in his paper that it was only the acute cases which counted. Everyone knew

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1908.]

that the majority of cases in our asylums were incurable ; nothing more could be
done for them than at present. It was to the early acute cases that his views were
particularly meant to apply. He had been asked what were his views as to how
the executive medical officers would work and what his general scheme would
be. He again replied that that was a detail, which would have to be settled later
on. He was very much in the position of the Socialist. The Socialist could not
give any definite picture of what his ultimate Utopia would be like; it would
be evolved as he went on. It was the same in regard to the present subject.
As Dr. Orr said, the difficulties would vanish as the reform went on. He
thought Dr. Percy Smith had rather laboured the point about the medical
student. He had great sympathy with the unfortunate medical student; he had
a son at Cambridge now, burdened with every kind of “ ology,” and it was true
that he did not want any more on his already overloaded back. His views had
been directed entirely to post-graduate training. How was it that when he
advertised in the Lancet and British Medical Journal for an assistant medical
officer he got only two applicants, and they were not suitable for the vacant
post. It was that condition of things which he wanted to alter. That would,
as Dr. Bond truly said, be altered by his scheme, and as soon as a diploma
in Public Health was required there was a rush to the portals to secure it. He
agreed with the President that Dr. Orr depreciated his own pioneer work in
pathology. He could not go the length of agreeing with Dr. Mercier as to the
position of the British alienist compared with that of his colleague abroad. The
President had asked where the men were to come from, and had said that the
heads must be taught, so that they could encourage the young men. But a
beginning must be made at the other end, with the juniors, the newly-fledged
graduates. One could not begin at the top and train the superintendents. He
was much obliged for the way in which his paper had been listened to. He had
perhaps been somewhat brusque, and called a spade a spade, but it was not likely
to go forth that he had done any injustice to the great work of the men who had
preceded them. At the beginning of his paper he said that everlasting honour
was due to the men who had done so much for asylums and asylum work in the
last fifty years.

The President said, with reference to the proposal at the end of Dr.
Thomson’s paper, that Dr. Clouston in his letter seemed to make a helpful
suggestion, namely that at the Annual Meeting a motion should be brought up on
the subject. He feared that under the rules anything done that day would be of
such a small character that no real good could come of it. He suggested that
Dr. Thomson should give notice of his intention to bring forward a motion on
the subject at the Annual Meeting.

Dr. Mercier pointed out that Dr. Thomson’s motion referred the matter to
the Educational Committee now. By the present suggestion three months would
be lost.

Dr. Percy Smith asked that the motion might be read again.

Dr. Thomson said he moved that the Education Committee be instructed to
consider some scheme on the lines he had suggested, for post-graduate training in
mental diseases, so that the Association might approach the Universities and
teaching bodies on the subject. He did not bind himself to that, but was inclined
to agree with the President’s suggestion that he should give notice of a motion at
the Annual Meeting.

The President said the matter could be referred to the Educational Committee
as well.

This was agreed to.

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TOXIC LESIONS OF THE SPINAL CORD, LJuly>

Some Points in the Histology of Lymphogenous and
Hcematogenous Toxic Lesions of the Spinal Cord.i})
By David Orr, M.D., and R. G. Rows, M.D.

At a quarterly meeting of this Association held last year at
Nottingham, we showed the results of our experiments with
toxins upon the spinal cord and brain of rabbits. Our main
conclusion was, that the central nervous system could be
infected by toxins passing up along the lymph channels of the
perineural sheath. The method we employed in our experi¬
ments consisted in placing a celloidin capsule filled with a broth
culture of an organism under the sciatic nerve or under the
skin of the cheek ; and we invariably found a resulting degene¬
ration in the spinal cord or brain, according to the situation of
the capsule. These lesions we found to be identical in morpho¬
logical type and anatomical distribution with those found in
the cord of early tabes dorsalis and in the brain and cord of
general paralysis of the insane. The conclusion suggested by
our work was that these two diseases, if toxic, were most
probably infections of lymphogenous origin.

That the lymph stream in nerves is an ascending one and
capable of conveying infection has been demonstrated by a
variety of experiments, principally by observing the course of
organisms and coloured fluids after their injection into the
nerve substance. In addition we have found after smearing
Indian ink paste upon the surface of the sciatic nerve that the
granules percolate into the perineural lymph spaces and are
carried upwards towards the cord in the lymph current.

But it is obvious that the brain and cord may become in¬
fected in another way, viz., by the circulation of toxins in the
general blood stream. To the lesions so produced our attention
has been directed for the past year ; and although the research
in this direction is still far from complete, we think we are now
in a position to put forward one point especially, viz., the
difference in anatomical distribution which exists between
lymphogenous and haematogenous infections of the posterior
columns.

This difference seems to be so clearly defined as to suggest
that system lesions, such as tabes dorsalis and those occurring

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JOURNAL OF MENTAL SCIENCE, JULY, 1908.

Fig. I.—From a case of G.P.I. Dorsal cord ; Wolter’s method.

1. Sclerosis of root entry zone. 2. Fibres around median septum normal.

Fig. II.—From a case of Addison’s disease. Cervical cord; Wolter’s method.
1. Root entry zones normal. 2. Sclerosis around the median septum.

To Illustrate the Paper by Drs. Orr and Rows.

Adlard & Son, Imfr.

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1908 .] BY DRS. DAVID ORR AND R. G. ROWS.

561

in the cord and cranial nerves of general paralysis of the insane,
fall into the lymphogenous group, while those found in acute
insanity, leukaemia, pernicious anaemia, Addison’s disease,
metallic poisonings, and other forms of general intoxication
fall into the haematogenous group.

Clinical cases and experimental evidence show that in the case
of lymphogenous infection (Fig. I) it is the intra-medullary portion
of the infected nerves which suffers first, so that the degeneration
is confined to their entry zones for the most part. Thus, for
example, in the posterior columns of the cord the degeneration
shows first in the postero-external fasciculus, while the fibres
around the median septum remain normal. The more toxic
the lymph passing into the cord is, the greater tendency there
is to diffusion of the lesions; with diffusion, changes are
observed round the cord margin and along the septa. The
morbid process spreads from below upwards. Marchi’s osmic
acid method gives a positive reaction.

Hcematogenous lesions (Fig. II), the result of a general intoxica¬
tion, contrast markedly with the above. For example, in the cords
taken from visceral cancer the degeneration is very diffused ;
in the posterior columns it affects the fibres around the median
septum first and spares the external fasciculus. It implicates
the basis bundles, partly the crossed pyramidal tracts and the
fibres in the grey matter, and to a slight extent the cord
margin. The lesion is more marked in the cervical and upper
dorsal cord ; the lumbo-sacral region may be practically healthy,
although it may be implicated by downward extension of the
morbid change. The type of degeneration differs from that in
lymphogenous lesions. Frequently the Marchi method is
negative. The morbid change usually consists in slow atrophy
of the myelin, but with increased blood toxicity the myelin
sheath becomes greatly swollen, thinned, and varicose, and the
whole cord cedematous.

(*) Contributed at the Quarterly Meeting in London, May 19th, 1908,

LIV.

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[July,

Clinical Notes and Cases.

General Paralysis in Father , Mother and Son ('). By
Colin F. F. McDowall, M.B., M.R.C.S., Assistant
Medical Officer, Newcastle City Asylum.

When as a boy at a Grammar School in 1892 I knew
slightly another pupil, J. D. E—, and it was an open secret among
us that his mother was a patient in the County Asylum in the
immediate neighbourhood. In 1893 1 lost sight of him as I
changed my school, and so it came about that I did not see
him again until he was admitted to Morpeth as a patient. I
had long known the mother by sight as a patient in the
asylum, but I learned more concerning her mental condition
during the time I acted as clinical assistant.

So far as I can ascertain no record is in existence where
a father, mother and son died of general paralysis. These
cases, therefore, appear to be worthy of publication as a
remarkable family history, and as an addition to our knowledge
of a disease which constantly increases in importance. The
clinical records of the mother and son are particularly inter¬
esting, and raise points of great clinical importance, but any
remarks that seem necessary I shall defer until I have given
the histories of the three patients :

The facts I am able to give about the father are few, but not with¬
out importance. When he was admitted to a private asylum in 1878
he was stated to be forty-three years of age, married, and suffering
from general paralysis. He was described as tall and well made, cheeks
hollow from recent illness, feeble in body : he walked irregularly, arti¬
culation was much affected, sometimes unintelligible. A note made a
few days after admission says: “There is nothing special in this case,
except that the speech and memory are much more affected than the
spinal symptoms. The duration is said to be about ten months, and
the cause “ too free living.” His memory is bad, and he does not
know where he is ; thinks this an hotel. Has various fancies. Is just
recovering from severe excitement, which has pulled him down, and
which recurs occasionally. Sleeps badly, and not without a draught of
chloral.”

He improved in bodily condition for about two months, though men¬
tally he was more childish. He suddenly became affected with hemi-

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plegia of the left side, and was speechless. He continued unconscious
for three days, and then died.

The cause of death was certified to be general paralysis.

The history of the mother as to her mental condition extends over
twenty-two years. The original notes are very voluminous, but I shall
omit all that are not essential to a true understanding of the case.

It is believed that the patient had her first attack of insanity in the
year 1880, when she was thirty-two years of age, that is about two
years after the death of her husband, but she was not sent to an
asylum for care and treatment.

In November, 1886, she was admitted to the Holloway Sana¬
torium suffering from her second attack. She was described as a
gentlewoman, which she really never was, as not suicidal, but
occasionally dangerous.

The certificates on which she was admitted give a very good descrip¬
tion of her condition.

The first says: “ She tells me that she is much annoyed by her
children and neighbours using offensive language to her and making
noises, which she thinks are intended to vex her. She said that
she was once so much annoyed that she violently beat the piano
and broke one of the keys. She admits that this seems strange,
but will not be reasoned out of it, though she cannot account for
people doing these things.

" Her eldest child (a daughter) tells me that she has beaten her
without provocation, on one occasion kicked her out of bed and made
her get a tumbler of water, which she then threw at the child and cut
her lip.”

The second certificate is as follows: “ She tells me she hears
voices constantly impelling her to perform acts of violence, but is
unable to say whether the voices are male or female. She says that
she is unable to resist the impulses. She says that an impulse led
her to thrash her son on last Saturday night when he was lying
asleep. She complains that she has no memory; that some months
ago she felt an impulse to stab her lodger.

“ Her daughter tells me that her mother two or three months ago
broke her umbrella over a strange lady’s back in Finsbury Park;
that she thrashed her little boy at night two weeks ago. I examined
the child at the time and found him bruised.”

Description and condition on admission: A tall, moderately good-
looking lady, dark brown hair, pale clear complexion; rather large
chin; figure slight and rather graceful; conversationally she is fairly
agreeable and rational on most points; says unreservedly that she
hears voices talking to her, at night especially. She says that latterly
these voices have troubled her a good deal, and have urged her to
do things she would not wish otherwise to do. She is very exact¬
ing in the amount of attention that should be shown her by nurses
and others; would like to be waited on in every particular, and if she
does not receive everything she expects in this way she becomes ex¬
tremely irritable and positively rude at times. She seems to have a
very big idea of her own importance. Sometimes she talks aloud to
herself and laughs without any apparent reason.

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November 7th.—She is still the same; seems to have settled down
fairly comfortably; says that she is still troubled by hearing voices
talking to her.

November 30th.—Is somewhat better; seems very fairly satisfied
with her surroundings and willing to be guided by the advice of others.

General health fair.

March 10th.—She still complains of hearing voices at night, which
disturb her, otherwise she seems quite rational, with the exception of
an occasional outburst of bad temper, when she is very rude to every¬
body indiscriminately.

In May it is noted that no change has occurred; on May 12th a
similar note occurs ; on May 18th she was discharged on leave, and on
December 30th, 1887, she was written off as recovered.

On December 30th, 1892, she was admitted into the Northumber¬
land County Asylum, Morpeth, suffering from mental symptoms closely
resembling those she exhibited in her former illness. The exact dura¬
tion of the attack was not known, but it was put down as about two or
three years. The medical certificate stated that she used violent
language, and had delusions as to people coming into her house and
interfering with her water taps and dirtying her house. As a result of
these delusions she abused her neighbours, threatened violence, broke
the windows, and threw the kettle through the sash.

Her grandfather on the mother’s side was insane. Her sister is a
certified lunatic at the present time, and her brother committed suicide.

On January 3rd, 1893, she was certified as labouring under delusional
insanity. She stated that the neighbours tormented her by knocking on
the wall night and day; that a power beyond her control made her
throw things about; it also affected her back and the lower part of her
body. She was in excellent bodily health.

A week later it is noted that she has been transferred to another ward,
where she had settled down very well and was working industriously at
her sewing, but associating very little with the patients and nurses,
though ready at any time to answer questions put to her by the medical
officers. A week later it is stated that she had several attacks of tran¬
sient violent excitement and bad temper. Thus many months passed:
she was reserved, suspicious, occasionally sleepless, generally industrious,
but occasionally excited. She frequently concealed her delusions, and
so led the nurses to believe that she was forgetting them, but they were
there as before, and were the cause of frequent rows with her neigh¬
bours. On November 22nd, 1893, it is noted: “She remains in the
same condition ; is dangerous and impulsive, throws furniture about.
She killed a cat by dashing it on the floor with great force; she said it
was annoying her. When the morning visits are made she sits quietly
in her chair and smiles benignly, only to break out into violence when
the medical officers have left.”

Six months afterwards it is recorded: “ Not altered, for days she may
be quiet and well disposed, but there is always a storm in the end, when
she will be very vicious and strike innocent patients and nurses.”

On December 1st, 1896, the continuation certificate was as follows:
“ She labours under delusional insanity. She states that in her sleep men
molest her sexually, that the women in the ward are more like men and

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CLINICAL NOTES AND CASES.

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56s

affect her in the same way; although they do not come into her single
room, they affect her with their breath.”

Again in April, 1897, it is noted that she has perverted sexual ideas
and delusions, and so she continued until January, 1899, when the
following note occurs : “ She has exalted notions regarding her position
in life, and objects to having anything to do with or sitting near the
other patients, and is easily excited by them. She has a very deficient
memory for time and recent events. Fine tremors are noticed at the
angles of the mouth during speech, and her articulation has gradually
become very indistinct. Her pupils are unequal and irregular. Her
general health appears to be good. Weight is 152 lb., her usual
weight.”

This note contains the first hint that the patient suffered from
general paralysis. During the next eighteen months the disease made
no progress, for the continuation certificate, dated December 8th, 1899,
says : “ She is labouring under delusional insanity. She states that the
people about her read her thoughts and give her chills. She is very
suspicious and hypochondriacal. Bodily condition good. Heart and
lungs normal. Some signs of general paralysis are present.”

Except that she became gradually very moderately demented no marked
change occurred in her mental and bodily condition until January, 1901,
when it was noted : “ It has been noticed for a while that patient has
been quieter and less inclined to talk. Her appetite was also poorer.
About three days ago she became very restless and insisted that she felt
that she could not remain in Ward 6. She was accordingly transferred
to Ward 2. For several mornings she has refused breakfast, and is
taking her other meals very badly. This morning she was so noisy and
excited that it was necessary to put her to bed in a single room. She
will keep no clothes on her whatever, says that everything is ‘ rotten,*
that she is rotten ; wishes all her hair cut off and her teeth pulled out.

“ She got a dose of sulphonal, had a good night, and was able to be out
of bed next day much improved.”

January 14th, 1901.—Yesterday she seemed better on the whole and
she slept well last night, but this morning about seven o*clock she
fainted. She refused her breakfast and said that she felt ill. She was
given a little whisky and put to bed. When seen at morning visit her
pulse was fairly good but rapid. She refused to allow any thorough
examination, and the muscular tremor was so great that nothing definite
could be discovered in her chest. She speaks with extreme difficulty ;
says that she is “ breathless and cannot swallow.** She is very pale and
the muscles of face extremely tremulous. She was persuaded to
swallow a little warm milk but otherwise refused all food. Pupils very
contracted.

February 4th, 1901.—Patient is sleeping very badly again; is excited
and noisy at night. Still gives much trouble about keeping on her
clothes, and the whole day she spends in spitting a copious supply of
saliva on the floor. She has been ordered a draught of sulphonal gr.
xxx every night.

March 4th, 1901.—Since February 14th she has had a sleeping
draught every night, yet she is frequently restless and noisy all night.
During the day she does not voluntarily converse, but spends the time

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CLINICAL NOTES AND CASES.

[July,

in sitting in a chair assuming peculiar attitudes and expectorating in¬
cessantly. She is absolutely idle and has been making very peculiar
faces, as she says, because of the nasty smells. Appetite somewhat
improved, but she has lost fourteen pounds in weight during the past
three months. This is easily accounted for by the continued excite¬
ment and by the administration of sleeping draughts.

April 8th, 1901.—Patient is not now so restless at night and as a rule
sleeps fairly well under the influence of whisky and hot water, the sul-
phonal having been discontinued. During the day she sits quietly in
her chair, paying very little attention to her surroundings. She appears
to be trying to pull out her front teeth with her fingers. When not so
employed she grinds her teeth so firmly that the noise can be heard
over the whole ward, she also picks her nails until they bleed. Her
general health is less satisfactory and she looks ill, though she now
takes her food readily.

May 6th, 1901.—She is steadily going down in weight; is dirty in
her habits night and day, and frequently sleepless and noisy.

July 15th, 1901.—Her speech has been for some time typical of
advanced general paralysis. She sits in her chair in the conservatory
sleeping and grinding her teeth. All her front teeth are now loose as
the result of her constant pulling at them, and one had to be removed
on account of its inconvenient looseness. Although so demented as
practically to know nothing she still thinks that people have a spite at
her. She is now quiet and well behaved, and even tries to do a little
sewing. Eats and sleeps well. Weight 131 lb.

She improved physically and increased much in weight (up to 160
lb.) until March, 1902, when she again began to fail in bodily
health.

March 21st, 1902.—Patient seems very feeble and has been sent back
to bed in the infirmary. She is very pale and her pulse exceedingly
feeble. She seems to be unable to speak. She has a curious and
inexplicable protrusion of the lower jaw, as if it were dislocated forward;
but it is not dislocated as the jaw can be easily pushed into position,
and the deformity appears to be due to muscular action. She is taking
little nourishment and is exceedingly restless at night. She is spoon-fed
and is on four ounces of whisky daily.

March 22nd, 1902.—At morning visit patient seemed much the same
as yesterday, but was a little quieter and possibly slightly more feeble.
Her pulse was almost imperceptible. She had slept fairly well Was
dirty in habits.

About 1 p.m. the nurse noticed her to be breathing heavily and sent
for the assistant medical officer. Patient was cyanosed, pulse impercep¬
tible, and she was evidently sinking fast. She was unable to swallow.
She died at 5.50 p.m.

The preceding notes do not contain any reference to a few matters
which may be mentioned. The patient had retention of urine on a
few occasions, perhaps three or four, during the last weeks of her
life. Whilst in the infirmary before she finally went to bed she had
attacks of excitement once or twice a day, during which she shouted,
laughed, threw her arms about, and sang. She extemporised both
the words and the music; the words were about her children.

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567

During these attacks she seemed to be distinctly happy. Though
becoming very demented in the infirmary she still had the delusions
about men coming into her bed. She shouted and got out of bed as
quickly as she could, saying she could not lie in bed for men attempt¬
ing to interfere with her. These attacks were very frequent, occur¬
ring several times a day. She also had attacks of excitement of a
different character. Whilst in bed she drew up her legs tightly
and clasped her kness in her arms and revolved on her buttocks,
shouting all the time as if she were afraid, but what she said was
unintelligible. If approached at such times by the nurses she bit and
scratched them.

I will now give a condensed history of the son, J. D. E—. When
admitted to a private asylum on April 20th, 1900, he was twenty-three
years of age.

The first certificate states: “Patient imagines his late employer to be
Jack-the-ripper and the next-door neighbour to be his secretary ; says
they constantly persecute him with intent to murder him, but that he is
protected by two talismans which he calls a moonstone and a knuckle¬
duster, and which are able to counteract the machinations of these two
persons. He constantly sees these persons in places where they cannot
possibly be, and often imagines that they are following him in disguise.
His brother informs me that patient says he received a message from
God last night forbidding him to sleep, and he spent a long time on the
door-mat of his bedroom watching for Mr. — (late employer) and
Mr. — (neighbour), whom he said he heard in the house. When in
London a short time ago he applied to Scotland Yard for protection
against these two persons, who were following him as he thought.”

The other medical certificate records some interesting delusions of
the same kind as those already given. It states : “ He says that he is
persecuted by a band headed by Jack-the-ripper, who is the same as
his former employer and at the same time is the Devil. They act upon
his ‘ power of will * which he has had to fight against; they connected
an electric battery to his bed one night and gave him a shock. He
jumped up quickly and heard them laughing. They are all devils and
track him from place to place. The patient’s brother informs me that
at a performance at the Hippodrome he said that the performers were
royalties and the lion tamer was the German Emperor.”

He was certified as labouring under delusional insanity by the asylum
medical officer. He was described as a tall, intelligent-looking young
man with an abstracted expression. Bodily health good. His attack
of insanity was stated to be of six weeks’ duration, and due to influenza.
The notes further describe him as variable and strange in his ways,
incoherent, deluded with strange religious views. Occasionally he was
rather violent, but as a rule absent-minded.

On account of his limited means he was transferred to the Cumber¬
land and Westmorland Asylum on September 18th, 1900. From the
copious notes made as to his condition there comparatively few extracts
are necessary. Physically he was a healthy young fellow. His patellar
and plantar reflexes were normal, and his pupils equal, dilated and
reacted normally. During the two and a half years he remained at
Garlands he had numerous attacks of excitement and violence. He

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CLINICAL NOTES AND CASES.

Duly,

was tried with depressants and hypnotics but with no very great success.
During one of his wild attacks he fractured his right fibula. Even
when so disabled he attempted several serious assaults, and at that and
other times he evidently had homicidal tendencies. At night he
became dirty in his habits, and occasionally so troublesome that he
had to be removed from the dormitory and placed in a single (strong)
room.

In April, 1901, he is described as much quieter and more easily
managed.

In March, 1902, he was dull and stupid. He seldom spoke, and, as
usual, was quite idle.

Then he had a succession of attacks of excitement and violence,
requiring sedative treatment.

In November, 1902, he was transferred to the Northumberland
County Asylum. During the last three months of his residence at
Garlands he was in his quiet mood. He gave no trouble, seldom
spoke, and was boorish in manner.

When he arrived at Morpeth he was in excellent bodily condition.
It was noted that his reflexes were all normal.

The following notes conclude the record of his life :

November 6th, 1902.—It is with great difficulty that one can get
him to answer questions. He states that he came here to oblige a man
called Dixon. He does not know day or month. He won’t look at
me when I speak to him but turns his back, at the same time putting
his hands to his head and keeping his eyes closed.

November 10th, 1902.—Medical report. He labours under

delusional insanity, probably with general paralysis. He laughs immoder¬
ately and without apparent reason. He is as a rule obstinately silent but
occasionally makes incoherent answers; says his father was legislative
linguist and Russian Consul. He blew out a taper and then said that
no other man could do that. His bodily health is good, but he
probably suffers from general paralysis.

November 17th, 1902.—There is no change in this patient. He
likes to attract attention by standing in front of one of the airing
courts, or stuffing his pipe full of paper. He is incoherent in speech
and laughs vacantly. Eats and sleeps well. Does no work.

November 24th, 1902.—There is no change to note in this youth.
He smiles fatuously when looked at; is generally silent.

December 8th, 1902.—This young fellow was found dead in bed
this morning in an ordinary dormitory. He was lying in a natural
position on his back, as if sleeping, with the bed clothes just above his
eyes. The body was quite warm but the feet and hands were beginning
to cool. The face wore a placid expression. There was a quantity of
froth oozing from the mouth, and the tongue was held tightly between
the teeth. Post-mortem rigidity was well-marked, and post-mortem
lividity was beginning to show in back and buttocks. There was no
evacuation of faeces. Corresponding to the neck band of his shirt there
was a distinct constriction of the neck right round, and along this line
the cuticle has been ruffled at numerous minute spots. The line of con¬
striction was most marked in front; it was not appreciably depressed;
was about half an inch in breadth in front and disappeared to nothing

“X

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CLINICAL NOTES AND CASES.

S69

at back of neck. The neck and face were of a distinctly dusky hue, and
were also swollen. An examination of the mouth was impossible owing
to the firm closure of the jaws. The appearances of the body and the
circumstances under which death occurred seemed to indicate that
death was due to accidental strangulation occurring during a congestive
attack.

The details of the post-mortem examination need not be given in
detail. It may be stated generally that the organs in the thorax and
abdomen were quite healthy. The condition of the lungs, cardiac
cavities, and blood indicated clearly the mode of death.

Head : Scalp very thick; skull rather thin, somewhat engorged.

Dura mater thickened, adherent to skull in several areas and to brain
in both parietal regions.

Sinuses contain fluid blood.

Pia-arachnoid slightly thickened, and in a few places in parietal
regions milky.

Brain weighs sixty-five ounces. Convolutions slightly flattened.
Substance apparently normal. No excess of fluid in lateral ventricles,
and no granularity of lining membrane. No atheroma of vessels at
base and no local lesions in basal ganglia. The fourth ventricle is
markedly granular.

Such are the records of the three cases. Naturally, as they have been
compiled from the case-books of four asylums, the histories are wanting
in some details which would have added materially to their value,
but even as they stand they are of much interest. There is one point in
the history of the mother about which an additional remark may be
made. It is stated that when admitted to Holloway Sanatorium and to
Morpeth Asylum her pupils were normal. That may be so, but it is
nevertheless a fact that for several years before her death she had pin¬
point pupils. This sign naturally gave rise to some discussion, and at
various times the possibility of the patient being really a general paralytic
or a possible case of tabes was mentioned.

The history of the son requires to be added to in one place only:
When admitted to Morpeth the report on his condition stated that he
probably suffered from general paralysis, but the reasons for that opinion
were not given. At that time the patient's speech was strongly indicative
of that disease, and it was also observed that the muscles of the nose
and the angles of the mouth presented well-marked fibrillary con¬
tractions.

It is not intended to discuss the whole subject of general
paralysis in connection with these three cases, but a few brief
remarks may be made on one or two points, leaving others for
discussion by the members present.

Although general paralysis is such a common disease,
examples of husband and wife are not common, and compara¬
tively few have been recorded. It may be stated with confi¬
dence that medical literature does not contain a record similar
to what has now been read, where father, mother and son died

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CLINICAL NOTES AND CASES.

Duly,

from the disease. About the diagnosis in these three persons
there can be, I think, no doubt ; that the father and mother
were typical and undoubted cases no one of experience would
question. Perhaps about the son some might be inclined to
doubt, but it appears to me practically certain that he had the
misfortune to die during his first congestive attack, and thus
deprived us of the opportunity of further and minute obser¬
vation of what must be regarded as a singularly unusual and
interesting condition. No doubt some of the classical signs
were wanting, but there were enough found during life and
after death to make the diagnosis certain to my mind.

To have read a clinical account such as this upon general
paralysis and to have omitted the word syphilis, must appear
strange. We have no absolute proof unfortunately of specific
infection in the case of father or mother.

The reason is that minute information could not be obtained
which at the same time should be absolutely reliable regarding
a person so long dead. The father was a loose liver—that is
known. We cannot with certainty include syphilis, but at the
same time it cannot be excluded.

The boy did not present any absolutely typical signs of
congenital syphilis ; he had, however, a large head, with
prominent parietal eminences, and he had irregular teeth.
Many cases of juvenile general paralysis show no signs of
syphilis on their body, though they are proved to be the
offspring of syphilitic parents. The boy himself had never
acquired syphilis. My own belief is that the boy was a
juvenile general paralytic, the offspring of two people the
subjects of general paralysis, who had in their earlier days
acquired a specific infection.

(') A paper read at the Spring Meeting of the Northern and Midland Division at
Storthes Hall, April 30th, 1908.

A Case of Cretinism . ( ] ) By Guy R. East, Assistant
Medical Officer, Northumberland County Asylum.

S. B—, of no occupation, was born in co. Durham forty years ago
and came under observation at the Northumberland County Asylum in
March, 1908.

His certificate reads:

He states that his age is 45. He cannot read or tell the time, or

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CLINICAL NOTES AND CASES.

571

count beyond twelve, though he was taught. His whole conduct is not
that of an adult, nor is it developed as that of a young child. His speech
and appearance are those of a cretin.

His intellectual powers are undeveloped in proportion to his age. He
is childish and is incapable of answering the simplest question in spell¬
ing and arithmetic. He is mischievous and subject to fits of temper,
and is quite incapable of managing his own affairs.

The family history is negative. None of the patient’s relatives suffered
from goitre. The parents were in no way related to each other previous
to marriage : the father died of “ some internal complaint ” at the age
of 57, the mother died of senile decay aged 78. Seven children were
bom, of which four died in infancy, but inquiries elicit the fact that none
of these presented signs of cretinism.

Regarding his personal history, the goitre appeared during his first
year, and since then has gradually increased in size. At the age of two
he was seized with convulsions, and from that date onwards did not
develop mentally, though endeavours were made to teach him. All
his life he has required attention like a child, and has been incapable
of learning a trade or useful occupation. During childhood he was
never treated with thyroid extract.

His condition on admission was as follows :

He stands 4 ft. 9 in. and weighs 8 st. 2 lb. The relatively normal
size of the head contrasts with the dwarfish body. He has a degraded
type of face—a receding forehead, eyebrows absent, eyes set rather
widely apart, bridge of nose depressed with thickened alae nasi, a
prominent chin, a wide mouth with broad, thick lips, hair thin and
brittle. The limbs and body are short and stunted, whilst there is some
enlargement of epiphyses of knees and elbows. The long bones
are generally shortened with the exception of the clavicle. There is
heaviness in the limbs and movements are sluggish and clumsy. The
hands are stunted and undeveloped. The thyroid gland is hyper¬
trophied, the enlargement being chiefly confined to the right lobe, and is
about the size of a man’s fist; there is also some slight swelling of left
lobe. The tumour is somewhat elastic to touch, is freely movable,
quite painless, rises and falls with deglutition and in no way hampers
respiration. The increased vascular supply to the gland is conspicuous
on account of the dilated thyroid veins. There is a well-marked bruit
on auscultation. The recurrent laryngeal nerve is evidently implicated,
resulting in alteration of voice, which is harsh and croaking.

The temperature is subnormal, 96*4° F.

The tongue is hypertrophied and indented, teeth mostly carious,
palate high-arched. He has a good appetite, but the bowels are
obstinately constipated and require the frequent administration of
aperients.

The heart-sounds are faint, but a tricuspid regurgitant murmur is
audible at the lower end of sternum.

The pulse is weak but regular, the rate being 48 per minute. Exami¬
nation of the blood reveals a reduction in the quantity of haemoglobin,
this diminution being about 30 per cent., otherwise the blood exhibits
little or no change. The liability to catching cold is one of the
characteristics of cretinism, and this man is no exception, as he is acutely

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572 CLINICAL NOTES AND CASES. [July,

sensitive to any change in temperature and at present has an obstinate
cough.

It may be mentioned in passing that these patients usually succumb to
pulmonary complications.

The total quantity of urine passed during twenty-four hours averages
sixty-five ounces; specific gravity, 1025, acid in reaction contains no
sugar or albumen, but there is an increase in the amount of urea excreted.
This increase may be in part accounted for by the fact that lack of
perspiration is a constant feature in cretinism, and in this way the ex¬
cretion of urea is augmented.

The skin generally is dry, harsh, and thickened; It has a waxy, lemon
tinge. The sweat and sebaceous secretions are absent. The nails are
fragile and striated.

One of the most striking points in the nervous system has already
been mentioned, namely, the abnormal sensitiveness to cold, the patient
having to be supplied with extra under-clothing to promote warmth and
comfort. The muscular nutrition is unimpaired whilst the motor
functions, beyond clumsiness in movement, call for no further comment.
Both the superficial and deep reflexes are diminished. The pupils react
normally to light and accommodation.

The intellectual state is marked by apathetic enfeeblement, and cere¬
bral torpor reveals itself in sluggish mentation, defective memory, slow
speech, and lethargic movements. He is quite indifferent to his sur¬
roundings, never speaks to his fellow patients, nor attempts to work or
amuse himself. The simplest questions are beyond his intelligence;
he has no idea of time or place. He is childishly pleased with the
slightest attention given to him. Is slovenly and untidy in dress, but
has been educated to cleanly habits. He is indolent, both mentally and
physically, having no muscular energy, and is promptly fatigued with
the least continuous effort. He sleeps rather heavily and is with
difficulty roused.

The patient has been under treatment with thyroid extract, this being
administered in tabloid form. Starting with a dose of six grains daily
this has been gradually increased until at the present time he is taking
twenty grains per diem .

There has been a loss in body-weight amounting to 5 lb. The tem¬
perature has risen from 96*4 to 98*4° F. There is an increase in the pulse-
rate, which on admission was 48 and is at present 80. The percentage
of haemoglobin present in the blood has increased 5 per cent., whilst the
amount of urea excreted has been slightly augmented. The skin
remains inactive and the patient still complains of feeling cold. He has
an excellent appetite, and the action of the bowels is regular.

As yet there is no alteration in his mental state, this condition being
in all probability beyond improvement. Although not reported as
epileptic, a few days ago patient had a typical seizure. This was
evidently not his first attack, as just previous to it he informed an atten¬
dant that “ he was going to have a fit.”

During the whole time patient has been undergoing thyroid treatment
he has been kept continuously in bed.

Regarding the manner in which defective thyroidation affects the
trophic apparatus and induces mucoid deposits, two general points of

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CLINICAL NOTES AND CASES.

573

view depending on opposite physiological hypotheses are maintained.
Many believe that the normal thyroid elaborates some substance indis¬
pensable to the proper action of the nervous system. Others maintain
that the thyroid eliminates certain harmful elements in the blood, and
in confirmation of this statement attention must be directed to two main
points.

As previously stated, since the administration of thyroid extract to
this patient, there has been a slight increase in the percentage of haemo¬
globin present in the blood together with an increase in the output of
urea excreted. This fact seems to prove the theory that the thyroid
gland normally excretes a substance which, while aiding the oxygen¬
carrying power of the haemoglobin, at the same time assists in the
removal of toxic agents from the blood.

The conditions of origin of sporadic cretinism are obscure.
Some authorities attribute it to parental consanguinity, others
to alcoholism and syphilitic disease, but in the case under
notice there is a point of importance. It has been observed
that when a woman has frequent pregnancies this is often
followed by an interval of sterility of some years’ duration, and
as she approaches the menopause fertility is again established.
A child born at this time is usually smaller and not so well
developed as the other members of the family. I am
acquainted with two families in which the youngest child in
both exhibits well-marked achondroplasia, the parental stock
being healthy. I have a similar history in this case ; the
patient, a seventh child, was born when his mother was forty-
three years of age, ten years having elapsed since her last preg¬
nancy.

It is said that the offspring of two goitrous parents is
invariably a cretin who may or may not be goitrous. In the
goitrous cretins the thyroid disease may appear at any period
of life, and acts, then, exactly as does spontaneous myxcedema
or operative myxoedema, to stunt growth and stop mental
development. The distribution of endemic cretinism is
identical with that of endemic goitrous disease, and is probably
due to some obscure telluric cause. A distinction between
endemic cretins and other myxoedemic patients is the goitrous
enlargement. This may be only a difference of degree,
because the cystic degeneration and interstitial hypertrophy of
a goitrous enlargement of the thyroid is destructive in character
and effect, and in consequence myxcedema and mental
disturbances will be developed proportionately to the
functional inactivity of the thyroid. When the thyroid is entirely

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574 CLINICAL NOTES AND CASES. [July,

wanting as in non-goitrous congenital cretins, or destroyed as
in the present case, the myxcedema is correspondingly intense
and the mental degeneration proportionately developed.
Sporadic or congenital cretinism appears to be of two distinct
kinds. The first in which a child at birth is found to present
the most marked cretinous changes, being also invariably bom
dead ; the second, in which the child is bom apparently quite
normal, but at a variable period, from a few weeks to a few
years after birth, begins to show symptoms of commencing
cretinism which soon reach a maximum. The skull is full
behind, contracted and narrow in front; often the fontanelles
remain unclosed. The features are flabby and thickened, nose
snubbed, lips thick, eyelids swollen and drooping, mouth open
and the tongue hypertrophied. Dentition is delayed and the
teeth decay early, the neck is short and lipomatous, the
abdomen swollen, the limbs dwarfed and crooked, the skin
infiltrated and inactive. The thyroid is atrophied or absent;
the mental condition is usually one of idiocy. It is in this
type of case that thyroid treatment is most beneficial.

Though cretins are comparatively rare in asylum populations,
in certain mountainous regions throughout the world the
disease is endemic. While on this point it may be advanta¬
geously remembered that the cause is distinctly hereditary in
these districts where it largely prevails, and the birth of
cretinous children can be avoided by emigration from affected
districts. It is perfectly conceivable that insanitary or
climatic conditions, which appear to determine the incidence of
goitre or cretinism in these cases, do actually bring about one
or more of these affections in certain instances. Professor
Lebour, who has conducted the strictest inquiry into the
geological distribution of this disorder, states that the greatest
proportion of cretins are to be found in carboniferous limestone
districts. The rarity of cretinism in asylums is in no small
measure to be accounted for by the fact that the majority die
in infancy or childhood, few—if Untreated—reaching manhood.

(’) A paper read at Spring Meeting of the Northern and Midland Division at
Starthes Hall, April 30th, 1908.

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RECENT MEDICO-LEGAL CASES.

575

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.]

Re William Henry King : An Inquisition in Lunacy.

This inquiry, which lasted five days, and for the report
of which I am indebted to Dr. Percy Smith, exhibits several
features of interest.

The subject of the inquiry, a wealthy gentleman, some 63
years of age, had been epileptic from the age of six. His
weakness of mind was recognised by his father, by whom a
settlement of the property of the respondent was procured to
be made. In 1881 the respondent married, and during the
whole of his married life his income, amounting to between
.£3,000 to £4,000 a year, was administered by his wife, he being
allowed for his own use only £1 per week. During his
married life he never drew a cheque or even wrote a letter. In
June, 1907, the wife died, and the wife of the respondent’s
brother, the only relative then available, made arrangements
that the defendant should be cared for by two attendants, to
one of whom the respondent took a dislike, complaining of ill-
treatment by him, but there was no evidence to justify this
complaint. The complaint was made, however, and seems to
have reached the ears of some neighbours—members, in com¬
mon with the respondent, of the Society of Friends, who
considered it their duty to interfere and to protect the respon¬
dent from a danger which was wholly imaginary, and existed in
their minds alone, of being sent to an asylum. Without any
communication with the relatives or with the trustees of the
respondent, these two well-meaning but misguided gentlemen,
Messrs. Harold Jackson and Mason, visited the defendant,
accompanied by a solicitor named Tilly of their own choosing,
and by Dr. Roberts, the ordinary medical attendant of the
respondent, and Dr. Harrison. The medical men made a
certificate that the respondent was capable of managing his

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576 RECENT MEDICO-LEGAL CASES. Duly,

own affairs and that he fully understood the document which
he had that day signed. The document was in effect a power
appointing Messrs. Jackson and Tilly as his attorneys, and
authorising them in the first instance to turn the two atten¬
dants out of the house, and, beyond this, to manage his affairs
generally and conduct litigation on his behalf. Under this
power of attorney, the gentleman, Mr. Davies, who had for
many years managed the respondent’s affairs and who, with
three others, had signed all his cheques, was served with notice
that henceforward respondent would sign all cheques himself,
and demands were made on Mr. Davies to give up all keys,
accounts, shares, and vouchers, and a policeman was stationed
outside the house to see that respondent was not “ molested.”
The half-brother of the respondent meantime returned from
America and went to see respondent, but access was denied
him. Many acts of insanity—some of them of dangerous
violence on the part of the respondent—were proved by
different witnesses. Among other things it was proved that he
consulted his wife on her deathbed as to the choice of her
successor, and had spoken about marrying one or other of his
servants.

Dr. Percy Smith had examined the respondent, who did not
understand the nature or object of the inquisition, but thought
it had reference to the way his brother had treated him.
When asked if he had signed the power of attorney, the
respondent replied, “ I have no question to put.” He was
unable to do sums in multiplication and addition that were
set to him. Summarising, Dr. Percy Smith considered the
respondent weak-minded, and suffering from loss of memory
of important events, from unreasoning hostility to his friends,
from inability to grasp business matters, from delusions, and
that he had a childish reliance on his attendant. He was not
capable of managing himself or his affairs.

Dr. Bedford Pierce had found the respondent had a fair
knowledge of how his money was obtained, and made some
shrewd comments with respect to his investments. Respondent
made, however, a number of misstatements, contradicted
himself, and denied that he had signed the power of attorney.
Witness, as a result of his interview, considered respondent
decidedly enfeebled in mind, but not sufficiently so to be
incapable of managing himself or his affairs. But having

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1908.]

RECENT MEDICO-LEGAL CASES.

577

heard the evidence in court, he admitted that he had modified
this conclusion, and now considered him not able to manage
his own affairs.

The case for the defence was then taken, and as is
customary, plenty of witnesses were produced to testify that
they had not observed anything unusual about the conduct of
the respondent. Among others, the witness-box was occupied
by Mr. Tilly, the solicitor who prepared the power of attorney,
and his brother. During the evidence of one of the brothers
a dramatic incident occurred. An anonymous telegram was
received by the cross-examining counsel, prompting counsel to
inquire about a will. The hint was followed up, and
admissions were drawn from the witness that during the
administration of the respondent’s affairs by the self-appointed
committee, and during the term of office of the attendant
Wade, whom the committee had appointed to take care of the
respondent, respondent had made a will. The will was called
for, and after some demur was produced in court, and a very
remarkable document it proved to be. The draft of the will
was prepared by Wade, the attendant, who at that time had
been for three months attending on the respondent. Under
the will the executors to his previous wills were displaced, and
in lieu of them the members of the self-appointed committee
were associated with the attendant Wade as executors, and
the will gave to each executor a legacy of ;£ 1,000. Further,
Mr. H. Jackson, Dr. Roberts, Mr. Mason, and Mr. Tilly, the
members of the committee, were to have each a second ;£ 1,000,
while the attendant Wade was left a quantity of furniture, and
the house and grounds were to be sold, and to go, with the
residue of the estate, after providing legacies for charitable
objects, to the trustees for their own use. Counsel for the
respondent submitted that a more sensible or proper will could
not have been made.

Out of a jury of nineteen, one was found who considered
that the respondent was of sound mind, and capable of
managing himself and his affairs. The other eighteen found
a verdict that he was of unsound mind, so as to be incapable
of managing his affairs, but was capable of managing himself
and not dangerous to others.

It should be stated that, apart from Wade and Tilly, the
members of the managing committee seem to have known

LIV. 41

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578

OCCASIONAL NOTES.

Duly,

nothing at all about the will until it was mentioned in Court.
They seem to have acted perfectly bond fide , under the
impression that the respondent was being ill-used and neglected
by his family, and that the bruises that he had received by falls
in his epileptic fits were due to the violence of his attendants
They acted perfectly bond fide , but they acted hastily,
injudiciously, on ex parte y untrustworthy, and untested evidence,
and without regard to the interests or feelings of the relatives
and natural protectors of the respondent. Under the circum¬
stances, they must consider themselves fortunate in merely
having their imprudence exposed in Court, without having to
bear any of the costs of an unsuccessful action at law.

Occasional Notes.

Special Education in Mental Diseases .

The Medico-Psychological Association has for years past
made attempts to advance the education of medical men in
mental diseases. The extension of lectureships and the com¬
pulsory study of this subject as a part of the medical curriculum
have been greatly promoted by these efforts. The attempt to
give special education to those entering asylum service by
means of a special examination and certificate, although succes-
ful to a certain point, has fallen far short of the usefulness that
was anticipated, and the time has now arrived when considera¬
tion might well be given to the best method of improving or
extending the teaching and examination of medical men in¬
tending to devote themselves to this special branch of
medicine.

That the certificate of the Medico-Psychological Association
has failed to attract a large number of candidates is due mainly
to the fact that it was based on a very limited amount of ex¬
perience and study of mental diseases. The holder of this
certificate, in applying for an asylum post, was not so superior
in qualification as to ensure his selection, and since the compul¬
sory study of mental diseases has been established, the relative
value of the certificate has been still further reduced.

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1908.]

OCCASIONAL NOTES.

579

Until some examining body has undertaken to confer a degree
in mental diseases, it would seem to be advisable to make the
Medico-Psychological examination more valuable by conferring
it only on medical men who, subsequent to their qualification,
had resided and worked in an asylum for a definite period. If,
in addition to this, definite instruction by lectures on the patho¬
logy of mental diseases could be arranged as a part of the curri¬
culum for the examination, a certificate could be given which
would entitle the bearer to special consideration in applying for
asylum appointments, or for any post demanding knowledge of
mental disease.

Lectureships on the pathology of insanity in connection with
universities and the pathological laboratories of asylums are
already under consideration, and would thus at once find a
definite reason for attracting students. The certificate of the
Association would probably pave the way to the granting of a
diploma in mental science by one or more of the universities,
similar to that granted in public health. The need for such a
diploma has been frequently discussed, and attention was drawn
to the subject in a recent article in this journal. Any action
of the Medico-Psychological Association in promoting these
ends will certainly tend to enhance the standing and reputation
of the specialty.

Female Suffrage .

The female suffrage question would not appear at first sight
to be of interest to the medico-psychologist, but it involves such
a far-reaching change in the habits of the larger half of the
community that it demands considerStion from all who are
concerned with the nervous and mental health of the nation.

Excitement from politics, or rather from party feeling, is
not frequently recorded in the statistics of the causation of
insanity. Like religious excitement, however, it plays a part
in some cases of mental breakdown, and although it may be
an additional interest in life to many, it is an extra stress to
individuals of an emotional type. Women, as a rule, are more
emotional than men, especially so during the reproductive
period, and at the times (during pregnancy, etc.) when this
function is in greatest activity. It is certain that emotional

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OCCASIONAL NOTES.

580

[July,

stress should be avoided under such conditions, as being
injurious both to the mother and her offspring.

The example of the suffragettes is not to be taken as a
criterion of the probable result of participation in politics by
women in England. The outrageous conduct of the suffragettes
is due in the main to the necessity of parties to yield to the
fads of any persons who will make sufficient noise. The
suffragettes act on a reasoned principle, and although their
feminine emotionality carries them to greater lengths of mis¬
conduct than men would arrive at, it is not a proof that the
general body of women would be so uncontrolled in their
political action.

The trend of party politics, as a recent writer in the
Nineteenth Century has ably demonstrated, is to engineer
excitement in the constituencies so as to reduce them to the
level of an emotional crowd. This tendency is likely to
increase rather than to diminish, and the emotional stress of
party politics will become greater to those taking part in it

The medico-psychologists as such need not consider the
right or wrong of giving votes to women, but it would seem
that they should consider whether it is not advisable to direct
public attention to the possible ill-results, and to raise the
question whether young marriageable women and married
women should not be shielded from this possible danger to
the national health.

The Asylum Workers' Association.

The Annual Meeting of the above-named Association is
principally noteworthy from the announcement of the retire¬
ment of Dr. Shuttleworth from the editorship of Asylum News .
The services which Dr. Shuttleworth has rendered to the
Association from its very incipiency are very great indeed ; his
aid not only conduced greatly to the success of the Association,
but principally helped to guide its activities into the admirable
channels in which they now run. The Association thus
avoided taking the form of spurious unionism, which the chair¬
man (Sir W. J. Collins) described as seeking to organise all
employees against the authorities that employ them. This was
the great danger in the infancy of the Association, and that it

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OCCASIONAL NOTES.

1908.]

5*1

has been avoided is mainly due to Dr. Shuttleworth’s fore¬
sight.

The report shows that the increase in membership has
received a check, but this is probably temporary, and in all other
respects the work of the year has been satisfactory.

The Homes of Rest Fund is in great need of increased
support owing to the advance in the number of cases aided
during the year. The subscription by the members of the
Association of sixpence per year would satisfactorily meet
the need, but some outside help would be very welcome.

Members of the Medico-Psychological Association would be
doing good service in directing attention to this useful form of
mutual self-help.

Statistics .

Statistics of lunacy have been compiled in English asylums
over an extensive period, and should afford valuable material
from which to draw conclusions in regard to insanity at the
present and past periods. Hitherto, however, little decisive
information has been derived from these statistics in regard to
the character of the occurring lunacy and the results of
treatment.

The recovery rate during the period in which the most
important advances in treatment have been made shows no
advance, but rather the reverse, although the death-rate has
shown considerable diminution.

Is it possible that these statistics really point to the con¬
clusion that while modern treatment preserves life, it fails in
promoting mental recovery, or is this apparent anomaly due,
as has been often suggested, to the different class of cases
admitted to asylums in recent years ?

Is it not possible by careful examination of the statistics to
obtain some definite and reliable information in regard to the
classes of insane persons admitted at the various periods,
in regard to age, previous duration of insanity, causation and
forms of insanity, etc., together with the results of treatment
in these various classes ?

Such analyses of the statistics have been made in one or two
asylums, but to be satisfactory should be made on a much

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582

REVIEWS.

[J“'y.

larger scale, and on carefully considered principles. Is it not
possible that a committee of the Association appointed for such
a purpose might devise a plan for the analysis of these
statistics, which should not leave our asylums exposed to the
above crude conclusion, that while the lives of the insane
are prolonged, their mental disorder is not correspondingly
benefited ?

The Conolly Norman Memorial .

An influential meeting of medical and other friends of the
late Dr. Conolly Norman, held at the Royal College of
Surgeons, Dublin, decided on promoting a memorial, to take
the form of an after-care association bearing his name. If
the funds collected admit of its being done, it is proposed also
to present Dr. Norman’s portrait to the Royal College of
Physicians of Dublin, of which he was the Vice-President.

The after-care association would be a most appropriate
memorial of Dr. Norman’s work on behalf of the insane, and
it is to be hoped that the funds collected will be sufficient to
ensure its being carried on in a satisfactory manner.

The Honorary Treasurers of the fund are Dr. Dawson, of
Farnham House, Finglas, and J. R. O’Connell, Esq., LL.D.,
of 34, Kildare Street, Dublin.

Part II—Reviews.

Las Nuevas Teorias de la Criminalidad. By C. Bernaldo db Quiros.

Madrid: Hijos de Reus, 1908. Pp. 258, 8vo.

Following up his excellent little book on the special features of
Spanish criminality, the author now puts forward a treatise on the wider
aspects of criminology with reference to the most recent theories.
It is based on an earlier and slighter work published ten years ago.
Dr. Nacke writes an introduction in which he remarks that Sehor
Bernaldo de Quiros has here produced a book which is a complete
summary and an impartial criticism of the new theories of criminality,
worthy to be translated into all the chief languages of Europe. Nacke
is so energetic an antagonist of Lombroso that his approval is at all

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REVIEWS.

583

1908.]

events proof that the book is not too partial to the famous Turin
professor. It is, however, interesting to see that Nacke here admits that
Lombroso has at least performed two services: he has taught us to
occupy ourselves with the personality of the criminal and not merely
with his criminal act, and in the second place he has made
admirable suggestions alike for the prophylaxis of crime and the
treatment of the criminal. These surely are no mean services.

Bernaldo de Quiros divides his work into three long chapters: the
first on criminology, the second on penal law and penal science, the
third on scientific police methods, the chapters being divided and sub¬
divided in a clear and methodical manner. In the first chapter, after
tracing the history of criminology, he deals with the three great innovators,
Lombroso, Ferri, and Garofolo, and discusses the main criminological
theories, anthropological (*.*., atavistic, degenerative, and pathological)
and sociological. The second chapter, after setting forth the three main
channels of influence in penal matters, the traditional current, the move¬
ment for reform (Liszt, Hamel, etc.), and the radical movement for the
abolition of punishment except in so far as it is necessary for the treat¬
ment of the criminal and the protection of society, discusses in detail
the various questions involved in the treatment of the criminal. The
third chapter, which is much the shortest, is concerned with the
methods of identification, etc.

The author concludes that the new movement for the study of the
criminal unquestionably represents a real conquest of the scientific
spirit; its simultaneous and independent appearance thirty years ago in
three different countries (as represented by Lombroso, Benedikt, and
Maudsley) sufficed to show that it was a natural and spontaneous move¬
ment, and it is now becoming definitely accepted. Lombroso’s name is
properly associated with this movement, as Beccaria’s name was
with the earlier criminological movement, not on account of any special
value in Lombroso’s writings, but because of “the fertility of thought in
this field which he has produced throughout the civilised world ” ; it is
owing to Lombroso’s initiative that the vast army of workers now in the
field, even those most opposed to his special ideas, have been set to
work. In regard to the treatment of the criminal, the author believes that
the day of quantitative punishments is nearly over, and that in the future
qualitative measures will prevail; this is the outcome of a movement
which began with Beccaria. Society must exercise a public guardian¬
ship over criminals in which punishment, as such, has no place. The
question of responsibility will gradually cease to have any significance ;
whether a criminal’s action was due to free will or determination makes
not the slightest difference in the need for controlling and treating him,
any more than it does in the case of a diseased person.

Bernaldo de Quiros writes with a wide knowledge of the literature of
his subject and in a calm and impartial spirit. He naturally devotes
special attention to conditions in his own country, and he shows that,
just as Spaniards were the pioneers in the rational treatment of the insane
six centuries ago, so they have also to-day been pioneers in advocating
the rational treatment of criminals. Dorado, whose name is still almost
unknown in England, deserves special mention in this connection.

Havelock Ellis.

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584 REVIEWS. [July,

The Psychology of Dementia Prcecox [ Uber die Psychologie der Dementia
Prcecox\ By C. G. Jung. Halle: Carl Marhold, 1907.

This book is the result of an attempt to apply the psychological
principles worked out by Freud for hysteria and the obsession-neuroses
to the sphere of dementia praecox. The investigation is carried con¬
siderably deeper than the purely clinical work of Kraepelin, and deeper
even than the method which Janet has applied to hysteria and
psychasthenia. The latter really attempts little more than to determine
the mode of reaction, what we may call the M form ” of the mentality,
whereas Jung seeks to explain the actual content of the hallucinations,
speech, actions, etc.

The keynote of the work is its strenuous opposition to Neisser’s view
that the laws of normal thought have no application in the mind of the
patient suffering from dementia praecox. The author endeavours to
show that the psychological mechanisms at work in these two cases
differ only in degree. There can be no question that the realisation of
the truth of this point of view, together with recognition of the fact that
chance plays no part in the words and actions of a lunatic, is of enor¬
mous importance for the future of psychiatry.

Jung's main thesis is that the symptoms of dementia praecox are due
to the existence of “ complexes ” or systems of ideas possessing a strong
emotional tone. It will be seen that this corresponds precisely to
Freud's conception of the nature of hysteria, and a chapter of the present
book is in fact devoted to a consideration of the numerous points of
resemblance between hysteria and dementia praecox. But whereas the
former is mobile and removable the latter tends to be fixed and pro¬
gressive. The differences between the two diseases may be summed
up as follows: In hysteria the complex leads an independent existence
and lessens the amount of mental energy at the disposal of the person¬
ality, but sufficient remains to enable the individual to adapt himself to
the needs of his environment In dementia praecox, on the other hand,
the complexes ultimately dominate and distort the personality, so that
the individual and his environment finally become altogether in¬
congruous.

In the third and fourth chapters the effect of the complexes on the
personality is worked out in detail, and the origin of neologisms,
stereotypes, negativism, etc., is thereby explained. Considerable use
is made of association experiments, which are already familiar to English
readers through Jung's papers in Brain and the Journal of Abnormal
Psychology .

The final chapter contains the detailed analysis of a case of paranoid
dementia praecox, as an illustration of the method of research employed.

The whole work is extraordinarily illuminating. It is difficult to
predict to what extent Jung's avowedly tentative conclusions will
ultimately be substantiated, but that they point to an extremely fruitful
line of research cannot be doubted. They have been subjected to con¬
siderable criticism on account of their dependence upon certain of
Freud's doctrines, which have not been generally accepted. But the
author has carefully defined his precise relation to Freud, and points
out that he has only adopted well-grounded psychological principles.

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REVIEWS.

585

In any case the validity of Jung’s work is by no means entirely
dependent upon that of Freud. It may be confidently asserted that the
book constitutes one of the most considerable contributions to the
progress of psychiatry which has been made of recent years.

Bernard Hart.

The Intermittent Psychoses \Les Folies Intermittentes], Maniacal Depres¬
sive Insanity . {La Psychore Maniaque Depressive ). By Drs.

Denny, Physician to the Hospital of Salpetiere, and P. Camus,
House-Physician of the hospitals of Paris. One vol., 96 pp., illus¬
trated by ten photographs {actualitis ml die ales), Paris : Baillifere.

The subject is dealt with in eight chapters, the first of which relates
to the historical interest of the disease, the second and third are taken
up with the symptomatology and clinical types. In the next two
chapters diagnosis and prognosis are dealt with, while in the remaining
three the aetiology, medico-legal aspect, and treatment of the disease are
introduced. The authors adhere wholly to Kraepelin’s views. The
book is interesting, but the differential diagnosis of the disease seems
to us somewhat tedious and hardly likely to be of use in practice.

The evolution of the term “ maniacal depressive insanity ” is traced
to Falret, who in 1854 described under “folie circulaire” a disease
made up of a succession of maniacal and melancholic attacks, succeeded
by a lucid interval of varying duration. Baillarger at the same time
described a disease which he called “ folie a double forme.” This disease
corresponded exactly with Falret’s description except for the fact that
Baillarger omitted the “ lucid interval ”; the views of neither of these
writers were received with any enthusiasm. Kraepelin in 1899 made
a new classification of mental diseases, and under the term “ maniacal
depressive insanity ” included the psychoses formerly called intermittent,
periodical, circular, etc The writers define the disease as constitu¬
tional psychoses, essentially hereditary, characterised by the repetition,
the alternation, the juxtaposition, or the co-existence of the states of
excitement and depression. Pure mania and pure melancholia are very
rare. The symptoms are divided under the states of mania and melan¬
cholia and these two conditions mixed. The predominant symptoms
are disorders of the affections, of voluntary movement, and of the
intelligence. The personality of the individual is changed ; the affec¬
tions may be increased or diminished. Inhibition of the higher psychic
functions, that is of the will, is present. All voluntary movement is
difficult. In the maniacal stage there is a great flow of words but a
poverty in thought. A recitation may be correctly done, but the action
is reflex and automatic. No definite aim characterises the movements;
everything is touched but nothing grasped. In the melancholic type there
is seen marked inhibition of thought, certainly of speech. It is apparently
too much trouble to speak, to move, or to walk. Stupor may supervene,
in which case all response to outward stimuli is lost. Consciousness of
their surroundings remains throughout. Under accessory symptoms
are included confusion, delusions of wealth, etc.; illusions are not
uncommon, hallucinations rare. There are certain distinctive physical

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REVIEWS.

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signs, but none pathognomonic. Analgesia when present is of psychic
rather than pathological origin. In the depressed type the respirations
are shallow, while in the maniacal stage they are deep. Acceleration
of the pulse-rate is by no means uniform, even in the acutely maniacal
condition. The blood changes have been found to be not sufficiently
uniform to be convincing; the same remark applies to the urine.
Weygandt finds that the melancholic type gains weight while the
maniacal emaciates. Weeping is rarely seen. Salivation, reflexly pro¬
duced by the constant movement of the jaws, produces an abnormal
amount of expectoration. The clinical types are described as maniacal,
melancholic, and mixed, the latter being that in which the phenomena
of excitement and depression co-exist. It is the fusion of the two
former states. There are many varieties of this type. Grief is readily
turned into anger, joy is always of a morbid type. Excitement is often
accompanied by anger or sorrow, and may suddenly change to joy. This
class of patient is a source of constant trouble; they make groundless
complaints, are mischievous, spiteful and quarrelsome. The mixed
form of the disease may be considered the links of a long chain, at
either end of which is placed melancholia and mania. The onset of
maniacal depressive insanity is always preceded by an initial stage of
mild depression, which ultimately becomes the stage of depression
proper, while the subsequent stage of mania is more or less abruptly
entered upon, but is frequently ushered in by a “ herald sign,” usually
represented by a visionary hallucination. The length of the attacks
vary from a few hours to months or years, becoming longer as the
disease progresses. The disease persists throughout life. The so-
called lucid intervals have confused the profession at large; they are
part of the disease. A recurrence of the excited or depressed stage is
certain. The disease is never followed by dementia. Neurasthenia,
the authors agree, is a much-abused term. Lassitude, weariness, lack
of energy are common to both diseases. The points to rely on are:
a history of previous mental disturbance, an alteration in character, and
hereditary influence. All indicate maniacal depressive insanity, and
especially if the character of the patient gradually changes from depres¬
sion to light-heartedness and a general feeling of bienetrc is present
The melancholia of involution differs from the disease under discussion
in that in the former the grief is acute. Agitation and unceasing rest¬
lessness are marked. The differential diagnosis is discussed at con¬
siderable length, but we think that in many cases the points to rely on
would hardly be serviceable in a practical examination. Finally, how¬
ever, a single symptom must not be considered, but rather an opinion
formed from a preponderance of symptoms on one side or the other.
The disease is more common in women than in men. In the author’s
experience it forms 17*5 per cetit . of the asylum population. A medico¬
legal point is raised as to the responsibility of the individual during
the lucid interval. The opinion is given that a limited responsibility
exists only. The treatment of the disease is merely symptomatic ; no
known drug will shorten the disease a single hour.

Colin McDowall.

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587

Recent Therapeutics in Nervous Diseases [Les Therapeutiques recentes
dans les maladies neroeuses\ By Drs. Lannois and Porot, of
Lyon. 1 vol., 96 pp. ( actualitis midicalts). Paris : Baillifere.

The authors have written an epitome of modern therapeutic measures
in relation to nervous diseases. The medical and surgical aspects
are dealt with. They indicate the best treatment and give their
reasons for whatever selection they make. Very definite views are
held regarding the curability of general paralysis by anti-specific treat¬
ment. They severely criticise Leredde in his assertion that mercury
will cure general paralysis and tabes dorsalis. No case of cure has
ever been produced that was undoubtedly either of these two diseases.
The book is good reading and the opinions expressed are clearly
stated.

Lumbar puncture should be more generally employed than it is at
the present time. As an aid to diagnosis there is no contra-indication.
As a curative agent it should never be used in cerebral or cerebellar
tumour or brain abscess, or in a person the subject of advanced arterio¬
sclerotic changes. In tubercular meningitis it is more useful as a
means of diagnosis and may be used to relieve pressure as a palliative.

Lumbar puncture repeatedly applied together with hot baths is the
best treatment of cerebro-spinal meningitis or a meningitis the result of
a pneumococcal or post-febrile infection. Benefit has been obtained
in haemorrhagic pachymeningitis, and as a means of diagnosis it is of
use in traumatic affections of the meninges. Regarding hydrocephalus,
lumbar puncture should only be used in those cases which are
inflammatory in origin. In those cases in which there is evidence of
pressure symptoms and a palliative is urgently required lumbar puncture
may be exceptionally employed. In general paralysis it is useless.
Its use in lunacy has been limited and so far unproductive of good
results. In head and spinal injuries if coma is present the authors
advocate immediate puncture and the repetition of the operation till
the fluid is not blood-stained. Subarachnoid injections are not per¬
missible on account of their danger. Epidural injections, that is,
insertion into the sacral canal, composed of cocaine or stovaine, are
occasionally used to relieve pain. The process repeatedly applied has
been known to cure incontinence of urine of nervous origin.

Tic is a term frequently misapplied. The writers describe it as a
psychomotor disease. Its prognosis formerly was bad, owing to the
co-existing mental condition. The best treatment and that which
possesses further possibilities is a system of re-education. Methodical
exercises are gone through in which the affected muscles are kept at
rest by an increased mental effort. The system must be under the
personal care of a competent medical man, and if patience and tact are
combined a good result can be looked for. The treatment of syphilis
is reviewed at some length. The intra-muscular injection of mercury
is regarded as the most useful and least inconvenient. Chorea is
treated by gradually increasing doses of arsenic. The best method of
administering the drug is in butter. The advantage claimed for this
method is that the alimentary system is not upset. The manufacture
of the mixture is minutely given. For chronic nerve lesions, accom-

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EPITOME.

[July,

panied by pain, which do not resolve under medicinal treatment, the
subcutaneous injection of air followed by vigorous massage is strongly
recommended. No inflammatory reaction results and the cure is due
entirely to mechanical means.

Colin McDowall.

Part III—Epitome of Current Literature.

i. Physiological Psychology.

Freud's Doctrine of the Sexual s,Etiology of Neuroses [Kurze Bermer -
kungen zu den Freudschen Lehre iiber die sexuelle sEtiologie der
Neurosen ]. {Neurolog. Clbtt. y October , 1907.) Friedldnder , A .

The author, recognising that Freud’s teaching has to-day become
“actual,” and that his followers have accomplished much fruitful work,
has devoted special attention to Freud’s doctrine and methods, and him¬
self to some extent practised the psycho analytic method. He here
summarises his conclusions. Freud draws the circle of the sexual
causation of neuroses far too widely. There are cases of hysteria of
purely sexual origin; these belong to the psychic traumatism type
established by Brewer and Freud, and by them investigated with such
subtle skill; in these cases suppressed emotion lies at the core of the
condition, and the neuro-psychic symptoms are a defence. Symptomato-
logically, indeed, every hysteria is an emotion-neurosis. The psychic
traumatism, however, is by no means always sexual. The psycho¬
analytic method of treatment is not suited for all cases, and not always
desirable when it involves detailed investigation of sexual perversions,
more especially as other methods of treatment also prove effectual.

Havelock Ellis.

Classification of the Homosexual [Einfeilung der Homosexuellen\. ( Allg .

Zt. f Psychiat ., Bd. 65, 1908,/. 109.) Nacke, P.

Nacke remarks that there is much ignorance concerning sexual inver¬
sion' as such cases seldom come before the alienist, though some¬
what more often to the specialist in nervous disorders; and as the cases
thus seen are usually of an extremely pathological type they are not
typical of ordinary inversion, the subjects of which rarely consider that
they need medical treatment. To base a knowledge of homosexuality
on cases seen in an asylum is as unreasonable as to base a knowledge of
anthropology on abnormal or deformed individuals. He has himself
given special attention to this subject in recent years, both inside and
outside the asylum.

Nacke is at many points in agreement with Hirschfeld (who has a
vast knowledge of such cases), and considers that homosexuality is “ no
vice, but perhaps even a normal and rarer deviation of the sexual impulse,

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PHVSIOLOGICAL PSYCHOLOGY.

589

apparently not in itself pathological.” He considers that it is always
congenital, but that there is seldom any hereditary element (this latter
conclusion, however, is due to the difficulty of investigation, and there is
evidence against Nacke's view), though there may be a neuropathic
heredity. There is no unusual prevalence of stigmata of degeneration.
Sometimes the perversion begins to manifest itself in childhood ; some¬
times it first appears late in life, but in these latter cases, by Krafft-Ebing
termed u tardive,” the condition is not really acquired; there must be a
congenital predisposition. Seduction or masturbation, it seems pro¬
bable, never alone suffices to produce inversion. The real causation of
the condition is obscure, but Nacke leans to the view (which is that of
Hirschfeld and many others) that it largely rests on the general ana¬
tomical and psychic bisexuality more or less latent in all persons.

Nacke distinguishes between homosexual persons who are exclusively
attracted to individuals of the same sex, and bisexual persons who are
attracted to persons of either sex. The novel point of his classification
is, however, the attempt to place it on a chronological basis, according
to the period of life at which the condition appears: (1) The cases mani¬
festing inversion in childhood; these Nacke considers a small minority,
and he believes they are usually of feminine type, but admits that more
knowledge is required. (2) The cases appearing at puberty; these are the
majority. (3) The “ tardive ” cases, appearing in adult or even old age;
this is a very small group, and still very imperfectly known. Nacke
further subdivides the second and third groups according as the con¬
dition is temporary, periodical, or continuous. Havelock Ellis.

Organic Changes and Feeling. (Amcr. Joum. Psychol. % October, 1906.)

Shepard^ J. F.

The important but vexed question of the relationship of psychic
changes to organic changes has been carefully worked out in the
Psychological Laboratory of Michigan University during three years
and is here elaborately recorded. Shepard scarcely settles the question,
but he shows how complicated the relationship is.

The experiments were planned with a view to test Wundts tri-dimen-
sional theory of feelings. The processes studied were change in the
volume of the hand, in the volume of the brain, in the heart-rate, in
depth and rate of breathing, and in plethysmographic pulse in brain and
hand. For the brain experiments a subject was secured from whom a
portion of skull covering the right Rolandic region had been removed
two years before; the capsule of a tambour, covered with thin rubber and
fitted with a piece of cork to dip into the pulsating spot, was firmly
attached and connected by a flexible tube with a delicate recorder, the
subject being kept in a dark room and the recording apparatus in another
room. In this case the subject was a labourer; most of the experiments
were carried out on people more or less familiar with experimental
methods.

Shepard concludes, as a result of his experiments, that feelings can¬
not be classified on the basis of vaso-motor and heart-rate changes
There is no reverse relation between the accompaniments of agreeable
ness and disagreeableness, much less three such pairs of reactions

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Agreeable, agreeably exciting, and agreeably depressing states all give
faster pulse and fall of volume, though both Wundt’s and Lehmann’s
theories call for slowed pulse under these conditions, and also for in¬
crease of volume. In Shepard’s experiments there is no decrease of the
brain volume with either agreeable or disagreeable stimuli. All moderate
nervous activity tends to constrict the peripheral vessels and to increase
the volume of the pulse in the brain. AH moderate nervous activity
likewise increases the heart-rate. Strong stimuli cause both an exciting
and inhibitory effect, especially in the heart-rate. The activity of any
part tends to counteract constriction of that part.

In explanation Shepard suggests that moderate nervous activity also
causes constriction of the splanchnic vessels, and strong stimuli an ex¬
citing and inhibitory effect upon them. The increased volume of the
brain is probably due to increased blood-pressure from constriction at
the periphery, and is simply reflex; it is not attention, as such, that causes
the change. Shepard finds by experiments during sleep (in opposition
to Lehmann) that it is probably not necessary for the stimulus to reach
consciousness. Havelock Ellis.

Glossolalia [Classification des Phcnomhtcs de Glossolalie\ {Arch, dc
Psychol ., Jutyy 1907.) Lombard , E.

This interesting and comprehensive study of “ speaking with tongues”
is rich in illustrations from many by-paths of literature and religious
history. Glossolalia is defined as “ phonic automatisms taking (or
tending to take) the form of a tongue or a language other than that which
the subject speaks in his normal state.” The various forms of glossolalia
are investigated in the order of their increasing complexity:

(1) Inarticulate phonations and allied phenomena. —These are simply
confused vocal emissions, cries, sighs, murmurs, sometimes loud, but not
attaining to organised articulated words; the subject is in a more or
less somnambulistic condition and behaves like a child, as St. Paul
remarks in a passage of remarkable penetration (I Cor., xiv, 20). In
all glossolalia Lombard considers there is a basis of infantile mentality.

(2) Glossolalia proper , in various stages. At this point a subconscious
design begins to preside over the glossolalic manifestations, and the
listeners are inclined to believe that it is no longer the subject himself
who is speaking, but a higher power through him; he himself also realises
that he is not responsible for the stream of words rushing from his
mouth. The words are unintelligible, and often have mo meaning even
to the speaker ; this has been insisted on as proof of their supernatural
origin by Jamblichus, Irving, etc. The first result of this verbal
elaboration is a pseudo-language, i.e ., an assemblage of articulate sounds
simulating a discourse, but with no regular correspondence between
sounds and ideas. Lombard considers that the pseudo-language is
analogous to that form of paraphasia in which the subject, though able
to think correctly, can only translate his thoughts into a meaningless
jargon to which he yet gives the intonation proper to his thought, and
Lombard recalls that when children at play wish to speak the
language of savages they succeed best when they have a clear idea as to
what their words are to express. But the assemble of words in a pseudo-

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PHYSIOLOGICAL PSYCHOLOGY.

591

language is never absolutely, only relatively, arbitrary. Mental repre¬
sentations cannot fail to have some connection, even if merely fugitive,
with the sounds. In this way definite new vocables tend to be formed,
having a vague kind of appropriateness to the objects they are connected
with, sometimes based on emotional associations. In the next stage
these neologisms become systematised, and we have automatic glosso-
poiesis. It is sometimes possible to unravel the associations by which
these new words have been made. This has been successfully done
with the “ Martian ” language of H^tene Smith, who has been so
elaborately studied by Flournoy, Henry, and others. Martian is not a
mere jargon, but a real slang tongue on an infantile basis. The words
seem invented, but they are really adapted under the stress of a parti¬
cular emotional disposition. From the highest to the lowest the
phenomena of glossolalia are due to a conversion —the alteration of a
self whose phonic manifestations reveal its special emotional character.

(3) Xenoglossia , or the speaking of languages which have never been
learnt, is the final form of glossolalia. It is commonly supposed that
this was the form of glossolalia which appeared among the early
Christians at Pentecost, though Paul's words exclude that assumption.
The subjects of glossolalia frequently believe that they are speaking a
real language that is unknown to themselves. Occasionally, however,
this really occurs, and there is true xenoglossia varying from occasional
words to phrases or even long passages. Lombard summarises various
examples, notably that of Richet’s Madame X—, which has been most
carefully analysed; she was able, in a state of somnambulism, to write
pages of Greek, although quite ignorant of Greek. Lombard concludes
that two factors are concerned in xenoglossia when fraud has been
excluded—forgotten memories and mental transmission from a person
present. Havelock Ellis.

Quantitative Psychology and its Results [Za Psychologic Quantitative'].

{Rev. Phil., June , 1907.) Van Biervliet.

The efforts of Fechner and his followers to establish a science of
psycho-physics have, as is now widely recognised, led only to results of
secondary importance; the attempt to regard roan as a physical
instrument from which very precise results could be obtained has
scarcely proved profitable. There is, however, another method, that of
quantitative physiological psychology, as mainly established by Wundt,
and Van Biervliet here discusses its validity and results, choosing more
especially reaction-time and the duration of mental operations. He
points out that the conscious act can only be investigated at its
extremities; the central, the truly conscious part of the act, is not
measured but only estimated. This fact diminishes the precision of
psycho-physiological laws.

The personal element which intervenes in all the biological sciences
here plays a specially large part, yet at the same time it must be
admitted that the addition of the method of scientific observation,
experiment, and measurement to the method of simple observation and
introspection which ruled previously constitutes a real revolution in
psychology. The study of the results reached by various investigators

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EPITOME.

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as regards reaction-time, which is yet the simplest process for investiga¬
tion, shows, Van Biervliet points out, a very considerable range and
variation of results ; even in the same subject the results are very far
from uniform. It is extremely difficult to equalise the conditions for
experiment, and it is very seldom that experiments are made on a
sufficiently large number of subjects. The author's general conclusion
is that the labours of psycho-physiologists in measuring the direction of
conscious phenomena have furnished indications rather than results,
but that these indications are of capital importance and serve to open
a road which is much wider and safer than that which the psycho¬
physicians had attempted to create. Havelock Ellis.

Timidity as a Factor in Psycho neurotic Conditions [Le R 6 le de la
Timidite dans la Pathogenie des Psycho-n/vroses], (Rev. de
THypnotisme, January, 1907.) B/ril/on, Damoglou, etc.

Bdrillon considers it an astonishing fact that few recognise how often
timidity is at the basis of all psycho-neuroses. He regards the
intimidated person as in a state psychologically analogous to that of a
hypnotised person. Blushing or pallor are the vaso-motor signs of a
real shock which cannot fail, if often repeated, to have an overbalancing
or depressing influence on the central nervous system. Bdrillon's
inquiries among a very large number of patients for some years past
led him to believe that nearly all the subjects of hysterical and
neurasthenic troubles are affected by timidity before their disorders
begin, apart from the fact that in a considerable proportion of cases the
appearance of a neuropathic affection is directly connected with some
act of intimidation of which the patient has been the victim. In such
cases the affection resembles the traumatic neuroses in prognosis and
duration as well as in symptoms.

Education and social environment are the chief factors in the
development of timidity. In countries like America and Switzerland,
where there is much social equality, timidity is comparatively infrequent
It is very frequent in France, where there is a marked social hierarchy. For
the same reason it is extremely common in England (as well as among
Americans of English origin), and no country produces so many cases
of the phobia of blushing as England.

Damoglou, who occupies the same standpoint as Bdrillon, follows
with a paper on “ Timidity in the East." Here the social conditions
are very favourable for the production of timidity, which has become a
kind of hereditary and endemic disease. Inferiors are in a perpetual
and exaggerated state of timidity before superiors, and the young in the
presence of the old. Damoglou considers that this has had a disastrous
result in paralysing the will and asphyxiating the social life of the peoples
of Turkey and Egypt. Havelock Ellis.

Resistances and Retardation in Brain-work [ Wiederstdnde und Brem-
sungen in dem Him]. {Arbeit. Psychiat. Klinik zu Wurzburg,
H 2, 1908.) Rieger, C.

Dr. Rieger has made some careful experiments to measure the relative
time in which mental processes can be performed. Using the ordinary

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593

divisions of minutes and seconds } he divided the last into sixty parts,
which he calls tertians. He used a watch graduated with twelve tertians,
five in the second. He arranges his letters, words, and sentences into
staccato and legato, i.e., single and connected.

A letter looked at alone takes longer time to write than as the com¬
ponent of a written or printed word. He observes that it is astonishing
how little the particulars which go together to make up a view of a
landscape, or the letters of a page are noted. Unconnected words take
longer time than when they flow in an intelligible sentence. Sixty
letters can be read in legato in a second if the sentence is easy; longer
words take more time than shorter words unless the latter are uncouth,
and from ten to eleven are read in the second. Copying the alphabet in
the usual sequence is quicker work than copying from “ z ” to “ a,” also
copying or reading a sentence when the meaning is easy. The sense
should be grammatical but need not be logical. Twelve words can be
counted in the same time as a hundred words are read; some letters
take double the time to write than others; this gives an advantage to
the typewriter, who can do each letter with one tap. One can write two
letters staccato and four legato in the same time.

To write a word in the usual way can be done in half the time than
if the letters are written wide apart. The general result was that
intentional separation of the natural flow of letters, words, or sentences
takes longer time as it costs more effort.

Rieger pursues the same kind of inquiry into the apprehension and
naming of outer objects and with the same results. The mind habitually
classifies and arranges what is seen, throws the objects into groups,
passes over some particulars and rests upon others. What interrupts or
disjoints this process costs more effort and more time.

It would be curious to measure the utterances in the flow of staccato
words which we often have in maniacal delirium in which the usual
association of thought is so utterly broken.

William W. Ireland.

2. Clinical Psychiatry and Neurology.

On a Mode of Combination of Psychasthenia and Delusional States
[Sur un mode de combinaison de la Psychasthenie et du dilire\
( fourn . de Psychol., Mai-Jui?i, 1908.) Arnaud, F

At one time it was almost universally considered that obsessions and
true delusions were incompatible conditions, belonging to two entirely
distinct categories. Of late years, however, such an opinion has been
considerably modified, and to-day it is recognised that not only are com¬
binations between the two types possible, but they are indeed frequent.
The author describes three forms in which such associations may
occur :

(1) Those cases of psychasthenia whose peculiar symptoms are for
the time masked by a supervening delusional state arising merely as an
accidental occurrence. When these acute mental conditions clear up
the original symptoms reappear unmodified.

LIV. 42

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EPITOME.

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(2) Those cases in which delusions and obsessions exist together at
the same time, each set of symptoms remaining distinct horn one
another. The delusions are usually persecutory and tend to become
fixed and systematised.

Both these varieties have one feature in common, viz., the delusions
are composed of elements quite distinct from the obsessions themselves.
It is a complication of one mental state by another of essentially
different type.

(3) In this variety the delusions have their origin in the obsessions
themselves and retain the general characters of such obsessions, which
exist, as it were, in an extremely exaggerated form. This development
of the disorder is the main subject of this paper, the author terming it
psychasthinie delirante (delusional psychasthenia).

Given a psychasthenic, with feelings of insufficiency, obsessions,
impulsions, emotional crises, abulia, phobias, manias and ruminations,
it is shown that he may go a step further and put some delusional
interpretation on his altered feelings: e.g., personal unworthiness, ideas
of crime, persecution, possession by some malign influence, etc. Such
delhsions have characteristic features, viz .:

(a) Their enormous exaggeration and absurdity in contrast with an
almost complete retention of reason and judgment in respect to every¬
thing unconnected with them.

( b ) The passionate and unceasing attempts to logically uphold them.

(< c) Remissions with almost complete insight. They are sudden and

very brief, differing entirely from those of the periodic psychoses.

The author critically examines to what extent such ideas are truly
delusional and not merely conscious obsessions of extreme type. That
there is a considerable degree of conviction, comparable to that in
ordinary vesanic delusions, is evident from the fact that the conduct of
the patients is in conformity with their abnormal ideas. On the other
hand they retain the essential traits of obsessions in their variations of
intensity and a certain incompleteness, revealing only a partial assimi¬
lation and acceptance by the personality. After a time conscious
criticism of these ideas lessens and they constitute a true secondary
systematised delusional state. At this stage there is no possibility of
any alleviation of the symptoms. H. Devine.

A Case of Reversed Orientation [Le renversement de Vorientation, ou alio-
chirie des representations ]. (Joum . de Psychol. Norm, et Path .,
March, 1908.) Janet, P.

The patient, a woman, aet. 29, complained that her environment
was always “the wrong way round.” When actually walking in a
certain direction she felt that she was walking in the opposite direc¬
tion. The trouble was, however, purely subjective, and did not
interfere with her movements. She invariably orientated herself cor¬
rectly by a process of reasoning.

A complete physical examination showed that no lesion of the sensory
organs was present. The ears and eyes were normal, also the semi¬
circular canals when tested by Mach’s apparatus.

After considering various possible hypotheses as to the psychological

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595

mechanism at work in this case, Professor Janet comes to the conclu¬
sion that the condition is probably due to a kind of allochiria of the
sensory memory-images. The lesion lies in a reversal of the feeling of
right and left. Only memory images are, however, affected—the actual
perceptions preserve their normal orientation. The patient’s memories
constitute a mirror image of reality. Hence, when she perceives the
actual position of things, she is obsessed with the idea that their direc¬
tion has been reversed. Bernard Hart.

Psychical Phenomena in Migraine and its Relation to Epilepsy [IFenomeni
Psichici NellEmicrania e i Rapporti di questa con PEpilessia],
(Rivista Sperimentale di Freniatria t vol. xxxiii,fasc. 1.) Fork.

In the clinique at Rome, Dr. Forli has made careful observations upon
185 patients affected with migraine, especially with a view to ascertain¬
ing the degree of mental disorder in that distressing malady. Liveing,
writing in 1873 on megrim, published sixty observations of individuals so
affected, in which he laid stress upon the presence of mental aberrations
under the form of incoherency of ideas, confusion, and vague fears.
Mobius, on the other hand, while he admitted that during the attack of
hemicrania there was an incapacity for mental activity, irritability and
distress, still held that these disturbances depended upon the pain. Dr.
Forli, as the result of his study, comes to the conclusions that mental
disturbance is frequent in migraine. Sometimes they precede the pain,
and while these derangements involve all the fields of mental activity
they have most effect upon the senses of sight and hearing. Forli
observes that such patients have a dislike to light; luminous flashes
appear before the eye, or there are coloured spots, or everything appears
yellow. One man, aet. 28, saw during the attack of hemicrania
bright coloured points and a kind of target with a black centre
and clear circles, and menacing and disgusting figures. These
appearances do not stand with the pain in the relation of cause and
effect, but constitute two symptoms of one type of disease. There are
painful attacks of hemicrania attending some other nervous diseases
like tabes, general paralysis, and abscess of the brain, but migraine con¬
stitutes, at least in most cases, a disease distinguished by many
characters, and it ought not to be confused with any other nervous dis¬
order. William W. Ireland.

Visual Verbal Amnesia due to Arrest of Post-natal Development .

( Psychology . Clinic , April 15 th t 1907.) Witmer , Lightner.

In the case here described (which may also be called one of visual
aphasia), a youth, aet. 15, of more than average intelligence, who had
received the ordinary school education, although able to express his
thoughts adequately in spoken language, and with good memory for
sounds and good visual memory for colours and even separate letters,
could not read nor spell correctly except such words as he could spell
from the sounds of the component letters. In the Psychological
Laboratory it was discovered that, though the boy had practically normal
vision in each eye, he saw double because from defect of the external
ocular muscles he was unable to co-ordinate the eyes accurately, and

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EPITOME.

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he could never properly see a whole word. The defect was corrected
so far as possible by glasses, but the boy was still unable to read ; his
visual memory and imagination had had no training in this field, and
his brain was not stored with visual verbal memories. The brain centres
concerned with reading and spelling were as undeveloped as those of a
child of six. He was now submitted to careful training by skilful
teachers, but though he became fond of reading he never acquired
ordinary skill in reading or spelling, even at his death ten years later
from tuberculosis. The author finds that bad spelling in individuals
otherwise mentally normal is always associated with some eye defect,
though he is not convinced that it is necessarily caused by the eye defect,
and in some cases there seems to be congenital incapacity to develop
the normal visual functions of language.

It may be added that The Psychological Clinic is a new monthly
journal “ for the study and treatment of mental retardation and devia¬
tion,” and is edited by Dr. Witmer, of Pennsylvania University.

Havelock Ellis.

The Insane in the Russian Army during the Japanese War \_Die Geistes-
kranken im Russischen Heere wdhrend des Japanischen Krieges\
(Allg. Zt.f. Psychiat ., 1907, H. 2-3.) Awtokratow , P. M.

The author was the Red Cross medical officer at the head of the
organisation for the care of the insane on the Russian side during the
Japanese War. He claims that this is the first time that special attention
has been bestowed upon the cases of insanity occurring in an army in
the field, partly because military surgeons have not had a proper psy¬
chiatric training and partly because there has never before been a
suitable institution in the field for the reception of the insane. In this
respect, the author believes, the Russian Red Cross Society and Govern¬
ment have shown themselves much more humane than any other
nation.

The Central Psychiatric Hospital was at Harbin, and here in the
course of fifteen months 1,347 men (about one officer to four privates)
were received. The organisation of the hospital is fully described.
Only cases of insanity were admitted, another institution being
established for cases of nervous disorder.

It appears from the tables given that among the officers chronic
alcoholism was responsible for more than a third of the cases ; among
the privates epileptic psychoses came first. General paralysis and
neurasthenic insanity are placed next in order among the officers, and
among the men alcoholic psychoses and confusional insanity.
Among the officers 7 5 per cent . of the cases are thus accounted for, and
among the men more than 50 per cent .

It appears that in times of peace general paralysis comes first in order
among cases occurring in officers and alcoholism second, while among
the men alcoholic insanity is very rare. Epileptic insanity frequently
occurred after prolonged battles in individuals who could give no history
of previous attacks; on investigation, however, it was usually found that
they had had nocturnal enuresis as children. These cases all rapidly
recovered in, at longest, three weeks. Alcoholic insanity was chiefly

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597

increased during the war by acute poisoning from the consumption of
Chinese spirits. Among the officers, in whom it is common in peace,
its increase was largely due, the author believes, to heightened sus¬
ceptibility resulting from nervous exhaustion, it often occurred in young
officers who had never taken spirits before this campaign.

Neurasthenic insanity was the most special form encountered. It was
marked by depression, exhaustion, nervous irritability, accompanied by
headache, restless sleep and apathy, with ideas of suicide and complete
inability for exertion; at the same time these patients were extremely
sensitive to every external impression; they could not endure society
and at the slightest sound they trembled all over; in their broken sleep
they lived over again the terrible events they had passed through. Most
of them had obsessions and visual or auditory hallucinations. They
saw piles of putrefying corpses ; they could not escape from the smell of
them; they felt themselves crushed by the weight of them. Sometimes
they heard the cries of the wounded or the voices of their dear ones at
home. Some, though not all, were able to judge their experiences
critically, and most on recovery were able to recollect their condition.
There was extreme hyperasthesia and irritability; not merely the touch
but even the approach of a hand was sometimes unendurable, and
sometimes the knee-jerk was so exaggerated that it involved a convulsion
of the whole body, and an involuntary scream. Most of these cases
recovered completely within four weeks. Havelock Ellis.

Two Cases of Destruction of the Lower Juft Frontal Gyrus [Zwei Falle
von Zersioruttg der unteren linken Stirnwindung\ (Jourtt . f
Psychol, u. Neurol ., Bd. ix, 1907.) Liefmann .

Liepmann has contributed two cases to sustain the controversy
raised by Pierre Marie, who has tried to show that the lower part of the
third frontal gyrus has nothing to do with aphasia though injury to it
may cause anarthria % /.<?., difficulty of articulation. Marie regards the
region about the nucleus lenticularis as implicated in motor aphasia.

The first of Liepmann’s cases was an old woman admitted into the
Charity Hospital in Berlin affected with senile dementia and delusions of
suspicion. In the Charity Hospital she was seized with cortical motor
aphasia. She became unable to utter a word, could not comprehend
writing, reading, and could only copy writing. She retained the
capacity of understanding speech. After being above two years in this
speechless condition she died.

On examination the dura was found adherent to the skull, the
convolutions small, the sulci deep and broad ; in place of the third
frontal gyrus there was a cavity over w'hich the pia was stretched.
Nothing remained of the gyrus save a piece about two centimetres
broad in the front part. There were yellow spots on the vessels of the
base of the brain. Marie’s lenticular zone was unaffected.

While this case gave support to the old view advanced by Broca,
the second one detailed by the Berlin professor seemed to strengthen
the thesis of Marie that the third frontal has nothing to do with
language. This was a case of senile mental decay. The man could
still count, knew the multiplication table, and could read and write.

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EPITOME.

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His speech was slow and somewhat deficient in sense, but he was
talkative. He said that he had several paretic attacks which affected
the left side. He died of failure of the heart's action after being four
weeks in the hospital.

On examination, there was noted adhesion of the membranes with
the skull, paleness of the pia, sclerosis of the vessels, and general
atrophy of the brain, which weighed 1,200 grammes. There was
extensive destruction of the lower part of the left inferior frontal
implicating the whole of the pars triangularis and the anterior half of
the pars opercularis. The foot of the gyrus and the pars orbitalis
seemed to be intact. There is given an engraving of the lateral aspect
of the left hemisphere. At the time of publication of the article the
brain had not yet been sliced for further study. From such a serious
lesion to Broca's convolution one might have expected a manifestation
of motor aphasia, and as nothing of the kind appeared the injury
discovered might be considered a confirmation of Marie's disbelief.
On inquiry into the man’s antecedents it transpired that ten years before
he had a severe apoplectic attack with what was recalled as left¬
sided paralysis. For a fortnight he spoke a little, after which he
became speechless. This mute condition lasted for three weeks, after
which he began to learn slowly again to speak ; but half a year elapsed
before he regained ordinary speaking capacity. Writing was lost along
with speech, although he was always able to understand what was said
to him. The man was naturally right-handed. Liepmann’s explana¬
tion is that at this time the patient had motor aphasia, and that during
the ten years there was a restitution of the speech faculty by the
vicarious function of other parts of the cortex.

William W. Ireland.

3. Pathology of Insanity.

On the Alkalinity of the Blood in Epilepsy [Z’Alkaliniia del Sangue negli
Epilettici\ {II Manicomio^ N. 1,1907.) Tolone>J\

Dr. Joseph Tolone, Assistant Physician in the Provincial Asylum of
Catanzaro, has made some careful researches upon this subject, which
has already been studied by several Italian and French observers.

He divided his patients into three groups. In the first, ten in number,
the epileptic attacks recurred at long intervals; in the second group of
four the intervals were short, sometimes two or three attacks in the
day ; in the third five cases the attacks habitually recurred from three to
eight days. With all his epileptic patients the blood was less alkaline
than with healthy persons. Where the fits returned after long intervals
the alkaline reaction of the blood, though less than the normal, was
higher than in the other groups. In those cases in which the intervals
were short the alkalinity was lowest just before and after the attacks. In
the group between those of medium frequency the degree of alkalinity
rose almost up to normal and then sunk till the epileptic attack, after
which it mounted.

Dr. Tolone put the question whether the diminution of the alkaline

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PATHOLOGY OF INSANITY.

599

reaction of the blood be due to the diminution of the alkaline salts
proper in the circulating fluid, or to the excess of acid substances owing
to retarded elimination.

It is not easy, he remarks, to answer this question. The observation
of Biemaki that the diminished alkalinity is owing to the accumulation
of lactic acid has not been accepted by any other observer. The
epileptic attack cannot be caused by the lessened alkalinity of the blood,
since Charon and Briche have found that it cannot be put off by re¬
peated injections of alkaline solutions, nor can the alkalinity depend upon
the attack, because it is actually lessened in degree thereafter. Tolone
himself thinks that the diminution of alkalinity depends upon the pro¬
duction of substances due to retrogressive changes or to diminished
elimination, perhaps owing to the lessened action of the liver. Thus
toxic matters accumulate in the blood, which act upon the cortical
matter of the brain, but the resulting disturbance represents a reaction
and favours the elimination of the toxic products especially by restoring
the power of the hepatic cells. ' William W. Ireland.

Investigations upon the Spinal Fluids in Mental and Nervous Diseases
[ Untersuchungen der Cerebrospinalflussigkeit bei Geistes und Nerven -
krankheiten\ (Arch. /. Psychiat ., Heft. 2, Bd. 42.) Henkel.

The study of the state of the cerebro-spinal fluids in disease has
been mainly initiated by French pathologists. Schoenborn was the
first to take it up in Germany. He was followed by Siemerling and
Meyer.

Lumbar puncture has been principally useful for diagnosis; its thera¬
peutic value has been slight. Meyer found that in almost all cases in
which there was organic disease with chronic meningitis there was an
increase of lymph cells in the cerebro-spinal fluid. He describes these
lymph cells as small round nuclei with indistinct contour, at one part
clearer but without granules. In general paralysis he has found bigger
blue nuclei, which within the cells are surrounded by red granules.

As the result of his observations in the Psychiatric Clinique at Kiel,
Dr. Henkel gives the following conclusions: He has regularly found
a considerable increase of lymph cells, abundance of serum albumen, and
increase of serum globuline in progressive paralysis, tabes, lues cerebri
and cerebro-spinalis, and in all the forms of meningitis. These appear¬
ances were also constantly observed in cerebral tumours although in a
lesser degree. It is much the same in myelitis, only there is a greater
relative increase in the amount of albumen. In arterio-sclerosis, multiple
sclerosis, and syringomyelia the changes in the cerebro-spinal fluid
were variable; perhaps they depended upon the seat of the lesion.
In early syphilis without organic implications there was sometimes a
small increase of lymphocytosis. No such production of cells could be
found in infantile paralysis or in functional disease. One had the im¬
pression that in chronic processes single nuclei, in acute processes cells
with several nuclei, were most abundant. Inflammations seemed to
favour the increase of cell-formation, but the manner of this increase
could not be made out. William W. Ireland.

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EPITOME.

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Changes in the Blood , especially in Insanity [Le Alterazioni del Sangue
in Rapporto specialmente alle Malattie Mentah\ (II Manicomio ,
N. i and 2 , 1907.) Galdi.

Formerly, there was too much solidism in our pathology, but of late
years there has been a closer study of the varying conditions of the
circulating fluid in health and in disease.

Such researches are enormously difficult, and often the results of
different observers clash with one another. Dr. Galdi has undertaken
the useful task of collecting from the medical literature of Europe and
America the more recent studies on the blood in mental and nervous
diseases. His two papers fill one hundred pages, and he cites 270
works which contribute to the subject. According to Schaeffer the
coagulation of the blood takes place under the influence of a ferment
(trombina), which is formed by an unknown reaction of a nudeo-
proteid (protrombina) with atoms of calcium. This protrombina is
found in various cells, principally in the leucocytes. After the protrom¬
bina forms an enzyma with the salts of calcium, coagulation becomes
possible. In some conditions the formation of the nucleo-proteids and
their reaction are hindered, causing the coagulability of the blood
to vary. The whole of the fibrin ferment is not used in the process of
coagulation ; some of it still remains free in the serum. Galdi observes
that in spite of the large number of observations, in which Italian
pathologists have taken a large part, it is difficult to arrive at any certain
conclusions. He, however, sums up in five pages :

The coagulability of the blood is much diminished in epilepsy,
especially when the convulsive attacks are frequent, which may depend
upon a reduction of the functional activity of the liver. The alkalinity
of the blood is constantly diminished in epilepsy and in pellagrous
insanity. The alkalinity of the blood has also been found to be
lessened in mental confusion and dementia prsecox, general paralysis,
and in mental disorders in which there is great motor restlessness; but
it is increased in the alcoholic forms. Hypoglobuly, diminution of the
red corpuscles, is a symptom of intoxication, infection, malnutrition,
and morbid diathesis, while hyperglobuly indicates a state of molecular
concentration of the blood. These states have only an indirect rela¬
tion to the mental disorders depending upon divers conditions and
constituting the substratum upon which the derangements implant
themselves. Hypoglobuly with a deficiency of haemoglobin was
noticed in mania, melancholia, dementia, and general paralysis—condi¬
tions of great agitation, especially at the beginning and with female
patients. The deficiency of haemoglobin is observable before the
hypoglobuly. The alteration of the red corpuscles commences with a
diminution in their colouring matter.

Hyperglobuly was observed in maniacal states in epileptics after the
convulsive attacks, in the optimistic stage of general paralysis and
in the excited phases of maniacal depression. In patients with
goitre, myxoedema, and acromegaly the haemoglobin is diminished
while the red corpuscles appear normal. Some interesting observations
have been made in vascular neurasthenia. Cabot, Vigoroux, and
others have observed an alteration in the number of the red corpuscles

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1908.]

after the application of static electricity, massage, and baths. In these
results, which are sometimes contradictory, one must bear in mind the
influence of the tonicity of the vessels, so variable with the neurasthenics,
exercised upon the quantity of the globules at the different times when
the blood is examined. Cheron has described a vascular neurasthenia
characterised by the apparent anaemia (hypoglobuly with hydraemia),
which may appear at any time. This is solely owing to relaxation
of the muscular coats of the arteries. In these cases of functional
anaemia, Cheron used an injection of from 5-10 c.c. of salt water,
1 per cent, of which was followed by a considerable elevation of arterial
tension and an increase of red globules from one-fourth to one-third.
The apparent hypoglobuly is entirely owing to the stimulus exercised
upon the nervous system by the injection. It diminishes gradually to
be replaced by the antecedent hyperglobuly.

It was found by observation upon the influence of the emotions on
the constitution of the blood and the state of the capillaries, which are
under vasomotor influences, that the number of the blood-corpuscles
varied. Joy induces an active dilatation of the capillaries anfl then
hypoglobuly. Sadness, on the other hand, causes constriction with
hyperglobuly. Hypoglobuly and hyperglobuly accompany the first
vasomotor variations often before the mental affections, which is a proof
that the alterations in the vessels are anterior to the emotions.

Careful observations were made upon the state of the haematoblasts.
Like the red corpuscles they were found to be diminished in quantity
at the beginning of attacks of insanity, to resume their normal proportions
in dementia.

The results obtained by different observers about the globular resis¬
tance in insanity were sometimes discordant. What is meant by this
expression is the more or less readiness with which a specimen of blood
parts with its haemoglobin to a graduated saline solution. It may be
said that in general the globular resistance is less in insanity than in the
normal condition, and that the greatest alterations in the blood are met
with in processes of intoxication or of altered metamorphosis as in
pellagra, dementia paralytica, and the first stage of dementia praecox.
Also in mania, melancholia, and alcoholism, senile dementia, and in
epilepsy the globular resistance is always found diminished. In epilepsy
the greatest loss of tone may either accompany the convulsive attacks,
precede or follow them.

From recent studies upon infection, it has been supposed that the in¬
crease of polynuclear white corpuscles indicates the reaction of the
organism when an acute infection demands a prompt defence. In fact,
it has been found that an increase of such polynuclear leucocytes, a
diminution of leucocytes with a single nucleus and of lymphocytes, takes
place at the outset of insanity of toxic infective origin, and the process is
reversed on recovery. In the first stage of dementia praecox, in tabes,
and in dementia paralytica there is an increase of the white corpuscles,
especially with those which have several nuclei; but as these diseases
progress a return to the single nuclei leucocytes and to the lymph
corpuscles is observed.

Galdi remarks that the treatment of mental diseases by serum,
notably in pellagra and epilepsy, has as yet yielded no beneficial results,

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602 epitome. [July*

while it has sometimes done mischief. In spite of many researches
these experimenters are still sailing in the sea of hypothesis.

It has, however, been proved that the serum of the blood taken from
patients suffering from pellagra and epilepsy has a malign influence upon
the development of the embryo, arresting growth or producing mon¬
strosities. A similar power seemed to be possessed by blood taken from
cases of mania and melancholia.

Cappelletto, while admitting the recurrence of various microbes in the
blood which may come from the intestines, denies that they have any
importance as causes of mental derangement Ceni believes that the
morbid factor of acute delirium cannot be single and that the various
microbes found in the blood (stafilococci, streptococci, micrococci
tetrageni) can only be a true secondary auto-infection, and that they
constitute a complication which always aggravates acute insanity.

Galdi assigns to Dr. Johnson Smith a priority in observing the density
of the blood in forms of insanity. After explaining the researches of
Dr. W. Ford Robertson upon the pathology of general paralysis and its
assigned factor, the diptheroid bacillus, Galdi observes that it is still to
be proved that the bacterium of gastro-intestinal origin is the primary
cause of the malady and not secondary to the morbid process in the
brain, and that the diphtheroid bacillus is really specific and nothing
more than one of the many bacteria of “ the intestinal flora ” which, in
ways not yet clearly known, enters the circulating fluid already
depraved.

In conclusion, Galdi tells us that the catalytic power in the blood has
been found much diminished in different forms of insanity, especially in
dementia praecox and dementia paralytica, in epilepsy and in acute
delirium. The activity of catalysis seems to hold some relation to the
intensity of the insanity.

Catalysis is a name given by chemists to an obscure process by
which the presence of one substance aids in the decomposition of
another without itself appearing to be changed. Thus a small quantity
of platinum minutely divided acts as a decomposer of oxygenated water,
setting free the oxygen. In like manner Senter found an enzyma in
the blood which he named emasi , and Issayew isolated another enzyma
from the cells of a ferment which were found to act upon oxygenated
water in the same way as pulverised platinum. Schonbein first showed
that many vegetable and animal structures when brought in contact
with oxygenated water set free oxygen. Ferments which acted in a
similar manner have been found in animal tissues, especially in the
liver, kidney, spleen and glands, and also in the blood, heart and
brain.

The researches of pathologists in this difficult inquiry have been few
and doubtful, but catalytic products have been found in some urines and
in pus. Iolles and Oppenheim found the reducing action of the blood
upon oxygenated water diminished in tuberculosis, nephritis, and in
many intoxications produced by acids and carbonic oxide. They
think that the symptoms of death through freezing and comatose
conditions may be sustained by the failing activity of catalysis.

Pighini has endeavoured to study the catalysis of the blood in mental
diseases. He began by making experiments on animals. Some dogs

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PATHOLOGY OF INSANITY.

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1908 .]

of medium size and age were made to inspire carbonic oxide, while on
others there were practised injections of aspergillus, and from others
the parathyroid glands were removed. Before and after the intoxica¬
tion blood was taken from the external jugular and then subjected to
examination.

It was found that catalytic products were contained in the blood
during the acute and potential stages of the intoxication, but their
action on oxygenated water was less powerful.

Pighini studied the catalytic power of the blood in sixteen insane
patients; two of these were suffering from maniacal depression, five
from dementia praecox, five from epilepsy, and one from acute delirium
and three from dementia paralytica. The general result was that the
catalytic power was found to be notably diminished in the different
insane patients examined. It appeared likely that there was some
relation between the acute state of the insanity and the dynamic power
of the catalysis; but there are many causes which may modify the
activity of the blood. William W. Ireland.

Contribution to the Study of Auto intoxication in Mental Confusion
[Contribution d Ffijude de FAuto-intoxication dans Confusion
Mentale\ (A Thesis.) Prunier % Andrt.

In this thesis, Dr. Andr£ Prunier discusses the question of auto¬
intoxication in confusional insanity by an estimation of the toxicity of
the urine. The subject of a toxicity of the urine has been of interest
for many years, for Maron in 1868 first injected some subcutaneously,
but obtained negative results and declared that it was inoffensive.

In a short review of the literature upon the subject the author refers to
the observations of several workers at the Congress of Mental Medicine
held at Rochelle in 1893, at which the *hole question was discussed.

Gilbert Ballet and Roubinovitch stated that the urine of melancholiacs
was hypertoxic, and that of maniacs less so, whilst from “mental
degenerates ” very variable results were obtained. Lavaure compared
the toxicity of serum with the urine, and in two cases of mental
confusion found that both were distinctly hypertoxic.

The author then describes how he carried out his experiments in
guinea-pigs, taking especial care to correct the general causes of error
in the technical details. He selected the urine from six patients who
were suffering from mental confusion, and who at the same time
showed signs of gastro-intestinal disturbance (constipation, diarrhoea,
attacks of vomiting, excessive appetite, etc.), and he describes it as
being hypertoxic in each case. He repeated each of his experiments
on three different occasions.

He concludes from his own cases and from a review of the literature
that there exists in most patients suffering from confusional insanity
some gastro-intestinal trouble, as shown by abnormal fermentations,
altered secretions, constipation, etc., all tending to exaggerate the
production of intestinal toxines. Owing to an excessive production
and absorption the kidney is stimulated to further work, so that there
appears “a hypertoxicity of the urine.” But this “hypertoxicity of
deience” is not equal to the amount of toxine absorbed from the

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604 notes and news. [July,

intestinal canal, so that an auto-intoxication of the body is produced
which manifests itself by various physical signs and by the appearance
of mental confusion. After injection of the hypertoxic urine, all the
animals died in convulsions—in opisthotonos with trismus, never in
coma; and he attributes this to the presence of a ptomaine in the
injected urine.

Although the toxicity of the urine has been determined in several
diseases, />., general paralysis, epilepsy, etc., yet the value of the
method has been seriously disputed, and these results must be
accepted with considerable reserve. The author jumps too readily to
the conclusion that the hypertoxic urine indicates the body is poisoned
with toxines. Moreover it is very difficult to decide whether the
observed or alleged disorder is the cause rather than the result of the
disease in the central nervous system.

The question of auto-intoxication is most interesting and fascinating,
and about which much has been written, but of exact observations
there are but very few. Sidney Clarke.

Part IV—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF THE UNITED

KINGDOM.

A General Meeting of the Association was held at n,Chandos Street, Caven¬
dish Square, London, on Tuesday, May 19th, 1908, Dr. P. W. MacDonald, Presi¬
dent, in the chair.

Present: T. S. Adair, C. Aldridge, H. T. S. Aveline, C. H. Bond, A. N. Boy¬
cott, J. Chambers, M. Craig, W. R. Dawson, 1 . F. Dixon, T. O’C. Donelan, A. C.
Dove, T. Drapes, F. W. Edridge-Green, F. H. Edwards, F. A. Elkins, J. A. Ewan,

C. H. Fennell, N. J. H. Gavin, T. D. Greenlees, H. E. Haynes, J. W. Higginson,
H. G. Hill, Robert Jones, N. Lavers, H. Wolseley-Lewis, H. J. MacBryan, J. H.
MacDonald, P. W. MacDonald, M. E. Martin, W. F. Menzies, C. A. Mercier,
W. J. Mickle, A. Miller, C. S. Morison, D. Orr, H. Rayner, D. Rice, R. G. Rows,
G. H. Savage, G. E. Shuttleworth, R. Percy Smith, R. H. Steen, C. T. Street,

D. G. Thomson, F. Watson, T. Outterson Wood.

Apologies for absence were received from : Drs. Bedford Pierce, Clouston,
Hamilton Marr, H. H. Newington, Nolan, Turnbull, and Urquhart.

At the Council meeting were present: The President and Drs. Aveline, Hubert
Bond, Boycott, James Chambers, Craig, Dawson, Drapes, Ewan, Fennell, Robert
Jones, Wolseley-Lewis, Mercier, Miller, Orr, Rayner, and Steen.

The Minutes.

The minutes of the last meeting having already appeared in the Journal, were
taken as read, approved, and signed.

The President said that, arising out of the minutes, a letter had been received
from the Commissioners in Lunacy, which he asked the Secretary to read.

The Secretary (Dr. Hubert Bond) said members would remember that he was
instructed to forward to the Commissioners in Lunacy a resolution passed at the
last meeting of the Association in reference to the Factory and Workshops Act,
1908.

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1908.]

NOTES AND NEWS.

60S

Obituary References.

The President said : Before we enter on the work of this afternoon, I crave your
indulgence for a few moments while I endeavour to convey an expression of our
sympathy and condolence with the relatives and friends of those members whose
loss by aeath we have to-day to deplore. Since our last meeting we have lost three
distinguished members: Dr. Conolly Norman, Dr. M. D. MacLeod, and Dr. G. R.
Wilson. Fitting and appropriate tributes to their memories have already appeared
in the pages of our Journal, and therefore but few words are needed from me
to-day. Dr. Conolly Norman was a man of many parts, a true lover of all things
beautiful, whether in literature, science, or art, a gifted companion and a true
friend. As an able physician, he has left a noble and inspiring memory. As I
think we may say he died on the field of battle, another name is thus added to the
long roll of Irishmen who through life’s journey claimed the proud title, “ Without
fear, without reproach.” When the sad news of his all too early and unexpected
death reached us, one was reminded of the noble peroration, as if it were Conolly
Norman’s last farewell: 11 The hour of departure has arrived, and we go our ways
—I to die, you to live; which is the better, God only knows.” Dr. MacLeod was,
as I think most of you know, stricken down with a serious illness at an early age,
yet his interest in and love for his work remained as keen as ever throughout years
of advancing physical weakness. The proud possessor of a great name, by nature
a true clansman, keenly interested in many walks of life outside his profession, our
departed friend was the most generous and large-hearted of hosts and companions.
In Dr. G. R. Wilson we have lost an able worker in many fields of inquiry, and his
all too early death is a distinct loss to science and the profession of which he was
such a devoted member. I am sure it is your wish that appropriate letters con¬
veying our sympathy and condolence be sent to the sorrowing friends.

The suggestion was acceded to, all the members present upstanding.

Election of Members.

Dr. C. C. Bullmore and Dr. Richard Kelly were duly elected ordinary members.

The President said all would have noticed a vacant chair that day. No one
felt more than he did the loss of one of the greatest pillars of the Association at the
meetings, the honoured Treasurer, Dr. Hayes Newington, and he asked the permis-.
sion of the meeting to send to that gentleman a telegram of sympathy in his en¬
forced absence from the meeting.

Agreed.

Contributions.

Dr. David Orr read a contribution by himself and Dr. R. G. Rows on ” Some
points in the Histology of Lymphogenous and Hsematogenous Toxic Lesions of the
Spinal Cord ” (see page 560). This was followed by a lantern demonstration.

The President said he was sure all must admire this most interesting demon¬
stration. He did not anticipate that there would be any difference of opinion that
the two gentlemen who were working so diligently and earnestly were on the right
track. He hoped they would continue their work, as he and all felt sure they
would have their reward. The authors had informed him that they did not invite
a general discussion at this stage of their work, and that they hoped to makea
further contribution at a later date.

Dr. D. G. Thomson then read a paper on " The Teaching of Psychiatry ’’ (see
page 550).

A discussion followed in which Drs. Savage, Percy Smith, Orr, Mercier, Bond,
and the President took part.

A letter from Dr. Clouston was read, suggesting that the matter being so im¬
portant might be brought up again at the Annual Meeting, the Educational Com¬
mittee in the meanwhile to be asked to consider it.

It was agreed that a motion dealing with the subject should appear on the
Agenda paper of the Annual Meeting, in Dr. Thomson's name, and that the matter
should also be referred to the Educational Committee.

The members and several visitors subsequently dined together at the Cafe
Monico.

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NOTES AND NEWS.

[July.

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South-Eastern Division was held by the courtesy
of Dr. Seward at the London County Asylum, Colney Hatch, on Tuesday, April
28th, 1908.

Among those present were Drs. MacDonald (President), Harvey Baird, C. H.
Bond, P. E. Campbell, Jas. Chambers, R. H. Cole, H. Corner, J. F. Dixon, W. J.
Donaldson, J. O’C. Donelan, A. C. Dove, F. A. Elkins, J. S. Gordon-Munn, N. J.
Gavin, T. D. Greenlees, H. E. Haynes, J, W. Higginson, Robert Jones, Mary E.
Martin, A. S. Newington, G. E. Peachell, W. Rawes, W. J. Seward, J. G. Smith,
James Stewart, D. S. Thomson, P. W. Turnbull, F. Watson, R. Whittington,
T. Outterson Wood, H. Wolseley-Lewis, and R. H. Steen (Hon. Sec.).

The visitors included George Billings, Esq. (Member of the Visiting Com¬
mittee), W. C. Clifford-Smith, Esq., and Drs. Birt, Howden, Jones, and Blandy.

Apologies were received from Drs. Alliott, Amsden, Boycott, Bower, Ewart,
S. J. Fielding, Haslett, Kingsford, Moody, Mott, Shuttleworth, R. Percy Smith,
Taylor, and H. V. Walker.

The wards of the institution having been visited Dr. Seward entertained the
members to luncheon. At the termination of the lunch the President proposed a
vote of thanks to Dr. Seward for his kindness in so hospitably receiving the
Division.

The meeting of the Divisional Committee was held at 2.15 p.m.

The general meeting was held at 2.45 p.m., the President in the chair. The
minutes of the last meeting, having appeared in the Journal, were taken as read
and confirmed.

The following members were elected by voting papers to take office for 1908-9

Hon. Secretary of the Division.—Dr. R. H. Steen.

Representative members of the Division on the Council.—Drs. Boycott, Fennell,
Wolseley-Lewis, and F. W. Mott.

The following gentlemen were elected as ordinary members of the Association;

Dr. Edgar Faulks, Assistant Medical Officer, London County Asylum, Bexley, 4
and Dr. Francis Arthur Knox Stuart, Assistant Medical Officer, West Sussex
Asylum, Chichester.

Drs. Seward, R. H. Cole, and J. G. Smith were elected as members of the South-
Eastern Divisional Committee of Management, which now consists of the follow¬

ing:

Retire in 1909. Retire in 1910. Retire in 1911.

Dr. Donaldson. Dr. Taylor. Dr. Seward.

Dr. Crookshank. Dr. R. Langdon-Down. Dr. R. H. Cole.

Dr. Stoddart. Dr. Dixon. Dr, J. G. Smith.

The invitation of Dr. Elkins to hold the autumn meeting of the Division at

Leavesden Asylum was unanimously accepted with much pleasure. The date was
fixed for October 6th, 1908. The date of the spring meeting was fixed for April
27th, 1909.

Contributions.

Dr. W. J. Seward read a* paper entitled, “ Notes on the History of Colney
Hatch Asylum.”

It having been suggested to me that it might be of interest on this occasion if a
short account were given of the history of the Asylum, I very willingly undertook
the duty, but 1 have to ask for your kind indulgence as I have been unable, owing
to unforeseen circumstances, to devote as much time as I intended to the pre¬
paration of the following notes :

As you are doubtless aware, this Asylum originally belonged to the old County
of Middlesex, and was transferred in 188910 the new County of London under
the provisions of the Local Government Act of 1888. Hanwell, which was the
first asylum erected for the County of Middlesex, was opened in 1831, with
accommodation for about 500 patients, which was gradually increased, till in
1846 the number of patients was 972. By this time such a large increase had
taken place in the number of patients needing asylum care and treatment that
Hanwell was unable to supply half of the required accommodation. It was there-

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NOTES AND NEWS.

607

1908.]

fore evident that a second asylum must be provided, and in January, 1847, the
Court of Quarter Sessions appointed a Special Committee to select a suitable
site, and they eventually secured the property on which the Asylum now stands,
its area being 119 acres, and the price paid being at the rate of £150 per acre.

Premiums were then offered for plans, and a number of leading authorities in
connection with asylums and hospitals having been consulted, those submitted by
Mr. S. W. Daukes were eventually selected. The estimate based on the original
plan was .£80,000, but many additions and alterations were subsequently made,
including the Recreation Hall, and when the plans were finally settled the lowest
tender amounted to £138,000.

On the 8th May, 1849, the Foundation Stone was laid by the Prince Consort,
and at the conclusion of the ceremony the Lord Lieutenant of the County (the
Marquis of Salisbury of that day) announced by the Queen’s command that Her
Majesty had been graciously pleased to found a fund, to be called the Victoria
Fund, for the relief of patients discharged on recovery.

The building, as far as the original contract was concerned, was completed in
less than eighteen months, and was handed over to the Committee on the 31st
October, 1850; but much work remained to be done, including a costly system of
heating and ventilation, which eventually proved to be a failure. The chapel was
dedicated and the cemetery consecrated by Dr. Blomfield, Bishop of London, on
the 1st July, 1851, and on the 17th of the same month the first patients were
received. The final total cost, including the land and equipment, was £292,000,
and as accommodation was provided for 1240 patients, the cost per bed was about
£235. This would now be considered a moderate expenditure, but the Com¬
mittee evidently feared that it might be thought extravagant, and they were
therefore careful to point out that they had considered it their duty to provide an
asylum “ complete with all that modern science and the present enlightened views
of humanity had rendered available for the care and comfort of the unfortunate
class of invalids to whose use it was to be dedicated, and that they would not
show a proper estimate of the generous sympathy of the ratepayers towards this
suffering portion of their own poor neighbours if they sacrificed to a feeling of
false economy anything that could minister to the mind diseased”; and they
concluded their first report by reminding the ratepayer of 11 those encouraging
words of Scripture, * He that hath pity upon the poor lendeth unto the Lord:
and look, what he layeth out, it shall be paid him again.’ ”

When completed the building was described as “standing unrivalled as a lunatic
asylum, unique in size, elevation, and accommodation, in this country or perhaps
any other,” and a printed guide was prepared “ for the use of the numerous
visitors, English and foreign, who visited the Asylum during the period of the
Great Exhibition in the Crystal Palace in Hyde Park, among whom were many
men of high standing in the ranks of philanthropy, art, science, medicine, and
architecture.” It does not seem to have occurred to anyone that this building,
which was considered to be so perfect, would within a few years be regarded as
being altogether out of date, and that it would be necessary for very large sums
to be expended in order to bring it up to something approaching the requirements
of the future in regard to comfort and sanitation.

The elevation is generally considered to be handsome and artistic, but the
interior of the wards then presented an extremely gloomy and depressing aspect.
An arched fireproof ceiling of tiles and concrete, similar to that still to be seen in
the corridors, gave to the wards a tunnel-like appearance, and the very small iron
window-frames admitted a minimum of light and air. The w.c.’s consisted, even
in the largest wards, of two small rooms, opening directly into the ward, and each
provided with a single seat. As regards furniture nothing was provided beyond
plain deal tables and benches, the rough unplastered walls were not even painted,
but simply whitewashed, and there was a total absence of pictures or any kind of
decoration. Some of the arrangements of those days for the health and comfort
of the patients seem strange to us now. In the original rules for the weekly
bathing it was provided that not more than three patients should be bathed in the
same water, and' it was considerately added that the more sensible and cleanly
patients should have the privilege of entering the bath first.

Incidental reference has been made to the erection of the Recreation Hall, and
although it will not compare with the magnificent halls of our modern asylums, it

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6o8

NOTES AND NEWS.

[July,

is not without historic interest, as it was described as a “great new feature,” and
it would seem probable that it was the first hall of the kind which was ever erected
in connection with an English asylum. It was not, however, originally intended
for entertainments and dances, but as a place in which the patients might take
exercise in wet weather, and the words “ Exercising Hall,” which appeared in
large letters on the front of the gallery, were removed only a few years ago.

The Medical Staff consisted of two medical officers, who had charge of the
male and female sides respectively, and their salaries were £200 per annum.
They were not then called Medical Superintendents, and it was only two years
later that an Assistant Medical Officer was appointed as an experiment. The
first medical officers appointed were Dr. (afterwards Sir Charles) Hood and Dr.
J. G. Davey, both of whom resigned their appointments in the year following the
opening of the Asylum, the former on his election as Resident Physician at
Bethlem, and the latter on obtaining a Government appointment in Ceylon.

The beneficent work of Dr. Connolly at Han well was still so far a novelty, that
it was thought necessary to draw special attention to the fact that mechanical
restraint would not be used at Colney Hatch. In the first report reference was
made to the large number of patients who were brought to the asylum in restraint,
many of whom had for a long time been tied down in their beds in the work-
houses.

It would seem, however, that chemical restraint was freely used in the form of
opium, and there is a curious account in the first report of the administration of
chloroform on two occasions “ with most decided success ” in the case of a female
patient who was in a condition of acute maniacal excitement. The report is as
follows: “ I found her in a dreadful state of excitement, plunging about in so
violent a manner that to leave her alone even in a padded room, was deemed
impracticable and unsafe. Such continuous and exaggerated insane impulse I
have never before seen. The attendants were exhausted, literally worn out with
fatigue; the inhalation of 5iss chloroform not only deprived her directly of all
muscular power, but threw her into a profound slumber, in which she continued
for nine consecutive hours. It was some days before she recovered the free use of
her lower extremities, her gait assuming that of a person partially intoxicated;
and, what is worthy of notice, perhaps, the use of the catheter was for some eight
or ten days after its inhalation rendered necessary.” It was added that the use
of chloroform in such cases was probably not unattended with some danger, an
opinion with which most of us are likely to agree. Within a few months
of the opening of the asylum there was a severe outbreak of dysentery in the
wards, many of the cases ending fatally. As a preventive, and as an aid to con¬
valescence, an experiment was made in the substitution of cider for the customary
allowance of beer, it being thought that the free acid which it contained might
give a healthy stimulus to the digestive organs, and it was believed that some
benefit resulted from this treatment.

On the last day of the year 1851, what was described as “ a novel and extra¬
ordinary experiment” was made, which is thus recorded in the first annual report:
“on New Year's Eve the committee was enabled (such was the perfect order and
discipline established in every department) to allow a festival to be given to the
patients, of the nature of those so much approved and enjoyed at Hanwell, but
with this additional and remarkable feature, that the lunatics of the two sexes met
at the same time in the large exercising hall and danced together, enjoying several
hours of rational amusement, to the honour of the non-restraint system, without a
single incident to . cause alarm, annoyance, or regret, either at the time or after¬
wards, the asylum during the night being more tranquil than usual.” If we are
tempted to smile at this rather quaint account of what has long been part of the
ordinary routine of every asylum, we must I think admire the courage of those
who made a novel departure, which evidently caused them no little anxiety.

Time will permit me to refer but briefly to the subsequent history of the asylum.
Through successive enlargements the number of patients gradually increased,
until in 1883 they reached a total of 2240. In 1896 the deficiency of accommo¬
dation in the County of London had become so great, that it was necessary to
provide additional beds with as little delay as possible, and temporary buildings
for 300 female patients and the necessary staff were erected and occupied within
little more than six months, the number of patients being thus increased to 3584.

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NOTES AND NEWS.

609

1908.]

These buildings were destroyed by the disastrous fire which occurred in January,
1903, and will shortly be replaced by the new buildings which are now in course of
erection. The area of land belonging to the asylum has been increased by suc¬
cessive purchases, and now amounts to 165 acres.

Some thirty years ago the structural alterations and improvements were com¬
menced, which have been in progress from time to time ever since. The arched
ceilings were removed, the prison-like windows replaced by large sashes, sanitary
blocks were built, and in the majority of the wards the walls have been plastered.
The drainage system has recently been entirely renewed, and the male wards are
now warmed by means of steam from a central boiler-house, an arrangement
which is being extended to the remainder of the building. Much still remains to
be done, and it is hoped that the work of improvement may be continued.

Our population is unique among the asylums of this country in the number
of Jewish patients which it includes, all the pauper patients in the county who
are of this faith being sent here. They now number over 400, and are rapidly
increasing. Arrangements are made for their religious requirements, a minister
holding services twice weekly, and they have a special dietary, which is prepared
by a Jewish cook in a separate kitchen. As a large proportion of them are aliens
of Russian nationality, who speak little or no English, it is necessary for us to have
an interpreting attendant on our staff. All these special arrangements necessarily
involve a considerable additional expenditure.

As already mentioned, both of the medical officers who were originally ap¬
pointed resigned in the year following the opening of the Asylum. Sir Charles
Hood, who subsequently held the position of Lord Chancellor’s Visitor, was
followed by Mr. D. F. Tyerman, and he was succeeded in 1862 by Dr. Edgar
Sheppard, who was for many years Professor of Psychological Medicine in King’s
College, London, and to whose enthusiasm for hydrotherapeutics we owe our
very useful Turkish bath ; he retired in 1881. Mr. W. G. Marshall was appointed
to succeed Dr. Davy in the charge of the Female Department, and he held office
for more than thirty-eight years. On his retirement in 1890 it was decided that
in future there should be one Medical Superintendent for the whole of the
Asylum. The memory of my two old chiefs, with whom it was a privilege to be
associated, will always be cherished by me. I must also refer to our former
Chaplain, the late Rev. Henry Hawkins, who was so well known to many who
are here to-day. As the founder of the After Care Association his name will
long be remembered and honoured. A tablet #0 his memory has been placed in
the Asylum Chapel.

The work of bringing an old asylum up to the level of modern requirements is
very costly, and can never be completely satisfactory. It has been suggested
that it was a mistake to attempt it, and that it would have been better to entirely
demolish and rebuild. From what you have had an opportunity of seeing to-day
you will be able to judge to what extent success has been attained.

Discussion.

The President said he was sure that all present were very much indebted to
Dr. Seward for the excellent way in which he had brought before them the history
of so well-known an institution. He complimented Dr. Seward and the com¬
mittee for the admirable arrangements made for the care of the Jewish patients.

Dr. D. G. Thomson said that as superintendent of the oldest existing public
asylum he had been extremely interested in hearing the historical references in Dr.
Seward’s paper. He thought it would be difficult to answer Dr. Seward’s question
as to where an entertainment room was first established in a public asylum,
because many asylums some time before 1851 had dining halls, and the practice in
earlier days seemed to have been to remove the benches and tables from the halls
and to allow the patients to dance and have entertainments in them. Certainly
long before 1850 there were associated entertainments at the Norfolk County
Asylum.

Dr. Robert Jones pointed out the great changes for the better which had taken
place at Colney Hatch Asylum since he was Assistant Medical Officer there many
years ago. He stated that he was much interested in the question of Turkish
baths as a means of treatment of the insane, and he expressed the hope that some

LIV. 43

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NOTES AND NEWS.

6lO

[July,

day Dr. Seward would be able to find time to write a paper on the value of this
treatment.

Dr. Outterson Wood having also spoken,

Dr. Seward replied.

Mr. W. C. Clifford Smith read a paper entitled, “ A Descriptive Account of
the Buildings now in course of erection at Colney Hatch/'

The opportunity of providing in new buildings for the deficiencies of the old
occurs so frequently in asylums that I almost require to submit an apology to you
for offering for your consideration a description of the structures now in course of
erection here, but I put forward as an extenuating circumstance my belief that in
these new buildings some accommodation of a special character is being provided.

The Colney Hatch Asylum was brought into existence very rapidly, and its
enlargement followed quickly upon its opening, and although considerable addi¬
tions have been made from time to time, the accommodation for sick and infirm
cases in the female division remained insufficient until the temporary buildings
were erected in May, 1896. These structures, all of which were for female
patients, provided the infirmary wards required, but the calamity that befell them
in January, 1903, and caused their total destruction, again brought the institution
to its old condition.

When it was decided to replace the beds lost by the fire, Dr. Seward formu¬
lated his requirements to meet the conditions at that time existing, with the result
that the buildings now in course of erection will not only give the necessary
infirmary space, but also provide separate blocks for female patients suffering
from phthisis and dysentery.

The total accommodation is for 314 patients and 20 staff, viz.:

1 Villa for Boys

Dormitory.

Single Room.
4

Staff.

1 Block for Phthisical Cases

1 Infirmary Block

1 „ „ .

1 Block for Chronic Cases

1 „ Acute Cases .

1 „ Dysentery Cases

274

Thus there are seven buildings, six being for female patients, and a seventh for
the reception of the boys who are at present distributed in the wards of this
Asylum. I should state that the majority of the boys who come under certificate
in the County of London are sent here. The six buildings for the female patients
are arranged on the site occupied by the temporary structures before referred to.
Five are grouped together, and are connected below ground by subways through
which the steam and hot-water services are to be carried, while communication on
the surface between the buildings will be by covered ways open at the sides. The
sixth building, that for phthisical cases, is wholly detached above ground from
the others, but for heating and kindred purposes it is connected with the system
of subways. These buildings will obtain their heating and hot-water supplies
from the boiler-house shown on the general plan to the south-east of the block for
dysentery cases. This boiler-house and its plant is not only designed to provide
heating and hot-water supplies for the new buildings, but it is also arranged to
provide the heating and hot-water supplies for a section of the wards in the main
asylum which at present derive their services from a number of independent
boilers contained in separate stokeholds some distance apart. All the new build¬
ings will be lighted by gas from the asylum works, and the water-supply will be
furnished by the well on the estate. The heating will be by low pressure steam,
radiators being employed in the day rooms and dormitories, and pipes in the
single rooms. The hot-water supply will be delivered by a forced circulation.
Besides the steam heated radiators, both central and ordinary fireplaces are to be
installed, and I may mention that the central stove is particularly well adapted for
use in wards and dormitories.

The arrangements for ventilation are simple, and I repeat them here because of

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1908.]

NOTES AND NEWS.

6l I

the excellent results obtained from similar arrangements in other buildings I have
designed. All radiators and pipe circuits have adjustable fresh-air inlets, and
there are also fresh-air inlets provided below the window-sill levels in the day-
rooms, dormitories, single rooms, and stores. The outlets from all important
rooms except the single rooms are in the ceilings, and these openings are fitted
with curbs and baffle plates to prevent down draughts, and from the roof spaces
the heated air which rises from the occupied apartments finds its way into the
open atmosphere through the louvred ventilators which are shown on the ridges.
The outlets from the single rooms are the gratings over the doors.

All the buildings occupied by the patients are of single floor height, the design
being a plain one, Fletton bricks being used for facing work and ordinary tiles for
roofs. The disposition of the wards and dormitories is such as to obtain the
maximum advantages of sunlight and air. The day rooms have a south by west
aspect, and it will be seen that both dormitories and day rooms are arranged to
obtain cross ventilation. Verandahs are to be erected at each building for the
benefit of the more helpless patients. There are no special arrangements of the
buildings to which your attention need be called, unless it is in the method of
access to the sanitary annexes, where the disconnecting corridor is accessible
both from day-room and dormitory. The administrative block includes the
quarters and offices for a medical officer, staff offices, nurses’ messroom, and the
general bathroom, the dressing-room of the latter being also the visiting room.
The bath house is to be equipped with spray baths, but there will be a slipper
bath in each ward also.

The treatment of the site for the five grouped buildings necessitated some
consideration, as it had originally a fall of 34 ft. in 712 ft., or 1 in 20*9, and
although the temporary buildings were erected upon it, the difference in the
levels of the wards was such that the corridor connecting them could not be
comfortably negotiated. To improve this condition I designed the buildings at
the lower part of the slope to stand well above the ground and at the upper part
below the level. The ground excavated from the upper part has been used to
raise the level of the lower, and by this means something approaching a series of
plateaux has been obtained which will render communication comparatively easy.

The estimated cost of the buildings, with which is included everything but
furniture and clothing, namely, buildings, fittings, padded rooms, roads, paths,
fencing, etc., is ^130 per bed, and in considering this cost it must be borne in
mind that one half of the accommodation is entirely for infirmary cases, and, as
you are aware, the accommodation provided on infirmary lines is 33 per cent,
greater than for chronic patients.

In the discussion which followed the reading of this paper, the President, Drs.
Thomson, Elkins, Robert Jones, J. F. Dixon, Hubert Bond, Donaldson, Seward,
and Steen took part.

Mr. Clifford Smith, in his reply, stated that the reason gas was to be used in
place of electricity for lighting purposes was that they had a gas plant already in
position, and the expense would have been much greater had electricity been used.
He then dealt with the discussion which had taken place with regard to the best
means of heating asylum wards, and expressed himself as well satisfied with
central stoves, which were not only valuable as heating arrangements, but were
also excellent for the purposes of ventilation. The advantages and disadvantages
of heating by steam and hot-water systems was then dealt with, and he expressed
the opinion that in the future a minus pressure steam system would come into
vogue and be most satisfactory.

Dr. Harvey Baird read a paper on “ Some Observations on Insanity in Jews ”
(see page 528).

In the discussion which followed, the President, Drs. Robert Jones, Seward,
Hubert Bond, Donaldson, Stewart, and Steen took part.

Dr. Baird having replied,

The President announced that Dr. Thomson’s paper on “ A few Remarks on
the Teaching of Psychiatry,” had been postponed till a future date.

In the evening many of the members dined together at the Cafd Monico.
Among the members were Drs. Bower and Edwards, who had been unavoidably
prevented from attending the meeting.

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6 l2

NOTES AND KEWS.

[July,

SOUTH-WESTERN DIVISION.

The Spring Meeting of this Division was held at Barnwood House, Gloucester,
by the kind invitation of Dr. Soutar, on Friday, April 24th, 1908.

The following members were present: The President, Drs. Bond, Braine-
Hartnell, Henley, Lavers, MacBryan, Marnan, Nelis, Soutar, Stilwell, Townsend,
and Aveline.

The chair was taken by the President.

The following candidate was elected an ordinary member of the Association :

Henry Felix Fenton, M.B., Ch.B.Edin., Assistant Medical Officer, Worcester
County and City Asylum, Powick. Proposed by Drs. Braine-Hartnell, Taylor, and
Thomson.

Dr. Aveline was re-elected Hon. Divisional Secretary, and Drs. Goodall and
Bullen representative members on the Council.

Drs. Nelis and Morton were elected to fill vacancies on the Committee of
Management.

The Autumn Meeting was fixed to be held at Bath on October 30th, 1908, and
the Spring Meeting at the Newport Borough Asylum, Caerleon, by kind invitation
of Dr. Nelis, on April 30th, 1909.

Dr. Townsend read a paper entitled “ Notes on Sedatives and Hypnotics.” He
stated that he did not class himself with those who entirely discarded the use of
sedatives and hypnotics in the treatment of mental disorders, but, on the contrary,
he believed that the judicious and carefully considered use of these drugs was
essential to the most efficient treatment of many cases. He dwelt upon the fre¬
quency of insomnia as an early symptom of mental disease, and he expressed his
opinion that many cases of mental trouble might be averted if this sleeplessness
was overcome. In fully developed cases of mental disorder coming under care in
hospitals and asylums, sleeplessness manifested itself both in deficient amount and
in defective quality of sleep, and he considered in detail the various drugs which
are used to combat this trouble, and pointed out that the selection of the drug was
dependent upon condition and circumstances, which called for particular considera¬
tion in every individual case.

Alcohol, paraldehyde, sulphonal, veronal, chloral, the bromides and hyoscine
were separately considered, and the practical utility of each was dwelt on with
reference to the condition of the patient, and the general conclusion reached was
that paraldehyde effectively met the requirements as an hypnotic more fully and in
a larger number of mental cases than any of the other drugs discussed. The
necessity for using sedative drugs by day to control undue motor and mental rest¬
lessness leading to exhaustion was insisted on, and the beneficial effects of this
treatment were exemplified by many instances. Dr. Townsend contended that we
should not be deterred from the use of these drugs by dread of the opprobrium of
chemical restraint, a term which had its origin in the abuse of these drugs. He
gave examples of the type of case in which sedatives by day should, in his opinion,
be used, and pointed out that after all the number was comparatively small, but he
contended that to neglect giving sedatives and hypnotics to these patients would
be to fail in efficient treatment.

The President said he was quite sure there could be but one opinion, and that
was that they had listened to a most interesting and valuable paper. It was one
of those papers which brought home to the members of the Association their daily
work, but it had done much more than that. He considered that Dr. Townsend
had that afternoon touched upon some of the most difficult problems with which
the members as physicians to the mentally afflicted had to deal. Dr. Townsend
had told them of those cases in regard to which each and every one of those present
must often have said: “ What can I do with this patient ? ” He had told
them how he had overcome those difficulties, and he thought his hearers would
agree with him when he said that the instances Dr. Townsend had given of
the methods adopted certainly showed that in his hands they had proved suc¬
cessful. He was very glad to hear Dr. Townsend say that while he used sulphonal,
he did so sparingly. He did not mean to say that sulphonal was not a useful
drug, but he did look upon it, at any rate in his own experience, as one of the most

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1908.]

NOTES AND NEWS.

613

dangerous drugs they had to use. That being so, they could not but strongly con¬
demn the scandalous use which was made of the little pocket bottle with a tiny
cork by so many people, not only of the male sex, but, he feared, of the other sex
also. Dr. Townsend also touched on the dangers of hyoscine, and he mentioned
the dread which was sometimes experienced in regard to its administration. Hyos¬
cine sometimes reduced a patient to a condition absolutely akin to epilepsy, and he
did not think it was a very safe remedy to use. He was also very pleased indeed
to hear Dr. Townsend say that where there seemed to be a chance of recovery he
used sparingly everything in the nature of sedative and hypnotic drugs.

Dr. Bond said that he also had been much interested in listening to Dr.
Townsend’s valuable paper. The description given of the use of sedatives and
hypnotics in Dr. Townsend’s hands was, he felt, a very faithful picture of his
own experience, and he cordially agreed with most of what the reader of the
paper had said. He thought most of them must feel that in paraldehyde
they had a very valuable ally. Dr. Townsend deprecated the use of sulphonal,
but he thought that much of its dangers—and he agreed they were very great
—had been through the difficulty of watching individually the patients who were
taking it. He believed that so long as they did that and made certain of two
points—firstly, that the bowels were acting freely, and secondly, that the patients
were getting sufficient exercise—they need not fear so much the dangers of the
drug, the existence of which he freely admitted. He thought that the same
principle applied also to the bromides. He quite agreed with what Dr. Townsend
said with regard to hyoscine. Along with that drug he did not mention one which
he supposed hardly anybody would ordinarily put in the category of sedatives, but
which he had given with advantage in certain maniacal states associated with
extreme frenzy—he alluded to apomorphine. Given in small doses the seda¬
tive effect of apomorphine was very great. A tenth or twentieth of a grain
could be given, and provided there was no cardiac weakness he was sure that drug
was valuable in certain cases. Dr. Townsend said he was not going to deal with
the question of indirect sedatives or hypnotics. As he happened to have had
considerable experience of the use of verandahs attached to wards, he would
like to emphasise the value of fresh air and sunshine as a hypnotic. He had
no doubt at all but that the provisions of such verandahs reduced the call for
hypnotic drugs.

Dr. Aveline also thanked Dr. Townsend for his interesting paper. Although
Dr. Townsend said there was nothing new in his contribution, some of his
suggestions were very practical and useful. He was of opinion that veronal, from
which they had expected so much, had proved a very disappointing drug. He
had fallen back upon sulphonal as being more generally useful. One great thing
about it was that it did not seem to interfere with digestion, whereas veronal did—
at least, that had been his experience. In fact, in some feeding cases where sul¬
phonal had been given he had found that the patients had taken food voluntarily
almost directly after getting under its influence.

Reference had been made to injurious effects following the use of sulphonal, but
he could not help thinking that they were due to idiosyncrasies such as were found
in connection with many other drugs.

Dr. Soutar, who was invited by the President to contribute to the discussion,
said he did not know that he could usefully add anything to what Dr. Townsend
had stated in the course of his paper and the remarks made by the subsequent
speakers. He had had the pleasure of working with Dr. Townsend for a good
many years in dealing with a great many cases, and his paper was a very faithful
epitome of the practice which they had pursued in that period. There were, per¬
haps, one or tw’o very mild reservations which he might make. Of course, no two
men could be absolutely agreed in regard to such an important subject as the ad¬
ministration of hypnotics and sedatives ; and he thought they were all more or less
biased—and bound to be biased—by the recollection of one or two particular cases
in which they had either had almost unexpected success or unexpected failure.
He could go back a bit farther than Dr. Townsend—fortunately for the latter—and
he remembered the time when chloral was much more freely used than it was now.
He could also recollect some extraordinary benefits which were derived from the
use of chloral. Therefore he was not quite so positive that chloral was a drug
which ought to be eliminated from their use in the treatment of mental disorders.

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614

NOTES AND NEWS.

[July.

He remembered a type of case, not so common now as it used to be, which was
characterised by what might be described as explosive mania, the patients being
very violent ana destructive. Very often those patients displayed before the actual
explosions occurred certain danger-signals which enabled precautionary measures
to be taken in time, and in that type of case chloral acted better than any other
drug he knew. With regard to what had been said about hyoscine, before they had
that drug hyoscyamine was used, and he had seen some very unsatisfactory results
therefrom—nothing fatal, but certain results which made one reflect as to the
advisability of continuing its use. Then came the introduction of hyoscine, and
since they had used it they had undoubtedly got rid of those paralytic results which
had previously obtained. With hyoscine, however, they did undoubtedly get a con¬
dition of terror induced in the patient which made it a cruel drug to use. The
patient undoubtedly suffered very much from mental torture and dread in the
case of the use of hyoscine, apart altogether from any question as to the
drug not being pure. He was rather pleased—though sorry from the point
of view of the variety which such remarks would have imparted to the dis¬
cussion—that in the South-Western Division there seemed to be nobody who was
prepared to champion the abolition of the use of sedatives and hypnotics in the
treatment of mental disorders. How any man could think he was doing full justice
to his cases by proceeding upon such a theory as that he must not and ought never
to use a hypnotic or sedative to patients suffering as those did who came under the
treatment of members of that Association, he must say he really could not under¬
stand. Was a patient who was all day long tortured by most acute mental dis¬
turbances, dreads, and fears, to be permitted to go through the night in that terrible
state without steps being taken by means of a sedative to induce sleep ? The very
fact that they were able to give rest for six, seven, or eight hours from that misery
was in itself an advantage to the patient, who was thus given a chance of improving
in condition and steadily proceeding towards recovery. In the use of hypnotics
and sedatives, as in that of aperients or anything else, they had to consider each
individual patient; they had to decide what was the right thing to do for that
patient and then do it. He thought there was rather a tendency in their speciality
to get hold of a theory and try to square the facts with that theory, instead of
recognising that each case should be considered upon its own merits and dealt with
accordingly. As he did not say that every case should be treated in the open air,
given exercise, or put to bed, so he did not assert that each patient should be given
a sedative or hypnotic, and so on. He wished to emphasise the point that each case
should be considered on its own merits, and the applicability of all or either of tbe
available methods of treatment duly taken into account; whether it was a question
of giving castor oil, cascara, or anything else, was a matter for individual con¬
sideration and decision. With regard to the use of paraldehyde, one way in which
it had been of service had been in the treatment of patients who required to be fed
forcibly, and who had a tendency to vomit their food. By the use of paraldehyde
in such cases they had been able to overcome difficulties hitherto experienced in
regard to vomiting. With reference to the use of bromide, Dr. Townsend had
mentioned one case. As those present knew, a great many melancholic patients
dwelt upon their supposed miseries to such an extent that a certain brain habit
became established. The particular case to which Dr. Townsend referred was that
of a lady who had given continued expression to her mental misery. As time went
on she increased in weight, and, physically, was looking much better. It was
noticed that her expression of mental pain was entirely voluntary; the involuntary
expression, which was characteristic of the earlier stages of the illness, was no
longer observed, and they came to the conclusion that a brain habit had been
established. Of course they usually sought to remove those brain habits by divert¬
ing the patient’s attention, by endeavouring at a certain point to get the patients
to take an interest in something else, such as a garden, etc. In the case to which
Dr. Townsend referred they could do nothing of the kind. It was found neces¬
sary to completely “ bowl over” the patient by means of large doses of bromide;
and when the influence of the bromide was removed it was found that the brain
habit had been interrupted, and from that time the patient steadily improved. As
to the value of fresh air, sunshine, and exercise, he believed the reason why all who
were accustomed to asylum work had for giving so few hypnotics was that they
recognised the value of such drugs as an ultimate resort when the other methods

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NOTES AND NEWS.

1908.]

615

had failed. But that they should resort to them when necessary for a patient he
had not the slightest hesitation in saying.

Dr. Norman Lavers added his congratulations and thanks to Dr. Townsend for
his very valuable paper. He remarked that in the use of paraldehyde he thought
there was sometimes a tendency to gastric catarrh. He had noticed the symptom,
and while it had been attributed to other causes he was forced to the conclusion
that paraldehyde was the cause of it. The gastric catarrh certainly got better
when the paraldehyde was stopped. In the acute excitement of general paralysis,
he thought unless they gave a sufficiently large dose of paraldehyde at once a
smaller and inefficient dose was likely to increase the excitement. With regard to
hyoscine, he had had a run of rather trying experiences with that drug. Two or
three cases showed alarming attacks of heart failure, and afterwards he always gave
hyoscine in combination with digitalin. He found the combination was rather
better; in fact, he had had no more of those alarming symptoms for some time.
Sul phonal he had given up practically because, contrary to the experience which
had been mentioned that afternoon, he thought it had a considerable effect on the
gastric secretion and was rather apt to cause distaste for food—to increase the
difficulty of getting a patient to take his or her food. However, he might have
been unfortunate in that respect. One other point: he thought, perhaps, that
opium was not altogether to be condemned ; he thought there were cases, especi¬
ally those of restless melancholia, in which it could be given with some amount of
success.

Dr. Townsend, in replying on the discussion, said he was very much obliged to
those who had taken part in it for the kind manner in which they had received his
paper. His remarks were simply intended to represent their own work at Barn-
wood House with regard to the actual use of drugs. Of course, as Dr. Soutar had
said, they only fell back upon drugs when other things failed, and among those
other things he was perfectly certain that the most powerful hypnotics of all were
sunshine and fresh air. From the structural point of view, it was impossible for
them to make arrangements for all patients to have that amount of open air that
they could have in places where there were verandahs specially built for the pur¬
pose ; but, nevertheless, they made every effort there to get patients out in the open
air as much as possible. He felt very sure that, although it might be impossible
or impolitic for them to treat all cases alike, where they could keep their patients
in the open air they would get excellent results and the less need would they have
to fly to hypnotics and sedatives in the form of drugs.

The proceedings then terminated with a vote of thanks to Dr. Soutar for his
kind hospitality.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division of the Medico-
Psychological Association was held by the kind invitation of Dr. Adair at the
West Riding County Asylum, Storthes Hall, Kirkburton, near Huddersfield, on
Thursday, April 30th, 1908, at 2.30 p.m.

The President of the Association (Dr. MacDonald) took the chair.

There were present the following members: Drs. Adair, Archdale, Cross, East,
Evan, Exley, Geddes, Groves, Herbert, Kay, Colin McDowall, Mackenzie, Mac-
phail, May, Middlemass, Pierce, Mould, Stewart, Vincent; also two visitors. Dr.
Kelly and Dr. Austin Priestman.

The minutes of the last meeting were read and confirmed.

On a ballot being taken, Henry Roscoe, M.R.C.S., etc., Assistant Medical
Officer, Cheddleton Asylum, was unanimously elected an ordinary member of the
Association.

Dr. Bedford Pierce having expressed his wish to resign the position of Secre¬
tary to the Division, Dr. Macphail proposed, and Dr. Ewan seconded the proposal,
that Dr. Adair should be appointed Secretary. This was carried unanimously.

In considering the appointment of representative members of the Council, the
President pointed out that the rules of the Association in respect to voting
papers did not appear to have been observed. He said the existing members not
having served three years might be re-appointed, and on the motion of Dr.

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6 i6

NOTES AND NEWS.

[July,

Middle mass, seconded by Dr. Stewart, it was proposed that Drs. Macdowall,
Ewan, and Orr be re-elected as Representative Members of Council. This was
carried unanimously.

Resolved, that the next meeting be held, if possible, in the Birmingham Dis¬
trict on October 22nd, 1908, and that the spring meeting be held on April 20th,
1909. The place of meeting to be arranged by the Secretary and the Divisional
Committee.

A letter from Dr. Sankey, relative to the desirability of having more meetings
in the Midlands was read and considered.

Upon further consideration it was resolved that it was not desirable to proceed
further with Dr. Ewan’s proposal to divide the Northern and Midland Division.
Dr. Ewan himself, as well as the Divisional Sub-committee, agreed that the
number of members in the Division was not sufficient to justify any change being
made.

The President made a feeling and fitting reference to the loss the Division and
the profession had sustained by the death of Dr. MacLeod, late of Beverley. He
went on to say that underneath that fine and true Highland surface there was the
most lovable and kindly nature, a fine character, a true friend, and the best of
companions. He proposed that a letter be written expressing the sympathy of the
members with Mrs. MacLeod and family, and the members present signified their
assent to the vote of condolence by silently rising in their places.

Contributions.

Dr. Guy R. East, of Northumberland County Asylum, Morpeth, read a paper
on “ A Case of Cretinism,” illustrated by photographs (see page 570).

The President (Dr. MacDonald) remarked upon the rarity of cretins in asylums,
and that after careful enquiry he had not found a single case in Dorset.

Dr. Macphail joined in the discussion, and

Dr. East replied.

Dr. Colin McDowall, of the City Asylum, Newcastle, read a paper upon
“ The Occurrence of General Paralysis in Father, Mother, and Son ” (see page
562).

In the discussion which followed,

The President (Dr. MacDonald, Dorset) suggested that there was not sufficient
proof that syphilis was present, and he did not accept the proposition “no
syphilis, no general paralysis.” He could name cases of general paralysis in
country districts in which he was satisfied there was no syphilitic taint. He said
it was remarkable that the mother had such a long period of excitement.

Dr. Middlemass (Sunderland), remarked on the long history in the mother’s
case and the weight of the son’s brain (65 oz.) was unusual. He quoted a case of
a congenital imbecile developing general paralysis in Morningside Asylum.

Dr. Gilbert Mould (Rotherham) continued the discussion, and

Dr. Colin McDowall replied.

Dr. Harold R. Cross, Senior Assistant Medical Officer at Storthes Hall
Asylum, Huddersfield, showed two interesting cases, one presenting marked
conical cornea ; the other atrophy of the right deltoid and weakness of the muscles
of the arm, the cause of which could not be ascertained.

Dr. Michael William Kelly, Assistant Medical Officer at Storthes Hall
Asylum, also showed two cases. L. K—, a boy, aet. 14, with petit mal. During
the attacks, which last about twenty seconds, he uses had language. He wakes at
night with a shout as if dreaming, but states he does not dream. Sometimes he
has twenty of these attacks during the night; at other times he may go four or
five weeks without a fit. L. R—, female, *t. 39. January, 1906.—Acute melancholia
with active suicidal tendency. September and October, 1906.—Refused food and
tube fed, and appeared to be becoming demented. Transferred to Storthes Hall,
March 5th, 1908, began to take interest in her surroundings, and now appears on
the road to recovery.

Dr. Bedford Pierce’s remarks upon a case of “ Automatic Wandering ” were
deferred, and a hearty vote of thanks to Dr. Adair for his hospitality concluded
the business of the meeting.

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1908.]

NOTES AND NEWS.

617

MANUAL FOR NURSES IN HOSPITALS FOR MENTAL DISEASES,
BY DR. JULES MOREL.

In regard to the footnote to the review of this manual in our last issue we are
requested by Dr. Morel to state that the Superioress of the Sisters of Charity paid
the printing expenses of copies of his manual for the Sisters engaged in nursing
the insane in their asylums.

CARE AND TREATMENT OF THE INSANE.

The Third International Congress for the Care and Treatment of the Insane will
be held at Vienna from the 7th to the nth October, 1908.

The Council of the Medico-Psychological Association have been asked to
nominate a Committee to represent the Association. It will facilitate the formation
of such if members, intending to be present or willing to read or send a paper, will
kindly at once notify the General Secretary of their intention.

THE SIXTEENTH INTERNATIONAL MEDICAL CONGRESS.

This Congress will be held at Budapest from the 29th August to the 4th Sep¬
tember, 1909. The General Secretary is Professor Emil Grdsz, M.D., Budapest,
viii, Esterh£zyutcza 7.

NOTICES OF MEETINGS.

Medico-Psychological Association.

The sixty-seventh Annual Meeting of the Association will be held on Thursday
and Friday, 23rd and 24th July, 1908, at the rooms of the Association, 11, Chandos
Street, Cavendish Square, London, W., under the Presidency of Dr. Charles
Mercier. There will be meetings of Committees as follows:—On Wednesday,
22nd July, Criminal Procedure Committee at 2 p.m., Parliamentary Committee at
3 p.m., Educational Committee at 4 p.m. The Council will meet at 9.30 a.m. on
Thursday, 23rd July.

The Annual Meeting will commence at 11 a.m. on Thursday, 23rd July, when
the usual business of the Association will be transacted.

Notice of motion by Dr. D. G. Thomson : That for the more efficient teaching
and training of the coming generation of Alienists in Psychiatry, the Medico-
Psychological Association—in the first instance, through its Education
Committee—consider some scheme for post-graduate teaching and training,
with or without the imprimatur of a diploma given after such a course (with
or without examination) with a view to its being brought before the Univer¬
sities and other qualifying and teaching bodies.

(Dr. Thomson’s paper leading up to this motion, which was read at the
last Quarterly Meeting, appears in this number, see page 550).

2 p.m.—The President’s Address, after which the adjourned discussion will take
place on “ Boarding-out of the Insane in Private Dwellings,” on which a
paper, with lantern illustrations, was given by R. Cunyngham Brown, M.D.,
at the meeting held last February (see page 532).

Friday, 24th July, at 11 a.m.— Robert Jones, M.D., F.R.C.P.(Lond.), F.R.C.S.,
will initiate a discussion on “ The Case against Dementia Praecox.” Lewis
C. Bruce, M.D., F.R.C.P.(Edin.), will introduce a discussion on " Folie
Circulaire and Manic-depressive Insanity—their identity ?, and the Relation of
the Depressed to the Elevated Stage.” Alan McDougall, M.D.(Vict.), will
read a paper 11 On the Principles of the Treatment of Epilepsy.”

LIV. 44

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6 i8

NOTES AND NEWS.

[July, 1908

Afternoon, 2 o’clock.—Lady Henry Somerset has kindly consented to open a
discussion on ‘‘Some Aspects of Inebriety.” Frank Ashby Elkins, M.D.
(Edin.), will read a paper entitled, “ Asylum Officials—is it necessary or
advisable for so many to live on the premises ?” Horatio B. Donkin, M.A.,
M.D.(Oxon.), F.R.C.P., will kindly give an account of the work of the Royal
Commission on the Care and Control of the Feeble-minded.

The Annual Dinner will take place on Friday, 24th July, in the Grand Hall,
Criterion Restaurant, Piccadilly Circus, at 7 for 7.30 o'clock.

An innovation is being made this year in that there will be several ladies among
the guests of the Association: it is, therefore, hoped that as many members as
possible will each be accompanied by a lady, and that the lady members of the
Association will be present.

N.B.—Places cannot be guaranteed to those who apply later than the 10th of
July, and members are requested to notify to the General Secretary their intention
of dining. (Tickets, wines included, One Guinea; for ladies 15 s.)

South-Eastern Division .—The Autumn Meeting will be held, by the courtesy of
Dr. Elkins, at Leavesden Asylum, on Tuesday, 6th October, 1908.

South-Western Division. —The Autumn Meeting will be held at Bath, on Friday,
30th October, 1908.

Northern and Midland Division. —The Autumn Meeting will be held on
Thursday, 22nd October, 1908.

Scottish Division. —The Autumn Meeting will be held on Friday, 20th November,
1908.

Irish Division. —The Autumn Meeting will be held on Saturday, 7th November,
1908.

APPOINTMENTS.

Campbell, Robert B., M.B.,C.M.Edin., Medical Superintendent, Stirling District
Asylum, Larbert.

Donelan, John O’Conor, L.R.C.P.&S.Irel., Resident Medical Superintendent,
Richmond Lunatic Asylum, Dublin.

Gray, Theodore, M.B., Ch.B.Aberd., Assistant Medical Officer to Kingseat
Asylum.

Mackenzie, Theodore Charles, M.B., F.R.C.P.Edin., Medical Superintendent of
the Inverness District Asylum.

Murphy, Edward E. A., L.R.C.P.Edin., L.M., L.R.C.S.Edin., L.F.S.Glasg.,
Assistant Medical Officer to the Devon County Asylum, Exeter.

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THE

JOURNAL OF MENTAL SCIENCE

[.Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.}

No. 227 [To“ 9 7 8 ] OCTOBER, 1908. Vol. LIV.

Part I.—Original Articles.

The Presidential Address , on The Physical Basis of
Mind, delivered at the Sixty-seventh Annual Meet -
ing of the Medico-Psychological Association , held in
London on July 23 rd and 24 th, 1908. By Charles
Mercier, M.D., F.R.C.P.

In whatever field of research man prosecutes his labours, in
whatever direction his energies are pushed, he finds himself at
last brought up against a barrier of unfathomable mystery. If
he contemplates the universe at large, he finds the orb of Earth
on which he lives is but an infinitesimal speck, and he is in the
presence at once of infinite extension in Space, and infinite
duration in Time, both of which are to him but verbal expres¬
sions, whose meaning he is for ever precluded from comprehend¬
ing. If he contemplates the properties of matter, and investi¬
gates its constitution, he speculates that it consists of molecules,
that the molecules are constituted of atoms, and that the atoms
are compounded of ions of negative electricity ; but of these ions
he can form no mental picture, and practically his knowledge
or his speculations amount to this, that every small part con¬
sists of smaller parts, and every smallest part, whatever he may
call it, is little, if anything, more than a metaphysical abstrac¬
tion. However far this process of imaginary division may yet
be carried, we are still immeasurably distant from any solution
of the problems of what matter consists of, and of why it
offers to us Resistance.

But of all themysteries by which the mind of man is bewildered,

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the mystery of mysteries is the constitution of mind, and the
nature of the connection between mind and matter. It is the
practical aspects of this connection that confront us in our daily
work. We cannot move a step in dealing with our patients
except we take for granted some hypothesis of the connection
between mind and matter. Yet of the constitution of matter we
are profoundly ignorant; and we have but a dim and imperfect
knowledge of the action of one portion of matter on another.
We speak glibly enough of chemical combination, cohesion,
surface tension, and so forth, but of the intimate nature of these
processes we know nothing. We can gain no concept of the
nature of mind, and we have but a dim and imperfect knowledge
of the modes in which it works. Yet the whole validity of the
daily treatment of our patients depends on the view we take of
the relation of one of these inscrutables to the other, and of their
action on one another. To speak of the action of either on the
other is, to many, to beg the whole question ; but yet that they
do act on one another is neither more certain nor less certain
than that matter exists. No aspect, quality, or faculty of mind
is more characteristically mental than Desire; and it is owing
to the operation of desire that cities are built, that networks of
railways intersect the civilised world, that countless ships traverse
the ocean, bearing cargoes of incalculable wealth to innumerable
ports. It is, in short, for the satisfaction of desire that all the
labours of man are undertaken. Judge, then, if mind does not
act upon matter. That matter acts upon mind seems proved
by every experience we have of sensation, and sensation- is the
raw material, if not of all consciousness, at least of all know¬
ledge. So that the interaction of mind and matter is just as
certain, and no more certain, as that matter exists apart from
mind, and mind exists differentiable from matter.

What are the ultimate relations of mind and matter I do not
propose now to examine. The problem is one of the insoluble
fundamentals already alluded to, and the various hypotheses
advanced to resolve it are verbal propositions only, which, in as
far as they arouse any answering concepts in our minds, fail to
command our assent; and, in as far as they do not arouse
answering concepts, are flatus vocis. The current hypotheses
are three in number: Dualism, the essential separateness of
mind and matter, which, however, act and react on one another;
Monism, the essential identity of mind and matter as obverse

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621

and reverse aspects of one substance or process; and Paral¬
lelism, the utter disparateness of mind and matter, whose pro¬
cesses are separated by an impassable gulf, but yet move in
perfect simultaneity and harmony with one another.

It may relieve your minds when I say that to these three
hypotheses I have no intention of adding a fourth. Whether
or no they exhaust the possibilities I do not propose to inquire.
I take for granted that there is an association, and more, a
causal connection, between the material processes of the brain
and the operations of mind; and taking this for granted, I
propose to put before you, and support by such evidence as I
am able to adduce, certain speculations as to the kinds of
material change in the brain that correspond with definite
kinds of mental operations. If it is true that mental changes
are always and invariably accompanied by, and correspond with,
brain changes, then it is probable that a certain kind of mental
change will always be accompanied by, and correspond with, a
certain specific mode of material brain process. The connection
between mind and brain, if it is true at all, pervades through¬
out Whatever its nature, if it is true simpliciter , it is true
secundum quid . What I propose to do is to follow the con¬
nection somewhat into detail, and try whether it is not possible
to discover a connection, not merely between brain-change and
mind-change, which everyone now assumes, but between specific
modes of brain-change on the one hand, and specific modes of
mind-change on the other.

A necessary preliminary to this task is to set forth the
main fundamental divisions, modes, or faculties of mind ; for
it is manifest that not until we have separated them out can
we speculate as to the material accompaniments or corre¬
spondents of each. The division that I shall adopt as most
convenient is that set forth in my book on Psychology , and I
need not now give the reasons which seem to make it most
appropriate for my purpose.

The basis of mind, the ultimate origin out of which all other
faculties seem to me to have been evolved, is the tremendous
experience of Pleasure and Pain. Immediately connected with
pleasure and pain, and, as I think, arising out of them, are the
members of the next couple—Desire and Aversion, the prompters
and motives to all forms of action. Desire and aversion are
the motives of all action but though they prompt to action,

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and though without them there would be no action, they do
not themselves directly excite action. Desire and aversion
may be long dormant, felt, experienced, but inactive. Action
does not follow unless and until they obtain the sanction of
Will, and it is will that is the immediate predecessor—I must
go further, and say that it is the immediate cause—of action.
Action gives rise to experience. By action we are brought
into relation with change in incident forces; and change in
incident forces produces Sensation, the raw material of Percep¬
tion and of all other forms of Thought. Lastly, we have to
recognise mind as a continuum, and as known as such.
Present consciousness owes its existence to past consciousness,
and is moulded into what it is by past experience. While the
vividness of present consciousness is owing to present experi¬
ence, the whole form and bulk and content of present con¬
sciousness is a remanet from the past; and the continuance or
the revival of past conscious experiences is conscious Memory.

These, then, are the modes of consciousness for which we
have to find answering modes of nervous activity—Pleasure
and Pain, Desire and Aversion, Will, Sensation, Thought and
Memory.

Let me take first the last that has been named, since it is
the easiest, and the one about which there is general consent
It is agreed that when a process—at any rate a process of
thought or of sensation—takes place in the mind, and an
answering process takes place in the brain, this brain-process,
whatever it is, leaves in the structure of the brain a permanent
alteration, much as, when a man walks over previously un¬
trodden snow, a permanent print of his footsteps will remain
as long as the snow is unmelted; or as, when a hatpin is run
through a cheese, the hole in the cheese remains after the hat¬
pin is withdrawn. Whenever this path in the brain is re¬
traversed, the brain-process is very much the same as when it
was traversed for the first time, but in some respects it is
different, for it now follows a beaten track, whereas on the first
occasion it had to make its own way. And as the brain
process is very much the same, but is in some respects different,
so is the mental process. The thought is the same, but—and
this is the difference—it is known to be the same. It is
recognised. It is known to have occurred before. This, then,
is the structural basis of memory. It is the recurrence in the

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623

brain of a process that had occurred before in the same part of
the brain. As to that I think we are all agreed. The
memory of a verse is stored in the brain in much the same
way as it is stored in a phonograph—as a structural change,
which is dumb until the structure becomes active again. If
this is so, then it is clear that, while each memory of each
event is localised in a particular area of the brain, there can be
no one region of the brain set apart as a store-house for
memories and for nothing else. Wherever motion passes in a
novel path through the cerebral substance, there a structural
modification is left; there a structural memory is formed ; and
when that path is re-traversed, a conscious memory arises.
And as far as we know, the whole structure of the brain is
adapted for nothing else but for the storage and re-distribution
of motion ; so that the whole brain, as far as it is organised, is
full of structural memories, and as far as it is unorganised, is
the possible seat of new memories. It is obviously wrong also
to think of memories—of events for instance—as being stored
in the cells of the brain. Structural memory is an affair of
nerve paths. Conscious memory is the accompaniment of the
passage of motion through these nerve paths.

While each individual memory is localised in a specific
individual structure—probably a network of nerve-paths, more
or less complicated, and these nerve-paths permeate the
whole of the brain, so that the totality of memories is not
localised in any one region, the reverse is true of Sensa¬
tions, and no doubt of Percepts, which are the simplest pro¬
ducts into which sensations are wrought by the process of
thought. There seems to be no doubt, from the evidence both
of experiment and of disease, that the sensations of the different
senses, and probably, to a less extent, the percepts which
cluster around each several sensation, are respectively loca¬
lised, not only individually but as groups, in more or less
defined areas of the brain. Of course, when I speak of
sensations and percepts as being localised in the brain, it
will be understood that I am using these expressions as
abbreviations for the brain processes corresponding with the
mental processes.

If it be the fact—and I think it is now generally agreed that
it is the fact—that the physical basis of memory is as I have
stated it, then it will appear that the only mental states and

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processes that are susceptible of being remembered, are those
whose physical basis is such a passage of motion through
the brain as I have described ; and that if there are other
mental states and processes whose physical basis is of a
different nature, and does not involve a permanent structural
change of this kind in the brain, such mental states or pro¬
cesses cannot be remembered. Now, it is worthy of note
that before I arrived at this d priori conclusion, I had already
asserted, on d posteriori grounds, that neither desires, nor
aversions, nor pleasures, nor pains can be reproduced in
memory. We can, no doubt, remember that at such a time
we did experience such a desire or such a pleasure, but I
averred in my book on Psychology —and if anyone should ever
read it he will bear me out—that we cannot reproduce in
memory the desire itself or the pleasure.

The only mental processes that can be reproduced in
memory are the factors of experience—sensations, thoughts, and
volitions.

Of Sensation the mind has a separate and distinct apprecia¬
tion and discrimination of various modes—light, colour, sound,
smell, taste, touch, tickling, temperature, muscular sense, crude
pains, and so forth. It is an interesting speculation to surmise
what differences in brain processes underlie these differences in
the quality of sensation. Do they correspond merely with
differences in the areas of the brain at which the currents from
the several sense organs are received ? Or do they correspond
with differences in the character of the currents of motion
which arouse those areas to activity ? Plausible arguments can
be found in favour of each hypothesis, and great difficulties lie
in the way of the adoption of either.

If the stimulation of one area of brain corresponds with a
sensation of colour, that of another with a sensation of sound,
that of another with a sensation of smell, and so forth, inde¬
pendently of the quality of the motion received, then it seems
to follow of necessity that within the main area for colour there
must be minor areas for each tint in the spectrum, at least for
those who can appreciate all the tints; and that colour-blind¬
ness must be due to absence of one or more of these areas.
Similarly, within the sound area must be a separate minor area
for every note, and that form of sound-deafness, which means
inappreciation of music, must be due to the non-development

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625

of these discriminate areas. The hypothesis seems crude,
and it seems to require that the sensory areas should be final
termini of ingoing currents, a condition inconsistent with what
we know or imagine of the working and arrangement of these
elevated regions.

On the other hand, it is quite conceivable that the apprecia¬
tion of different sensations may correspond with differences,
not in the structure or area of the brain-tissue in which the
currents of motion are received, but in the quality of these
currents themselves. Primd facie it would seem that diffe¬
rences of stimuli so wide as those between the vibrations of the
ether which constitute waves of light, the vibrations of air
which constitute sound-waves, the chemical action which
initiates the sensory currents of smell and taste, and the
mechanical action that initiates sensations of touch and pres¬
sure, it would seem that differences so wide, in the action of
external agents on nerve-endings, might produce differences, not
so wide indeed, but still very discrepant, between the qualities
of the respective currents of motion that they send inwards to
the nerve centres; and this hypothesis receives countenance
from the fact that, in structure, the nerves of special sense
exhibit decided differences. The olfactory nerve differs from
the optic, and both from the auditory portion. The fact that
the stimulus of pain and that of touch have each its own path
in the spinal cord is consistent with either hypothesis; as is
also the fact that the receptive nerve-endings on which the
stimuli are received are widely different. It is manifest that
the conversion of the fine waves of the ether into nerve-
currents requires a converting apparatus very different from
that which transforms the coarse aerial vibrations of sonority.
It is d priori improbable that the impulses transmitted by
different nerves belonging to the same system should be very
widely different in character.

In any case we may rest secure in the conviction that the
physical basis of Sensation is the reception of ingoing currents
at the highest level at which currents remain afferent. At
some point in their career the currents are reversed, and, after
change and recombination, become efferent. Sensation arises,
we may feel confident, when this point is reached.

The physical basis of Thought presents little difficulty. It
is agreed on all hands that the process of thought is the

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establishment of relations between mental states. It is univer¬
sally admitted that thought is comparison. It is the juxta¬
position of two or more mental states, and the consequent
discernment of likeness or unlikeness between them. Now, if,
as is agreed, the existence in the mind of any mental state is
conditioned by the activity of an area of grey matter, it seems
to follow as of course that the juxtaposition in the mind of two
mental states is conditioned by the activity, in immediate suc¬
cession to each other, of two areas of grey matter; and this
immediate succession of activity can be brought about no other¬
wise than by the spread of motion from one area to the other.
The ease with which two thoughts can be juxtaposed will
correspond with the permeability of the medium between the
two areas of grey matter which severally underlie them ; and
conversely, the difficulty of juxtaposing and comparing two
thoughts will lie in the barrier presented by an impermeable
medium between the area that is active and the area to which
the activity is to be spread, and in which the activity is to be
aroused. Herein we see the reason of the eminent memorability
of thoughts. If the establishment of a new thought is, on its
physical side, the extension of activity, that is the transference
or spread of motion, from one area to another, then this motion
spreads through certain channels, or passages, or lines of less
resistance, burrowed out then and there for the purpose ; and
the repetition of this transference through these same channels,
which, after once being traversed, remain more or less patent
and permeable, is the physical basis of Memory.

So far our progress has been plain sailing. The nature of
the physical bases of Memory , Sensation , and Thought are not
difficult to conjecture, and the surmises that I have suggested
are, I think, generally admitted to be probable, and to represent,
as nearly as we are ever likely to approximate, the true state
of the case. But with respect to the remaining factors of mind
the case is different. There is no general consensus of opinion
as to the physical changes in the brain that underlie and
accompany the mental experiences that we know as Will\ as
Desire , and as Pleasure and Pain . Here our ground is very
uncertain, and here we must proceed at once with hardihood
and with circumspection. Here, too, it is evident that we are
dealing with mental factors of a somewhat different character.
Our means of communication with one another leaves us in little

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627

doubt that our sensations, thoughts, and memories are so much
alike in different people that they may, in a sense, be regarded
as common to all. The blue of the sky, the green of the foliage,
the red of the sunset are the same to you as they are to me.
The witty juxtaposition of two incongruous thoughts affects
you precisely as it affects me. And if the originals are thus
alike and thus common, so, too, are their reproductions in
memory. Moreover, all these factors in mind, or rather these
products of mental action, are by us objectified. They are
regarded rather as our possession than as ourselves. As I have
said in another place, we speak of a man having a thought or a
memory in his mind much as we speak of his having a sovereign
in his pocket. It belongs to him, but it is no necessary part of
him. Before he had it he was the same man that he is now.
If he should lose it he would still be the same man. But, with
the mental factors that we now have to consider, the case is
different. If you have conceived a new thought, you can com¬
municate that thought to me, and then I have the same thought.
I can send it on ; “ ’twas mine, ’tis his, and may be slave to
thousands.” But the desire that you have in your heart, that
you cannot communicate, that is yours, and yours alone. I,
too, may have a desire, and for the same thing, but our desires
are not common ; they are not communicable; they are not
shareable ; my desire is not a possession of mine that I can
acquire and lose and still remain the same. It is a part of my
very self. Now I have it, I am different in character and
personality from what I was before. If I lose it, my character
and personality are changed again. And so with respect to
volition. My will is my own, but it is not a possession or
acquisition of mine, as is a thought, or a memory, or a sensation.
It cannot be communicated from without; it can only arise
from within. It is a part of my very self. It is myself. It is
the expression and outpouring of my whole personality. None
can share it; none can have it in common ; to none can I
communicate it. I can communicate the knowledge of it, but
not the will itself. And so it is of pleasures and of pains. You
and I can feel pleasure in the same experience, can be pained
by the same event. I can, by pleasurable news, arouse pleasure
in you, and by news of disaster I can give you pain. But the
pleasure you experience is your pleasure, not mine ; and though
we both feel pain, the pain is not common, but yours is yours.

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and mine is mine. They are not common, and they are not
comparable, for the pleasure or the pain is an affection of the
self, of the subject, and it is the object consciousness alone that
is communicable to others.

The three factors of experience have already been stated to
be the reception of motion from within, the re-distribution of
motion within the brain, and the emission of motion outward
from the brain. With the first factor, the reception of motion,
and its wash upon the shore of the highest regions of the brain,
corresponds the mental factor, sensation. As to that we are
agreed. With the second factor, the re-distribution and re¬
combination of motion into new arrangements, corresponds the
mental factor, thought. As to that there is no difference of
opinion. It seems an irresistible inference that the third
material factor, the emission of motion to the musculature,
should have for its mental correlative the third mental factor
in experience, viz., volition, and this inference seems unim¬
peachable. That the act of willing, the internal crisis, as Sir
FitzJames Stephen well calls it, the exertion of the whole self
in a certain direction, the up-springing and out-pouring of
mental activity, which seems to arise from a fountain in our inner¬
most being—that this is in experience associated with an emis¬
sion of energy from the superior nerve regions, seems too clear to
admit of doubt or discussion. Not only is every purposive
movement preceded by an exertion of will ; not only are very
many exertions of will instantly followed by muscular movement;
but even those exertions of will that are not at once followed by
conspicuous and manifest muscular movement are shown,
by the researches of muscle readers, to be associated with per¬
ceptible muscular tensions, which prove the reception of energy
by the muscles. About the association of emission of motion
with volition there cannot, I think, be any doubt. The doubt
arises when we ask the nature of the association, and here we are
brought up once more against the three hypotheses already
stated. Does the mental process precede and determine—why
should we boggle at a word and hesitate to say cause ?—the
nervo-muscular action ; or are the two but two aspects of the
same process ? or do they but occur simultaneously and parallel
with each other, on the hypothesis of Leibnitz ? For my own
part I must confess that, after five and thirty years or so of
consideration of this excruciating problem, after having inclined

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in turn to each, after having, many years ago, publicly, and, as
I thought, finally, embraced the hypothesis of Leibnitz, I am
now grown too old to be cocksure; but year by year I more
and more incline to the hypothesis of dualism. It seems to me
most consistent with the doctrine, now far too lightly treated,
far too often impugned, directly or indirectly, by members of
our profession, the doctrine which is at the base of all morality,
and therefore the foundation on which all society is built, the
doctrine of the inescapable responsibility of every individual
human being for his acts. His acts. It seems to me that the
use of this expression either settles or begs the question. If
my act is my act, it is the act, not of my body—for that can
act without my consent and without my knowledge—it is the
act of me, of my self, of my whole personality expressing itself
in my volition. It is an outpouring of my personality through
the avenue of will, through the channel of grey matter, through
the medium of the musculature, in resolute, purposive action.
I find it increasingly difficult to reconcile such action with the
hypothesis of parallelism ; and though I do not plump for an
Interacting dualism, I should never quarrel with those who do,
but rather should regard them, as I regard the authors of the
Athanasian Creed, with envy for the uncompromising certainty
of their convictions.

Leaving now the physical basis of volition let us turn to
that of desire.

In this case we are assisted to a certain extent by experi¬
mental evidence. Certain fundamental and representative
desires there are, whose physical basis is clearly indicated by
the circumstances under which they arise. Of all Desires, the
most fundamental, the earliest in origin in the race, though it
appears late in the individual, the fertile parent, as it seems to
me, of all other desires, is the desire of sex ; and the necessary
condition of the sexual desire is a certain chemical constitution
of the nerve regions involved. Desires of sex are not
experienced until the sexual glands arrive at maturity and
become physiologically active. If these glands are extirpated
before the period of their activity arrives, sexual desire is not
felt; and when the period of their physiological activity is
over, sexual desire disappears. It is quite clear, therefore,
that the desires of sex are dependent upon the existence and
physiological activity of the sexual glands—of the testis and

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ovary—and the only way in which their influence upon desire
is explicable is by the secretion of some chemical product,
which modifies in a specific sense the nutrition of the grey
matter of the convolutions, or of some of them. Upon this
hypothesis, the physical basis of desire is the chemical con¬
stitution of the nerve regions involved. Of course I do not
mean that the mere existence of this chemical variation in the
constitution of the nerve centres is the physiological basis of
desire. This can only be some subtle alteration in the mode
of action of the nerve tissue, which cannot take place except in
the presence of that chemical substance. But for practical
purposes it seems clear that we must regard as the basis of
sexual desire the action upon the nerve centres—the modifica¬
tion of their nutrition and of their mode of activity—that is
produced by the chemical product of the sexual glands carried
to the nerve centres in the blood stream.

Corroborative evidence of this view of the basis of desire is
found in the conditions under which other desires are ex¬
perienced. Scarcely any desires are more urgent than those of
hunger and thirst, and neither of these is ever experienced
except in circumstances that imply an alteration in the
chemical constitution of the nerve tissue. In the case of
hunger, the blood is depleted of nutritious material, and its
altered constitution must be reflected in an altered molecular
structure of the nerve tissue. In the case of thirst, the nerve
tissue, in common with the other tissues, is deficient in moisture,
and again its chemical constitution and action are interfered
with and modified. In the cases of other desires, the evidence
of chemical influence in the nerve tissue is more difficult to
obtain, but there are cases in which it is not wholly wanting.
Hybernating animals, as is well known, accumulate large
quantities of fat as the period of hybernation approaches, and
this is usually looked upon as an instinctive, or quasi-intelli-
gent, preparation for the approaching hybernation, which no
doubt it is. But I suggest that the accumulation of fat is not
merely teleological in the sense that it is to serve as a store of
nutrition during the period of abstinence in hybernation, but
that it is teleological in another sense, that is to say, that the
great accumulation of fat in the tissues, and the consequent
accumulation of unwonted materials in the blood, so modifies
the nutrition of the nerve tissue as to cause an alteration in its

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631

mode of action which is the physical basis of the desire for
hybernation. So with respect to the migration of birds. This
takes place at a settled season, and seems to be determined
more by lapse of time and recurrence of seasonal conditions
than by anything else ; but seasonal variations bring, amongst
other changes, changes of food, and changes of temperature,
both of which must have, and we know do have, important
influence in modifying nutrition generally ; and if of nutrition
generally, then in particular of the nutrition of the grey
matter of the convolutions. The combative instinct or the
desire of aggression and violence has been dealt with, as I am
told, in the same way and with the same result as the desire of
sex. It is, as I have heard, a practice among shepherds when
they have a dog otherwise valuable, but rendered unsuitable by
his ferocity, to remove one testis, with the result that his fierce¬
ness is mitigated, and if the effect is insufficient, to remove the
other, which never fails to have the desired result. These
instances seem to prove beyond doubt that some of the
primary and most fundamental desires at any rate, have their
foundation in the chemical constitution of the grey matter of
the convolutions, and if only one desire has this physical basis,
it can scarcely be doubted that the physical basis of other
desires is the same in character, though no doubt the nature of
the chemical constitution of the tissue is different in different
desires.

If this doctrine is true, and it seems upon the face of it
difficult to controvert, then we have in our hands, in the
preparation of various organic extracts, a means of modifying
desire, of diminishing desire that is excessive, and of reducing
to the normal a desire that is morbid in direction. Cases of
morbid desire are not extremely infrequent, and in some of
these I have adopted a treatment founded upon this principle,
and this treatment has certainly been attended with the appear¬
ance of success. I do not wish to be unduly sanguine, but I
do not regard it as at all beyond the reach of human endeavour
to reduce morbid desires to order by the administration of
appropriate materials. If we can reduce the desire of sex and
the desire of combat, as it appears we can, I see no reason why
we should not eventually reduce the desire of accumulation in
the miser and the desire of expenditure in the prodigal. Dr.
Nicolson, in a presidential address to this Association, delivered

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from this place, declared that every crime that was tried in our
courts could be referred to the influence of one of three passions
—lust, rage, and greed. I submit that of these the two former
could, if it were worth while to do so, be abolished, or at any
rate reduced to innocuous dimensions, by operative measures;
and I believe the same result can be obtained without operation.
Is it too daring a speculation to suggest that some day the third
may be rendered innocuous by similar means ? If you think
this is indeed chimerical, may I say that you have as good
reason as those who, thirty years ago, would have regarded as
preposterous the prediction that, before the close of the century,
it would be possible to photograph the bones in the living
body.

If we consider other desires of great and overwhelming pre¬
ponderance, we see that they, too, arise at times and under
circumstances that countenance the hypothesis that the physical
state that underlies desire is a chemical change in the constitu¬
tion of the nerve-tissue. It is difficult to conceive a desire
more imperative than that which compels a tiny bird, whose
longest flights in summer are from tree to tree, within the
limits of a moderate-sized garden, to start on a journey crossing
oceans and continents to a land hundreds or thousands of miles
distant. Under what circumstances is this amazing feat of
endurance undertaken ? It occurs at certain seasons of the
year. It occurs at times that have a definite relation to the
nesting season—to the reproductive season. The northward
journey is undertaken when the reproductive apparatus is
entering upon its seasonal activity ; and, as already shown, the
chemical product of the reproductive glands is certainly, by its
action on the central nervous system, the physical basis of some
modes of desire, and if of some, why not of others? The
question is most pertinent if we accept the hypothesis that I
have already advanced, that this desire of reproduction is the
root of all desires, the stock out of which all other desires are
developed, and to which the action prompted by all other
desires does, in the end, minister. So, too, the return journey
of migratory birds is made at the end of the reproductive
season, when all the reproductive apparatus is subsiding into
quiescence, is undergoing involution, and is without doubt
pouring into the blood the chemical products of its katabolic
change.

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BY CHARLES MERCIER, M.D.

633

Leaving the range of normal desires, let us turn to those that
are morbid, and again we shall find corroboration of our doctrine.
Of all desires that are classed as morbid, which is the most wide¬
spread, the most intense where it exists, the one that is indulged
in with the most reckless disregard of inevitable ill consequences ?
Surely the desire for alcoholic drink. The evidence that this
desire coexists with, and is due to, a certain metabolic factor is
very cogent. It is often alleged, it is still more often assumed,
that the difference between the sober man and the drunkard is
that the one possesses, and the other lacks, sufficient self-control
to enable him to overcome his urgent and masterful desire for
drink. The repetition from mouth to mouth, and from book
to book, of this obviously false doctrine is one of the most
striking instances of the ovine imitativeness of the human
intellect, and of the ingrained habit of yielding unquestioning
assent to authority. There are countless millions of sober men
and women in the world, all of whom are ready to utter the
parrot cry that they are sober because of their superior self-
control, because they have the strength to resist temptation,
and this they say in perfect good faith, when, if they would
only think for one moment and interrogate their own conscious¬
ness in their own experience, they could not fail to know, with
irresistible conviction, that in fact they are not tempted to
drink at all. Drink has no temptation for them. It offers
them no allurement. It yields them no delight. It satisfies
no craving. The taste of it finds them as indifferent as it
leaves them. They are drink-proof, not because of any
superior virtue, not because of any superiority of self-control,
but because drink holds out to them no temptation. And, not
being tempted, they do not fall. They are no more meritorious
for not getting drunk, than a cat is meritorious for not wetting
its feet, or a bird is meritorious for not falling to the ground.
Many such persons could not get drunk if they tried. The
sensations produced by the ingestion of alcohol are to them so-
unpleasant that they are compelled to leave off long before
they have taken enough to make them drunk. If, then, the
difference between the drunkard and the sober person is
not a difference in self-control, what is it ? Wherein does the
difference consist ? I submit that in this, as in all other
departments of knowledge, we must postulate uniformity in the
operations of nature. We must use Occam’s razor, entia non

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PRESIDENTIAL ADDRESS,

[Oct.,

sunt multiplicanda prater necessitatem . Unless we make this
assumption, speculation is vain ; knowledge cannot exist.
What are the facts ? The facts are that, on the one hand, when
alcohol is applied in solution in the blood to the brain tissue of
one person, there arises in that person a pleasurable feeling.
When applied in solution in the blood to the brain tissue of
another person, there occurs in that person no such pleasurable
feeling. The feeling is neutral, or is unpleasurable, or is
displeasurable. What is the inference? If the operations of
Nature are uniform, the inference is irresistible—the action of
the alcohol upon the brain of the one produces an effect
^different from its action on the brain of the other. It does not
matter to the argument whether the chemical constitutions of
the brains are different, so that the same substance produces
on them different effects ; or whether the constitutions of the
blood are different, so that the alcohol arrives at the brain in
different combination in the one case from what it is in the
other ; or whether the constitution of the liver or of some other
tissue is different, so that the alcohol in the one case arrives at
the brain unaltered or altered in one direction, while in the
other case it arrives unaltered or altered in another direction.
In any case, either the brain, or the blood, or some other tissue
is so different in the one person from what it is in the other,
that the action of the alcoholised blood upon the brain is
different; and these actions are chemical actions. Now, in the
matter of the action of alcohol upon the human body there
are very few things upon which everyone is agreed. There is
a large body of medical opinion which states dogmatically that
the action of alcohol on the human body is always, in all quan¬
tities and in all circumstances, harmful and poisonous. There
is another and very important body of medical opinion which
holds that, judiciously administered in proper circumstances
and in proper quantities, alcohol is a boon and a blessing to
men. I do not now enter upon this controversy, though I
have done so before, and am prepared to do so again on appro¬
priate occasion. What I wish now to point out is that both
parties to this controversy, who are extremely unwilling to
agree on anything if they can help it, agree in this: That the
craving or desire for drink does not arise unless and until
drink has been tasted—has been drunk. This is true of those
who have never tasted drink. They never experience the

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BY CHARLES MERCIER, M.D.

635

desire for drink until they have once tried it. It is true also of
those who are compulsorily deprived of drink. The prisoners
in the State inebriate reformatories do not, after a certain
period of detention, experience any craving for drink while they
are in the reformatory, nor do they after they are discharged
experience any craving for drink until they have tasted it; but
once let them taste it, and their craving starts into being as an
imperious desire, which must be satisfied at any cost of decency,
of reputation, of happiness of themselves or of those they hold
dear. In this case again it seems that the physical basis of
desire is a chemical change in the constitution of the central
nervous system. Happy are they in whom this change cannot
be produced!

We now arrive at the last of the primitive faculties or com¬
ponents of mind, and are to inquire what are the physical
bases of Pleasure and of Pain respectively. Dr. Mott, in his
interesting lectures on the emotions, says that “ The sense of
well-being of the whole personality depends on an adequate
supply of blood to each and all the important tissues of the
body, whereby they can function in harmonious co-operation/'
This is, I think, an important factor, but it is an indirect factor.
From our present point of view we must ask, What is the con¬
dition of the convolutions, of the substrata of consciousness,
that underlies the feeling of well-being and ill-being, of pleasure
and pain respectively?

Years ago I advanced the hypothesis that the determining
condition was the repletion or depletion of the highest nerve
regions with energy or motion, that when the contained motion
was great in quantity and of high tension, high amperage and
high voltage, then the feeling was pleasurable ; and that when
quantity and tension were low, then the feeling was one of
misery; but on re-consideration I doubt if this hypothesis can
be sustained. Observation of the facts of disease does not
bear it out. In many cases in which the feeling of misery is
extreme, movements are active and sustained, showing that
nervous energy is copious and of high tension ; and in stupor,
a state which gives evidence of utter emptiness and depletion
of motion of the nervous system, consciousness is not in a state
of misery—it is deficient or absent.

Pains may be divided into two classes—the crude pains of
bodily injury and disease, sometimes called physical pain or

LIV. 46

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636 PRESIDENTIAL ADDRESS [Oct^

bodily pain, and the elaborate pain of the disagreeable emotions
—anxiety, fear, disappointment and so forth. There can be
little doubt of the condition of the substrata of consciousness
in crude pain. The convolutions are disturbed by the arrival
and delivery into them of currents of motion that are excessive
in quantity or abnormal in quality from the diseased or injured
tissue. In the elaborate pains of fear, anxiety, disappointment,
and other painful emotions, there is abundant evidence of tissue
change, of disordered function, such as is consistent with a
widespread alteration of metabolism, and a resulting influx
from a wide area of currents of motion correspondingly altered.
I need only instance the pallor, the dry mouth, the disturbance
of the heart’s action, and the other well-known accompaniments
of painful emotion. In the misery of disease, in what we call
melancholia, there is very usually abundant evidence of dis¬
ordered metabolism, and I know of no case in which such
disorder can be excluded. My suggestion is that the physio¬
logical substratum of pain—of the pain of painful emotion as
well as of the pain of disease and of injury—is the delivery
into the convolutions of currents from tissues in which kata-
bolism preponderates over anabolism, or in which the tendency
is on balance towards dissolution and disintegration.

If this is the physiological substratum of pain, what is the
corresponding substratum of pleasure ? Whence do we derive
the feeling of well-being, of joyous elation, that is so con¬
spicuous in some conditions of health, and so exaggerated in
some conditions of disease ? As I suppose, from the delivery
into the convolutions of incoming currents that are vigorous,
copious and well-proportioned, that speak of tissues and
organs in a high state of efficiency, that tell of the preponder¬
ance of anabolism over katabolism in the body at large. Here,
it seems to me, is the reconciliation of Dr. Mott’s hypothesis
with that which I am expoundiog. Tissues and organs that
are in a high state of efficiency are tissues and organs which
receive a copious and well-proportioned supply of healthy
blood ; and thus it is that, indirectly, Dr. Mott’s explanation
expresses a large part of the truth. Youth is the time of high
spirits and abounding happiness, and youth is the time of the
preponderance of anabolism. Other things equal, wasting
diseases are accompanied by depression, unless the wasting is
merely the removal of superfluous fat.

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BY CHARLES MERCIER, M.D.

637

In this hypothesis one may find an explanation of a curious
occurrence that I have noticed in many cases of morbid
depression, and that is quite frequent in the normal depression
of misfortune and disaster. Whether the depression is normal
or morbid, when the sufferer wakes in the morning he is, in
many cases, for a few instants completely free from his
depression. He is happy and cheerful for a moment or two,
and then the black cloud rolls over him, and he is plunged in
misery which endures the day through. The explanation of
this curious occurrence seems to me to be as follows: By the
quiescence and ablation of function that occur in sleep, those
highest regions of the nervous system that are the substrata
of consciousness are cut off from the influx of currents belong¬
ing to the ccenaesthesis. Between the substrata of consciousness
and the tissues of the body at large there is interposed a
stratum of inert tissue, through which the currents from the
one to the other cannot penetrate. The substrata of conscious¬
ness receive no intelligence of the processes of metabolism, and
preserve in consequence a neutral tone that is reflected in a
complacency of mental affection. Upon waking, these dormant
areas regain their functions, and regain them in their order
from above downwards. Consciousness returns first, and with
the spread of efficiency, the convolutions that are the substrata
of consciousness are placed once more en rapport with the
body at large. The moment this takes place, the depression
is re-established ; but the spread of wakefulness from the
highest region to that just below takes time. The resumption
of function is not instantaneous, but occupies a small but
appreciable time, and hence it is that, until the resumption of
function is complete, there is no depression ; but as soon as the
influx from the body at large takes place, the depression is
re-established.

I have long held, and extension of experience induces me to
hold more and more strongly, that the metabolism of the body is
regulated in the last resort by those very convolutions that are
the substrata of consciousness. In many cases of vicious meta¬
bolism I believe the original fault is in the convolutions, not in
the tissues; and in cases of depression it seems to me a
vicious circle is established. Trophic influence from above
disorders metabolism ; return currents, from the tissue whose
metabolism is disordered, maintain and increase the disorder

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638 THROMBOTIC ORIGIN OF EPILEPTIC FITS, [Oct,

of the central nerve regions from which the trophic influence
issues. The difficulty of breaking into such a vicious circle is
extreme, and hence the intractability of so many cases of patho¬
logical despondency.

Some members of this Association I fear there are who
scout these abstract and recondite speculations as useless, and
as savouring of the futility of the speculations of the School¬
men. Such members I would remind of the undergraduate
who refused to have anything to do with the square root of
minus one, on the ground that it was not only futile, but
immoral.

But the square root of minus one has proved a very
magician’s wand in revealing the secrets of Nature. It is used
in calculating the capacity of condensers ; in plotting stream
lines of fluid in motion ; it is indispensable in calculating the
transmission and utilisation of electric power ; and it is not too
much to say that is has rendered wireless telegraphy possible.
Those who work on lines of research that yield results of im¬
mediate practical value need no encouragement. Their
reward is speedy and is sure. But I submit that no results
of permanent value have ever yet been reached except
upon foundations laid by far-reaching speculations into the
nature of things—speculations that at the time they were made
seemed to be but the dreams of an enthusiast, and to have no
practical bearing on the affairs of men.

Some Further Observations Bearing on the Supposed
Thrombotic Origin of Epileptic Fits (*). By John
Turner, M.B., Senior Assistant Medical Officer, Essex
County Asylum.

I HAVE again ventured to trespass on your time and atten¬
tion with some remarks on the pathology of epilepsy, partly
in order to refer to some criticisms on my views and partly
to amend them, because my most recent observations on the
coagulation-rate of the blood in this disease seem to indicate
that they require some modification.

My contention has been that epilepsy is a disease occurring

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BY JOHN TURNER, M.B.

639

in persons with defective structure of the nervous system,
either congenital or involutional, in whom there is an abnormal
state of the blood, characterised by a special tendency to clot,
and that the exciting cause of the fits is sudden stasis of the
cortical blood-stream, the result of a blocking of cortical vessels
by intra-vascular clots.

Now the point which from the further results of my exami¬
nation into the coagulation-rate of the blood in epileptics, I
think, requires modifying, is that postulating a special tendency
to clotting in epileptics* blood, apart from those periods when
they are under the influence of fits. The evidence now
shows that in certain cases, chiefly among those who have
infrequent fits, the coagulation-rate is only quickened during
the time that they are about to have fits. The rest of my
contention, I believe, still holds good.

(a) As regards the structural defect of the nervous system :
The evidence, both clinical and pathological, that epilepsy is
associated with structural defect of the nervous system amounts
in my opinion almost to demonstration. It is associated in a
very large number of cases with actual imbecility or idiocy, and
in perhaps a still larger number with various grades of weak
mind not amounting to actual imbecility. But I do not wish
to infer that the structural defect of the nervous system is
necessarily one that shows itself by intellectual shortcomings.
Some of my cases were certainly up to the average standard of
intelligence for people of their class, some above, and yet in
such of them as have come to autopsy I have seldom failed to
find evidence of immature or defective cerebral structure.

I believe that one of the most striking forms of defective
structure, and one which admirably lends itself to demonstra¬
tion, is met with in the character of the Betz cells.

In from 65 to 70 per cent of all epileptics there is present
a form of cell which there are very strong reasons for regarding
as an immature form, and which is very similar to an early
stage of reaction d distance .

There has been a large amount of literature concerning the
supposed relation between this form of cell and certain forms
of insanity.

Briefly put, my reasons for regarding it in epileptics as an
immature form, and not due to active interference with the
axon (as by injury or disease) are as follows :

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THROMBOTIC ORIGIN OF EPILEPTIC FITS, [Oct,

(1) When the axons have been interfered with in the way
of severance, as by a haemorrhage, the passage through the
various grades of change up to almost complete disappearance
is rapid, occupying only about ten to fifteen days ; so that if
in epileptics it was an active form of cell change due to this
cause, it is highly improbable that we should meet with such a
large proportion of cases, even in very advanced epilepsy,
showing such a very early stage.

(2) We have comparatively rarely any evidence of lesions
of the particular axons in question of a nature which would
suffice for the change.

(3) It occurs in nearly 40 per cent, of all the cases dying
insane, being least common in general paralytics, and in nearly
60 per cent . of all imbeciles, whether epileptic or not.

(4) It is found normally in some of the very large ganglion
cells of the forehorn in the lower animals (full-grown pigs, cows,
etc.).

(b) As regards the immediate or exciting cause of the fits
(of all kinds), I am still of opinion that they are due to sudden
stasis of the blood-stream in the cortex caused by the impac¬
tion of thrombi in the smaller vessels. I hold that this con¬
tention is supported by(i) experimental evidence, (2) byhisto-
pathological evidence, and (3) by clinico-pathological evidence.

(1) As I have already more than once stated the experi¬
mental facts which show that sudden stasis of the blood-stream
is capable of causing convulsions, I shall not enter into these
particulars again.

(2) And concerning the histo-pathological evidence, I will
merely mention that I have found intra-vascular clot, especially
in the form of small spherical bodies, in over 80 per cent, of the
brains of epileptics examined (now some fifty cases), a per¬
centage which is much higher than in any other class of cases
similarly searched.

There is one point I ought to mention in reference to the
nature of this clot. With the view of ascertaining whether it
was a nucleo-protein material, because if so this would support
the idea that it was a vital phenomenon, I tested it for phos¬
phorus according to Macallum’s method. In the first two or
three cases I closely adhered to his instructions, dehydrating
the tissue in hot alcohol by means of a Soxhlet apparatus, etc.,
and found that the clot in question took a bright green colour,

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BY JOHN TURNER, M.B.

641

indicating phosphorus, but as I got a quite similar reaction
in pieces of the same tissue merely dehydrated in cold alcohol,
I did not repeat the dehydrating in the Soxhlet apparatus for
the further very numerous cases tested, a procedure which would
have added very considerably to the labour of the investigation.
But whether I was justified or not in this proceeding does not
apparently now matter, for two independent workers, Bensley
{Biol. Bulletin , 1906) and Scott {British Medical Journal , Decem¬
ber 22nd, 1906), have thrown strong doubt on the reliability
of the test, and both have arrived at the conclusion that the
deductions drawn from its use, in so far as they relate to
nucleic acid, are worthless, so that if this be true the result of
my investigation into the chemical nature of the clot to collect
proof of its vital character must be looked upon as of very
doubtful value.

There are, however, features in the form and in the class of
cases in which the clot is deposited which afford some
evidence of its vital nature, and which help to show that it is
not due, as has been suggested (Ascherson in Mott’s
Archives ), to agonal appearances or the result of prolonged
status epilepticus.

(i) It is commonly met with in cases which have not died
in status epilepticus, and although acute inflammatory con¬
ditions undoubtedly favour its depositions, yet, so far as my
experience goes, this greater liability is especially associated
with inflammatory conditions occurring in epileptics. I have
examined several cases (not epileptics) dying from acute
inflammatory disorders without finding any evidence of intra¬
vascular clotting ; two of these I have referred to in my article
in the January number of the Journal of Mental Science . Two
others I may now add:

{a) A woman, aet. 38, at whose autopsy there was found
thrombosis of cerebral meningeal veins with purulent menin¬
gitis, with general septic infection (liver and kidney). Sections
from both ascending frontals and the left temporal lobe
showed no cortical thrombi.

{b) A woman, aet. 40, dying from typhoid with fatty
degeneration of the liver and cloudy swelling of the kidney.
(Temperature reached io4°F.) Sections of both ascending
frontals, medulla oblongata, spinal cord, and spinal ganglia
were examined, but showed no traces of intra-vascular thrombi.

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642 THROMBOTIC ORIGIN OF EPILEPTIC FITS, [Oct.,

(ii) Appearances indicating that the clot has produced a
bulging out of the capillaries in which it is deposited, and
which I take to be the result of the arterial pressure on the
blood-stream during the process of coagulation.

(iii) Actual rupture as the result of impaction.

(iv) The existence of clotted masses, half within and half
without the capillary vessels, which I take to be evidence of
vital transudation of fluid plasma which has undergone coagu¬
lation during the process of transudation.

(v) It also appears to me that the correlation of intra¬
vascular clotting in such a very large proportion of epileptics’
brains, with the fact that in these subjects there is, during
and before fits, a marked tendency of the blood to coagulate
quickly, are further strong points in favour of the idea that the
clotting is a vital phenomenon.

I should like here, also, to briefly point out my position with
reference to Herpin’s law which seeks to formulate the identity
of the incomplete and initial symptoms of the complete attack,
and the identity of type of the fits in a given case.

In the British Medical Journal (March 3rd, 1906), I en¬
deavoured to show that the identity of the symptoms of the fits
in a given case is not incompatible with the thrombotic
theory. The type of fit, and the pattern, so to speak, of the
symptoms, sensory and motor in each case, is, in my opinion,
pre-determined by the site and extent of the cortical defect—
this is a congenital affair. It would be, of course, absurd to
suppose that the block, which I hold excites the fit, would always
occur in a vessel in exactly the same region, but I imagine
that the lodgment of a thrombus in any area of the cortex,
which is linked to the defective area by open nerve paths, will
be sufficient to overturn the unstable equilibrium of the cells
of these defective areas, and issue in an epileptic attack of an
uniform character. And similarly I would suggest that in those
cases where the fits are ushered in by an aura, the defect of
cortical structure is not limited to motor areas, but implicates
also sensory areas, so that in proportion to the suddenness and
severity of the stimulus and the degree of cerebral defect in
sensory and motor regions, one or both, there may be produced
either a sensory phenomenon alone (aura) or an incomplete or
complete minor or major attack.

Loss of consciousness and not convulsions is by most

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BY JOHN TURNER, M.B.

643

authorities stated to be the cardinal feature in epileptic attacks,
and Dr. A. E. Russell, in a paper on 14 The Pathology of Epilepsy,”
read in the Medical Section of the Royal Society of Medicine
on November 26th, 1907, suggests that the unconsciousness
and convulsive seizures of the epileptic attacks are due to
sudden failure of the entire cerebral circulation. In his
criticism on my views he objects that if the clotting is very
localised, it is difficult to conceive how it would bring about
the phenomenon of a fit, and that if it were extremely wide¬
spread, the subsequent destruction of brain-tissue would be so
great as to be incompatible with the fact that after a fit the
epileptic shows so little material change, mental or physical, and
he questions whether the blocking of a few small capillaries
would result in sudden unconsciousness.

Dr. Russell, however, does not take into account a factor
which I consider to be essential in the production of seizures
in idiopathic epilepsy, viz., defective cerebral structure.

Facts are, I am afraid, lacking which would warrant one in
decisively stating whether consciousness may or may not be
abolished by the sudden cutting off of the blood-stream from
small cortical areas. What evidence we have (in the experi¬
ments by intra-venous injection of oily substances) in my
opinion is in favour of the view, that consciousness may be
abolished by very localised agencies in the cortical areas, and
more especially if the cells of the affected areas are in a con¬
dition of unstable equilibrium, from innate defect of structure.

As bearing on the question whether consciousness may be
abolished by minute cortical lesions I will quote a case of
senile epilepsy, where, at the autopsy, were found hundreds of
tiny cortical haemorrhages, from a pin's head to a pin's point
in size. These lesions were due to obstructive endarteritis of
small cortical arterioles. It seems justifiable to associate the
epileptic attacks (with loss of consciousness) with these
haemorrhages, as effect and cause, and if so then we must
admit that an extremely minute lesion is capable of causing
loss of consciousness.

The stasis does not lead to atrophy of the brain substance
except occasionally where the block is permanent and lodged in
a comparatively large vessel; because although probably the fine
cortical arterioles are terminal, I believe that it is possible for
the cells of the affected area to obtain sufficient nourishment

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644

THROMBOTIC ORIGIN OF EPILEPTIC FITS, [Oct,

from the lymph which everywhere surrounds and bathes them,
at any rate that by this means they can ward off necrosis until
the circulation of their nutrient vessels is restored by the dis-
lodgement or absorption of the impacted thrombus.

( 3 ) Clinico-pathological evidence .—I am dwelling more on

Fig. i.

■

■I

■

E33

■

this aspect of the question to-day, because it is that to which
my attention has been chiefly turned of late, and because it is
my further experience of the coagulation-rate of the blood
that leads me to consider that a modification of my original
view is necessary.

Fig. 2.

My observations on the coagulation-rate of the blood now
number many thousands, and include, besides healthy women and
epileptics, those suffering from the katatonic form of dementia
praecox, from acute mania, and from imbecility (high and
medium grade) without epilepsy. My colleague, Dr. de

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BY JOHN TURNER, M.B.

645

Steiger, and myself are still working in this direction, but even
at the present time the observations are believed to be suffi¬
ciently numerous to warrant our drawing certain conclusions.
Before referring, however, to these I will briefly recapitulate

Fig. 3.

the chief points which our observations in epileptic cases seem
to warrant us in drawing :

(1) That the average rate of coagulation in the severe

Fig. 4.

epileptics is quicker than in any other class of cases so far
examined.

(2) That in epileptics (and it must be borne in mind that I
am referring, with a very few exceptions, to those of average or

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646

THROMBOTIC ORIGIN OF EPILEPTIC FITS, [Oct,

above the average intelligence) who are subject to frequently
recurring fits, the average rate of coagulation during the time
that they are having fits is quickened (see Figs. 1-3).

(3) That before (up to twenty-four hours) and during fits
there is a further quickening.

(4) Occasionally, from twenty-four to forty-eight hours after
a fit, there is, as it were, a rebound effect and coagulation is
retarded (Figs. 2-4).

Fig. 5.

2.4000

2.2.000

20000

fffooo

16 000

tllOOO

/ 2 OO 0

! 0000

8 0 00

6000

U ov 0

□

■

1QO -

■

f /u -

■

1 5 o_

■

1LO -

—

■

1 4v -

/ 3 0 -

■

/ 20-

• *

■

//o -

■

1 yu —

■

puJUt

The accompanying chart (Fig. 5) shows the coagulation-rate
(continuous line), blood-pressure (broken line), and the number
of leucocytes per c.cm. (dotted line) for fourteen consecutive days
between the hours of 11 and noon in a female epileptic of
average intelligence. It shows the tendency for the coagulation-
rate to be quickened just before attacks, and to rise afterwards.

On two occasions there was a marked but temporary leuco-
cytosis after attacks . In my experience this is the most usual

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BY JOHN TURNER, M.B.

1908.]

647

alteration found in regard to the blood count, but sometimes
the leucocytosis occurs before and sometimes not at all.

Notice that for the first seven days the blood-pressure curve
closely follows the coagulation-rate curve, but afterwards, i. e,
during the period of fits, this relationship is no longer to be seen.
This woman was taking 10 gr. doses of potassium bromide at
bed-time.

(5) That in certain epileptics, especially those who have
single fits at long intervals, the average rate of coagulation is
not quickened ; it may, indeed, be retarded ; but still, in these
cases there is before and during fits a relative quickening. Also
cases who have a number of fits, and then go some weeks or
months without any, during the period that they are free from
fits do not very often show quickened coagulation.

This last conclusion appears to show that the special ten¬
dency to clotting is limited to periods of fits, and the question
arises : To what is this temporary quickening due ?

There is a large amount of evidence accumulating, the ten¬
dency of which is to indicate that epilepsy is a toxic disease.
It is not my intention to give an account of the work of
Krainsky, Ceni, Fere, etc., in this direction, but as bearing on
the question under consideration I would mention that, as Dr.
Aldren Turner points out to me, (1) quickened coagulation,
(2) excess of nucleo-protein in the blood, (3) elevation of
temperature in continuous fits, and (4) leucocytosis, two
of which are certainly, and all of which are probably factors
in many cases of epilepsy, are also factors which, apart
from direct experimental evidence, support the idea that there
is a toxin in the blood in epilepsy.

On these grounds I am inclined to regard the quickening
of coagulation found at certain periods in the blood of epileptics
as due to a toxin or toxins, which, by accumulation or
otherwise, at certain times lead to thrombosis which may,
under favourable circumstances, precipitate a fit or fits. The
toxin, from this point of view, is not the immediate cause of
the fits. The immediate cause is local stasis of cortical areas.

By this supposition many difficulties in the way of accepting
the usual toxic theory of epilepsy are removed ; and it has
also the advantage of bringing into harmony results obtained
by different observers working at the problem from very
different positions.

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648

THROMBOTIC ORIGIN OF EPILEPTIC FITS, [Oct.,

Minute thrombi, formed locally in the general blood-stream,
may not be able to reach the sites where they become efficient
excitors of convulsions, but the very small calibre of the cortical
capillaries, in comparison with the capillaries of the body
generally, immensely favour the impaction of small thrombi in
the former rather than in the latter.

Sir James Barr states [British Medical Journal , August 31st,

1906) that the diameter of the body capillaries varies between
7 and 13/4. Now in the cortex they are met with no larger
than 1 to 2/1, so that small thrombi able to pass easily
through the general capillary circulation would be arrested in
the cerebral cortex. Dr. Ford Robertson, I know, has
denied that cortical capillaries are ever so minute as the figures
I have given, and he gives 4 /i as the limit of fineness, but
this is an obvious error, as anyone may satisfy himself by
examining films of cortical matter. I have examined many
hundreds of such made by the method I described in the
Journal of Mental Science some years ago, and probably in
all, certainly in the great majority, capillaries of 1 to 2 p
were distinctly visible. These figures are smaller than the
diameter of an erythrocyte, but the elastic nature of these
bodies allows them, by lengthening themselves, to pass along
tubes of such fine calibre. I will show you on the screen
photographs of capillaries of 1 to 1*5 /lc in diameter, and also
elongated erythrocytes in the act of passing along a tube not
more than 2 /u in diameter.

Concerning the coagulation-rate of the blood in insane cases
other than epileptics having frequent fits, we found that there
was a tendency for the daily average of all the different classes
(*>., the maniacal, the precocious dements, the epileptics with
infrequent fits, and the imbeciles not suffering from epilepsy),
to group themselves around the daily average of the normals,
but that the averages of the maniacal and epileptics with
infrequent fits tended to rule the highest, and those of the
precocious dements and imbeciles (especially the latter), tended
to rule the lowest. Beneath all these (with three exceptions),
came the daily average for the severe epileptics.

The position of the imbeciles 1 curve is lower than any group
except the severe epileptics, and hence approximates most
nearly to the curve of these latter.

Remember that these curves represent averages of from

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BY JOHN TURNER, M.B.

649

three to eight individuals. Amongst precocious dements and
imbeciles some cases show an average no higher than some of
the severe epileptics; this seems to be especially so in advanced
cases of dementia praecox and in certain imbeciles of low
grades.

A very striking method of showing the increased tendency

Fig. 6.

Continuous line = coagulation rate in seconds.
Dotted line =» blood-pressure in mm. of Hg.

to coagulate in severe epileptics is to contrast the number of
instances where the blood coagulated at two minutes or less
(rapid rate) in them, with the number of instances in the other
classes. This was as follows :

In epileptics having frequent fits, 28 out of 83 observations,
that is, 33*7 per cent

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6 SO THROMBOTIC ORIGIN OF EPILEPTIC FITS. [Oct,

In epileptics having few fits, 4 out of 56 observations, that
is, 7*1 per cent.

In precocious dements, 8 out of 112 observations, that is,
7*i percent.

In imbeciles, 15 out of 84 observations, that is, 17*8 per
cent.

In maniacal cases, 2 out of 42 observations, that is, 4*7 per
cent.

In normal cases, 3 out of 98 observations, that is, 3*0 per
cent.

It has been shown by independent workers, (Biirker, Buck-
meister, McGowan,) that the coagulation-rate is much slower
in the morning than in the evening and this may perhaps help
to account for the tendency in many epileptics to have their
fits chiefly during the night.

There is one point which these further observations bring
out in a very striking manner, and that is the relationship
between slowness in coagulation and height of blood-pressure.
I will show you charts which illustrate this, where the daily
fluctuation in coagulation-rate is followed by corresponding
fluctuation in pressure (Fig. 6). At times disturbing factors
may mask or obliterate this relationship, but as a general rule
we may state that a high systolic blood-pressure accompanies
a slow rate of coagulation.

From my point of view this relationship may be of service in
indicating lines of treatment. We know that the secretions
from certain glands possess the property of raising the pressure;
if this property is associated also with one which causes a
retardation of coagulation—an assumption which the results of
our observations render probable—we may have in the admini¬
stration of extracts from certain glands a means whereby we
could permanently retard coagulation, and so be in a position
to test whether this did or did not affect the epileptic attacks.

( l ) Read at the Quarterly Meeting of the Medico-Psychological Association, held
at Warwick Asylum, February 20th, 1908.

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1908.] THE QUESTION OF DEMENTIA PRiECOX,

651

The Question of Dementia Pracox. By Robert Jones,
M.D.Lond., F.R.C.P.Lond.

In any province of experience the systematic arrangement
of the facts pertaining to it is regarded as one of the most
useful instruments in its comprehension and understanding, and
for this reason a systematic classification of the various forms
of insanity has long been accepted as one of the best signs of
psychiatric progress.

The saving of repetition, the avoidance of endless and useless
enumeration of single cases, the time saved by their arrange¬
ment into kinds or groups, and the assistance to diagnosis,
prognosis and treatment, have always justified attempts at a
classification of the insanities. So unsatisfactory has every
scheme hitherto presented proved itself to be, that it was no
new thing to hear murmurs of disapproval with the Table
presented by a special Statistical Committee of this Association
at the annual meeting two years ago. Yet so necessary and
helpful is a proper scheme that it at once strikes the merest
tyro, and we know that the first self-imposed duty which a
fresh medical officer in an asylum performs—and this with the
gratification and the excitement of a new discovery—is to
invent and evolve a classification of his own, dividing the
various forms into groups or kinds into which, in his opinion,
any case can with ease find a ready place and label.

It was upon a motion proposed by our President, Dr.
Mercier, in 1905, that a committee was appointed to draw up
a “ Table of Disease ” and to report thereon to the Association.
In their final summary presented by Dr. Percy Smith are these
words : “ In the existing Table ‘ Stupor and States of Con¬
fusion * and ‘ Primary Dementia * are found, and the com¬
mittee consider that they are of sufficient clinical importance
to justify separate headings, as is recommended. The question
of ‘ Dementia Praecox * was, of course, carefully considered, and
the Committee did not desire to re-insert this term.” The
latter statement has undoubtedly been a disappointment to
some who appreciate and follow the teachings of Kraepelin,
and this special title has certainly received the adherence of
many of the younger authors and writers, more particularly in
America and in Germany.

Liv. 47

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652

THE QUESTION OF DEMENTIA PRAsCOX, [Oct,

It is no easy matter to divide pathological mental states
into groups characterised by the possession of such common
characters and marks, that upon a survey any occurring case of
insanity can with confidence be therein included. The con¬
junction of characters that agree and the separation of those
which differ do not enable us to classify with facility and con¬
fidence diseased forms of every mental constituent, and much
care requires to be exercised to use terms exactly and
definitely. There is no unanimity even in regard to the
classification of the normal mind, for Sir William Hamilton
taught that mind could be analysed into three main funda¬
mental constituents, and he considered cognition or thought,
feeling, and will or conation to be elemental faculties of the
mind, and in Bucknilland Tuke’s Insanity, p. 41, edition 1874,
a classification of the insanities appears based upon this
analysis. It would be correct to state that since the time of
Aristotle, who recognised only two main divisions of mind,
viz., intellection and conation, until to-day, when there is again
a tendency to revert to almost the same dual division, ultimate
mental constituents remain a matter of speculation and dis¬
cussion, and it is not surprising therefore that a classification
of morbid mental features as observed in insanity should meet
with a similar fate.

It is not my object to-day to review the whole systematic
arrangement presented in a classification of the insanities, but
to deal with one division only, and I would point out that
although Esquirol described the so-called dementia praecox
under the term “ acquired imbecility, ” it was not until
twenty years or so ago that an attempt was made to group
together several more or less allied forms of insanity in the
adolescent under the same heading, but under a new name.

I doubt if a more expressive term could be found for this
group than was used by Esquirol under “ acquired imbecility.”
It singles out what appears to satisfy the needs of a perfect
definition and supplies the whole connotation of the term.
Morel, in France, and Christian also, in his description of
“ juvenile dementia ” anticipated this grouping, which has been
further dealt with by Sdrieux, but to Kraepelin belongs the
distinction of inventing dementia praecox, not as the discovery
of a new disease, as some of his disciples urge, but as the
grouping together of symptoms which are characterised in the

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BY ROBERT JONES, M.D.

653

main by progressive deterioration. Whether this grouping is
a justifiable one it is the object of this discussion to elicit. It
may be observed that the term “dementia praecox” receives no
mention in Tuke’s Dictionary of Psychological Medicine , and
neither Dr. Clouston nor Dr. Savage mention it in their earlier
works ; moreover it does not appear in the index to Dr. Bevan
Lewis's text-book, yet no one who has read these manuals will
deny that all the symptoms descriptive of this condition were
not fully realised, accepted, and described.

Let us consider for a moment the meaning attributed to the
word “ dementia,” and so far as I understand the term, it con¬
notes, in the first place, an un-emotional state, for there is
neither excitement nor depression, only pronounced inactivity,
it is characterised by a negative manifestation of brain action
as contrasted with any positive symptoms of excitement. In
the second place the term pre-supposes a full development of
the mental powers. It is contrasted with amentia, which
implies a congenital state, and it is accepted as describing a
form of mental disorder characterised by acquired, as compared
with congenital enfeeblement of the mental powers. It is not
easy to fix any particular degree of mental impairment or
inactivity as definitely fixing or constituting dementia, but use
and custom associate the degree of loss with a depth from
which there is usually no recovery, and if there be any one
symptom which with confidence can be taken and relied upon
as characteristic of dementia, it is loss of memory.

The qualifying “ praecox ” merely signifies ripe, untimely,
before its time; but it has in this particular, as will be seen
later, a somewhat extensive application.

In the short printed abstract of what I had intended to
say I made, somewhat didactically but “ with malice afore¬
thought,” the statement that stupor was the most prominent
symptom, and also that there was a feeling tone of depression
in these cases, a condition which was accepted under the very
apt definition of melancholia cum stupore.

The presence of stupor is in agreement with the principle
laid down by Kraepelin when he added katatonia to the group
of general insanities in young people first described by Hecker
under the title of hebephrenia, an insanity which he described
as beginning at the age of puberty, but which has of late
received further extension of time from puberty through adoles-

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THE QUESTION OF DEMENTIA PRiECOX, [Oct,

cence and into maturity, and ending in general intellectual
enfeeblement. Kraepelin further added a variety of mental
aberration characterised by unsystematised and varying delu¬
sions described as paranoid insanity. To this class or group
the term “ dementia praecox ” was applied. Kraepelin did no
more than group together these three varieties, but many of
his pupils allege that he created a new entity, and has thus
described what some believe to be a new disease.

It may be well to consider more fully the varieties included
under this heading, and firstly hebephrenia, which Kraepelin
describes as commencing with hallucinations and delusions, but
these tend to disappear ; there is jerky mannerism and eccen¬
tricity, there is loss of voluntary attention and activity, loss of
interest, and apathy, ending, it may be, in speechlessness or
“mutism.” The cases in this category include those with
maniacal excitement followed by depression and ending in
permanent mental enfeeblement, although it is stated that about
8 per cent, of dementia praecox of this variety recover.

Katatonia (koto, riivw — to stretch or strain oneself) is applied
to a form of insanity characterised by hallucinations as well as
by apathy, loss of interest and of attention, merging into a
state of stupor with muscular tension. There is also what is
described as “ negativism ”—refusing to speak, or “ mutism,”
being the best example of this; and here I would venture to
ask for a definition of this term. Does “ negativism ” describe
the patient's state to the examiner, or does the term apply to
the patient's own mental state and imply loss of consciousness ?
If the latter, then, I would|prefer to describe the patient's mental
condition as “ positivism ” rather than “ negativism.” Cases of
this kind are often most resistive and refuse to do anything
requested of them. In addition there is a state of increased
susceptibility to suggestion, and such opposite conditions as
“ negativism '* and “ suggestibility ** pass from one into the other
directly, or after impulsive excitement, and thus is seen what is
termed “ stereotypy,” or “ stereotyped movements,” which are
actions repeated purposelessly and senselessly. Although
13 per cent, of these cases recover, yet there are no means to
judge which cases will recover, or which may lead to different
degrees of deterioration.

The third variety, paranoid forms (irapa v6oq— distraught,
frenzied) are described as resembling those of chronic delusional

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BY ROBERT JONES, M.D.

655

insanity, only that the delusions develop more rapidly and they
are less systematised. Hallucinations and delusions of either
or both persecution and grandeur occur, and these are believed
to be more persistent than in the hebephrenic and katatonic
varieties, but they also tend—though less—to pass off as mental
deterioration progresses. There may be in this variety some
katatonic stupor, the paranoid patient being also subject to
apathy, loss of interest and activity, and the same “mannerisms”
of katatonic patients and the same “ stereotypy ” are also
observed.

It must be acknowledged that there is no hard and fast line
to indicate any one of the above groups; the symptoms overlap,
and they are interchangeable—for the symptoms of the one are
not infrequently observed in the other; indeed, it may be stated
that many of the symptoms are common to all three forms.

Such a classification, with the symptoms of each variety
overlapping, fails in one of the fundamental necessities of a
logical division, for the varieties are not mutually exclusive. Such
an absurd classification would resemble a division of the army
into infantry and commissioned officers rather than into cavalry,
infantry, and artillery.

Can anyone, with experience of the above, and who has
a knowledge of practical insanity, for one moment consider
these closely-allied varieties to be different kinds or forms of
insanity or that they are limited to adolescence? If this be
the case then it is impossible to include any one class of
dementia praecox as “ a form of insanity at any one time,” such
as at the time of observation or of noting, although there are
some who propose to diagnose these varieties by so simple an
action as a <( shake of the hands.” If the above classification
be a typical one, then I can only say that in the Claybury
Asylum, with nearly 2,500 patients, there are not more than
5 per thousand cases of dementia praecox among the total
population ; whereas Kraepelin, I believe, considers that the vast
majority of the residents in institutions for the insane are cases
of this form.

It is not surprising that there is a difficulty in fixing definite
types of insanity during the period of youth, for it is one of
extreme complexity and variety. The gradual unfolding of the
sexual function is accompanied pari passu with an expansion
of the emotional life, and during the special epoch of life the

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656

THE QUESTION OF DEMENTIA PRjECOX, [Oct.,

mind becomes charged with latent changes, which on the
emotional side may well be described as dreamy longings and
per-fervid passions.

During this period, as Dr. Clouston says, intelligence is
nascent, ideas are inchoate, and the whole mind is lacking in
precision and conscious power. The period of puberty—from
12 or 13 to 15 or 16 years of age—has its special mental
formula, and so has the period of adolescence. In both the
mental states are different from that in maturity. There is a
difference not only of degree, but also of kind between the
several stages of youth and those of manhood, or womanhood,
or maturity; and the same causes, or set back, or disturbances
give rise, in precisely the same effects, to the same dementia.
It is the same shedding of the last acquired and least organised
attainment, and the injury to the mind is the same in youth as in
subsequent periods of life, the only difference being in its mani¬
festation. In the one period the delusion is tinted with the
hopes, the ideals, or the tender sentiments of youth, whereas in
adult life it is the result of mature experience.

Pulmonary tuberculosis in the adult lunatic is precisely the
same disease as in the stuporose adolescent, although there has
been no cough and no expectoration in the latter. Dementia
is the same injury in both, only with different manifestations,
depending upon the period of life which has its special mental
state. Acute rheumatism in adults affects particularly the
joints, but in youth the endocardium and the blood-vessels, yet
no one considers these to be different diseases requiring a
special nomenclature. Osteo-arthritis in adults affects the joints
generally, yet when it occurs in the young one joint alone is
seen to be affected, still it is precisely the same disease. In
just the same way dementia is the same whether affecting
young or old, and it needs no special nomenclature.

The grandeur, the false ambition, the mannerisms, and the
neologisms of the adolescent lunatic have their roots in the
romance, the poetry, and possibly the artistic sensibility of
normal adolescence; whilst the ambitions of the adult mono¬
maniac are the result of his maturity, his past experience and
the effects of his competition for a place in the struggle for
existence. The delusions reflect the environment as well as
the personality of the individual, and he is persecuted, jeered
at, or admired as external or internal associations predominate.

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BY ROBERT JONES, M.D.

657

The delusions of the hebephrenic or of the paranoid are
exactly of the same mechanism as occur in adult life, and
Dr. J. S. Bolton has aptly illustrated this by his theory of the
inherent neuronic durability, which admits the same injury at
varying periods and depending upon the special neuronic
resistance. Kraepelin himself accepts this to some degree when
he extends the period of this dementia to middle age.

The fact that in adolescence there is great fluctuation of
feelings and sentiments accounts for the fantastic delusions on
one hand and the languor or stuporose depression on the
other. Even in health periods of enthusiastic energy give
place to dissatisfaction and introspection; in youth this is
especially characteristic. But is there a real difference between
the apathy and stupor of katatonia and that observed after any
great mental disturbance, such as that seen in the adult after
acute attacks of mania, melancholia, folie circulaire , epilepsy, or
even general paralysis and other forms of dementia? Indeed,
the tendency to-day is to regard all suspension of psychical
operations and all stupors in which the mental processes are
more or less in abeyance as coming under the term “ katatonia ”
and being closely allied. I believe that the varieties of what
are described as dementia praecox are closely allied, if not
identical with what occurs in primary dementia at any period
of life, the only difference being due to the different stage of
evolution at which the dementia occurs, and at the onset I
venture to deny the very existence of such a special form of
mental disorder as “ dementia praecox.”

“ There is no new thing under the sun ” was observed by
Solomon in Ecclesiastes , but he was probably not so well
versed in insanity as his father David, and if his wisdom were
appealed to to-day it would draw attention to the neologisms
of the modem alienist.

Take, for example, hebephrenia! I wish to know what is
the relationship between Hebe, the daughter of Juno and the
wife of Hercules, with insanity ? Why should this goddess be
associated with mental deterioration and decay ? Again, in my
dictionary “ stereotypy ” is stated to be the art of casting by
means of a mould, and in another place the art of making
stereotype plates !

The term “ negativism ” does not exist either, but “ negative¬
ness ” does appear, and is the quality of being negative, a

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658 THE QUESTION OF DEMENTIA PRjECOX, [Oct,

negative being further described as a “ picture on glass in
which the light parts of the original are opaque and the dark
semi-transparent! ”

There is no connection suggested between these terms and
insanity, although they appear to be the stock-in-trade of the
alienist of to-day, and I cannot but deplore the coinage of new
terms when our own language is so rich in descriptive applica¬
tion.

It would appear from this account of dementia praecox
with its teeming multitude of new names—echopraxia, intra¬
psychic ataxia, echolalia, psycho-anaesthesia, heboid insanity
—that such a group of mental disorders never existed before ;
but what about the condition described by Esquirol as “ acute
dementia,” by Hayes Newington as “ anergic stupor,” and by
another as “ apathetic stupor,” in cases where the patient is
deprived of all manifestations of mental as well as of motor
energy ? The older classification of “ mental stupor ” gave the
hope of recovery which does and did occur, but the term
“dementia” conveys the idea of mental degeneration and
irrecovery, yet, as stated, recovery not infrequently occurs.
Regarding this point Dr. Clouston states : “ Kraepelin has taken
the term ‘ dementia prsecox * and applied it to practically the
whole group of my adolescent cases as described by me in
1873, making it cover the curable and incurable; I object
strenuously to the word * dementia * as applied to any recent
and curable varieties of mental disease as being confusing and
unscientific.”

I confess that many cases of mental stupor demonstrate upon
careful examination the existence of delusions, and the term
“ dementia ” is hardly applicable to them. I have such a case
recently within my memory (photographs exhibited). A man,
aet. 25, was admitted under my care with marked stupor and
rigidity. He had general anaesthesia, for even deep pin-pricks
elicited no response, and yet he felt them but could not speak
or flinch from them owing to the paralysing influence of a great
dread. He was mute, cataleptic, and yet he retained full con¬
sciousness, for upon emerging from this state his mind was
clear and he repeated every occurrence which he heard around
him ; conversation was repeated in minute detail, but he was so
overpowered with imaginary dread and he was so apprehensive
of harm that he could utter no sound at the time. I prefer to

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BY ROBERT JONES, M.D.

659

call such a case by the old descriptive term “ melancholia with
stupor” or “melancholia attonita.” Another case of melan¬
cholia with stupor occurred in the case of a female, aet. 45,
and it was typical of the cataleptic variety. I think in
neither could the term “ dementia praecox ” be applied, for in
the one there was no dementia, and in the other it was not
precocious nor untimely. My personal feeling is that for cases
up to forty-five or fifty this term is too wide in its range, and
therefore it is improper to call such cases those of dementia
praecox.

I cannot appreciate the term “ para-noid why not manoid,
melancholoid, paraloid, if the one coinage be justified ? I have
the same feeling in regard to pseudo-general paralysis. A
thing is either what it is or it is not, and such a form of
disease is either general paralysis or it is not. A mental state
is either paranoia—and Dr. Percy Smith has settled this matter
—or it is not.

Again, the characteristic feature of dementia is, as I have
already said, loss of memory; the mental reflexes are blunted
and inactive and all interest in former concerns are ended, yet
the so-called cases of dementia praecox are most retentive in
their memories. After years of asylum residence they can
relate with wonderful accuracy what has taken place in their
daily lives, and this although they appear to take no pleasure
in the society of their kindred, the patient standing about in a
state of passive indifference to all environment.

Although I animadvert upon Kraepelin’s terminology I am
not here to suggest a new scheme of classification, but to
criticise the present and to elicit the opinion of others whose
experience and observation of all forms of mental disorders
exceed my own. Some who have written upon the subject
are delighted that Kraepelin has invented dementia praecox,
for they say he has thereby encouraged the alienist to make a
diagnosis at once, and not “ postpone prophecy until after the
event,” which nevertheless the use of this term demands.

A terminology which suggests the ultimate termination of a
disorder is in my opinion somewhat premature and inapplic¬
able at its inception, more especially if, as in these cases, there
is occasional recovery.

In an interesting paper by Dr. Drapes {Journal of Mental
Science , 1906) upon the unity of all insanity, there are very

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THE QUESTION OF DEMENTIA PR/ECOX, [Oct,

cogent reasons presented for the exclusion of dementia praecox
and I believe the same view is entertained by Dr. Mercier in a
paper printed in the Journal of Mental Science , January, 1905.
A further paper by Dr. McConaghey {Journal of Mental
Science , April, 1905), proposes the subdivision of adolescent
insanity to represent the varieties covered by dementia praecox,
a view which has long been adopted by Dr. Clouston, who
gives valuable statistical experience upon the subject. In my
experience for the last five years at Claybury, 2,879 young
men and women between the ages of ten and twenty-five have
been received, a slight majority of these being females, and
recoveries occurred in 36 percent . Clearly, therefore, the term
“ dementia ” is out of place. I have included in this group all
cases of mania and melancholia, for Kraepelin appears to
embrace all forms of insanity of adolescence in his group, yet
all know the grave prognosis there is in certain stuporose cases,
which some of us still term “ primary dementia,” and which
Dr. Savage has so very epigrammatically included in his maxim
that it is often “ better to be sixty than sixteen ” in regard to
the termination of such cases of insanity.

I have been frequently struck by the association and relation¬
ship existing between motor and psychic states, and I have
witnessed a kind of mental chorea accompanying certain
impulsive, motor states. It may not be unlikely that there
exists a physiological relationship between mental stupor and
certain forms of motor spasm or rigidity, just as there is an
association between certain muscular paralysis and the mental
symptoms of general paralysis, but hitherto it cannot be said
that this form of mental enfeeblement in adolescence has been
illuminated by any definite pathology, and up to the present
the researches of Drs. F. W. Mott and J. S. Bolton have
approached the subject with the most light.

I cannot conclude without expressing obligations to Dr.
Johnstone, of Leeds, who by his excellent and clear translation
has brought the valuable researches of Kraepelin within reach
of the ordinary student.

Summarising my conclusions:

(1) There is no definite disease “dementia praecox”; the de¬
scriptions applied cover almost every possible variety of insanity.

(2) The term “dementia” is inapplicable, because it connotes
permanent and irrecoverable loss of mental function.

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DEMENTIA PRiEGOX.

66l

(3) The application of “dementia ” is unsatisfactory to cases
in which loss of memory is not a prominent early symptom.

(4) The term does not state whether it is the terminal stage
or the stuporose condition which is of primary importance.

(5) The qualifying adjective “ praecox ” is equivocal, in so far
as it leaves it doubtful whether the diseased condition evolves
precociously, or whether it is stated to occur in early life or
youth. It is therefore a vague and indefinite term, as these
symptoms are also known at maturity and even at the meno¬
pause, and therefore they should find no place in a scientific or
logical classification.

(6) A term which implies a definite entity, and which is
with some becoming more accepted as such, should be dis¬
tinguished by definite pathological findings, which is not the
case.

(7) Finally, it is more in harmony with practice and of
greater help to diagnosis and treatment to use in place of
“dementia praecox" the term “adolescent insanity," suitably sub¬
divided as at present.

Dementia Prcecox . By A. R. Urquhart, M.D., F.R.C.P.E.

FRANCISQUE Sarcey says that originality consists, not in
thinking new things, but in thinking for yourself things that
thousands of generations have thought before you, and that
your idea will appear new because you will strongly impress
upon it the turn of your mind and tinge it with the colour of
your imagination. Something of this kind has occurred in the
presentation of dementia praecox. Kraepelin does not even
claim the term as his own invention, but refers to it as the
original proposal of Pick. We have duly recognised the dis¬
tinguished position attained by them both, and appreciated
Kraepelin's work, especially in investigation and teaching, and
his achievements in elucidating morbid mental phenomena. If
one is led to differ with him in the light of observations
already made in this country and years of personal experience,
that difference must be expressed in terms of esteem and
respect.

Have we really advanced, in the matter of classification

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662

DEMENTIA PRwECOX,

[Oct,

at least, beyond the position attained by Griesinger in 1861 ?
I think not. The mair divisions of ordinary insanity are still
representative of states if depression, states of excitement and
states of weakness. Sankey’s great generalisation has been
revived and quickened, and rendered fruitful in a measure which
is a gratifying tribute to his memory. Apart from distinctly
pathological groups, these three phases may be successively
recognisable in one insane person, while another may present
but one or two. The progressive nature of mental disease is
thus set forth. Much complicated writing becomes less difficult
to understand. No doubt similar cases may be advantageously
grouped under special designations as subsidiary to the main
generalisation; but we have been, all along, too much occupied
with protean, kaleidoscopic appearances, too much distracted
by irrelevant or unimportant details, too much set upon the
discrimination of variable and varying symptoms. Our hopes
lie rather in the methods of physiology, a clinical procedure
relevant to the underlying facts and a pathological knowledge
which shall issue in a pathological classification. The toxic
nature of insanity, even the toxic nature of fatigue, offers an
explanation of morbid mental phenonena which Kraepelin has
been quick to recognise, and on which we may more securely
advance. Consequently, I have consistently advocated the
simplest form of classification of symptoms in terms of time,
except for those conditions, such as general paralysis, which
are already known to be grossly pathological—although even
that disease is conveniently regarded as melancholic, maniacal
or demented in its various phases.

No doubt such a term as melancholia would be rejected to¬
day if it were proposed for the first time. Black bile is not a
desirable designation, but it has been so long in use that the
group of symptoms which characterise the condition is never,
in practice, referred to the malevolent bilious secretion. It is
a term consecrated by use. The difference is marked when a
new name is offered for acceptance. Derivation and first-hand
meaning are closely scanned, and it can only win its way into
our nomenclature by express and undeniable suitability.

Dementia prcecox has thus been offered, and its passport, its
letters of credit, are carefully scrutinised. Is it dementia ? Is it
prcecoxt Or is it something else disguised under a classical
A garb? Adolescent insanity has long been familiar to us as

r \

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1908.] BY A. R. URQUHART, M.D. 663

indicating a fairly constant group of cises. Is the Association
to indicate a preference for the new importation? I hope not.

Let us see how dementia ends in nAy experience, which was
certainly not recorded with such an investigation in view. I
have considered all my cases diagnosed as demented during the
last twenty-nine years. All have proved incurable with the
exception of five. Those five are instructive; they were each
and all deeply alcoholic. They recovered. To the alcoholic
it would seem nothing is impossible—they conform to no rule.
Three were men, of whom two continue sane and sober; two
were women, of whom one continues sane and sober. The
others have been lost sight of in the course of years. There¬
fore, dementia has been in my experience an incurable condi¬
tion, invariably incurable but for those alcoholic exceptions.

No such results can be formulated in regard to dementia
praecox. The condition is not thus hopelessly incurable.
Kraepelin himself states that the disastrous ending of ordinary
dementia is not by any means the rule in dementia praecox.
The exceptions are too numerous to establish any such definite
failure of medical skill. It follows that dementia praecox is
not really dementia; and further, that there is a serious dis¬
advantage in thus confusing the issues, an unnecessary and
objectionable labelling of patients as hopeless and already
doomed. I trust that I shall not be misunderstood. All
insanity is mental weakness, more or less pronounced, but all
insanity does not touch that lower level of mental degradation
which is classed as dementia—that final wreckage of mind which,
at least in my experience, permits no opportunity of salvage. I
am free to confess that there was a time when I thought that
Clouston painted with too big a brush, and that his sweeping
assertion that dementia is altogether incurable might be
modified on careful scrutiny. Now, I can only say that my
experience corroborates his ultimate assertion, since my register
of medical facts has been completed and examined with an
open mind. In this register are recorded, inter alia, the ages on
first attack, and those persons of less than twenty-five years of
age, as adolescent. A brief examination of these records is of
interest, and I make this resuint of them not as applicable to
asylum life only, but as they are entered from the time of
the first attack until the present, so far as I have gained that
information. Inevitably a certain number have disappeared

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664

DEMENTIA PRiECOX,

[Oct.

from our purview in th <4 course of years, but these are com¬
paratively few. I would note also that the figures represent
all cases admitted down |to the moment of writing.

It would clear the ground if completed histories in sufficient
numbers were available for these inquiries, and the Association
has been repeatedly urged to enter on collective investigations
of the kind in order to establish statistics which would be more
valuable proportionately to the extent and trustworthiness of
the records. My present information is inevitably both faulty
and incomplete, and can only serve as a general indication of
results.

It will be convenient to adopt a tabular form referring to
certified patients in the Perth Royal Asylum at the beginning
of 1880, and since admitted, the whole numbers of these being
464 male and 442 female, total 906. Of that total the
persons received after first or repeated attacks of insanity
occurring between the ages of fourteen and twenty-five numbered
225, as follows:

Persons admitted aged 14 to 25 on

first attack.

The percentage on all admitted

128

225

270

21'9

Of whom neuropathic heredity was

ascertained.

The percentage on adolescents being

102

*75

79*7

75*2

77*7

Of these admissions recovered and so

remaining.

The percentage on adolescents being

4 *

17*2

* 9*5

18*2

Of these recovered, relapsed, re¬
covered and so remaining

Percentage.

109

* 3*4

12*0

Of these recovered, relapsed and so

remaining.

Percentage.

3 1

250

3**9

28*0

Of these no recovery was recorded
Percentage.

468

350

4*7

Total ....

128

225

100

Second only to the age period, the notable common factor in
these cases is the neuropathic heredity as ascertained in 777
per cent . On all kinds of patients my percentage is 71*81, but

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1908.]

665

BY A. R. URQUHARjT, M.D.

these statistical results are evidently understated owing to
absence or falsity of information. S^ill, the fact remains that
there is an adverse difference for adolescents of 6 per cent.
This is in accordance with the general finding and it is not unex¬
pected. It is recognised that those who suffer most deeply and
hereditarily from gout are those who manifest the disease in
early life—the stronger the predisposition the earlier the failure.
It is the same with rheumatism, which is so constantly recorded
among insane families. It is obvious that the constitutional
defences of the individual are innately defective. Again, the
“ recoveries” from rheumatism bear a close resemblance to the
“recoveries” from insanity. The recoveries, the relapses, the
chronic incapacity are even statistically similar. Or, taking a
wider view, the medical results of general hospitals are prac¬
tically the same as those of hospitals for the insane. Since
Professor Karl Pearson has shown that the expectation bears a
mathematical relation to the antecedent facts, this need not
be laboured further. The faulty heredity finds expression in 70
per cent, of failures, regarding recovery from mental disorders as
the re-establishment of mental soundness in so far as to permit
of return to ordinary life without need of the care and super¬
vision of others. I have reason to believe that this test of
recovery is not universally accepted, but the word is used in
that strict sense in these calculations.

We see this early failure at an average age of 19 years on
first attack, an average age at death of 48 years, and an average
age of survivors still insane of 42 years, so far as ascertained.
Thus:

Insanity of Puberty and Adolescence.

M. F. T.

Average age on first attack . 19*6 . 18*1 . 19 0

„ „ death . . 40 8 . 60*3 . 48*5

„ „ of those alive and insane 40*6 . 45*0 . 42*5

Oliver Wendell Holmes said that “ the angel of life winds
up our brains once for all and then closes the cases of these
seventy-year clocks,” but the defective in construction noto¬
riously run down before the wear and tear of the mechanism
has well begun. The winding up has proved an ineffective job.

We are dealing with an affection which issues in failure

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666 DEMENTIA PRAECOX, [Oct,

in 70 per cent . of the whdle. On the other hand, recovery is
gained in 30 per cent,, 1 & percent . after the first attack, and
12 percent . after one or npore than one attack. In the circum¬
stances, therefore, there is already a reasonable chance of success,
and the future may afford better results. It is evident that,
like other classes of ordinary insanity, this affection of puberty
and adolescence is not all dementia.

Clouston says that Kraepelin applies the new designation
practically to the whole group of adolescent cases described by
him in 1873 i but some of us have been told that we do not
understand the position. Perhaps that is so, for the extension
to include persons arrived at forty years of age before the first
attack and the indefinite characters of the syndrome are cer¬
tainly difficult to comprehend in our insular ignorance.
Perhaps we might be to some extent enlightened if Kraepelin
could be induced to give us a clinical demonstration of patients
whose histories had been submitted beforehand. Johnstone,
however, is well qualified to instruct us, and he explained,
three years ago {Journal of Mental Science, 1905), that we
must admit that up to forty years of age evolution and develop¬
ment are still going on. That is a hard saying for the anato¬
mists and physiologists, who have been teaching us that the
limit is a quarter of a century only. Indeed, it seems to me to
be a disturbance of settled beliefs which is unwarrantable, a
confusion which is misleading. No doubt the sound mind in
the sound body may continue to develop, but that development
is not the process which finds the boy and leaves the man.
Johnstone also tells us that the diagnostic point is a peculiar and
fundamental want of any strong feeling of the impressions of life.
That is an observation which can be made in any ward of any
asylum from which dementia praecox has been rigidly excluded.
I need not pursue the details further, for dementia praecox has
been so fully and frequently discussed of late years that refe¬
rence need only be made to the Journal of Medical Science and
Conolly Norman’s paper in the British Medical Journal of 1904.

One can appreciate an insanity somewhat differentiated by
the adolescent period of life in neuropathic persons ; one can
recognise the general appearances of protean disorders of an
immature brain threatened with irreparable damage, tinged with
the half-fledged experiences of life in the turmoil of sexual
development and the stress of physical development That

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1908.]

667

BY A. R. URQUHART, M.D.

these disorders are melancholic, maniacal, delusional, stuporose
catatonic, destructive is evident enough and in accordance
with daily experience ; but they are assuredly not exclusively
the manifestations of dementia praecox nor of* adolescent
insanity. Indeed, Kraepelin has been forced to include a case
beginning at the age of fifty-six, which has not hitherto been
regarded as a precocious period of life.

One does not desire to be captious about mere names, but it
is admitted, and it is on proof that this group is not uniformly
characterised by dementia as understood in this country, but
rather included in Clouston’s memorable phrase— a tendency to
dementia.

I believe that general malaise, dyspepsia, and depression
almost invariably usher in an attack of insanity. Observations
throughout a long series of years have confirmed me in this
opinion of Griesinger’s, and the importance of the teaching of
Schroeder van der Kolk in this connection. Now, Kraepelin
states that he would diagnose dementia praecox if he had
ascertained that vivid hallucinations and confused delusions
occurred in the very beginning of the initial depression. But
I have recorded numerous instances of these early aberrations
in cases quite unrelated to dementia praecox as authoritatively
described, and yet Kraepelin claims to be able to predict the
issue on the first attack, and immediately adds that the pro¬
gnosis is by no means simple (Johnstone, p. 29). It is this
constant confusion of statement which arouses antagonism
and leads to the rejection of this proposed change in nomen¬
clature. One can quite well accept stereotyped movements as
a descriptive phrase ; but is there any need for us to substitute
mutism for taciturnity or negativism for resistiveness? The
excuse for scientific jargon is exactness of expression, but in these
proposals there seems to be little to induce a change from what
is already well understood in favour of any equivocal substitute.
By mute we describe a person dumb from birth, not a person
silent because delusional. By imbecile we describe a person
mentally defective from infancy, and to write about acquired
imbecility at this time of day actually prevents clarity of
language.

The prognosis of a case of adolescent insanity is most diffi¬
cult and uncertain. It cannot be formulated by means of any
brief dictum or any outstanding symptom. There are too

LIV. 48

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668

DEMENTIA PRAECOX.

[Oct.,

many dissenters to admit of a short way with them. Prognosis
can only be the mean result of a consideration of all the factors,
weighed successively and in combination. It does not differ
in all the various cases of insanity—one method here and
another method there. We may possibly advance to a more
exact prognosis provided it can be shown that we have to deal
with different diseases, if the present variety of ordinary insanity
can be sharply divided by pathological findings.

Bianchi definitely rejects the conception of dementia praecox
as a clinical entity, because we get no clearer knowledge of the
case by so endeavouring to discriminate. He cannot decide
how the disorder will end. I cannot discover that Kraepelin
has affirmed that it is a clinical entity; although he leans
towards the theory of auto-intoxication it has yet to be shown
that the toxic nature of the group differs in any particular from
that of cases occurring in the maturity of life.

In what do we gain by accepting dementia praecox and
rejecting adolescent insanity as clinical conceptions ? We have
found the latter term useful in selecting for study certain well-
marked cases, but the former affords us no such definite con¬
tent. Would it aid us in practice ? Would it strengthen us
in diagnosis, in pathological understanding, in prognosis, or in
treatment ? I see no grounds for such a hope. The principles
and details of treatment are identical with those applicable to
other cases of ordinary insanity, the pathology is vague and
unspecialised, the diagnosis is elusive, the prognosis is uncer¬
tain. Much ink has been shed over dementia praecox, many
contentions have ensued, and it would appear that we shall
continue to regard this untimely birth as an undesirable alien.
Dr. Jones would refer it to the wisdom of Solomon, but Solo¬
mon has already spoken—“ I gave my heart to know wisdom
and to know madness and folly. I perceived that this also is
vexation of spirit.” It made him tired.

Note. —The discussion on this subject was adjourned from the Annual Meeting
till the next Quarterly Meeting, which will be held on the 19th November, 1908.
The adjourned discussion will be opened by Dr. Thomas Johnstone, and his con¬
tribution will be followed by a series of short papers by other members of the
Association.

The General Secretary will be glad if members who desire to contribute to the
discussion, whether able to be present or not, will send him a synopsis of their
papers. j

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1908.] leucocytosis in acute mental disorders. 669

Leucocytosis: Its Relation to , and Significance in , Acute
Mental Disorders . By Colin F. F. McDowall,

M.D., M.R.C.S., Assistant Medical Officer, Newcastle City
Asylum.

This paper has for its object the placing on record of a con¬
siderable number of observations made during the past eighteen
months upon the blood of the insane. It was after the perusal
of Dr. Lewis Bruce’s work upon the clinical aspect of mental
diseases that this special subject suggested itself to me as one
deserving minute and extended study. Whereas Bruce deals
somewhat minutely with the various constituents of the blood,
I have confined my observations to the changes that occur in
the number and variety of the white blood-cells, and the
relationship these alterations have to the dcute mental diseases
in which they are found. These researches, though still in their
infancy, hold out great encouragement to the belief that in such
directions we may yet succeed in arriving at a true knowledge
of the pathology of mental diseases, and at the same time
advance at least one step in what has hitherto baffled all
research—the conditions governing the mutual relations of
mind and matter.

At the outset a difficulty occurs, that of nomenclature, for of
recent years it has become increasingly common to alter the
designations of even the more commonly recognised forms of
insanity, and to apply a great variety of names to one and the
same mental condition. The consequent confusion is bewilder¬
ing, but it may be here explained that throughout this essay I
adhere to Bruce’s descriptions and designations.

When Pasteur, Lister, and Koch led the way into a new
sphere of knowledge and demonstrated the world-wide distribu¬
tion and power of micro-organisms, it was scarcely anticipated
that these bodies and their products would be proved to be of
primary importance in the aetiology of mental diseases, yet the
belief has gradually developed that here we have found the key
to future knowledge regarding morbid mental processes, and it
is now believed that we have demonstrated the presence of
toxins in the blood of the insane—the result of bacterial action.

Though it is of comparatively recent date that the leucocyte
has attracted the attention of scientific observers in its relation

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670 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

to general diseases, medical psychologists were not slow to be
attracted by this fascinating subject, and Bruce and Peebles in
this country, Dide, Chenais, Cannes, and others on the conti¬
nent, have during the past few years published valuable material
relating to the leucocyte and its alteration in number and kind
in the insane.

The natural consequence of the introduction of new processes
into clinical medicine has led to the employment of various
terms and definitions, and it may be well to notice four of them
with some care.

Leucocytosis, as is well known, means an increase of leuco¬
cytes in the peripheral blood over the number normal in the
individual case, this increase never involving a diminution
in the polymorphonuclear varieties, but generally a marked
absolute and relative gain over the number previously present
(Cabot). The number of leucocytes found in 1 c.mm. of blood
varies in health between 4,000 and 8,000. In feeble shrunken
persons a count of 3,000 would not be abnormal; and conversely,
a leucocytosis of 10,000 would undoubtedly be highly suggestive
of a pathological condition.

Leucopenia is the converse of leucocytosis. It occurs in
persons suffering from malnutrition, especially the starving.
In the case of the professional faster Sacco, the leucocyte
count fell to 1,530 after the first week. Von Limbeck records
the case of a melancholic patient who had not tasted food for
seven days, and whose leucocyte count was 2,800.

Eosinophilia .—An increase of eosinophile cells is said to occur
during menstruation; an immense increase is sometimes pro¬
duced by helminthiasis, and certain drugs, such as camphor,
pilocarpine, and nuclein have the property of producing an
eosinophilia. The eosin count is lowered during a febrile con¬
dition, but in the post-febrile state there is frequently found a
mild eosinophilia.

The fact that during severe muscular exercise there is a
diminution of eosinophile leucocytes is of much interest. During
excitement with confusion (acute mania) there is frequently, at
the commencement of the disease, a marked eosinophilia. Here,
then, we have a remarkable contrast in the two conditions of
great muscular exertion with mental excitement, in the normal
and in the diseased. The behaviour of the coarsely granular
eosinophile cells clearly indicates the pathological nature of the

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BY COLIN F. F. MCDOWALL, M.D.

671

1908.]

condition in acute mania. That they play an important part
in mental diseases shall be more fully discussed later; mean¬
while it may be stated that excitement alone has no relation to
their increase or decrease in numbers.

Lymphocytosis .—Ehrlich describes it as merely a mechanical
process as opposed to chemiotaxis, which is the basis of a
neutrophile and eosinophile leucocytosis.

As authorities differ regarding the names they apply to the
varieties of white blood-cells, I shall briefly enumerate those
usually recognised and described.

(1) Polymorphonuclear or polynuclear neutrophile leucocytes .—
They form about 60 per cent . of the total number. Treated with
Jenner’s stain the cell is seen to consist of a nucleus which is
irregular and frequently bilobed, staining dark blue. The
protoplasm round the nucleus has scattered through it numerous
small granules which have an affinity for acid dyes and stain
pink with eosin.

(2) Mononuclear leucocytes. —They are termed large or small
according as they vary in size. They are smaller than the
polymorphonuclear cell and possess one nucleus only, and this
occupies the major portion of the cell. The protoplasm, like
the nucleus, takes the blue stain, while the periphery of the
protoplasm frequently shows dark pigment and is deeply
stained. The percentage value of these cells varies between
20 and 30.

(3) Lymphocytes .—Large cells containing a single nucleus,
which is either circular or kidney-shaped and stains faintly
blue, while the surrounding protoplasm is free from granules.
They form about 10 per cent, of the total leucocytes.

(4) Eosinophile leucocytes. —Large polynuclear cells similar to
the neutrophile cell, but whose structure is looser. The granules
found in the protoplasm are larger and coarser than in the
polymorphonuclear cell, they are closely crowded together and
stain a brilliant red with eosin. These cells have a percentage
value of 4 to 4.

(5) Basophile or mast cells. —Small mononuclear blood elements
whose nucleus stains deeply with basic dyes. Scattered through
the protoplasm are numerous large granules staining blue with
Jenner’s preparation. They occur only about once in 400
leucocytes.

Although these are the five varieties of white blood-corpuscles

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672 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

usually described as occurring in health, it is to polymorpho¬
nuclear and the eosinophile cells that I desire to devote most
attention in this paper.

It is known that leucocytosis may make its appearance in a
physiological process or in a pathological state. Concerning
the former it is not necessary to say more than that it is found
after a meal, after violent exercise, and in the moribund. It
may be also explained that, in order to avoid a possible fallacy
due to the blood phenomena connected with digestion, all my
observations were made at a time as far removed from meals as
possible. During the muscular exertions, restlessness, and
excitement present in acute mania, we have a state closely
analogous to violent exercise in a healthy person. In each
there is a state of unrest, physical as well as mental. It is
therefore not surprising that in both we find leucocytosis.

The leucocytosis of the moribund state is by no means
invariable in general diseases. The longer the patient is mori¬
bund the higher the count reaches (Cabot). I have had the
opportunity of examining the blood of only one case of insanity,
which, without any intercurrent disease, terminated fatally.
The patient was moribund for three days, and when a blood
examination was made two hours before death very marked
leucopenia was found.

Pathological leucocytosis .—The extent of the leucocytosis varies
within wide limits, and it is not always easy to say what should
be considered a pathological state and what should not. In
order to draw correct deductions we should first know the
normal leucocyte count of the individual, but this is not by any
means always possible. Leucocytosis is found in most of the
diseases which owe their origin to a staphylococcus or strepto¬
coccus infection. Many of the acute fevers show similar reaction.
I would, however, refer briefly to pneumonia. In those cases
of this disease which end in crisis there is found shortly before
that event a marked fall in the number of leucocytes. This is
a most interesting fact, because pneumonia is a disease very
liable to relapse, just as certain acute mental disorders do; and
my experience points to the conclusion that a recurrence of the
mental symptoms is to be feared in those cases which present
at their termination a low leucocyte count. Another general
disease whose blood phenomena are very suggestive is pulmonary
tuberculosis. In the early stages no appreciable change can be

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1908.]

BY COLIN F. F. MCDOWALL, M.D.

673

found in the blood. Theoretically this is the period at which
any of the psychoses may develop, and in practice we find that
this is what really takes place. During the late stages, when
cavity formation is present, there is very marked leucocytosis.
Simultaneously with this high blood count we find insane
patients, far advanced in phthisis, and who had previously
shown no mental improvement, making rapid and unexpected
mental improvement, sometimes amounting to recovery, but
only eventually to die as the result of the lung condition.

It is now necessary very briefly to refer to the three mental
conditions dealt with in this paper:

(1) Excitement with confusion (acute mania). —Reference to any
text-book will provide details of this disease in all its stages, and
they need not be further mentioned. It is estimated by Bianchi
that from 80 to 90 per cent, of these cases recover, and one
sentence from that author maybe quoted here: “ The recovery
may be instantaneous and happen in consequence of inter-
current diseases, after blood-letting (Raggi and Bergonzoli),
pleurisy (Wellendick), or pharyngitis (Schultze).” In the light
of modern scientific research these cases assume a new aspect,
and point to paths of inquiry and treatment unthought of in
former times.

(2) Depression without excitement (melancholia). —This well-
known condition is only too familiar to all of us, and calls for
no detailed description.

(3) Depression with excitement. —Most observers are inclined
to the belief that, in all essential respects, this condition is only
a form of acute mania, with this distinction, that whereas in the
one there is exaltation and more or less hilarity, in the other
the excitement is combined with misery and acute distress.

Clinical Records.

Excitement with Confusion ; Acute Mania.

Case i. —S. E. L—, single, aet. 33, domestic servant. Fourth attack
of one week’s duration. Age at first attack, 25. No history of heredi¬
tary insanity. She has always been of a nervous disposition. The
three previous attacks were of the same character as the existing one.

Admitted in a very excited condition. Noisy, boisterous, and
loquacious. Laughs and grimaces, meanwhile carrying on an in¬
coherent conversation. Her replies to questions are irrelevant and
facetious. Her habits are clean but her hair is untidy, and she throws
t he bedclothes off and becomes abusive when remonstrated with.

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674 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct.,

Blood examination shows a leucocytosis of 5,000, while the poly¬
morphonuclear percentage is 79. The eosinophile percentage reaches
as high as 9. For the two days following admission no material change
was observed in the blood condition except that the eosinophile count
fell to 3*5 per cent. Mentally she was improving. The excitement
was appreciably less, though she was still incoherent and noisy. She
took her food well, but required paraldehyde to obtain any sleep. At
the end of two days she was allowed up as she had become quieter and
more settled. The leucocyte count was now 7,400, while the neutro-
phile and eosinophile percentages remained unchanged. The experi¬
ment was not a success as the excitement returned and she was as
troublesome as on admission. Leucocytosis was now 12,000. This
count is the highest registered in this woman's attack. She was again
put to bed and at the end of a week was allowed up. A gradual im¬
provement was noted from this date in the mental state, but the leuco¬
cyte count fell as gradually, and this prepared us for the relapse
which occurred eight months later. The decline in the leucocyte
count continued till it reached 4,800; no similar fall, however, was
noticed in the polymorphonuclear percentage, which remained 80.

The relapse was accompanied by excitement and incoherence, but
she was not noisy. The blood count showed a leucocytosis of 10,000,
while the neutrophile percentage remained unaltered. This attack was
of short duration, and an improvement set in which has been maintained,
though unfortunately the leucocyte count has fallen slightly.

The features of the case are the low leucocytosis, occurring in a case
not primary, and the marked eosinophilia.

Case 2.—E. M. C —, set. 41, widow, no occupation. First attack of one
week's duration. No hereditary insanity could be ascertained. Married
when seventeen years old, and has had a very unhappy life owing to
husband's drunken habits. He died two years ago. Since then she
has suffered from privation. She was of strictly temperate habits.

On admission she was wildly excited. Shouted filthy abuse on all
around her. Aggressive, noisy, and filthy in her habits. Her conversa¬
tion was incoherent, and answers to questions quite irrelevant. Sleep
was absent notwithstanding draughts. She was too excitable to feed
herself, and had to be spoon-fed. Blood changes consisted of a leu¬
cocytosis of 20,000 with the exceptionally high polymorphonuclear
percentage of 96. No eosinophile cells were seen. The patient re¬
mained wildly excited for six days, at the end of which period the
leucocyte count had fallen to 12,000 while the neutrophile percentage
was 82. A unit of eosinophile cells entered for the first time into the
percentage count. The marked excitement abated slightly but left
the patient in a very stuporose and dazed condition. She would not
answer to her own name, was restless, and constantly removed her
clothes in attempts to get out of bed.

The contents of the bladder and rectum were voided into the bed.

Food was refused absolutely, and recourse had to be had to the
oesophageal tube. Slowly the mental state improved till an occasional
rational reply was given to an interrogation. The disease had now
been in progress five weeks.

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1908.]

BY COLIN F. F. MCDOWALL, M.D.

675

Leucocytosis was 13,000, with a polymorphonuclear percentage of 80.
Again the total absence of eosinophile cells was an interesting phe¬
nomenon. Erratic, unreliable, and excitable, the outlook remained
bad. A basophilia of 5 per cent, was noted. She could not give
correct answers to the simplest questions.

The stage of excitement had now passed and a gradually increasing
dementia took its place. When the disease had been in progress six
months the leucocytosis was 12,000, while the polymorphonuclear per¬
centage was 82, a single basophile and a single eosinophile cell being
found in the leucocyte percentage. By degrees the leucocyte count fell,
and with it the polymorphonuclear percentage diminished. This patient
is now hopelessly demented. States she has resided in the asylum one
week. Is erratic and childish ; runs after any stranger and asks him to
take a seat by the fire. Her habits are clean. She has a leucocytosis
of 5,200 with a neutrophile percentage of only 51, while there is a baso¬
philia of 3. The ultimate prognosis is absolutely hopeless.

The points of special interest are the high leucocytosis at the beginning
of the attack, which was a primary one, the marked diminution of
coarsely granular eosinophile cells and the presence of a mild basophilia.

Case 3.—M. E. W—, married, aet. 24. Father a chronic alcoholic;
was badly brought up and poorly fed as a child. Has had two children ;
after the birth of each was mentally deranged. On the first occasion,
twelve months ago, was melancholic, but was not certified, and recovered
at home.

The present attack commenced a month after the birth of her second
child ; she was restless, noisy and incoherent. On admission she was
much emaciated and in very poor health. Mentally she was wildly
excited, noisy, abusive and foul-tongued; her habits were filthy.

Blood examination showed a leucocytosis of 8,000, with a poly¬
morphonuclear percentage of 80. The very large increase in eosinophile
cells, which had a percentage of 10, was interesting, and the phenomenon
remained throughout her attack.

At the end of a fortnight her leucocyte count had reached 11,500,
while the polymorphonuclear percentage fell to 61 and remained low for
two months. The leucocyte count, however, kept up and reached
12,000. Her mental condition at this time was somewhat improved.
She was able to be up regularly; excitement was less marked. Her
conversation remained, however, incoherent, and her answers to ques¬
tions were irrelevant and impertinent. She continued dirty and untidy,
but put on flesh rapidly. The mental improvement was maintained,
but her memory for recent events was bad. She had no idea of time,
could not say how many children she had had, and generally gave the
impression that her case would terminate unfavourably in dementia.
The clinical examination of her blood, however, gave what I have learned
to be favourable evidence of recovery, for a leucocytosis of 10,000 was
found, and though the polymorphonuclear percentage was only 65, the
eosinophile count reached as high as 9. The blood changes were now
not very interesting, till at the end of six months a leucocytosis of 16,000
was found, with a normal polymorphonuclear percentage and an eosin
percentage of 2. This hyperleucocytosis is particularly interesting, as it

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676 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

has been noticed by another worker on the subject, and though the count
subsequently fell, the improvement in her mental condition dates from
the high leucocyte count She gradually became less confused, and took
an interest in her surroundings and made a good recovery. Another
point I would draw attention to is the presence of the eosinophile cell
throughout the patient’s illness.

Case 4.—M. E. R—, single, aet 26, housemaid. No hereditary
history of insanity obtained. No cause could be attributed to the
present attack, which is her second. During the three months before
admission she had gradually become restless and flighty.

On admission she was very excited—asked incoherent questions in
quick succession. She was not violent, but very restless.

Blood changes show a leucocytosis of 11,800 with a neutrophile per¬
centage of 73. An eosinophilia of 7 was found. The acute excite¬
ment had gone in two days, but she remained rather noisy and very
incoherent, laughing and chattering to herself. She was clean in her
habits. The blood remained practically as on admission. After a
month she was much more settled and would sit and sew industriously,
talking incoherently to herself meanwhile. The leucocyte count was
slightly raised, being 12,000, but the neutrophile percentage had fallen
some points to $5. During the following months of her illness no
marked change took place in the blood, but the leucocyte count was
gradually falling; on the other hand, the polymorphonuclear percentage
was gradually rising. The eosinophilia had continued throughout the
illness and at the end of four months the leucocyte count was normal,
but the polymorphonuclear percentage had reached as high as 90.
Mentally, she was still incoherent in her speech and in her conduct.
She was an industrious worker and her general health was good. She,
however, was not putting on much weight.

The inferences to be drawn from the facts in this case are: that the
disease will be of long duration, but will probably end ultimately in
recovery. This prognosis is made from the persisting moderate
eucocytosis and presence of eosinophile cells.

Case 5.—E. C —, widow, aet. 57. Third attack of a week’s duration.
No hereditary history of insanity was ascertained.

She was admitted in a noisy excited state. She would not stay in
bed, but threw her clothes off, upset her food and did as much mischief
as she was able. She slept badly and was dirty in her habits; her
answers were incoherent and irrelevant.

Blood examination showed no abnormality on admission, but three
days later she had a very marked eosinophilia, the percentage reaching
as high as 9. She continued very noisy and troublesome, incoherent
in her speech, sat idly making faces when spoken to, or muttering to
herself. Leucocytosis was never present while the acute symptoms
remained, while the neutrophile count was also subnormal, almost
without exception. The eosin cells, however, have been a constant
feature of her blood. She gradually began to show improvement, was
less restless, and did some household duties.

She now is quiet and contented and a useful ward woman, but is

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BY COLIN F. F. MCDOWALL, M.D.

677

1908.]

still easily upset and agitated. One notes the low leucocytosis occurring
in a non-primary attack, the high eosinophilia found early in the
disease together with a low leucocytosis suggesting a lengthy duration
but ultimate recovery.

Case 6.—J. G—, married, aet. 43. First attack of a few days’ duration.
No cause could be ascertained; there was no neurotic heredity.

On admission she was wildly excited. Noisy, incoherent, abusive,
and dirty in her habits. Refused her food and was with great difficulty
kept in bed or persuaded to wear any clothes at all.

Her blood showed a leucocytosis of 12,400 with the low neutrophile
percentage of 73. No eosinophile cells were found. The excitement
did not diminish; she raved and shouted almost without ceasing. Pot.
brom. in half-drachm doses thrice daily was given with but little benefit.
At the end of a week the blood count had fallen as low as 5,400, but
the polymorphonuclear percentage improved to 87, and for the first
time eosinophile cells were present to the extent of 3 per cent. The
blood count subsequently rose to normal and the polymorphonuclear
percentage also fell to normal simultaneously, but again an absence of
eosinophile cells was noted. Mentally, she was very noisy, excitable
and troublesome, but was now up and required constant watching; she
would strike other patients or break ornaments out of sheer wantonness.

Her general health was very poor; she was pale and sallow, took her
food fairly well, but slept badly. She could not answer any questions
relevantly. The blood changes continued to show little alteration, and
the leucocyte counts were irregular, while the polymorphonuclear per¬
centage kept high.

This state of things continued to the present time. She now is an
altogether hopeless case as far as recovery is concerned. She is noisy,
incoherent, and restless. A very probable factor in the case of her
disease is alcohol, but the suggestion is denied by the friends.

The almost entire absence of the eosinophile cell indicates a bad
prognosis especially in this case, which is accompanied by a low
leucocytosis.

Depression with Excitement .

Case 7.—M. A. P—, aet. 52, single. First attack. No neurotic
heredity; always a steady woman. For some time before admission
she hail attended spiritualistic meetings. On admission was very
agitated and appeared oblivious to her surroundings. Accuses herself
of having done many unpardonable sins. Refuses her food. Lies in
bed with her arms clasped. Is restless at times and incoherent in her
wailings. Blood examination showed a leucocytosis of 9,000 with the
high polymorphonuclear percentage of 94. No eosinophile cells were
found. She required catheterisation, and was dirty in her habits.

The leucocyte count subsequently rose to 10,400, while the neutro¬
phile count remained as before. Gradually the mental excitement
disappeared and the patient lay in bed moaning in a subdued manner
to herself. The leucocyte count fell gradually and remained for four

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678 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct.,

weeks between 4,000 and 5,000. The polymorphonuclear count simi¬
larly fell but remained abnormally high, ranging between 80 to 85. No
eosin cells were found at any count. She again became restless and
excited, refused to remain in bed, fell on her knees, and prayed for
forgiveness. Her general health also gradually failed. She tore out
her hair, refused her food, and slept badly.

This stage of excitement ultimately passed, and an increasing de¬
mentia replaced it. She became well enough to get up, but merely sat
about holding her face in her hands—a position of misery. She could
not tell her age or her own name, but would say in a childish fashion
“ Maggie wants bread.” She had to be fed, dressed, and generally
looked after. The blood at this stage shows a leucocyte count of
4,000, and a polymorphonuclear percentage which was 62, while for the
first and only time an eosin cell entered into the percentage count

The leucocyte count later rose to 6,000, and the polymorphonuclear
percentage reached 90, while the red cells also showed some slight
poikilocytosis.

She now is a hopelessly demented woman, never speaks except when
spoken to, and cannot answer correctly the simplest questions.

The continued low leucocyte count indicates, especially in this case
as accompanied by an entire absence of eosinophile cells, a bad
prognosis.

Case 8.—M. P —, set. 27, single, came of a neurotic stock. She had
for over a year nursed a delicate relative, and also had all the cares of
household duties thrown upon her.

When admitted she was very excited and restless ; threw her clothes
off; was incoherent in her ramblings. Prayed at intervals for forgive¬
ness. She was too agitated to reply to any questions; refused her
food ; was dirty in her habits. The excitement rapidly passed off and
she became silent, miserable, and dejected. As she lay in bed tears
welled into her eyes.

Blood examination showed a leucocytosis of 10,000 with a poly¬
morphonuclear percentage of 86. No eosinophile cells were found
She remained restless and agitated. Talked incoherently about her
parish priest; refused her food, saying the priest had forbidden her
to eat.

She lapsed into a state of silence ; was resistive and perverse. She
tore off a toe-nail. When the disease had lasted two months the
leucocyte count was 8,500, but the polymorphonuclear percentage had
fallen as low as 66, and remained so for a month, notwithstanding the
fact that there was a sudden rise of the leucocyte count to 12,800.

This sudden rise was the crisis of her illness, for whereas formerly she
had been in very poor general health she now began rapidly to put on
flesh. Mentally, she still was silent, erratic and dull.

She would fall on her knees and commence praying at any casual
moment, whether at meals or out for a walk. Her general aspect was
now less melancholy, though she would not enter into conversation.
The improvement once commenced rapidly progressed. Simultaneously,
the previously marked leucocytosis fell, but the neutrophile percentage
rose. She began to take an interest in her surroundings, could be

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1908.] BY COLIN F. F. MCDOWALL, M.D. 679

drawn into conversation; her memory was, however, defective, and she
still attached great importance to spiritual things.

The following are the points 1 would lay stress on. A moderate
leucocytosis followed by a sharp rise in the blood count is of good
prognosis. No similar eosin rise, however, was seen, the cells being
absent throughout; and as the fall in the leucocyte count was accom¬
panied by a deterioration in the mental state a guarded prognosis must
be given.

Case 9.—E. D—, single, aet. 25, domestic servant. First attack of
about one month’s duration. Her sister was insane.

On admission was most miserable, restless and agitated. Sat up in
bed wringing her hands and crying.

She refused all food, and was fed with the oesophageal tube. She
was afraid apparently of those around her and shrank from any one
approaching her.

Blood counts showed a leucocytosis of 12,000, with a polymorpho¬
nuclear percentage of 78. No eosinophile cell of the coarsely granular
type was found, and the entire absence of these cells was a remarkable
feature of the attack.

In three days she was less excitable and agitated. She was spoon¬
fed; dirty in her habits. The blood changes showed an increasing
leucocyte count, which reached 17,000, with the high neutrophile
percentage of 96. The patient was now in a typhoid condition.
Temperature ioi° F., pulse 130; her breath was foul and the teeth and
lips covered with sordes. She was too agitated to answered any questions,
and slept badly even with the aid of drugs. She remained in this con¬
dition for two days, during which time no marked changes were observed
in the blood. At the end of seventeen days there was a leucocytosis of
12,000, with a polymorphonuclear percentage of 87. From this date the
leucocyte count gradually fell. The patient became less excited, she
lay helplessly in bed, never spoke, took her food automatically, was of
faulty habits. She was very much emaciated, notwithstanding careful
feeding.

The temperature remained at ioi° F. Slowly but steadily the deterio¬
ration continued. She remained stuporose and the physical state
became worse. The blood count was now 4,800, but the polymorpho¬
nuclear percentage had reached 90. She remained in this stuporose
condition and ultimately died. During her gradual decline the
leucocyte count became gradually less, while a blood examination
made two hours before death showed a leucopenia of 3,500 with a
leucocyte count of only 64.

The facts worthy of note are: The leucocytosis, which gradually
declined but was not accompanied by a mental improvement. The
complete absence of coarsely granular eosin cells.

Case 10.—E. T—, widow, aet. 62. She came of parents who were
neither of an insane nor drunken stock. She had had a great deal of
trouble with polypi of the nose and had undergone several operations,
none of which gave her complete relief. She gradually had worried

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680 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

herself about this trouble till she became sleepless and restless, while
she also was under-fed and suffered from privation.

On admission she was thin and very dejected in appearance. She
lay in bed moaning and was obviously afraid of some unseen agent
She paid little attention to what was said to her, but continued moaning.
She thought that people were going to murder her, and prayed us to
help her. She was restless, but remained in bed, wringing her hands.
Her temperature vas ioi° F. She slept badly and refused her food.

Blood examination revealed a normal leucocyte count, but a per¬
centage of 84 in polymorphonuclear cells and of 4 in eosinophiles.
She continued to make no mental improvement, but began to take her
food well though she still slept badly. Leucocytosis was not in evidence,
but the neutrophile percentage rose to 90. Gradually the leucocyte
count had risen till it reached 10,000. She now presented a picture of
continued dread of something—“ Are you going to kill me,” etc. Her
memory was good, she knew her surroundings, the day, etc., but was
unhappy, bemoaning her fate.

A gradual fall followed by a gradual rise was then noticed in the
leucocyte count, which ultimately reached 12,000, while the poly¬
morphonuclear percentage also rose to 90. She was constantly in a
state of dread : “ Where are the knives ? ” “ Are they going to kill me
now ? ” and so on. She, however, took her food well and slept fairly
well. This stage may be taken to be the crisis, for in a week the
leucocytosis had fallen to normal; nevertheless, the neutrophile per¬
centage kept up and with it was a complete absence of eosin cells.
Mentally she became less agitated. She no longer apparently suffered
from auditory hallucinations, but the depression never left her. She
would formerly walk from one place to another moaning, weeping and
wringing her hands ; now she sits silently with her face in her hands.
She never speaks; she automatically rises when meals come or exercise
is to be taken, but she takes no interest in anything. At the end of
five months her blood count, both as regards leucocytosis and per¬
centages, was normal, except that the eosinophile was replaced by a
basophile percentage of 2. She now is a hopeless melancholiac. No
leucocytosis has been found in her case, though the neutrophile per¬
centage still continues high. Occasionally a large eosinophile cell has
been met with, but never persistently, and never anything approaching
an eosinophilia. Basophile cells are present in abnormal quantities at
irregular intervals. Poikilocytosis was frequently found.

What appears the most striking feature of the case is the high poly¬
morphonuclear percentage throughout, and the low leucocyte count
raised by two irregular phases of leucocytosis.

Case ii. —M. E. S—, single, aet. 24, bakeress. First attack of one
months duration. Family history good. She made two attempts to
strangle herself before admission.

When seen she was wildly excited, cried out passionately that she
was a wicked women, and that she must die as forgiveness was impos¬
sible. She tried to strangle herself with her hands and a strip she tore
from her chemise.

Blood examination revealed the very high leucocytosis of 30,000 with

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1908.] BY COLIN F. F. MCDOWALL, M.D. 68 I

a polymorphonuclear percentage of 89. No eosin cells were seen.
The mental state continued one of acute anguish. She was restless
and excited, tried to escape by the windows, and slept badly. The
blood count ultimately reached 33,000, while the neutrophile count fell
two degrees. Slowly and gradually the excited state became less
marked; at the same time the leucocyte count fell to 14,000, but the
neutrophile percentage increased tiil it reached 92 per cent . As yet no
eosinophile blood cell had entered into the cell percentages.

Dementia gradually set in. She could not answer the simplest
questions; when asked her name could only give her Christian name.
The leucocytosis remained high, however, oscillating between 14,000 and
20,000. The neutrophile count at the same time fell. She has at the
present time a leucocytosis of 20,000, and a polymorphonuclear per¬
centage of 82. On one occasion a single eosinophile cell was found.

The points of particular interest are: The marked hyperleucocytosis
present with the absence of eosinophile cells. The prognosis must be
considered bad, notwithstanding the leucocytosis remaining high, as in
this case the reaction of the patient, though marked, has not been
sufficiently strong to overcome the invading toxin.

Case i 2.—D. W—, single, set. 38, waitress. Second attack of about
one month’s duration. Her brother was insane.

On admission she was most unhappy; said she wished to die;
muttered incoherently and continuously to herself.

Blood changes showed a leucocytosis of 10,000, with a polymorpho¬
nuclear percentage of 90. Eosinophile cells were absent. She con¬
tinued restless and agitated, jumping out of bed, wringing her hands
and saying that she wished to die. She asked for poison. The leuco¬
cyte count had fallen to 7,000, but the percentage of neutrophile cells
remained high. She was now noisy and restless. She committed self¬
abuse in the despair of finding anything to alleviate her misery. The
leucocyte count gradually fell, while the neutrophile percentage fell to 82.
An improvement slowly set in ; the excitement was less marked; she,
however, was easily distressed and very nervous. No marked blood
changes were seen, but the eosinophile cell returned in the percentage
table, and now that the woman is well she has a leucocytosis of nearly
7,000 with a polymorphonuclear percentage of 83 and an eosinophile
count of 3.

Depression without Excitement.

Case 13.—E. J—, married, set. 60. First attack of about one
month’s duration. No hereditary history was obtainable. She had
been in very reduced circumstances for a long time.

On admission she was silent and depressed; wished for death, and
presented a very unhappy picture. She took her food badly and slept
badly.

No leucocytosis was present nor was the neutrophile percentage
increased. No eosin cells were found. She remained in bed and was
very erratic in her mental state. At one time was in the depths of
misery, whilst a few hours afterwards she would converse in quite a

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682 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

hopeful fashion. She began gradually, however, to become more
cheerful, coincidently leucocytosis rose to 10,000, while eosinophile
cells again formed a factor in the percentages. A week from this
day she had so markedly improved that we find her industrious, cheer¬
ful, and anxious to be home again. She took her food well and slept
well. The leucocytosis, however, was not maintained; it had fallen to
6,000, but mentally she appeared well. She continued to do well but
was always carefully watched for a relapse, which the falling leucocyte
count had warned us of. Nor were we disappointed, for within a week
she was again miserable, possessed of the belief that her son and
husband were dead. Again the leucocytosis rose and with it there was
a slight eosinophilia, but the polymorphonuclear percentage remained
low.

This acute exacerbation of misery was overcome in a few days, and
from that day on she continued to do well mentally. Blood examination
again showed a falling leucocytosis, however, so that when she was
discharged on the urgent appeal of her husband we were not surprised
when she was brought back to the Asylum with her throat cut

Case 14.—M. J. L—, single, aet. 50, needlewoman. Second attack
of about two months* duration. She had nursed her mother through
her last illness, and was in very poor condition when admitted.

She lay in bed, quietly sobbing to herself. Accused herself of killing
her mother, and of having neglected her during her illness.

Blood examination showed a leucocytosis of 12,000 with a normal
polymorphonuclear count and a mild eosinophilia. She remained
reticent and depressed for some weeks, and then rapidly began to
improve. The leucocyte count fell as the improvement set in, and
after remaining about 10,000 reached 6,200, when she was discharged
recovered.

The points of interest are the slight alterations seen in the blood
from that found in a healthy individual

Case 15.—E. S—, married, aet. 56, housewife. Second attack of
two mouths* duration. She had been in very reduced circumstances
since the death of her son-in law, who died shortly before the present
attack commenced. No hereditary history was obtained.

When admitted she was absolutely silent She lay in bed with her
eyes shut, and paid no attention to anything that was said to her. She
refused her food and had to be fed. She did not sleep well but was
not restless.

A leucocytosis of 6,000 was found on blood examination, while the
polymorphonuclear percentage was 82. No eosinophile cells were seen
during the first month of her illness. At the end of a month she would
answer questions put to her in a whisper and was allowed up for a short
time daily. A mild eosinophilia was observed and a distinct mental
improvement set in simultaneously. The improvement, once commenced,
continued uninterruptedly and without any special feature. When dis¬
charged she had a leucocytosis of 5,800 and an eosinophile percentage
of 6.

The unusually high eosinophile count is the only really noteworthy

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1908.] BY COLIN F. F. MCDOWALL, M.D. 683

incident in this case, together with the low leucocyte count in an elderly
person who had previously been insane.

Case 16.—M. P—, married, aet. 40. First attack of about three
months’ duration. Uncle is insane; had been drinking during the
last few weeks prior to admission.

She had attempted to strangle herself, and the night following
admission repeated the attempt. Blood examination showed a
leucocytosis of 11,000 with a polymorphonuclear percentage of 81,
while a unit of the percentage was made up by an eosinophile cell.
Repeated blood examinations during the next two months failed to
elicit any marked change from the initial count. Mentally she remained
depressed and reticent. Never spoke above a whisper. She again tried
to strangle herself. Slowly the polymorphonuclear percentage fell and
it now is normal. The eosinophile cell has disappeared from the cell
percentages. Mentally, this woman remains as unhappy as ever and is
constantly on the outlook for an opportunity to end her unhappy
existence.

Case 17.—M. H—, married, aet. 27. First attack of about one month’s
duration. She had a child seven weeks before admission.

Mentally she was miserable and dejected. Never spoke; refused to
answer any questions. Had to be spoon-fed, but slept fairly well.
Blood examination showed a leucopenia of 5,200; the polymorpho¬
nuclear percentage was 77. Throughout her illness the blood count
has remained low, while the neutrophile percentage has never reached
above 80 with one exception. The eosinophile count is normal.

She remained silent and depressed, and gradually has lapsed into a
hopeless state of silence, though she does a little work.

In this case the low leucocytosis is all against a good prognosis.

Case 18.—M. M—, married, aet. 28. Fourth attack of five months’
duration. Her present attack followed lactation. Her mother is
insane.

On admission she was absolutely silent. She lay in bed, answered
no questions, and paid no attention to outward stimuli.

Blood examination showed a leucocytosis of 18,000, with a poly¬
morphonuclear percentage of 58. She remained in this stuporose con¬
dition for four days, and then for the first time replied to a question put
to her. The blood count had diminished 50 per cent and the poly¬
morphonuclear percentage 20 per cent . No appreciable change occurred
in the blood during the next month. Mentally she, however, made
rapid progress towards recovery. The leucocyte count subsequently
rose to 12,000, while the neutrophile count fell to 50 per cent.
Throughout the illness no change occurred in the coarsely granular
eosinophile cells. The leucocyte count ultimately fell to 8,000, and the
patient was then uncertifiable and about to be discharged.

The points of interest in this case are:

The unusually high leucocytosis in a case of depression without
excitement, together with its singularly rapid fall.

The normal relation of the eosinophile cells is another point of note.

LIV. 49

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684 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

Mental diseases can be divided into two great groups—
those of toxic origin and those of non-toxic origin.

To instance the latter group first, an imbecile, who may be
devoid of the power of speech and reasoning, nevertheless may
enjoy good bodily health. Again, a secondary dement may
show no signs of physical deterioration. Compare these two
examples with one labouring under acute mania or melancholia
with excitement. His physical characteristics are exactly the
opposite. He appears to suffer from a disease of the body as
well as the mind. The face is flushed and anxious, the skin
clammy and moistened with sweat. The pulse is rapid and
small. The whole of the digestive tract is disturbed. The
breath is foul, the tongue furred, while the teeth and lips are
covered with sordes. There is no appetite for food, and the
bowels are confined. The urine is concentrated, and albumen
is occasionally present. There is frequently a febrile tempera¬
ture, the thermometer registering ioi° or even I02°F. The
whole condition is suggestive of toxaemia, and a blood exami¬
nation confirms the suggestion.

Bruce records a case of acute mania in which the leucocyte
count was 30,000. Dide, on the other hand, has not found
any such marked blood changes, while Mackie records a case of
acute mania in which, when somewhat improved, a leucocytosis
of 10,000 was found. A high polymorphonuclear percentage is
always found when the attack is in its early stages. The
highest percentage present in any of my cases was 94 (Case 2).
Bruce quotes numerous percentages over 80, and the highest
count reached was identical with mine—94. It occurred, how¬
ever, in a case of metabolic poisoning which developed typhoid
symptoms and died. Dide has not been able to find an in¬
creased polymorphonuclear percentage in any of the cases he
examined, but adds that further work on this subject is
desirable. I have found in every recent primary case of
excitement with confusion (acute mania) and in every recent
primary case of depression with excitement (Cases 1-12) a leu¬
cocytosis more or less marked. The extent of the leucocytosis
varies between wide limits; my results show that the leucocyte
count may reach as high as 34,000 per c.mm. (Case 11). A poly¬
morphonuclear percentage of 75-80 has been present in nearly
all my cases of acute mania and depression with excitement.
The blood changes in depression without excitement have

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1908.] BY COLIN F. F. MCDOWALL, M.D. 685

purposely been omitted as they will be separately dealt with
later.

Excitement with confusion and depression with excitement
many distinguished observers believe to be very closely related,
if not absolutely identical.

For a moment let us consider alcohol and its effect upon
the nervous system. It is a toxic agent of great potency; the
form in which it is taken is of no account, but the results of
excessive drinking may be vastly different in separate individuals.
In all it produces intoxication, but the psychic state varies
greatly. In some there is found hilarity and light-headedness,
in which excitement is a prominent symptom.

In others it produces a feeling of depression with reticence,
silence, and morbidity as predominant features. Here clearly
we have the same agent producing, in persons to all appearances
equal, very different results, and this must be attributed to the
personal coefficient. Similarly, it may be that there is as a
common cause in acute mania and in depression with excitement
a single toxin, and if this is so the two conditions should be
considered the same disease.

Regarding depression without excitement my results are not
so convincing as in the two diseases just referred to. A possible
explanation is the late admission of these cases into asylums.
My work shows that there is an occasional leucocytosis found
even in this disease. I have noted a leucocytosis of 18,000 per
c.mm. in the case of a young married woman (Case 13). The
polymorphonuclear percentage was 88, but the counts fell
remarkably quickly. Bruce quotes a case in which he found a
leucocytosis of 13,700 and a polymorphonuclear percentage of
69. He attributes this disease to metabolic poisoning.

It is now necessary to note the chief characteristics of the
leucocytosis as it occurs in the three mental diseases under
discussion—the variations in the leucocytosis, and to what
phases in the mental condition the blood phenomena correspond.

Primary and recurrent attacks require to be separately dealt
with.

Excitement with confusion .—In this disease, when primary,
there is always at the commencement of the attack a leucocy¬
tosis, which varies between 10,000 and 20,000 (Cases 2, 3, and
6). The polymorphonuclear cells are always increased in
number, and form a percentage which varies between 75 and

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686 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

85, and even higher. In those cases that do well (Case 3)
the leucocytosis gradually falls, so that at the end of three
weeks the count is only slightly above normal. At the same
time as the leucocyte count is falling the mental symptoms
improve. Excitement, as distinguished from excitability, is
absent, and the patient, though still incoherent, is visibly
improving. After a short while the leucocyte count again rises,
and with this second rise a marked amelioration in the mental
symptoms takes place. There may again be a fall in the blood
count, but it is followed by a similar rise, and the patient upon
complete recovery has a leucocytosis of 10,000. The inter¬
change that takes place in the blood cells is between the
polymorphonuclear leucocyte and the mononuclear cell. When
the leucocyte count falls the mononuclear cells are relatively
increased, while when the leucocytosis rises the polymorpho¬
nuclear cell is increased in numbers.

In those cases that do not recover, still referring to primary
cases only, the leucocytosis is very irregular, but the count
never falls below normal (Case 2). It ranges irregularly between
20,000 and 8,000. Borrowing a term from the expression as
applied to a temperature, this variety of leucocytosis might be
termed “ continuous. 1 ’ The polymorphonuclear percentage is
high and remains high. It may reach 90 per cent . With this
high leucocytosis no amelioration in the symptoms takes place,
except that the excitement abates, but incoherence and irrele¬
vance in speech continue. The habits are faulty. Weeks may
pass and still the leucocytosis remains high, showing the
virulence of the attack. Gradually the leucocytosis falls, and at
the same time signs of dementia are found to be present. When
the leucocyte count has fallen and the polymorphonuclear
percentage is below 50 in a patient showing signs of secondary
dementia the prognosis is hopeless (see Case 2). The out¬
look is always grave if the polymorphonuclear percentage falls
without any appreciable mental improvement. Conversely a
case must never be regarded as quite hopeless if the poly¬
morphonuclear percentage keeps up (Case 3). Dr. Bruce had
an example in which the leucocytosis was never above 10,000,
and with a falling leucocyte count signs of secondary dementia
were seen. Gradually, however, the polymorphonuclear per¬
centage rose, and with it signs of mental improvement set in.
Ultimately the patient made a good recovery.

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1908.] BY COLIN F. F. MC DO WALL, M.D. 687

In those cases which have previously suffered from some form
of insanity the leucocytosis is seldom high. It may reach to
16,000 (Case 4), but more commonly it does not rise above
8,000. The polymorphonuclear percentage, however, is high,
and may reach 90 per cent . (Case 1). Bruce says, regarding
recurrent attacks of either excited melancholia or acute mania,
the reaction to each subsequent attack becomes less and less
marked. Another class of patient who give evidence in their
blood of little or no reaction is the senile. I have seldom
obtained a leucocytosis of even limited dimensions in the old
people suffering from acute insanity. This finding is quite
opposed to the physiological phenomenon, that old age produces
leucocytosis. It nevertheless corresponds to the actual state of
affairs in regard to the acute senile lunatic. It is common
knowledge that a very slight attack of acute excitement
frequently precedes senile dementia. Bruce has affirmed that
in an acute insanity in which there is no reaction the prognosis
is bad. So it is that we frequently find old people become
rapidly demented after an acute attack of insanity, for their
blood phenomena show that they can offer only a small resist¬
ance to the invading toxin.

Depression with excitement .—The blood phenomena in this
disease in respect to leucocytosis are so closely allied to those
found in acute mania as to be almost identical in Cases 7-12.
Bruce has, however, found that the leucocytosis of excited
melancholia is more irregular than that of mania with con¬
fusion.

Depression without excitement. —As previously stated, a leu¬
cocytosis of 13,000 has been found in one case. Bruce maintains
that when present it is due to some concomitant disease. I
am, however, hopeful that when these cases are examined in
their early stages a definite reaction will be discovered.

Eosinophilia. —The results published regarding the phenomena
connected with the coarsely granular eosinophile cell are not
uniform. McKie found no alteration in these cells in the cases
of acute mania he examined. Dide’s results were confirmatory.
Cannes and Thermette, in their observations upon several cases
of dementia praecox, found an average percentage of 4, and in
one case the high count of 23. Dide, in his observations upon
the occurrence of eosinophilia in the same disease, gives the
mean of 95 cases. His conclusions are that when the mental

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688 LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS, [Oct,

state is about to undergo an alteration there is a rise in the
number of the eosinophile cell. He finds that io per cent . is
not an unusual occurrence. Bruce states that in regard to
acute mania and melancholia with excitement, at the commence¬
ment of the attack eosinophile cells are rarely present. It is to
be regretted that opinions differ so widely on this matter, as my
observations lead me to believe that great importance attaches
to the eosinophile cell, and it is the centre of very definite
phenomena.

Its appearance varies as the ultimate outlook of the case
varies.

In those cases of excitement with confusion which recover, there
is invariably an eosinophilia found early in the disease (Cases i
and 3). The extent of the eosinophilia varies between 4 and
10 per cent . The count when the excitement is at its height
may be the highest. Here it may be of interest to refer to the
physiological action of the eosinophile cells. There is in
health a reduction of them during excitement and exertion.
The converse is found in mania and excited melancholia.
Clearly, therefore, we are dealing with some toxin in the blood
of the insane patient, since we find exactly the opposite of what
we should naturally expect. In favourable cases the eosinophile
cells continue throughout the disease to be found in an ab¬
normally high ratio. Bruce describes a second rise in the
eosinophile count at the same time as the polymorphonuclear
rise.

In cases that do badly the eosinophile cell is rarely found
(Cases 3 and 6) during the acute stage of the disease. An
occasional cell may be seen, but never is there anything
approaching an eosinophilia detected. During examinations
extending over several months the eosinophile cell has been
found persistently wanting. When secondary dementia, how¬
ever, begins to show itself the eosinophile cell again makes its
appearance (Case 2), but then only in diminished numbers.
The behaviour of the eosinophile leucocyte is quite definite in
depression with excitement . During the acute stage of the disease
the cell is frequently entirely absent. I have in these cases
counted a thousand leucocytes and failed to find a single
coarsely granular eosinophile cell. During the excitement of
melancholia in those cases which certain writers would include
under the heading of katatonia, the eosinophile cell is always

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BY COLIN F. F. MCDOWALL, M.D.

689

1908.]

absent and remains so throughout the entire disease (Case 9).
When the excitement of melancholia commences to pass off and
signs of distinct mental improvement set in an occasional
eosinophile cell is found. There never is an eosinophilia, nor
have I been able to confirm Bruce’s statement that there is a
rise in eosinophile cells in those who make rapid recoveries.

Finally we must refer to the eosinophile cell and its relation
to depression without excitement .

There is, in my experience, no very definite or constant
feature in its occurrence. At the commencement of the attack
there is usually found a normal percentage (Cases 17 and 18).
Occasionally an eosinophilia of mild proportions is met with
(Case 14). There seldom is an absence of the coarsely granular
eosinophile cell for any length of time.

The basophile leucocyte has been met with frequently in each
disease. Such an increase of these cells has been occasionally
met with so as to constitute a mild basophilia (Case 2). It
occurred in all three diseases under discussion, but no constant
relationship with any of the mental phenomena could be
ascertained.

It seems to me not extravagant to hope that by blood exami¬
nations in actual mental disorders an early prognosis may be
made. It is by having regard to the character of the leuco-
cytosis and absence or presence of an eosinophilia that a con¬
clusion can be arrived at.

Leucocytosis indicates the reaction that is taking place in the
body of an individual between a toxin, the result of bacterial
growth, and the production of protective and germicidal agencies,
which have been termed “ alexines.” We therefore can by noting
the leucocyte count form an opinion as to how much toxic
material is circulating in the body and what attempt Nature is
making to overcome the poison.

In general diseases experiments have been made relating to
this matter, and three phenomena have been found to occur:

(1) If the quantity of bacteria with their accompanying
toxins is so great that the animal is overwhelmed with the
poison and quickly dies no reaction takes place, and con¬
sequently no leucocytosis is found.

(2) Reduce the amount of poison and there is found in the
blood a marked reaction. A high leucocytosis with a large
preponderance of neutrophile cells is found. Once this has

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69O LEUCOCYTOSIS IN ACUTE MENTAL DISORDERS. [Oct,

occurred a struggle ensues between the alexines of the leuco¬
cytes and the toxins of the micro-organisms. If the leucocyte
prevails the animal recovers, but if the toxin is the stronger
the result is fatal to the animal.

(3) The quantity of toxin introduced is so small that the
leucocyte normally in the blood can deal with it, and con¬
sequently no appreciable reaction takes place and no alteration
is found in the leucocyte count.

Applying these facts to the observations made upon the blood
of the acutely insane, it may be stated that in those cases in
which the leucocytosis is over 18,000 and remains above that
figure for more than one month, together with*an absence of any
eosinophilia, the prognosis is very bad. Dr. Bruce says that if
the leucocytosis falls instead of rising after the acute stage is
past the prognosis is bad, and especially bad if the polymorpho¬
nuclear percentage falls below 50 per cent. I have only had the
opportunity of examining one case of acute insanity which died
—that of excited melancholia in a young girl (Case 9). The
leucocytosis in this instance at the onset of the disease was
15,500 but gradually fell. The acute excitement remained
though the leucocyte count fell to normal. Gradually the
acute symptoms subsided and were replaced by apathy and
lethargy. Dementia rapidly supervened, and the patient’s
habits became faulty. The neutrophile percentage remained
high, ranging between 80 and 90 per cent. At no period of her
illness was an eosinophile cell found. She slowly became worse
and the leucocytosis step by step became less and less. Two
days before death there was a marked leucopenia, the count
being 4,400. At the examination a megaloblast was seen in the
blood. Death ultimately ensued, and an examination of the
blood was made two hours before that event. There was a
leucocyte count of 3,500, while the polymorphonuclear per¬
centage was only 62. This case very closely bears out Dr.
Bruce’s theory and is quoted for that reason. An irregular
leucocytosis in acute mania is of bad prognosis.

Great importance must be attached to the coarsely granular
eosinophile cell. Its presence during the acute stages of the
disease would signify to me that the outlook is not hopeless, but
the most favourable combination is a high leucocytosis together
with an eosinophilia. An eosinophilia with a low leucocytosis
indicates a slow convalescence but an ultimate recovery.

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ASYLUM OFFICIALS.

691

Asylum Officials: Is it necessary or advisable for so many
to live on the premises ?(}) By Frank Ashby Elkins,
M.D.

ASYLUM officials may be roughly divided into three groups.
In the first group are included artisans and others who are
paid weekly wages, have no emoluments, and live in their own
homes away from the asylum, whilst in the second and much
larger group are included nurses and attendants (estimated by
the Commissioners in Lunacy to number in England and
Wales more than ten thousand persons), laundrymaids, house¬
maids, kitchen-folk and others, who, in addition to their
monthly paid wages, usually have the emoluments of board
and lodging. In the third group are included chief officers
and others who are provided with houses, cottages and apart¬
ments on the asylum estate. The weekly paid or artisan class
are, as a rule, well paid, contented, and of long service. They
do not lead a cloistered life, and it is not with them that this
article deals. As to the second group, the public now happily
recognises the unselfish labours of the large army of workers in
direct attendance upon the insane throughout the country, and
it is not necessary to enlarge upon their usefulness to the
community. Their hours of duty are very long, their pay is
not large, and the restrictions and disadvantages under which
they work are very great. Probably all asylums have allowed
a certain number of these officials to board and lodge off the
premises. Some asylums may be more favourably situated
than others, and thus have done more in this direction, but the
writer thinks that at all asylums more could and should be
done towards de-cloistering the staff. In an asylum constructed
to meet the circumstances and placed in suitable surroundings,
the sane resident population could be reduced to very moderate
proportions. It is urged that when the abnormally long and
trying hours of duty are over, as many officials as possible
should be altogether freed from institutional restraints. The
cost of the erection of asylums would be decidedly lessened if
they were built to provide accommodation only for (1) the
patients, (2) such members of the staff as must of necessity be
boarded and lodged on the premises, and (3) such officials as

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692 ASYLUM OFFICIALS, [Oct,

must have houses provided for them on the estate. Has any
asylum authority ever prepared an estimate showing the cost
of the erection and upkeep of quarters, and of the provision of
necessities and conveniences of every description specially made
for members of the staff who do not need, for any particular
reason, to be provided with lodgings on the asylum estate?

If, on the male side of an asylum, there are sufficient staff
living inside, in case of fire, or to be near at hand should the
night staff require assistance, there is surely no necessity for
others to sleep on the premises. Some have urged the
necessity of building cottages on the asylum estate with a view
to keep the married attendants within call and under institu¬
tional control, and though still an advocate for the building of
asylum cottages, the writer is now convinced it is better to
allow the demand to create the supply off the estate, whenever
this is possible. It is as well to consider the possible dis¬
advantages of asylum cottages. Asylum authorities do not
appear able to build as cheaply as the local builders. When
the asylum authorities have built a cottage for a certain sum,
they naturally desire that the rent shall be in proportion, so
that the ratepayers’ pockets shall not suffer unnecessarily. If,
however, this decision is adhered to, one of two results follows.
Either the attendant is compelled, perhaps against his will, to
live in the cottage in lieu of receiving lodging money and
choosing his own home, or else there is difficulty in letting the
cottage because the neighbouring cottages suitable for atten¬
dants and built more cheaply are let for a less rent An
asylum official may wish to leave his cottage, perhaps because
he dislikes his neighbour in the next cottage, or because he
sees a cottage vacant which he covets as a home, yet he is
deterred from moving because he fears he may lose his lodging
money and perhaps his post too if he gives up the asylum
cottage. With the best possible intentions, too, the committees
of asylums place certain restrictions upon occupiers of their
cottages. For instance, they perhaps may not have guests to
sleep in their houses without the consent of the authorities, for
this may lead to lodgers, their houses are regularly inspected
to see that they are kept in good order, and to ascertain what
repairs are necessary, and although in the country maybe, they
may not keep dogs, poultry, or pigs, for profit or amusement
without consent. In fact, the asylum atmosphere pervades the

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1908.]

BY FRANK ASHBY ELKINS, M.D.

693

homes. The proud vaunt that an Englishman’s home is his
castle, frequently does not apply to asylum officials* houses.
A tenant likes to make his own bargain with his landlord, and
when he has rented the house, no matter how humble, he likes
to feel he only is master of it. As cottages are being advocated
and being built all over the country, it is well to bear in mind the
disadvantages from the attendant’s point of view. Surely it is
better for married attendants to live as ordinary individuals
among the general community, leaving their work and its
surroundings when that work is done. When attendants and
their families live together, often in a kind of compound, the
men never escape from the associations of their work, their
companions and associates are all similarly employed, the
women and children never get away from the asylum life, and
the individuality of the home is greatly destroyed. It has been
suggested that the night attendants sleeping outside will not
take proper rest, and so will not efficiently perform their duty.
Experience does not confirm this, and an official who does not
perform his duty properly should be dismissed from the
service.

Let us now turn to consider whether it is not possible for
some of the female staff also to live off the premises. The
public is now happily accustomed to see the village nurse and
the Queen’s nurse living like ordinary folk among the general
community. Anyone who has seen the stream of respectable
and well-behaved women pouring into and out of London and
other large centres of population every morning and every
evening to engage in business or other pursuits, knows how
ridiculous is the belief that women—even young women—cannot
look after themselves. On the contrary, they are treated with
the greatest consideration by the travelling public, and it is rare
indeed for them to show by their actions that they are unfit to
move about without chaperones. Even in asylum service
nurses and other female officials on leave for the day or after
duty from 8 p.m. to 1 o p.m. are allowed to do exactly as they
please, although it is considered essential, no matter how long
their service or how old they are, that they should sleep in the
asylum under the motherly and vigilant eye of the matron!
As on the male side, a certain number of day nurses must
always sleep within call of the night nurses, in case of emer¬
gency, and these should preferably be those who have last

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694

ASYLUM OFFICIALS,

[Oct,

joined and who are in training as asylum nurses. This will
give the authorities time to decide whether a new nurse is
suitable for the work, and she can decide whether she feels able
to continue the occupation. But in every asylum there must
be many nurses and other female officials whose characters are
well known, who it is certain would lead such lives outside as
would bring credit to the asylum, and there is no reason why
such nurses should not live off the premises. The unmarried
village dressmaker, school-mistress, and district nurse live among
the community without reproach. In an old-established
asylum it will be found that quite a perceptible proportion of
the female staff have near relatives with good homes in the
immediate locality, some near kin actually coming purposely to
live near a daughter or a sister employed in the asylum. For
the nurse of long service who has no relative at hand, the wife
of an artisan or attendant earning good wages is often willing
to receive a respectable lodger in her clean cottage, and why
not ? Female officials thus join a family circle when off duty,
and what could possibly be better for those whose days are
mostly spent in tending insane patients ? Former nurses, now
married and living near, are also often glad to receive old
friends and former colleagues. Experience shows that nurses
so lodged are happier and healthier. It might be thought that
nurses would find a difficulty in being on duty at 6 a.m., but in
a working population, and especially in the country, early
hours are the rule for everybody, and no difficulty is experi¬
enced. It must be remembered that the rooms vacated in the
asylum increase the accommodation for patients. In recent
years it has been the fashion to build nurses’ “ homes,” some
very elaborate ones, in order to make the lives of asylum
nurses more bearable and less sombre. May we not now ask
ourselves, have these nurses’ “homes” been a real success?
Do we find them appreciated as much as we hoped ? Some,
at least, of us feel reluctantly compelled to answer in the
negative. Whenever the weather permits most of the nurses
prefer to be off the premises, and do not stay in their so-called
“ home.” Wet days keep them in the privacy of their bed¬
rooms writing letters or attending to clothes, reading a book,
or resting. The nurses’ sitting rooms are really only used
when there is a little time to waste at meal times. It would be
of greater service to the public to convert asylum nurses’

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1908.]

BY FRANK ASHBY ELKINS, M.D.

695

“ homes ” where possible into villa residences for patients of a
suitable kind, paying a moderate board, a class of the com-
munity badly provided for in England.

What officials is it really necessary to provide with homes
upon the asylum estate ? Are there not far too many houses, as
a rule, provided ? It is acknowledged by all that, as head of
a large medical institution, the medical superintendent of an
asylum must always be resident on the estate, and whenever,
day or night, he is absent from duty, his deputy should take
his place. As a matter of fact he is invariably provided with
a house and allowed to marry. His house should certainly
not form part of the main building. It should be surrounded
by its own garden, and preferably should be directly approach¬
able from the public highway, so that the household of the
medical superintendent shall not mix in any way with the
asylum community, and so that the medical superintendent,
when he seeks some rest, may have privacy, and may feel that
he really is off duty although within easy call. Leading the
cloistered life he does, the visits of acquaintances and friends
should be encouraged, but the knowledge that a call at the
medical superintendent’s house means passing through the
main entrance gates, having one’s name booked, and walking or
driving right up to the asylum building, deters many visitors ;
and other institutional regulations of a similar kind act unfavour¬
ably to those whose houses are similarly placed. It is notorious
how many medical superintendents devoted to their work break
down at a comparatively early age, so that it is reasonable to
ask that the unfavourable surroundings in which they live
should be made as favourable as possible, and that the fewest
possible institutional restrictions should be imposed. The
importance of children not mixing with an insane community
when their habits and characters are being moulded, and the
unwisdom of having sane persons who are not officials subjected
to sights, sounds, and smells, not to speak of bad behaviour, all
the result of disease, emphasise the importance of building
houses, where these are really necessary, with the doors opening
off the estate. The medical superintendent, on account of his
position and in spite of the disadvantages he labours under in
living within the asylum gates, can generally manage, with some
little effort, to have as many acquaintances in the neighbourhood
as he desires, but the case is often different with the assistant

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ASYLUM OFFICIALS,

[Oct.

medical officers, the matron, the assistant matron, the superin¬
tending and head nurses, the steward and other chief officers,
female and male, occupying positions of high trust and respon¬
sibility. So far as the neighbourhood is concerned they may
live, unless special efforts are made, as a class apart, and
under a sort of social interdict. In such cases the asylum
gateway becomes an impassable barrier, and outside persons
in the same station of life either may not wish to know people
living in an asylum, or may not even know of their existence.
Special regulations, too, discourage or prevent visits altogether.
Being thrown upon each other for society, conversing upon
little else but asylum topics, and living in close daily contact
with the insane, they are apt to become pessimistic, hyper¬
sensitive, soured and dissatisfied with their lot, unless they are
able to cultivate optimism and enthusiasm under depressing
circumstances, take up athletics or other hobbies, or earnestly
set themselves to take an interest in the outside world. Some
asylum authorities, in the case of assistant medical officers,
have actually arranged that each officer must be re-elected
after the lapse of a certain time, and annually thereafter,
evidently considering that it is not good in some cases for
medical men themselves or the institution that they should be
continued in the service. With some chief officers, alas, who
should never have taken up asylum work, and who do not leave
so soon as they discover their error, life tends to be less and
less roseate, there is more and more centering of their thoughts
upon petty details and grievances of asylum life, they often
cannot be induced after duty hours to leave the surroundings
in which they work, and at last, being compelled to resign,
they become pathetic figures, more or less wrecked in health,
middle-aged, without an occupation, and lucky if they get a
small pension. In an asylum where medical emergencies so fre¬
quently occur, it is absolutely necessary that there should be suffi¬
cient medical help readily available day and night, but at large
asylums, where there are two, three, or more assistant medical
officers, the writer does not see why the senior or other assistant
medical officer, if he desires, should not be a married man with
his house on the fringe of the estate and outside the curtilage
proper of the asylum grounds, or even off the estate. Such an
arrangement would remove a real grievance of the senior assis¬
tant medical officers of large asylums, who at present are cora-

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1908.]

BY FRANK ASHBY ELKINS, M.D.

697

pelled to lead celibate lives, although holding positions of
considerable trust, and often by no means youthful. Of course,
such a medical man would have fixed hours of duty with time for
meals, and it would be clearly understood that when the medical
superintendent was off duty, day or night, the senior assistant
medical officer must take his place as a resident medical officer.
Such an officer would lead a more natural life, and would have
what every man after a certain age has a right to expect—a
home. It is a much better way than providing a house for
him within the curtilage, and bringing within the asylum
gates another family. This arrangement would not be a
reversion to the old practice of visiting physicians, as the
medical officer would clearly still be an assistant to the medical
superintendent.

It is almost a religious axiom, more especially near the
Metropolis, that the steward (often the assistant steward, too)
must reside on the asylum estate, yet that well-known and
large institution, the Royal Edinburgh Asylum, not to mention
other asylums, has been successfully administered for years,
although the steward and assistant steward live in their own
homes off the asylum premises. Can it be seriously believed
than anyone intending to rifle the stores would be deterred by
the knowledge that the steward lived on the asylum estate ?
The chaplain is another official for whom a house need hardly
be provided. With so much machinery about, and in case of
fire an engineer is a suitable official to have a house on the
estate, but a foreman of works does not need one. With an
efficient head night attendant there is really no reason why
the senior or other head day attendant should be provided
with a house. Similar considerations should be taken into
account in deciding who should and who should not be allowed
housing accommodation on an asylum estate. To take an
extreme example of what should not be. Assuredly a grave¬
digger ought not to be supplied with a cottage adjoining
a graveyard, in which he and his wife are to live and bring
up a family, under the most melancholy surroundings and
under all the restraints which result from living on an asylum
estate.

Any suggested scheme by which pressure in an asylum
laundry can be relieved is worthy of consideration. To erect
and equip an asylum laundry in accordance with the standards

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6 gS ASYLUM OFFICIALS, [Oct,

considered necessary by those who supervise and manage
asylums is a costly business, and the expense does not end
with erection and equipment, paid labour being a considerable
item year by year. At many asylums patients capable of
doing efficient work in the laundry or elsewhere are yearly
decreasing, whilst the percentage of patients for whom much
washing is required on account of their faulty habits or bodily
infirmity is on the increase, so that there is a constant demand
for more paid help. Lady visitors to asylums are nearly
always impressed with the beautiful way in which the caps,
cuffs, collars, aprons, and uniforms of the staff are “ got up,”
but it may be asked how far is all the time and labour thus
entailed at the public expense justified? Some, at least, of
the laundry equipment, with paid labour in proportion, is
mostly or wholly provided for the staff washing. Many
asylum authorities have become so alive to the cost of the
staff washing that they have limited the number of articles
which each indoor official may send to the weekly wash. The
linen of the village nurse “ got up " by the local washerwoman
may not look so immaculate and smart as that of her sister in
the hospital, yet it is clean, looks fresh, and serves its purpose.
Whilst uniform is to be encouraged as showing the profession
of the nurse, it is not worthy of worship and does not of itself
constitute the nurse.

It might be thought that the risk of the introduction of
communicable diseases among the patients would be increased
where so many officials in direct attendance upon the patients
come daily to duty from their homes and lodgings in the sur¬
rounding neighbourhood, but in practice this has not been found
to be the case. When the medical practitioner in attendance
upon an asylum official’s family discovers such a disease as
scarlet fever in the house, the custom—well-known both to the
medical men of the locality and to the members of the asylum
staff—is for the official to stay away from duty upon a medical
certificate stating the cause. He is thereupon required by the
asylum authorities to be absent from duty until his medical
attendant can certify that no harm is likely to result to the
asylum community if he resumes work, the committee paying
the wages in full during such enforced absence. The visits of
patients’ friends, many of whom are slum dwellers, are much
more likely to introduce communicable disease into an asylum

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699

1908.] BY FRANK ASHBY ELKINS, M.D.

than officials living, as a general rule, under the healthiest
circumstances.

A great deal more could, and should be done in the way of
allowing asylum officials to have their meals off the asylum
premises. Where it has been done, the improved health, more
especially of some of the older staff, is very evident, and no
doubt has been brought about by the compulsory short walks
in the open air before and after each meal, by the suitable diet,
and by the pleasant home surroundings in which the meals are
taken, together with the fact that the long day, from 6 a.m. to
8 p.m., in the asylum is completely broken into four parts by
pleasant interludes. The dietary scales in force at most asylums
are very generous. Indeed, a thrifty housewife, if shown the
raw materials, would at once say that with some slight and
inexpensive additions she could feed her husband, herself, and
her children with the amount apportioned to one official. In
recent years the diets of asylum officials have, in consequence
of recurring complaints, nearly always sympathetically con¬
sidered, become more and more generous. Yet it is notorious
that however generous, however well cooked, however well
served, and however varied the dietary is, it does not satisfy a
great number of the staff. The long hours of harassing duty,
the confinement to wards, be they ever so well ventilated, and
the nursing of patients of dirty and disgusting habits, particu¬
larly noticeable in infirmary asylums, these all undermine diges¬
tion, develop capricious appetites, and fully explain the grumbling
at meal times. The officials who most enjoy asylum diet are
the newly joined, because they are not used to such good fare.
Tastes vary enormously, and if, too, the appetite is impaired,
an official would much sooner have money in lieu of food, and
so make it possible to have meals prepared to his liking. More¬
over, if a married man, he has to provide food for his wife and
family, and it would therefore be a distinct gain for him to take
board-money home and share the family meal. It must at once
be granted that it is possible to carry on an asylum by refusing
to listen to complaints respecting the excellent food provided,
and by getting rid of those who grumble at the meals.
This has often been the attitude of asylum authorities, but
it is not in the interests of the patients to bring about
the resignation of good nurses and attendants just because
the nature of their occupation interferes with appetite
LIV. 50

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700 ASYLUM OFFICIALS, [Oct,

and digestion. One cannot, of course, treat officials with
capricious appetites as one would a patient by continually
changing the diet, but if real endeavours are made to board
out as many officials as possible, then those taking their meals
inside will either be newcomers or else those who remain by
preference, and so the whole difficulty will be solved. The
difference in the state of health between a male attendant who
boards and lodges in his own home and one of similar length
of service who boards and lodges in the asylum is very marked.
It has been seriously urged that if asylum officials are given
money in lieu of board they will be likely to steal the patients’
food. For this reason some think it most advisable that
nurses and attendants employed in the day time, and who see
to the distribution of the patients* food, should certainly take
their food in the asylum, that night-nurses and attendants re¬
ceiving an allowance in lieu of board should be made to pay
for food eaten during the night, and that those employed in
the preparation and distribution of food, such as bakers, stores
porters, kitchen men, mess-room attendants and general porters
should also take meals at their work. In other walks of
life to treat a person of known character and long service as a
potential thief would be considered very improper. The
elaborate precautions taken when issuing food from the stores
and the constant supervision of supervising officers should soon
detect thieves, and detection means dismissal. There are other
things to steal in an asylum besides food, and if the same argument
were universally applied, every asylum official would have to
be systematically searched each time he passed the asylum
gates. Moreover, asylum officials are now drawn from a
respectable class of the community and have a position to
maintain. The writer very much doubts whether a really
accurate estimate has ever been prepared showing the cost per
head of boarding asylum officials. Besides the cost of food and
drink there has to be taken into account the labour and other
expenses of the garden—for it is surprising how much of the
garden produce requiring much labour is used by the staff—the
provision and furnishing of messrooms which might in some
cases serve other and more profitable uses, the labour in the
kitchens and messrooms, the provision of napery, glass, crockery
and cutlery, the cost of the laundry, and lastly, the cost of
cooking and cooking appliances, many expensive cooking

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1908.]

BY FRANK ASHBY ELKINS, M.D.

701

appliances being got expressly for the staff. The amount
allowed for board to the few officials usually allowed to live
out is reckoned as approximately the worth of the emoluments,
but if more attendants and, perhaps, female officials, such as
night nurses, boarded out, and if the clerks* mess, the bakers*
mess, and the messes for kitchen men, stores porters and
general porters were altogether discontinued the result would
be economy to the institution and satisfaction to the staff.
The question whether labour could not be reduced in the
gardens, the kitchens and the mess-rooms would then arise.
The privilege cannot, however, be extended to all the staff—
for instance, a fire-brigade must always be on the spot.

Some deny that asylum officials living long in close contact
with the patients tend to degenerate in mind and body. In July,
1906, in answer to a question in the House of Commons, the
President of the Local Government Board replied that
roughly speaking in any given year 1 per cent of the average
number of attendants employed in asylums became insane.
This figure, he added, was slightly in excess of the percentage
of insanity in the general population between the ages of
twenty and fifty-four. He might have added that it was the
general rule of asylum authorities to choose men and women
who are much above the average as to physical condition, and,
therefore, that such officials should be less likely to be affected.
No account, too, is taken of the fact that many stay such a
short time in the service that the risks they run are very slight.
Those who have had much to do with asylums know that short
of insanity a number of breakdowns in health, due to the life
led, occur among the staff, particularly among those closely and
constantly in contact with the patients, and that officials who
resign “ for a change ** often do so because they feel they can¬
not continue the work without risk of breakdown. Any
reasonable steps, therefore, which can be taken with a view to
reduce the risk of breakdown should be most carefully con¬
sidered by asylum committees.

Some have urged the necessity of asylum authorities looking
after the lives and morals of the staff when off duty, and these
good people have explained that this is why officials should
not be allowed to live out. Surely it is the business of full-
grown men and women to look after their own lives and morals,
and people who cannot do so are not suitable to take upon

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702 ASYLUM OFFICIALS, [Oct,

themselves the great responsibility of caring for the insane.
Asylum authorities have quite enough to do in seeing that the
officials perform their duties efficiently. It cannot, however,
be for the best for an unnecessary number of nurses, atten¬
dants, and others when off duty to be subjected to the sights,
sounds, and smells inevitable in asylums and to live for the
most part of the twenty-four hours in close contact with insane
patients, many of whose expressions and actions tend to be
debasing to morals. As a matter of fact, the indoor life is
demoralising and throws unusual temptations in the way of
officials, so that it is surprising to the writer, not that a few fall,
but that the large majority pass scatheless through the ordeal
On the contrary, a large body of married attendants living out
will produce a healthy public opinion which will mature and
become more powerful in the future in its influence upon the
younger staff, whilst the female officials who live out will be
living under less dangerous circumstances. The public opinion
of a village is largely influenced by the middle-aged and
elderly. They are the persons who unerringly point out the
man or woman to be avoided, so that everybody knows the
risks run in having anything to do with such persons. Young
women desiring to be considered respectable dare not be seen
in such company. Village gossip when it pulls to pieces the
lives and characters of neighbours may be hateful, but it
certainly serves a useful purpose by acting as a warning, a
deterrent, or even as a punishment. A single woman living in
a village has every incentive to make herself respected by those
among whom she lives. The lot of the newly-joined nurse,
usually taken straight from a good home, but often with little
or no experience of the world, at a large asylum where most of
the staff, male and female, live in, is very different. She is at
once placed in a difficult position. She has no middle-aged
and elderly acquaintances who know the life—so apt to be
demoralising and full of temptation—she is called upon to
lead, and who can hold up the warning finger. There is no
healthy public opinion and no gossiping village circle to make
her extra careful how she walks. It is idle to expect the
matron of a large asylum to watch and know what each female
official does when off duty, though she could supervise a small
indoor staff. Can the good people who think that nurses must
sleep in the asylum prove that this form of cloistering has

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1908.]

BY FRANK ASHBY ELKINS, M.D.

703

resulted in asylum staffs being noted for a higher standard of
morality and for leading better lives than the rest of the com¬
munity ? If a man or woman is straying upon doubtful paths,
he or she will not be deterred by being compelled to eat and
sleep within the asylum. The public-house resorted to for
social purposes, particularly by those who have no good homes
of their own, naturally proves a great attraction to too many
indoor asylum officials, with the result that many a promising
young man develops drinking habits, and loses his character
and his post. When a man lives out he soon finds himself
with a home, a wife, and family, and these responsibilities and
incentives to keep his post, with the force of public opinion
behind them, may be relied upon to prove the best stimulus
towards leading a reputable life. It is idle to compare the
lives led by asylum nurses with the lives led by hospital and
infirmary nurses, for the circumstances are quite different, but it
may be hazarded that it would be better from the health point
of view if hospital and infirmary nurses, long at their work, did
not always live amongst their much less trying patients.
Village and Queen’s nurses have as high a standard of life as
hospital or infirmary nurses, indeed it has often been stated
that the influence of their lives upon the general community is
all to the good. It seems as if the greater freedom will
lengthen service, will diminish breakdowns, will make the post
more worth having, and will attract a better class to the service.
Nurses who have mothers or other relatives to support will
make a home for them in the locality.

It has often been said that nurses and attendants cannot be
induced to stay in asylum service unless the institution is very
near to a town where shops, crowds, and places of amusement
abound. Such an apology for constantly resigning officials is
plausible, but experience proves that the possession of a home
or suitable lodging is a much more potent factor in lengthening
service. Out of pity for their cloistered life, and with the
object of affording them reasonable amusement which may
keep them out of harm, the chief officers and committees of
asylums spend much energy and time in getting up entertain¬
ments for the staff, especially at the festive seasons, but when
once an official lives out he rarely troubles to put in an
appearance on these occasions, thus proving that the social life
of the village is all-sufficing.

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704

SOME ASPECTS OF INEBRIETY,

[Oct,

Where so many officials live in an institution, the question
was bound sooner or later to arise, what emoluments shall each
official be allowed ? How often shall these windows be cleaned
on the outside for this official ? Shall this man be allowed to
have his carpets shaken twice a year ? How many clothes may
this person send to the wash without charge? Does the emolu¬
ment “vegetables” include flowers, herbs, and fruit? Is this
official who is allowed a fixed quantity of coals also to get
sticks to light his fires, or must he buy fire-lighters or wood
from the outside ? Such inquiries must be worrying to com¬
mittees, and are highly vexatious to those who are unfortunate
enough to have houses or apartments within the asylum gates
Unless there are very good reasons indeed, the restrictions
placed upon officials living in an asylum should be very small
in number, bearing in mind the lives they are compelled to
lead. The obvious and natural remedy is to have as few sane
residents as possible to live upon the estate.

An asylum is intended for the patients, and all arrangements
connected with the institution or the staff must be subordinate
to the patients 1 interests. To improve the lot of officials on the
lines suggested by this article implies more skilled and trained
service by a more contented and happier staff, less break-downs
and resignations, fewer raw hands on duty, and therefore less
risks to the patients. Whilst asylum officials in following their
vocation, give, as a rule, without stint, their best services to
the insane, and are subject to all sorts of disabilities and
restrictions when on duty, it does not seem reasonable that
their lives when off duty should be—

“Cribbed, cabined and confined.”

(*) A paper read at the Annual Meeting, July, 1908 . The discussion on this
paper was postponed till the Quarterly Meeting in November.

Some Aspects of Inebriety. By Lady Henry Somerset.

I fully appreciate the very great honour which has been
done to me this afternoon in asking me to speak of the
experience which I have had in nearly twenty years of work
amongst those who are suffering from alcoholism. Of course

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1908.] BY LADY HENRY SOMERSET. 705

you will forgive me if I speak in an altogether unscientific way.
I can only say exactly the experiences I have met with, and as
I now live, summer and winter, in their midst, I can give you
at any rate the result of my personal experience among such
people. Thirteen years ago, when we first started the colony
which we have for inebriate women at Duxhurst, the Amend¬
ment to the present Inebriate Act was not in existence, that is
to say, there was no means of dealing with such people other
than by sending them to prison. The physical side of drunken¬
ness was then almost entirely overlooked, and the whole
question was dealt with more or less as a moral evil. When
the Amendment to the Act was passed it was recognised, at
any rate, that prison had proved to be a failure for these cases,
and this was quite obvious, because such women were consigned
for short sentences to prison, and then turned back on the
world, at the end of six weeks or a month, as the case might
be, probably at the time when the craving for drink was at its
height, and therefore when they had every opportunity for
satisfying it outside the prison gate they did so at once. It is
no wonder therefore that women were committed again and
again, even to hundreds of times. When I first realised this
two cases came distinctly and prominently under my notice.
One was that of a woman whose name has become almost
notorious in England, Miss Jane Cakebread. She had been com¬
mitted to prison over 300 times. I felt certain when I first saw
her in gaol that she was not in the ordinary sense an inebriate;
she was an insane woman who became violent after she had
given way to inebriety. She spent three months with us, and
I do not think that I ever passed a more unpleasant three
months in my life, because when she was sober she was as
difficult to deal with—although not so violent—as when she
was drunk. I tried to represent this to the authorities at the
time, but I was supposed to know very little on the subject,
and was told that I was very certainly mistaken. I let her go
for the reasons, firstly that we could not benefit her, and
secondly that I wanted to prove my point. At the end of
two days she was again committed to prison, and after being
in prison with abstention from alcohol, which had rendered
her more dangerous (hear, hear), she kicked One of the officials,
and was accordingly committed to a lunatic asylum. Thus
the point had been proved that a woman had been kept in

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7 06 SOME ASPECTS OF INEBRIETY, [Oct,

prison over 300 times at the public expense during the last
twenty years before being committed to a lunatic asylum.
The other case, which proved to me the variations there are in
the classifications of those who are dubbed “ inebriates/’ was a
woman named Annie Adams, who was sent to me by the
authorities at Holloway, and I was told she enjoyed the name
of “ The Terror of Holloway.” She had been over 200 times
in prison, but directly she was sober a more tractable person
could not be imagined. She was quite sane, but she was a true
inebriate. She had spent her life in drifting in and out of
prison, from prison to the street, and from the street to the
prison, but when she was under the best conditions I do not
think I ever came across a more amiable woman. About that
time the Amendment to the Inebriates Act was passed, and
there were provisions made by which such women could be
consigned to homes instead of being sent to prison. The
London County Council had not then opened homes, and they
asked us to take charge of their first cases. They were sent to
us haphazard, without classification. There were women who
were habitual inebriates, there were those who were imbecile
or insane; every conceivable woman was regarded as suitable,
and all were sent together. At that time I saw clearly that
there would be a great failure (as was afterwards proved) in
the reformatory system in this country unless there were
means of separating the women who came from the same
localities. That point I would like to emphasise to-day. We
hear a great deal nowadays about the failure of reformatories,
but unless you classify this will continue to be so.

You get women, for instance, from Battersea and Clerken-
well doing pretty well. The woman from Battersea is beginning
to get back some of her self-respect. The woman from
Clerkenwell is also recovering. Then there comes a woman
who previously lived in the same street with one of them, or at
all events in the same locality. We can imagine the old com¬
panion saying: “ What! you here ? Are you turned good
now ? ” and all the usual chaff. Immediately that woman is
dragged back to her former condition by meeting the com¬
panion of old days. These women must remain companions
for many months, as they are both consigned to the same insti¬
tution, and it is almost impossible to benefit them. I think
London people should be dispersed, and the country people

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BY LADY HENRY SOMERSET.

707

1908.]

also should be dispersed, and there should be a general system
of reformatories, so that each reformatory should take people
from various localities instead of each locality dealing with its
own inebriates, as at present. This can only be done by some
system of centralisation, centralising those reformatories instead
of giving them over to the Council of that particular district.
I think there has been some want of classification among
habitual inebriates.

Many criminals may drink as an incident in their life of
crime and yet are not primarily inebriates. Many inebriates
may commit crime and yet not be criminals; and I am sure
that until this has been very clearly recognised we are not
going to do very much in regard to public institutions for
reforming women. I cannot emphasise this too strongly.
There are women who are inebriates who will commit great
crimes under the stress of drunkenness, and there are criminals
to whom drunkenness is part of their life of crime. These two
have not been sufficiently separated and classified up to the
present time. The patients who come to us number about
seventy ip each year, and as a rule are people who take ordinary
alcoholic beverages to excess. There are those who take medi¬
cated wines, and proprietary medicines containing large propor¬
tions of alcohol, and there are those who drink methylated
spirits. I do not know how far this form of drinking is
indulged in, but it came to me as a surprise during the last
few years to find how many people there are who drink
methylated spirits, and how exceedingly difficult it is to cure
those who have that habit. I suppose it is because the
physical conditions produced by such a poison as that must be
specially bad, and worse that those produced by other alcoholic
beverages. Alcoholism has, in the lay mind, been regarded
too much as a taste for pleasant stimulation, but I am certain
it is not the taste of alcohol, or of wines, or of pleasant
drinks, that the alcoholic is after. He or she is after a sensa¬
tion, and whatever produces that sensation quickest is the
beverage or the drug to which they will become addicted.
That is why I think people will gladly drink anything, even
such horrible stuff as methylated spirits. I have known a
woman go down in the night and drink the paraffin out of the
lamp. Anything that produces that particular sensation for
which they crave satisfies the individual; and having ex-

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708 some aspects of inebriety, [Oct,

perienced it once they want to experience it again and again.
Another thing which has come to me very strongly is this: I
do not know that I have ever come across a woman who knew
she was drunk. She might know after she had recovered her
senses that she had been drunk, but at the time I do not think
these women have the slightest idea of their drunken state.
They think themselves very brilliant in conversation, or more
adequate to meet a situation, or more racy than usual, but
nothing more occurs to them at the time. That is the reason
why I am sure that time is of such importance in such cases.
One hears people talk of women who can be cured of drunken¬
ness in three months, four months, or six months. I believe
little or nothing can be done under a year, because for the first
three months they are unable to think or discriminate at all
reasonably. We have to talk to the women about their health
and things which may interest them. I never think it best to
attempt to bring home to them the sin of drunkenness during
the first three months of their residence with us, because they
cannot grasp it, or, in fact, face any difficult questions. That
is why relatives often mistake the best way of dealing with
them and talk unwisely and prematurely. It is impossible to
bring anything home to them until their minds are clear and
restored, and until they have regained a certain amount of
normal health.

Amongst the drug-takers we come across every conceivable
form. Women will take opium, morphia, and chlorodyne in
great quantities. Chlorodyne is one of the most dangerous
drugs because of the fatal ease with which it is obtained. I
have myself taken fifteen empty bottles out of a woman's trunk
on her arrival, and I knew that that was only a small portion of
what she had recently taken. People think it is a harmless
drug for colds, but they do not realise how the chlorodyne
habit is quickly formed. The same may be said about cocaine
and veronal. It seems to me that the practice of taking these
drugs is growing rapidly. We have women from almost every
class of society, but there is one feature which is common to all
classes. A woman entirely loses all trace of interest in her
personal appearance. They become absolutely careless how
they look, whether clean or unclean. Educated women come
to us as dirty as the poorest who come from the slums. This
is especially marked in the case of drug-takers, because drugs

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1908.] BY LADY HENRY SOMERSET. 709

seem to deprive them of all their personal self-respect as well as
of moral self-respect.

We have to ask ourselves often, What are the causes which
produce this state of things? From what causes do these
women sink so low ? It is useless for me to reiterate to this
audience, so well versed in the subject, what are the causes
which are apparent. When we think of the poorer classes,
and we consider the unhealthy conditions, the terrible atmo¬
sphere in which these women have to live, the horrible condi¬
tions in which they pass most of their existence, it is no
wonder that they should seek for something which acts as a
solace and gives them forgetfulness for the time being of their
misery. There is another feature of life which, I believe, affects
the women of the poorer classes in this country and the women
of the lower middle classes to an extraordinary degree, and that
is the absolute monotony of their lives. I have had that brought
home to me over and over again. Think of the life of a
working man’s wife living in a city, especially in the poorest
classes. We must realise that from year’s end to year’s end,
except perhaps for one picnic in the country in summer time,
she does not know what pleasure means. We have no places
of wholesome good recreation for men and women who cannot
afford much money, such as you find in France or Germany,
where they can go into gardens and listen to good music, and
where light wholesome refreshments can be procured at very
little cost. Such places are to be found everywhere abroad,
but in England I have realised over and over again that there
is absolutely no means of giving any sort of recreation to
women who live in the cramped conditions of our slum areas; but
strange to say we find that much the same conditions hold good
with the women of the lower middle classes. It is impossible
to conceive how extraordinarily dull life is to those who have
no mental resources, and when they begin to take a little
alcohol to forget the monotony of life by some form of stimula¬
tion, slight at first, but increasing afterwards, we see how
easily they become habitual inebriates. This question of
recreation is one which should be seriously considered among
those who are looking and working for the welfare of our
people at this moment. Among those who are in more
affluent circumstances we find often the exact opposite.
Women are spending their lives in one long rush of engage-

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710 SOME ASPECTS OF INEBRIETY, [Oct.,

ments and amusements, and they have recourse to alcohol or
drugs to produce a sort of sham vitality in order to get through
the plan of life which they have laid out for themselves. So
there are the two extremes to deal with : that form which is
constantly seeking excitement and trying to maintain an
excited condition, and those who are suffering from that
terrible monotony which I have mentioned. Drunkenness
among women is undoubtedly on the increase. There is one
feature which, I think, is accountable also to a large degree
among the poorer classes, and that is the unwholesome food
which is their staple diet. I was living for four years, before
I went to live permanently at the Colony in the heart of the
East End, and there I had the opportunity of watching the
daily diet of these women. They buy tinned things of every
description, cheap meat, foreign meat, bought in very doubtfiil
markets, and in a condition which just escapes condemnation.
They eat everything stimulating in the way of pickles and
sauces, and their diet is in all ways unsuited for every-day
work and healthy life. Again, the very bad bread which is the
staple food of the poor seems to me to result in the noticeably
bad teeth with which nearly all women come to us. Of this you
will be able to judge better than I. Their teeth are among the
first things which we endeavour to attend to. With two
exceptions I do not think I have had any women who came
with good sets of teeth in their heads belonging to the
lower classes—that is, among those who had given way to
alcoholism for any number of years.

The habit of taking highly-seasoned and unwholesome food
extends to the children to a marked degree. For some time I
had the children of the poorest classes during the summer, and
I have known many refuse the ordinary food and cry for
pickles or for kippers or for anything which was highly
seasoned, because they were not accustomed to the food
which is usually given to children. They had been reared on
unwholesome food from early infancy. The way we deal with
them is to build up the opposites, to give them all we see is
wanting in the woman.

We try to build up the ideal of home, and I think it is rather
different in this reformatory from most inebriate homes that I
know of; that we try to avoid every single thing which is in
the character of old associations which suggest to the mind the

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1908 .]

BY LADY HENRY SOMERSET.

7 11

institution. We know that in an institution the very methods
of life, the very labour-saving methods which are used, do not
savour of home. Even the way the bread is cut by machinery
does not remind them of home. My idea was to so create homes
that they should be models. That is why we have cottage homes
where groups of women can live the normal life, surrounded by
simple things which every self-respecting artisan should possess
in his own home. It is for this reason that many women who
have left us have gone away with a picture of what their homes
should be. I have dozens of letters which show that these
women after leaving us have tried to imitate what they have
seen, because it was so simple and so easily grasped. (Applause.)
When a woman first comes to us she is taken to hospital, where
every detail about her is registered. Next, she is given a large
dose of calomel, and that I believe is very beneficial. Our,
medical man is extremely insistent about the benefits of this
initiatory treatment, and believes it to be one of the best
preventatives of any dire consequences from the sudden
removal of alcohol. Then we give them simple but very good
food. I have always felt that these women needed feeding
well, and special care is given in this direction. Many of them
have very poor appetites when they first come to us, and their
digestion is necessarily much impaired. I think sometimes
that failure in reformatories lies in the fact that many do not
realise that the women cannot at first eat the food which they
will eat with avidity after a few months of abstinence, and I
think this is a point that ought to be considered, and some
differences should be made for the new-comers.

The question of occupation is, to my mind, very important.
It is a point that should be taken into careful consideration in
a great many places where human lives have to be reclaimed.
I endeavour, as far as possible, to make every woman who
comes to the home take up some occupation which she has
never engaged in before. I lay great stress on this. It breaks
off the continuity with the past. We want to give the women
new ideas, and to absorb them in their new occupations. We
do not want them to take up anything in a perfunctory way.
I am sure many women might be helped if this system were
adopted, but, unfortunately, in too many homes the women are
put to occupations with which they are already familiar. If
they are cooks they are put into the kitchen; if they are

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712 SOME ASPECTS OF INEBRIETY, [Oct,

sempstresses they are put to sew; if they are laundresses they
are turned into the laundry. It may be greatly for the con¬
venience of the institution that this classification should be
adopted, but it is certainly not a factor in successful treat¬
ment.

Then at our Colony we are very frivolous. We pay great
attention to trifles such as dress and new hats. In order to
rehabilitate the self-respect of women you are obliged to think
of these things, for a woman ought to care what appearance
she presents, and one of the first symptoms which shows that
a woman is getting back something of that self-respect which
she has lost is that she begins to care how she looks, how her
hat is trimmed, and whether it is becoming.

With regard to the treatment, I should like again to empha¬
sise the great importance of receiving women who first come
to us into the hospital, for two reasons. Firstly, because it
saves self-respect, it puts the emphasis on the physical and not
the moral side of the question. It is far better so ; the moral
side must come afterwards, and it comes with far greater force
then. Secondly, in many cases we find that women who drink,
especially among the poorer classes, are suffering from illness
for which they should have been treated, but which has been
neglected, suffering perhaps a martyrdom of pain which they
have never disclosed, and from which they have never had any
alleviation, and it is, perhaps, to dull this pain that a woman
has begun to drink. In many cases we find that neglect after
confinement or uterine disorders of all sorts have been at the
bottom of their failure. With regard to cases of mental
deficiency I think there should be stringent classification. I
have had women sent to me who came decidedly under this
heading, and who at no time will be able to guard themselves
where they are surrounded by temptation. These women
remain a constant menace to society, and I feel that there
should be colonies in England where such can be received,
people who are neither idiots nor insane, and yet who are
unable to take proper care of themselves, but who could main¬
tain themselves by useful labour if they were protected. A
number of women who come to us would gladly spend the rest
of their lives in our midst, but for the present that is impossible.
I am now refusing four to five hundred cases a year. In early
days I refused three thousand applications in one year. So

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1908.] BY LADY HENRY SOMERSET. 713

that here is sufficient proof that the work is needed, and could
be usefully extended.

With the wider knowledge that is coming to the public in
general as to the disease of alcoholism, there is one danger
which I think should be safeguarded, and that is the great
amount of harmful nonsense that is talked and written as to
hereditary predisposition to drunkenness. Many women come
to us saying, “ I cannot possibly be cured. My father and
mother drank, and it is hereditary; therefore it is no use my
trying.’* And the word “ heredity ” has become a sort of catch¬
word among many who do not understand these problems.

With regard to many drugs which are now advertised, and
which are generally proprietary medicines, I think some of
these advertisements have misled a great many people, those
who are at their wits* end to know how to help their relations
or their friends. (Hear, hear.) They have put'their faith in the
rash statements that are made, and have been direfully dis¬
appointed. There is one specific which has been advertised in
some of our daily papers, and which has received a great deal
of attention, which professes to have cured a vast number of
people, and for all I know may have done so, but I must state
that we have very few cases in the colony who have not tried it
at some time or other. There are undoubtedly remedies which
are of use, and it is a thousand pities that some of these useful
formulae should still remain proprietary secrets.

There is one feature in our homes in Surrey which, I think, is
unique, and that is that added to the colony we have a large
children’s home, of children who have nothing individually to
do with the women under treatment, but who are there because
I believe it to be bad for people to be in any locality where
everyone is treated for the same thing, for into every place I
think you must bring some natural happiness and joy if you
are going really to bring people out of their unfavourable
circumstances, and to my mind the presence of children is one
of the best factors of success. It is of very great value that
the women should realise that all are not there because they
have done something wrong, but that the children are there to
be happy and can 9pend a happy childhood in their midst.
The very spirit that this engenders does so much more than
we who have charge of them can do towards their recovery,
because the children’s trust and affection are so simple, and

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714

SOME ASPECTS OF INEBRIETY,

[Oct,

give the patient the definite impression that by-and-bye they
will be able to regain what they have lost in their own children
in their own homes. I look upon this intermixture of work
for reclamation and for education as of great value.

I cannot emphasise too strongly the great need there is for
training the workers who undertake reformatory work. At
this moment there is nothing, it appears to me, that could be
so useful as the starting of some place or institution where
women who have a desire to take up this or kindred work
could be properly trained—trained in the very many branches
in which knowledge is required in order to do successful work.

A truer understanding of psychology would lead to the
adoption of common-sense methods, which are often altogether
overlooked, methods which are valuable in dealing with all delin¬
quent and defective classes, not necessarily only inebriates. I
feel sure that such sound training is much needed in reformatory
work. I am convinced, from some long experience in getting
women to take the post of nurses or sisters in our cottages,
that many think such work is the last resort of those who have
to earn their bread, who have perhaps not the health or the
capacity for other things. It is the greatest mistake to imagine
that such work can be undertaken without training, and I
feel that herein lies much of the failure of our reformatory
system. Women will go to the most responsible work with no
special training at all, and the result of this is always evident.
I have found great success in training some who have themselves
been patients, who have been out in the world since their
treatment, and come back to the Colony having proved their
stability, anxious and often eager to do for others what has
been done for them. I have sisters who, six, eight, or even
twelve years ago, have been patients, and they often make the
most efficient and sympathetic workers. The spirit of the
worker means the success of the institution. The motive with
which they work is plainly reflected on those under their care,
and it is of the very first and highest importance that the workers
should have a real and earnest desire to reclaim and reinstate
their patients, and that a strong esprit de corps and a high ideal
should be preserved.

I am greatly of opinion that no success is possible unless a
strong religious influence be maintained. The patients should
feel that they have cast anchor in a sure haven, and that it is

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1908.] BY LADY HENRY SOMERSET. 7 I 5

one to which they can in time of stress or strain return. I am
not always disturbed when a woman breaks down after her first
return home. I have so often known women have a failure
when they thought they were strong, return after learning their
weakness, and in the end do well. A failure does not always
mean a failure for all time. I feel sure that success would often
attend these methods were they applied to those who are now
considered irreclaimable. They need frequently to feel that
they are looked on as individuals and not as cases, and that
care and thought are bestowed upon their treatment, and that
there is a sincere personal desire for their well-being.

Among the London County Council police cases sent to us
in early days was a woman who was as well known to the
police as any woman who has ever tramped the streets of this
city. She was known as “ Mogg the Fireman,” because she
ran up a fire-escape and eluded the police. She was sent to us
as practically irreclaimable, and was afterwards removed to the
Aylesbury Reformatory. During the whole time she was there
she had one idea, and that was to behave well enough to justify
her being sent back to us. After three years or more in
Aylesbury she did come back to us, and that is some time ago.
She is now on our under staff, and is as valuable a woman as
we have on the place. That is why I have ventured to come
before you to-day and speak what is in my mind. (Cheers.)

Discussion,

At the Annual Meeting held in London, July, 1908.

The President said the address to which the meeting had just listened was not
only eloquent, but was full of practical wisdom and human sympathy. He trusted
that those in the meeting who had had experience of inebriety would discuss the
address. Inebriety was so closely germane to the subject to which members of
that Association devoted their lives that the Association as a whole was deeply
interested in it—as much interested in that as in any subject which could be brought
before it.

Dr. Stewart said he ventured as one who had had considerable experience with
inebriates to say a few words on the subject of Lady Henry Somerset’s valuable
address. The question was complicated because one had invariably to think of
the case which came before one, not merely as a patient who was physically injured,
but who was morally injured also. He had great sympathy for the feelings which
actuated the mind of Lady Henry Somerset, that nothing could be done for the
inebriate woman unless her finer sentiments could be aroused in some way. His
own experience was somewhat different from that of Lady Henry Somerset, inas¬
much as his dealings were entirely with women of the upper class, and it was very
painful to observe during those years that, with one exception, none of these ladies
showed any interest in whether she was turned out neatly or not. Very many of
his cases, however, had perverted tastes, especially in such matters as dress. It
had been very gratifying to hear from Lady Henry Somerset that the disease of

LIV. 51

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SOME ASPECTS OF INEBRIETY,

716

[Oct.,

inebriety was one in which no miracles could be wrought by means of any drug
which could be brought to bear on the case.

Dr. Clouston said all were deeply obliged to Lady Henry Somerset for her
vivid but simple address. She had laid down that afternoon most admirable rules
for dealing with the patients under her care. He thought self-control was what
was required to be developed in the cure of the dipsomaniac, and without that the
case could not be cured. He thought Lady Henry Somerset would admit that her
sex was more difficult to cure than the male, and if that was true, the reason was
that their self-control could not be reinstated. There were fifty questions on the
subject which arose in his mind, but he would not stand in the way of other
speakers. From the point of view of insanity a good deal could be said
about drinking. Probably Lady Henry Somerset had had the experience that
many of her people were* not only imbecile, but that some, like Jane Cakebread,
were on the verge of insanity; that they had that restless morbid condition of
brain which existed at the beginning of an attack of mania. Self-control was
lost. It was not that there was a desire for drinking, but it was loss of self-control
which made a woman take to drink at a time when she was beginning to go off
her head. He would like to think that the marvellous system which Lady Henry
Somerset had so graphically described had a corresponding result, and that she
would have the reward for the great and sympathetic work she was doing. But
in common honesty he must say that the experience of most of them was such
that they had ceased to believe in the cure of most women who had taken to
excessive drinking. The conclusion was a sad one, but it was one which had
been forced on his mind by a somewhat extensive experience. He could not
sufficiently express the gratitude felt by all towards Lady Henry Somerset for the
address she had just given.

Dr. Yellowlees said he desired to express a like appreciation of the admirable
address to which the meeting had listened. They were all the better for being
reminded of the multitude of little things which were of great significance in
dealing with such cases. He was not surprised, but gratified, to learn that so many
of those women, who had been found by Lady Henry Somerset to be really defective
from the beginning, who had not the self-control of ordinary people nor the power
of defending themselves against evil and temptation, were the most ready to dwell in
her safe home when they reached it. It seemed as if the evil doings of those women
had not been their set purpose, but the result of inherited weakness, which they
had been able neither to understand nor resist. That was only another reason why
a “ Feeble-minded Commission ” should have sat long ago, and why one could look
hopefully for the result of their labours.

Dr. Robert Jones desired to add a word of thanks for the extremely
eloquent, practical, and kind address which had been heard from Lady Henry
Somerset. He had the subsequent treatment of the poor Jane Cakebread who had
been mentioned, and in connection with the hopefulness of the treatment he might
mention that she hated brandy, even the smell of it. She was at Claybury two
years, and in the last stages of pneumonia it was difficult to get her to take it at
all; she had, during the time she was under treatment, learned to dislike it. He
thought the whole treatment of inebriety was hopeful. Those present knew wbat
a long and difficult process it was, but it seemed to afford a good deal of
encouragement, and consisted in re-education and the development of the will¬
power.

Dr. Milsom Rhodes said that, as past president of the Inebriate Home for
Lancashire, he concluded that a large number of inebriates were mental defectives,
and Dr. Branthwaite, in a paper which he read not long ago, said that from 60 to
70 per cent, were mental defectives. And if those cases were carefully inquired
into it would be found that, as Lady Henry Somerset had said, it was the environ¬
ment of those people, in very many cases, which led them to drink. They lived
in horrible surroundings—slums, with their unhealthy atmosphere. That caused
depression, and they drank because they were not properly housed. The monotony
of the life of some of those people was fearful, and it was true that many of the
women were not out of their homes from one year’s end to another, and the only-
place which gave them light and cheer was the public-house. He did not think
town councils ever spent money better than when they spent it to provide bands
and concerts for the enjoyment of the poor people, so as to break the monotony of

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1908.]

BY LADY HENRY SOMERSET.

717

their lives. It should be the aim to give the people something higher and better
than they had ever had before. By providing a higher standard of living one
would be able to strike at the root of the drink evil.

Dr. Hayes Newington said the address was the address not only of an earnest
woman, but of a highly scientific woman. The Association would have gathered
much good from hearing the subject treated, as it should be treated, by the
scientist. He desired to mention only one point, that of heredity, which Lady
Henry Somerset very properly discounted as between drink and drink. But he
would like to ask if, in her inquiries, Lady Henry Somerset had not found a large
amount of heredity in the direction of insanity in the parents of those who were
inebriates. He thought that could not be discounted. Those who cared for the
mental state of the world must continue to sound that trumpetthat one of the
risks of insanity is a tendency towards drunkenness in the children. It was an
old-debated point, but he did not think it had ever been contradicted that insanity
tended to drunkenness.

Dr. Bedford Pierce said what had struck him most about the address was its
extremely encouraging note. Those who were much in contact with inebriates
became very much discouraged, and to hear what Lady Henry Somerset had to
say after living among female inebriates had done them all a great deal of good.
With regard to the essentia] nature of the malady, no doubt a great proportion of
inebriates were feeble-minded, but he thought that statement rather begged the
question. They were feeble-minded or they would not do such foolish things as
to continue to drink and ruin their families. But some of the people he was
thinking of were not feeble-minded in any way which could be revealed by
ordinary methods. There must be something wrong with them, otherwise they
would not neglect their future in the way they did. What struck him about the
relapsing cases was the very small amount of craving there was—people who were
sensible and cultured, who knew the future, and yet relapsed for no apparent
reason. He remembered a fellow student who was reclaimed after great labour
and sacrifice, but who took to his morphia again simply because he thought he
would like to. There seemed to be no other explanation. He was labouring
under no pressure from a craving for it. The President might say there was a
desire, but in that case there was none of the desire which meant impulsion. With
regard to the drug treatment of inebriety, a gentleman called on him and asked
him to use a secret remedy in his practice, freely mentioning Lady Henry
Somerset's name in connection with it. Of course he felt obliged to decline to
have anything to do with a secret remedy. He had been very glad to hear Lady
Henry Somerset disclaim any belief in the efficacy of this or other secret remedies.
He felt that they were very much indebted to Lady Henry Somerset for her
splendid address.

Dr. Rayner said he would like to express his general agreement with nearly
every point which Lady Henry Somerset had advanced, especially as to the very
large basis of intemperance furnished by defective teeth. He regarded it as an
extensive cause of many failures in life, especially in the matter of intemperance.
He had also been glad to hear her ladyship’s allusion to the large number of cases
in which there had been unrecognised physical suffering, leading to the develop¬
ment of the drug habit.

Lady Henry Somerset, in replying, stated that at Duxhurst nobody was con¬
sidered as cured who had not stood satisfactorily for a period of two years after
leaving the home, nor any who could not be traced or heard of at the moment of
making the reports. Lady Henry Somerset was aware that statistics were often
misleading, but taking the ground just mentioned, during the eight or nine years
they could go back, 57 to 60 per cent, of the cases remained free from recurrence
at the present time. (Applause.) With regard to the feeble-minded, in the
limited conditions from which she spoke, she believed that not more than 3 or 4
per cent, came exactly under that head in her view, 1. e. those who ought not to go
out into the world without protective care. Certainly many people might be
classed as being weak, but those coming under her care who might be regarded as
a menace to society did not number many. There were some who had epileptic
fits and were unable to battle with the world. With regard to remedies/the state¬
ment which she had made was perfectly true, that for twenty years—ever since
Keeley’s Gold Cure—she had looked into all the remedies which had been brought

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71 8 PRINCIPLES OF THE TREATMENT OF EPILEPSY, [Oct.,

out and their results. When Keeley made a boom in America she went to
Chicago and stayed there six months. Then she went to Dwight, and concluded
that she would have nothing to do with the remedy. When she was in America
four years ago a well-known leading medical man asked to see her and spoke about
a remedy of which he could not get the formula. He said he considered it so
much the safest thing he had seen that he would be glad if she would do her best
to look into it and make what trial she could of it. She used no secret remedy in
her home, but she had a year or two ago a small nursing home in the East End of
London for people who drifted in, and she allowed that gentleman to come and
make trials and demonstrations before her with the remedy. She saw what he
meant by “ cure,” but she did not think it was in any way a permanent cure for
women. Time, and time only, was needed for women, and necessarily so because
they recognised that the state in which women often were, made it impossible that
they could get well from such a long-standing illness as inebriety in a short time;
but she had seen men put on their feet and carried safely across this bridge which
was made for them between inebriety and sobriety, so that when landed into
sobriety they were able to appreciate what it meant to get over their failing, and
they had remained sober because they had been restored by a drug to sobriety,
which enabled them to start afresh. That, she thought, was the value of many
advertised 44 cures,” that they enabled people to get sober with less of the painful
struggle which was involved by sudden deprivation of alcohol, and men often said
when once they were sober , 44 1 mean to remain so.' 4 With regard to the fact
that her name had been used, she did all she could to procure the formula
of the remedy in question, because it seemed different from many of the other
remedies which existed, but she had not yet been able to get a satisfactory
formula. At the same time, she had seen just those results produced, namely, that
people who were brought in terribly drunk, especially in the case of men, became
sober in a shorter time than they would have done otherwise and started life again
from a standpoint which it would be difficult otherwise to attain. That was the
only connection she had had with proprietary medicines of any kind. With
regard to the remarks as to self-indulgence being the main cause of inebriety, she
could not say with regard to women in her experience that one could quite
generalise in that way. She had known women with very strong self-control
become inebriates because they had set themselves certain tasks, and they had the
impression that they could perform them more quickly under the influence of
alcohol, and in that way had slid into alcoholism from their very tenacity in
carrying forward certain work. She had known others slip into inebriety from a
disorganised and uncontrolled life. The results could be generalised and analysed,
but she did not think the initial stage could be generalised apart from that point
of view. (Applause.)

On the Principles of the Treatment of Epilepsy. By
Alan McDougall, M.D.

Some day there may be found a medicine to cure epilepsy.
After that day the treatment of the disease will be a simple
affair. But for the present he who undertakes to treat an
epileptic undertakes a very difficult and responsible task. He
must take a broad view of the situation, and use remedies not
mentioned in the British Pharmacopoeia.

In a recent case of epilepsy where the fits have been few it
is right to make a vigorous attempt to cure the disease. It is

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1908.] BY ALAN MCDOUGALL, M.D. 7 19

justifiable at this stage to subject the patient to many restric¬
tions, to make him an invalid, in the hope that thereby he may
come to have no more fits.

But if in spite of this the fits persist, then treatment on those
lines must be abandoned, once and for all, and treatment on
quite other lines substituted. Without ceasing to hope for
cure, it is then wisest to assume that the patient will for the
rest of his life periodically have fits. The chief problem in
these cases is how to diminish, not the frequency, but the
importance of the fits.

Whether epilepsy be one or several diseases, it is certain
that there are epileptics and epileptics. To many, perhaps to
most, it would be a gain to be free from fits; to others the fit
is a boon, the lesser of two evils. An epileptic may have a
hundred fits a month, month after month, and be in good
mental and bodily health ; he may then cease to have fits, and
become imbecile or dangerous. Epilepsy is much more than
fits; therefore it is a pity, a great pity, that the fit offers such
scope to the word-painter. The conventional text-book article
on epilepsy is a magnificent, pre-Raphaelite word-picture of a
major convulsion, and a little comic relief. Because of this,
the student, and subsequently the practitioner, is apt to take
far too narrow a view of the situation. Except at the very
beginning of a case, treatment that is simply an attempt to
rid the patient of his fits is pernicious and wicked.

We must treat, not fits, but a man who has fits. Our object
must be to enable him to lead as excellent a life as possible.
Now, the human being has two cravings—the craving to be
comfortable, and the craving to be useful. Elsewhere I have
called the desire to be important egoism, and the desire for
comfort egotism. So defining the two words, we may say that
with very few exceptions all human beings are both egoists and
egotists. Comfort and importance are rarely possible at the
same moment; life is a compromise between the two desires.
Some people are on the whole more egoist than egotist, others
are on the whole more egotist than egoist; but very nearly all
are both. And that is the key to the management of the
epileptic.

It is not enough to physic his fits, it is not enough to give
him a comfortable home; you must also provide a safe outlet
for his egoism. In so far as he is biological he is a creature

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720 PRINCIPLES OF THE TREATMENT OF EPILEPSY, [Oct,

evolved, or designed, to enjoy being useful to his community.
If you prevent that, the physiological will become pathological,
his very proper desire to be useful, his natural self-esteem, will
decompose into side, assertiveness, pride, vain-glory, and
hypocrisy, envy, hatred, malice, and all uncharitableness.

It is easy enough to point out the principle that underlies the
successful management of the epileptic: the difficulty lies in the
application. Is it possible to make an epileptic, unless the
disease in his case be very mild, useful in a non-epileptic
community ? The question is an open one. I am not unbiassed,
and my experience is one-sided, but I think the thing to be
rarely practicable. By mere reason of his fits, as well as for
other reasons, the epileptic is so much unlike his neighbours
that he and they cannot be happy together. He is a nuisance
to them, they are an annoyance to him. Except in mild cases,
where the epileptic can keep situations and do an ordinary
day’s work, he should, whatever his income or social position,
live in a community of epileptics. For there alone can you
make him know himself to be both useful and comfortable.

At a colony the patient’s fits are regarded as a matter of
course and as a matter of secondary importance ; the attempt
is made to promote his general well-being. In his home he
found that he was a peculiar person ; at a colony he finds that
he is a normal citizen. He comes to understand that he must
do his share of the work of the community. There is work for
him to do, work that he must recognise as useful work. Work
done for work’s sake, work done for health’s sake, is unsatis¬
factory ; it leaves the egoism aching.

Of course, a colony is no earthly paradise ; some of the
colonists continue to degenerate mentally. A few become free
from fits and return to the world to earn their living there.
Most, however, remain epileptic, but improve greatly in
behaviour, character and health. Most people who have lived
with one epileptic regard him as rather a dreadful person, a
great nuisance. We who work with many epileptics, play with
them, earn our living by them, have them always with us, we
regard epileptics as very likeable persons. Being, as a class,
more or less short of sexual feeling they tend to resemble
children, and so have some of the charm of the child. Owing
to their liability to fall and injure themselves, owing also to
their proneness to transient madness, they are, and must be,

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1908.]

BY ALAN MCDOUGALL, M.D.

721

sources of anxiety to those responsible for their safety. But
they repay trouble; and so long as they are sane, epileptics
are more easy to manage than are normal people. I have one
hold, and only one, over my colonists—their fear of being sent
away from the colony. It is enough.

Discussion.

At the Annual Meeting in London, July, 1908.

The President remarked that the true title of the paper would seem to be “ The
Treatment of Epileptics.”

Dr. Savage said he thought the present was rather a good opportunity to bring
before the Association what, he thought, had scarcely been considered hitherto—
the existence of an epileptic school colony in the south of England which was doing
really excellent work. It carried out in many respects what Dr. McDougall had so
well described. When he had been down to that colony on several occasions he
had been struck with the simple, commonsense way in which the fits were treated.
Those who had not lived in the atmosphere of an epileptic colony were alarmed
and disturbed somewhat when they heard a slight cry and saw a patient fall
down unconscious. But on several occasions when he was at the colony, in the
middle of a lesson, such as geography, there was a slight cry, the child fell, and
the nearest child, without hesitation, stooped down and undid the necktie and the
sleeves, and the child remained while the lesson was continued; no more notice
was taken of the incident by the children than if the child had sneezed. And the
children recovered from their fits with little consciousness that they had done
anything in any way peculiar. There could be no doubt that that colony system
had enormous advantages, not only for the patient himself, but also for those who
were not patients—for the other children belonging to the family. He desired to
say a word or two about that self-supporting colony. It was one at which only
educable children were received—a certain number of boys and a certain number
of girls. And the school had slowly evolved. Somebody had presented it with
the building, another with the laundry, and so on, and the cost of maintenance of the
children ranged from 125. 6 d. to 155. per week. They were received from all parts
of England from different unions and infirmaries. A year or two ago he volunteered
to be their honorary physician, so that all children, before going to that colony, were
seen by him that he might decide as to their educability. One recognised that,
after all, in dealing with the epileptic one was dealing with those who, even at their
best, were handicapped. The same thing must be recognised in educating them,
for when they arrived at the age of sixteen or seventeen and had to be removed,
some to farm work—and some were retained in farming in Sussex—they were not
fully capable of earning their living independently. That was one of the draw¬
backs. People asked what was the use of working at such children and calling
them educable when really at the end of their education they were only half-human
beings ? His reply was that it seemed very much better to have a half-useful indi¬
vidual than to have an actual encumbrance on the State; and he thought the
colony system was the only satisfactory one, whether for the education of such
children or for their treatment.

Dr. Milsom Rhodes, J.P., reminded members that on the previous day they
differed as to the merits of the colony system in the treatment of the insane. Any¬
one who had had large experience of the colony system could only arrive at one
opinion, namely, that it was the only really efficient system for dealing with the
epileptic. He had had much experience of it; and he found that one or the great
difficulties of dealing with epileptics outside was the sense of inferiority which they
had constantly before them in relation to their fellow men. But when they entered
a colony that feeling largely disappeared, for .they felt equal to their associates,
so that their self-respect was restored—an important matter. Thanks to sanita¬
tion, and perhaps still more to getting a large number of insane persons into our
asylums, epilepsy was now diminishing steadily, and he attributed that to the pro-

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72 2 PRINCIPLES OF THE TREATMENT OF EPILEPSY, [Oct,

vision for cases in asylums. A short time ago a woman brought her father-in-law
to the institution with which he, Dr. Rhodes, was connected, and he told her he
appeared to be perfectly quiet, and asked her whether she could not keep him at
home. She replied that she had got her husband and child who were epileptic, and
that she could do with two epileptics, but not three. He held a strong opinion that
these people should not be allowed to marry and propagate the unfit. The State
should take up the question of providing epileptic colonies for the. whole class.
At the present time the country was following a wasteful course. During the last
month or two he had been carefully into the question of the number of epileptics
in prison, and the number of feeble-minded persons in prison, and he had been
horrified by the number of epileptics at present in our prisons. A large number of
those men had committed their crime while in a state of epilepsy; and when the
report of the Prison Commission was published, the facts would stagger the
public. Dr. Donkin had said that 15 to 20 per cent . of prisoners were feeble¬
minded or epileptic, and if that was so it was high time the system was changed,
and that proper places were provided for those people where they could be kept
from committing crime. He thought many such people fell into crime because
they could not find occupation. Electricity had been a cause of great distress to
the epileptic. Sewing-machines which formerly were driven by the worker, and
therefore did not come under the Factory Act, were now being driven by power
from a central source, and hence came under that Act, and no epileptic could find
employment under the Factory Act. Consequently many of those poor creatures
could not find employment, and often drifted into crime. He hoped mem¬
bers of the Association would do all they could to spread and multiply such
colonies, and provide occupation on the land for these people, for he believed
Dr. McDougall would agree that occupation on the land was the best means of
diminishing the fits. By so doing they would not only be following a humani¬
tarian course, but one which would be of great benefit to the public at large.

Dr. Rayner said he thought the advantage arising from the association erf
epileptics together could not be too largely dwelt upon. His experience at
Hanwell at first was that of having insane epileptics scattered through the general
insane population. He then segregated the epileptics in one large ward. One of
his colleagues told him he would have plenty of homicides, and tried to frighten
him out of the project. However, he segregated them, and it gave him more relief
in the asylum than it was possible to imagine. And the sympathy of the epileptics
for one another was a very great element in the success of the segregation. Of
course, that had been adopted now everywhere, and it was an old story; still,
recollection of the period before the segregation was, he thought, worth mentioning.
After the segregation many of the epileptics under the favourable conditions which
were inaugurated went on improving; and his impression was that in a very large
number of cases the fits tended to become less frequent and in some they
disappeared altogether.

Dr. Shuttleworth said he would like to say a word about the educational
aspect of the auestion. He did not think it had been mentioned, but no doubt
it was generally known that the Act of 1899, which dealt with the education of
feeble-minded children as “ mentally defective," gave power also to educational
authorities to provide for the education of children who were prevented from
attending ordinary school classes by reason of severe epilepsy. That Act
was optional, and he feared it had not yet been adopted by the major portion of
the school authorities of the country, though it had been adopted in all the larger
cities and more intelligent centres of education. But he thought its universal
adoption would be a very great social benefit—he meant especially its adoption in
the case of epileptics. Because if, as Dr. Milsom Rhodes pointed out, the want of
care of epileptics produced a large number of criminals and caused all sorts of
evils in the community, not to mention the question of the reproduction of epileptics
if epileptics were allowed to marry at their own sweet will, the great thing was to
" detect early and protect always. He thought those were the principles which
they should go upon with regard to the treatment of epileptics. The Act of 1899,
wherever adopted, had given considerable facilities for that purpose. When some
years ago he, Dr. Shuttleworth, was doing work under the auspices of the late
London School Board, he had to examine and report on all epileptics known to
the attendance officer. There were 470 brought for his inspection, and his report

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BY ALAN MCDOUGALL, M.D.

723

1908.]

was that at least 40 per cent, required special treatment, not at day classes, because
that was only a small benefit, but in wholesome surroundings in a proper residential
school where they should have a fair proportion of outdoor work as well as some
indoor schooling. That report he feared had not been acted upon fully, though
he believed that the authorities which now regulated educational matters in the
Metropolis had taken advantage to some extent of the institution at Lingfield to
which Or. Savage alluded. Having visited that institution he could confirm Dr.
Savage’s remarks about the good results from the judicious treatment of the
children received there. He had also had the pleasure of visiting the Cheshire
institution about which Dr. McDougall had just been speaking; and that institu¬
tion was admirable in its arrangements, and he had no doubt it was of immense
benefit to the north of England.

Dr. Yellowlebs said that the first principle in the treatment of epilepsy was
the removal of that which induced the fit. He had found that among epileptics
the sexual instinct was often very strong, and he mentioned the case of a sane
epileptic who was so confident that his fits were caused by strong sexual emotion
that he resolved to be castrated. Other treatment having failed, the operation
was performed and the fits entirely ceased. Is castration not a neglected remedy ?
he asked.

Dr. Robert Jones remarked that Dr. Savage had referred to the economical
value there was in colonising epileptics. This was an age of classification, and the
Legislature had not been slow in taking advantage of classification. As Dr.
Shuttleworth had said, there had been an Epileptic and Defectives Act, and, apart
from colonising the epileptic, he would like to hear from Dr. Bond his experience
with regard to colonising the insane epileptic. There was only a very narrow
line of demarcation between the sane and the insane epileptic. He had had
experience of the young so-called educable epileptics at Earlswood Asylum. In
one year the admissions of educable epileptics were 25 per cent, of the whole.
And there was an experience of those children attending classes and getting worse.
He did not think that in his experience they discharged back to their parents any
epileptic at Earlswood, which was the case with some of the educable improving
ones. His experience—and it was within the knowledge of everyone—was that
colonising epileptics in the County of London was not so advantageous from the
ratepayers’ point of view. The maintenance-rate at a colony was not so satisfactory
as that for treatment in an asylum. But Dr. Bond, with experience at both, could
tell the meeting whether in the colony there was more contentment. He, Dr.
Jones, thought the epileptic specially required encouragement with regard to the
religious side. No school would commend itself to him unless there was some
local chaplain to minister in that special line. And although he advised that
it would be most desirable to have a special chapel at the Epileptic Colony at
Ewell, there was not yet a chapel of any kind there. For religious purposes the
epileptics had the use of the dining hall. He asked whether any foreshadowing
could be given as to the extent to which that economic necessity existed. What
was the percentage of epileptics to the ordinary population ? He had heard that
in prisons there were as many as 25 per cent., from Dr. Rhodes.

Dr. Milsom Rhodes: Weak-minded criminals; that is according to Dr.
Donkin. Branthwaite in Inebriate Homes bears that out. In epilepsy it is 2 per
1,000 of the population.

Dr. Robert Jones, continuing, said that left 12,000 epileptics in the county of
London alone, and one sees how vast is the possible expenditure, but he thought
that it was worth the expense. The second part of his remarks would be limited
to the question of prevention. He looked forward with interest to what the sealed
books of the “ Feeble-minded Commission ” would show as to colonies. From the
evidence in the Times , he thought there would be a strong recommendation to
concentrate—“ to detect early and protect always,” as Dr. Shuttleworth so well
said. The protection of the masses of the population against the epileptic was a
very necessary one. His own experience in the matter—a somewhat extensive one
—was a sad one with regard to the strong sexual feeling shown by the epileptic.
A large number of the patients the subject of epilepsy, at Claybury, were women
of about 18—some as young as 16; many were married and had had children.
One of the cases discharged at the last meeting was a man who had married a
girl who was one of thirteen children, all of whom were epileptics. The cause

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724 PRINCIPLES OF THE TREATMENT OF EPILEPSY, [Oct,

of his insanity and his admission to Claybury was the suicide of his eldest
daughter, his wife having already been an inmate there. His object in making
those remarks was to encourage the colonisation of the epileptic, even though the
plan might be expensive to carry out. Not long ago he was asked to foreshadow
some suggestion as to the prevention of insanity, from another aspect, and he
thought the present question bore a very close relation to the subject of the
protection of population against insanity, and its limitation by preventing unsuit¬
able marriages.

Dr. Clouston said he would be glad if Dr. McDougall would, in his reply, give
some information on two points. Firstly, were the epileptic patients in the colony
with which he was connected regularly getting bromide of potassium as a
medicine against epileptic seizures? Secondly, was there a standing rule that
after each fit the patient should be allowed to sleep it out—to lie and rest as
long as possible, until the immediate effect, both on the circulation and on the
brain cells, had passed off ? He thought everyone would be glad to hear those
questions answered. He had been surprised to hear from Dr. Rayner that he
segregated his epileptics. In the Scottish asylums there were comparatively few
epileptics, but they were most carefully scattered about among the other patients.
The good, pleasant, industrious epileptics were placed in the open convalescent
wards, where they proved very useful. The only rule they had was, that in walk¬
ing round the grounds those patients must not walk alone. They must either
walk with another epileptic, or with some patient who would look after them if
they had a fit. With regard to the special sexuality of epileptics, he did not believe
there was any difference between them and other people: they did not seem to
possess less or more of the reproductive instinct than anybody else, having regard
to the particular age of the individual. He desired to personally thank Dr.
McDougall for his paper, because he, Dr. Clouston, had now derived from his
description a different idea of the sort of place which the epileptic colony was
compared with what he had previously entertained.

Dr. Briscoe desired to support what Dr. Clouston had said with regard to the
physical side of epilepsy. He asked the reader of the paper whether any observa¬
tions had been made in the matter of dietetics in connection with such patients
and their management. It was very important that the general practitioner of the
present day should know how to manage epileptics. Many in general practice, and
others, looked to the Medico-Psychological Association for their knowledge in
regard to mental cases. The Journal of Mental Science was read not only by the
members but by many general practitioners, and he would be very glad if the
author would give some information bearing on the physical treatment of such
cases, especially as he said he treated, not the fits, but the man who had the fits.

Dr. Hubert Bond said he only rose to take part in the discussion because Dr.
Jones had associated his name with it, and had asked him some questions.
Unfortunately he was not present while the paper was being read. Dr. Jones asked
what his feeling was about the Ewell colony. His feeling was one of optimism
concerning its past and its future. His personal anxieties were great at first,
because a large proportion of the patients transferred there at the opening of the
colony had been under certificate many years, and had been detained in asylums
under the usual restrictions (locked doors, etc.), whereas on arrival at the colony
they suddenly found themselves in villas whose doors were left unlocked till sun¬
set and whose gardens were without enclosure of any kind ; in truth the colony's
estate was enclosed by no more than ordinary country hedges, and its main gate,
except at night, may always be found wide open. As to its financial aspect—a very
important one from the ratepayers’ point of view—he felt sure Dr. Jones would be
glad to hear him say he thought he was wrong. It was a difficult point to state
clearly without being verbose, but it must be understood that it did not follow that
because a particular class of patients had a higher maintenance-rate than the rate
of an ordinary asylum embracing all classes, that those patients were really costing
the ratepayers more than they would had they been kept in the ordinary asylum.
It would be tedious, but it would be quite possible, to dissect out from any given
asylum the different costs of maintenance for its different classes of patients. It
would then be found that the epileptics were one of the most costly classes to main¬
tain, because of the necessarily constant supervision both by night as well as by
day. Male patients were considerably more costly to keep than females. Now,

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1908.] BY ALAN MCDOUGALL, M.D. 725

at the colony all the patients were epileptics and required constant supervision by
night; and further, the sexes were in the proportion of four males to one female,
while in the ordinary asylums there were rather more females than males. He could
multiply those examples, but they would suffice to show what he meant. In other
words, if the colony’s maintenance-rate were ever the same as that of the other
asylums, it would mean that, owing to its special features, its patients were being
maintained more cheaply than if they were housed in the ordinary asylum. There
were, indeed, encouraging indications that its rate might ultimately approximate
that. Great reductions in it were made while he was there, and under his successor,
Dr. Spark, he knew that very substantial further reductions had taken place.
There was no doubt that the number of patients at the colony could with advan¬
tage be increased, not indefinitely to an advantage, but still considerably. He did
not know how many suitable patients there were now in the other London asylums,
but if ever, by a change in the law, the colony could receive voluntary boarders, he
felt sure the demand on its accommodation would be very great. There was no
doubt as to the contentment of the colonists. He did not know that at a colony
they seriously missed a chapel. Epileptics were certainly very religious and they
attended the services with avidity; their religious needs were well catered for
by ministers of three denominations. The question of prevention in his opinion
was very much more important than the treatment, concerning which as regards
curative effects he was, in conjunction with others, somewhat pessimistic. But if
curative effects were aimed at surely the whole matter hinged on how early the case
was secured, and most of the cases were unfortunately obtained too late to permit
of a hope of cure. From the preventive aspect better results may be hoped for now
that medical inspection of all school-children was coming about. But he would
like to go a step further and to urge that the medical inspection should be done by
somebody who had had a training in medical psychology. The question of diet
had also been mentioned, and it surely was extremely important. He, when at the
colony, had tried the effect of a dietary as purin-free as possible, and apparently
with some beneficial results, but such observations ought to be continued for a
lengthy period before drawing conclusions.

Dr. Eden Paul expressed himself as having been particularly interested in what
Dr. Yellowlees had said about the connection between epilepsy and sexual
activity. The same appeared to apply to women. It was the familiar experience
in women whose fits were not usually frequent, perhaps not more than five or six a
month, that fits became frequent at the date of the sexual period. That seemed to
establish a relationship between the sexual activity and the occurrence of the fits.
He did not think an investigation on the matter had yet been made, but when
fifteen or twenty years ago the operation of oophorectomy was so frequently done,
when, indeed, it seemed to be a fashionable operation, it must have been done in a
considerable number of female epileptics ; and he thought it might be possible to
investigate those cases and find out whether it had any effect in causing cessation
of the fits. His view was that there was some connection between sexual activity
and the occurrence of the fits.

Dr. Orr said he was particularly interested in the paper, because if the subject
of epilepsy and its treatment was to be studied, the question was, What conditions
were the most suitable ? There were epileptics who were said not to be insane. He
asked whether Dr. McDougall had tried Ceni's treatment, which consisted in
administering to them their own serum or the serum of other epileptics.
Ceni’s essay was so good that it gained the prize of the Craig Colony in
America. He, Dr. Orr, was particularly struck with Ceni's results, and he
would be very glad to know whether they had been either confirmed or found
wanting. Had Dr. McDougall seen anything at his institution which would
indicate whether Ceni’s treatment was worth a trial or not ?

The President said the time had arrived for bringing the discussion to a close.
It had touched on many points, and epilepsy was a subject which had not often
come before the Association, though it was a very important one, and it might be
well to discuss it more. The association of epilepsy with activity of the sexual
function he regarded as undoubted, but it was seldom so conspicuous as in the case
which Dr. Yellowlees narrated. Less conspicuous instances one saw from time to
time. He had now under care an epileptic lady whose fits occurred at irregular
intervals, but always coincided with the practice of self-abuse. And, having been

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726 PRINCIPLES OF THE TREATMENT OF EPILEPSY. [Oct,

induced to give up that practice, the fits had now ceased entirely. A very impor¬
tant matter was the effect of the Workmen's Compensation Act upon epileptics.
There were very few measures which were unmitigatedly good or unmitigatedly
bad, and the Workmen's Compensation Act had borne extremely hard upon
epileptics. They could not now get any occupation at all, and no insurance com¬
pany would accept them. A very painful case came before him recently in the
person of a young journalist, who at intervals of nine months or a year had an
epileptic fit. As soon as the Workmen’s Compensation Act was passed his
remuneration did not rise to the maximum provided by the Act, and he was
discharged from his employment and had not been able to get any since. He was
surprised that those who had a large number of epileptics under their control had
not made more crucial experiments on the diet. To change the diet of the whole
institution at once did not seem best calculated to give the best results. If he were
at the institution he would change the diet of half the inmates, leaving that of the
other half untouched, then turn round and change the diet of the other half, mean¬
time reverting to the usual diet for the first half, and then seeing if any deductions
could be drawn. His own view was that diet played a very important part, not
only in epilepsy, but in paroxysmal neuroses, and in the treatment of the latter he
haa had a success which surprised him by alterations in diet. Fortunately, or
unfortunately, those dietetic modifications were not reducible to rule; one could
not say that one particular element in the diet was deleterious generally, but there
was a certain balance, differing for each individual, in the elements of food which
were best for that particular person. If such balance was disturbed that person
suffered in health in one direction or another, and the problem for the medical
man was to discover in each case in what respect the diet was wrong. But it
must be always borne in mind that what was the right diet for one person might be
wholly wrong for another. In many cases, especially of paroxysmal neuroses, he
regarded the diet as the most important element in the treatment.

Dr. McDougall, in reply, said Dr. Yellow lees had referred to a case in which
the man was castrated, and ceased to have fits from that time. But he, the
author, contended that the same result would have followed any other operation.
After any operation on any part of the body the fits might cease, and that fact now
seemed to be fairly well established. Trephining was sometimes done for epilepsy,
but he believed the same results on the fits would follow an operation on the toe,
but the diminution of the fits was good only for the time being. So that operations
on the brain furnished no scientific data. He was convinced of the truth of his
impression that, as a rule, epileptics had less sex feeling than had other people.
He did not say that without deliberation. He believed that was the reason
epileptics were such children; they could be easily led. It was usual with him
to give doses of bromide of potassium, 30 grains, at night, but not in all cases,
because in the case of many of the colonists he wanted them to have fits—he did
not try to stop them. He would rather that a patient had four fits a day and be
docile, than that he should have none and be a murderer. He maintained that as
long as our thoughts were concentrated on the major convulsion, there would not
be successful treatment of epileptics. The man should be treated, placed under the
best possible conditions, and then, being given a good chance, the fits might go away
of themselves. There was a school for the children at the colony, and many of them
were free from fits, though they might relapse at puberty. When cases were
obtained early they did very well at the colony. He did not diet patients
particularly. Much meat was not given, but animal food was served twice a day.
Whether the children had a fit, or sneezed, they did not create any excitement
At the colony good scientific results were obtained, but so they were at other
colonies in England and abroad, and there was no need for his colony to tabulate
the results particularly. He would turn out better results with his own patients
than were usual, although he might not add much scientific knowledge to the world.

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1908.]

MORPHINOMANIA AND INEBRIETY.

727

The Atropine Treatment of Morphinomania and In -
ebriety . ' By Mary S. P. Strangman, F.R.C.S.I.

I FEEL highly honoured in being invited to read a paper
before you this afternoon on my experience in the treatment
of morphia habit by the method published by Dr. McBride in
April, 1904.

You will recollect that he laid stress chiefly on the value of
this treatment in dealing with dypsomania, but he also men¬
tioned that it had proved of value in morphinomania.

The habitual use of morphia, as you are all aware, has effects
on the system, mental, moral, and physical, which cause grave
difficulties in treatment, especially in general practice.

The tonic and stimulating effect of the drug is greatly
missed on its withdrawal, and the patient will feel miserably
low in himself and collapsed.

The fortitude of the patients in bearing pain and mental
distress is so greatly reduced as in some cases to render it
impossible to treat them successfully in their own homes and
family surroundings.

The loss of the hypnotic effect of opium is also greatly missed
during treatment, and it becomes a matter of difficulty to procure
them sufficient refreshing sleep without resorting to chloral and
other drugs which would be dangerous to them.

The effect of opium on the alimentary system is well known,
the uncertain and capricious appetite forming a very consider¬
able hindrance to the maintenance of proper nutrition. Also
the excessive vomiting and diarrhoea which occur in many
cases when the drug is withdrawn tend to weaken the patient
considerably.

The unreliability of the statements of a morphia habitui in
the absence of trained surveillance is another very considerable
difficulty in general practice. Osier, in his Practice of Medicine ,
states : “ Persons addicted to morphia are inveterate liars and
no reliance whatever can be placed on their statements.” My
own impression has been that their deception is not always
intentional. Their imagination, especially when under the
influence of the drug, is very active and vivid, and afterwards,
like Tennyson's Prince, they find it impossible to distinguish the
substance from the shadow.

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728 MORPHINOMANIA AND INEBRIETY, [Oct.,

My first case was a man, aet. about 60, who had been taking
opium for thirty-two or thirty-three years. In the careless
confidence of early manhood he frequented an opium smoking
club in London. He found the drug to be such a stimulant
to his mentality that he used it systematically when he had
important business to transact. He took the drug in three
forms—by smoking, as a patent pill or hassheesh compound he
was introduced to in Paris, which had a rather different effect,
and in a draught as laudanum.

After about four years, finding that he had contracted opium
habit, he placed himself in a medical man’s hands. This
gentleman encouraged him to drink wine freely, but what
other treatment he employed I could not discover; the result,
however, was that he was able to abstain from the drug for
about a year, though the desire was never quite absent. He
then took to it again, and his history from this time on was
one of gradual and steady degradation, till at the time that he
came into my hands he was a hopeless wreck, mentally,
physically and socially.

His usual daily allowance at this time was about 4 oz. of
laudanum taken in two doses ; without it he felt intensely
irritable, restless and miserable, and found it almost impossible
to get sleep—his own statement was that he hardly got an
hour’s sleep in twenty-four, suffering from hallucinations of
sight and sound, imagining that bells were ringing, lights flash¬
ing, and people creeping up the stairs into his room and up to
his bedside.

His appearance was not typical: he was stout and somewhat
corpulent, florid complexion, and his pupils were well contracted,
though not to pin-points. His gait was shuffling and uncertain,
but not ataxic, intention tremors were present in writing and
other fine movements, and his memory frequently failed ; some¬
times in the middle of a sentence he would completely forget
what he was speaking of, also when writing and totting up
figures, and at first he could never remember one day what he
had done the previous day. When I first saw him he had been
for a fortnight without opium—not having the wherewithal to
obtain it; he t was intensely miserable and depressed, threatening
suicide, and said he had had no sleep at all for some days, he
was also complaining greatly of vertical headache suggestive of
great need of sleep.

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1908.] BY MARY S. P. STRANGMAN, F.R.C.S.I. 729

He was a man of very determined will, most anxious to
take every advantage of the medical assistance I could give
him, and must earlier in life have had a splendid physique and
mental powers of a high order, though now a wreck through
dissipation and hardship.

I want you clearly to understand that the only factors in the
treatment of this case were, the man’s own honest will to do
better, my own moral influence and encouragement, and the
administration of atropine and strychnine hypodermically ; what
the value of each might be I shall leave to your own judgment.

Up to the time of his decease in November, 1907, he lived
in miserable lodgings, scantily clothed and fed, often in physical
suffering and need.

I began treatment on April 20th, 1906, with atropine sul¬
phate gr. combined with strychnine fa gr. thrice daily, in¬
creasing as rapidly as I thought advisable, till on the eighth day
of treatment he received three doses of atropine ^gr. anc *
strychnine nitrate ^Vgr.

The effects produced by the treatment appeared unmistak¬
able. The hallucinations of sight and sound began to yield on
the first night and disappeared on the third. The headache
also was completely relieved, and he got some refreshing sleep.
On the fifth day he felt a distaste for alcohol, which he had
habitually taken to excess, felt a bit hopeful of ultimate
recovery, and showed some regard for his appearance and
dress ; in his disregard of these he had resembled the chronic
inebriate. On the fourth day he complained of nausea and
vomiting, and the next day of diarrhoea. These disturbances
of the alimentary system caused him much suffering as time
went on ; he often complained of being disturbed eighteen and
twenty times in a night, and of the vomiting being so violent
as to cause haemorrhage. I believe him to have been trust¬
worthy in these statements, his weight and girth diminished so
rapidly.

On the fourteenth day of treatment he volunteered the
information that all wish for opium seemed to have left him,
and I never after knew him to have any desire for it. Early
in June I began reducing the dosage of atropine, and stopped
its administration on June 20th. He was now putting up
weight again ; his memory, gait, and appearance had improved
greatly. He slept on an average four hours each night—he had

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730 M 0 RPHIN 0 MANIA AND INEBRIETY, [Oct.,

never been a long sleeper—was in good spirits, and showed
pride again in dress and appearance.

I kept on giving him strychnine in small doses for some
months, but this was mainly as an excuse to see him daily, as
I looked on his cure as complete.

In May, 1907, he was so much improved that he was able
to get work as an accountant, looked a different man as regards
both health and dress, and expressed himself perfectly free from
craving for either opium or alcohol.

During the summer his health began to give way seriously,
and in November he died from a pulmonary affection. For
some months before his decease he suffered greatly from the
effects of an old injury without ever desiring opium except as
he would any other means of relieving pain ; indeed, towards
the end when offered him he refused it.

My second case was almost the same age but of very different
character. He had devoted all his energies to business ; exer¬
cising his mental faculties to the utmost, he lived generously
and led a sedentary life. All through his life he bore pain
and mental trouble badly, being very impatient and of badly-
controlled, quickly-fired temper; he was therefore a very bad
type of patient.

Two years before coming to me, during an attack of proc¬
titis lasting some months, his medical attendant administered
morphia hypodermically. In three months, when his ailment
was practically well, he was having 2-grain doses of morphia,
and was unable to do without it. Finding in time that his
doctor’s bill was getting heavier than he cared for, he found
means of procuring the drug and syringes and began self¬
administration. His maximum dosage some time before
coming to me was, according to his own statement, 7 gr. in
one dose and 37 grains in twenty-four hours. Finding his
failing memory and increasing irritability were fast rendering
him unfit for business he tried to pull up, and his medical man
administered belladonna in mixture which enabled him to
reduce his dosage to 12 gr. daily, but he could not get below
this. When he came under my care he was taking usually 4 gr.
in two syringefuls three times a day—about 2 p.m., 8 p.m., and
6 a.m. You can imagine what his arms were like; I regret
that I did not photograph them.

He was more typical in appearance than the first case, in that

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1908.] BY MARY S. P. STRANGMAN, F.R.C.S.I.

731

he had become very sallow ; he was in no way emaciated, and
was somewhat corpulent. His pupils were moderately con¬
tracted soon after a dose, but dilated as the effect wore off. He
complained of great irritability of temper, fearful dreams or
nightmares, failing memory, appetite and strength.

This patient was comfortably housed and fed during treat¬
ment, and was devotedly nursed by his wife. Having nothing
to do and little means of amusement he became morbidly
introspective, in a great measure no doubt owing to his
particular temperament.

He was greatly afraid that I would withdraw his dosage of
morphia too suddenly. In order to gain his confidence I gave
him permission to continue administering it himself, only
stipulating that he should use the smallest amount that would
give him ease, and that he would let me know at each visit
exactly how much he had taken.

I began treating him on July 25th, 1907. As in the other
case, sleep became more restful and refreshing, and the terri¬
fying dreams were replaced by pleasant ones on the second or
third night. On the third day of treatment three 1 gr. doses
of morphia were sufficient to keep him comfortable.

On July 30th (fifth day) he received atropine gr. 3*3, strych¬
nine gr. ^ three times, and had got down to \ gr. doses of
morphia. He had now no actual desire for morphia, but a
sensation as of cords being drawn tightly over his body and
heart, which he believed would only be relieved by a dose of
morphia. For six days I kept him in bed altogether, but he
was now feeling so much better and stronger that on the
seventh I allowed him up in another room for awhile. He
remained at a standstill now for a few days, but on administer¬
ing four doses of atropine and strychnine daily he got down to
one dose of \ gr. morphia daily. On August 10th he was
well enough to take a short walk, and took no morphia in the
twenty-four hours. The next day, however, feeling tired and
run down, he took a £ gr. without its giving him any relief.
This was the last dose he gave himself until September 8th,
when, in a restless, despondent, nervous mood, he gave himself
another £ gr. dose, but again without doing him any good.
He was so imbued with the idea that opium for him was a
panacea for all ills that the temptation to fly to it whenever
he felt in any way out of sorts was very great indeed. This

LIV. 5 2

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time he felt so very like breaking down that I increased the
dosage of atropine to ^ gr. for a few days. This caused
about twenty minutes after administration a sensation of
giddiness, which lasted about ten minutes. It settled his nerves,
but reduced pulse tension more than I liked, and made him
feel weak and languid and nervous about himself. On the 14th
I began reducing the atropine, and I stopped it on September
23rd. He was now worrying so much about business matters
that much against my will I had to let him return home. He
assured me before his departure that he felt perfectly cured of
the habit, but I doubted his fortitude should he feel tempted.
I regret to state that I heard from him later on that he broke
down in about a month after his return. From first to last he
kept possession of his syringes and supply of morphia, though
I tried several times to induce him to hand them over to me;
he evidently had little confidence in himself.

Though this case was eventually a failure, I think you will
agree with me in thinking that it illustrates well the effect of
atropine as an antidote to opium. I cannot help thinking that
if he had had the advantages of a special home for such cases
and had consented to remain there for a few months till cure
was more firmly established he would now be in the list of
successes—not failures.

I got into correspondence with half a dozen other cases, all
of whom expressed more or less desire to be cured, but for one
reason or another they failed to come to me.

Amongst alcoholics I have had three successful cases by the
same method and two failures :

No. 1.—Had tried several cures, including hypnotism, which
benefited for about a year and a half. This case showed
aversion to alcohol in eight days and has remained perfectly
well for four years.

No. 2.—An old man, who had become a dypsomaniac after
middle age, had been drinking excessively up to the day he
came to me and was showing signs of delirium tremens ; he
got quite delirious after a couple of days, and had to be
removed to hospital. In ten days I began again, but in twelve
more he began drinking again and was hopeless for two months.
He then returned and permitted me to treat him for two
months. He has remained perfectly well to date, two and a
half years.

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1908 .] BY MARY S. P. STRANGMAN, F.R.C.S.I.

733

No. 3.—A woman, who had returned to prison forty-five
or fifty times for drunkenness and vagrancy, without crime,
with a reputation of never being able to pass a public house,
was brought to me direct from prison. In a week she was
trusted by herself with money to buy some clothes and
returned with the change, none the worse. She has been doing
well for the past couple of years.

Nos. 4 and 5.—A man and a woman were forced to come to
me against their wills. They drank daily in secret while
coming to me, neither persevered for a full course, and, as might
be expected, both proved complete failures.

This concludes my experience of Dr. McBride’s treatment.

Discussion,

At the Irish Divisional Meeting, at Waterford, on July and, 1908.

Dr. Dawson expressed appreciation of the paper. He had himself tried the
atropin treatment in ten cases of inebriety; two were still undergoing it, and in three
sufficient time had not elapsed since the treatment; but of five which had been
treated three years ago or over three remained well. Of the two failures one had
done well for some months, but had then met with a severe shock and relapsed,
and no subsequent courses of treatment with atropine had had any effect, though
the patient had now been well for over two years after a course of " Normyl” treat¬
ment. The other failure was in the case of a woman, who had remained well for
two or three months after the first course, but later courses had been useless. He
thought that suggestion had a good deal to do with the cures—witness the first
of the above-mentioned failures—and it should also be borne in mind that
strychnine alone had a favourable effect in some cases. He endorsed Dr. Strang-
man’s views as to the necessity for a wish to be cured on the part of the patient.

Dr. Strangman said that suggestion could have played no part in her first case,
as she told the patient that it was an experiment. She thought that atropine had
an effect apart from strychnine, and she had seen actual aversion to alcohol pro¬
duced by it.

Dr. Leeper thought it gratifying that the treatment of alcoholism was being
taken out of the hands of the quacks, but was of opinion that the results should be
received with caution—he had seen a patient “ cured ” five times. It would re¬
quire a long series of cases to convince him.

Dr. Eustace had tried the treatment in one case of morphinism, which had re¬
mained well for eight months and then relapsed. He had also tried it with several
cases of alcoholism, but all had relapsed sooner or later except one, of whom, how¬
ever, he did not expect much. He looked for better results from preventive
legislation.

Dr. James Fitzgerald congratulated Dr. Strangman on her courage and
successful results. He had visited one of the “cure ” institutions to see a patient,
and thought he got all the whiskey he wanted. He considered that the profession
should set its face against the connection of medical men with such places.

Dr. West thought harm was done by ill-considered prescribing of morphia
hypodermically, and instanced two cases.

Dr. Leeper said that what was really wanted was legislation to enable one to
get hold of cases and treat them compulsorily.

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734

CLINICAL NOTES AND CASES.

[Oct,

Clinical Notes and Cases.

Acute Furious Mania in Cerebro-spinal Meningitis .

By JAMES P. STURROCK, M.A.,M.D.Edin., Assistant Medical

Officer, Midlothian and Peebles Asylum.

DURING the recent epidemics of cerebro-spinal meningitis it
often occurred to me that the furious mania which frequently
ushers in or complicates the disease might lead to a case being
sent to an asylum under circumstances similar to those that
apply to the mental excitement in cases of enteric. As far as
I am aware the following is the first case of the kind reported,
and as it possesses interesting features in itself, apart from the
main issue, I report it fully.

A. A— was admitted certified as insane, having been in a condition
of furious mania for eighteen hours previously.

For four months prior to his admission he had been working as a pit
labourer and lived more or less constantly in the model lodging-house
of the nearest town. He was generally looked upon by his mates as a
little queer. For days he would speak to no one any more than he
could help; at times he was very irritable without cause, making
unreasonable demands and inroads upon the routine of the house, and,
as the proprietor said, “would fight with his own shadow.” Three
weeks before admission he went to Glasgow, residing in a district
which, it has since been ascertained, was the centre of an epidemic of
cerebro-spinal fever. He seemed to be more than usually restless and
irritable when he returned to stay for a few days. He went back to
Glasgow, but returned in two days and came to the lodging-house in
the evening very drunk. At 4 a.m. he was reported by some of the
men as being in a very excited condition, jumping out of bed, and
rushing wildly round the room ; it was thought to be delirium tremens.
The proprietor found him under the bed close to the wall, stiff, and
apparently unconscious, but clinging firmly to the leg of the bed. On
being touched he became very violent. His eyes were wide open and
fixed and he seemed dazed. He had copious diarrhoea for some time.
He had quiet intervals, but ultimately became bo very violent, kicking
and biting, that he had to be strapped down. Three powerful
labourers were employed to sit on his bed throughout the day, and it
gave them great trouble to control him. His struggles continued till
he fell back exhausted for some time, only to resume as furiously as ever.
He seemed to recognise no one and did not answer questions; at times
he swore furiously in an excited period, but even this was confused.
The proprietor was certain that the patient had no hallucinations of any
kind. He was seen in the course of the day by four medical men. The
presence of two cases of cerebro-spinal fever in the town suggested to

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CLINICAL NOTES AND CASES.

735

one of these the idea of that disease, but there were no symptoms, and
the patient became so unmanageable that he was certified and removed
here.

On admission he had quietened down into a semi-comatose state.
His pupils were widely dilated, but there was neither retraction nor
ptosis. The conjunctival reflex seemed diminished. His appearance
suggested enteric to me, and before taking him over this idea was
further supported by noting the following symptoms, a temperature of
ioi*2° F., thickly furred tongue, copious watery diarrhoea, very inter¬
mittent and slightly dicrotic pulse, and slight enlargement of the spleen.
There were no muscular symptoms whatever to suggest cerebro spinal
fever.

In view of these facts I had him isolated. His blood was at once
tested for the Widal reaction, but there was no agglutination. There
were no spots on his body. During the first day he was confused and
restless. At times he was able to talk a little, but his conversation was
confused and wandering. It could be gathered that he suffered from
pains all over his body and he became very irritable and excited when
the nursing necessitated his being moved. There was no resistance on
passive flexion of the limbs and this did not appear to increase the pain.
His knee-jerks were decreased. His legs were not rigid; he seemed to
have marked loss of power in them from the knee downwards. It was
noted that in spite of attention to them his legs were markedly colder
than any other part of his body and they were apparently very anaes¬
thetic. He refused to lie on his back, and it was gathered from him
that he could not move his legs at all unless he lay on one or the other
side.

On the afternoon of the second day he had severe epistaxis. The
same evening it was renewed, and on the third day he had bleeding at
frequent intervals. He passed urine in large quantities frequently,
although he did not take much fluid the first few days. From the third
till the sixth day he was very constipated.

An examination of his blood gave a leucocyte count of 6700. This
favoured the diagnosis of typhoid. Osier says : “ In cerebro-spinal fever
there is a leucocytosis which may help to diagnose it from typhoid.” A
second Widal test gave a negative result.

His mental condition was one of confusion without excitement till
the fourth day. On that day he became quite clear, and although he
remembered nothing since the day before admission, he could go back
in his history quite clearly. He stated that at the age of fifteen he had
been violently excited during an attack of pneumonia. His bodily
pains still continued, but he was less irritable. On the ninth day he
complained of stiffness in the back of his neck and lay with his head
slightly retracted. Kernig’s sign had been repeatedly tested for, but on
the eighth day for the first time was there any indication of it, and that
very slight. His condition did not vary till the evening of the eleventh
day, when he suddenly got out of bed and rushed out into the corridor
in a state of slight delirium. That evening his head was very painful.
His temperature, which for six days had been continuous, was now
markedly oscillatory. On the morning of the twelfth day the neck
rigidity suddenly increased, and in two hours he showed marked

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736

CLINICAL NOTES AND CASES.

[Oct.,

opisthotonos. A lumbar puncture was immediately done, io drachms of
fluid being withdrawn. The fluid flowed very freely and was very
slightly turbid. On examination it showed numerous polymorpho¬
nuclear cells and intra-cellular Gram-negative diplococci. The presence
of the meningococcus was afterwards confirmed in a sample of fluid at
the Laboratory of the College of Physicians. The patient experienced
immediate relief from the muscular pains, the opisthotonos disappeared,
and the temperature fell from 102° to 99 0 F. The pulse, which up to
this time had averaged about 76, rose to 98. About an hour after the
puncture he had distinct rigors. These were confined to the upper part
of the body and the arms : they lasted about a minute and recurred very
frequently for about three hours, after which they did not recur. The
temperature fell next day to normal, and though exhausted he was free
from pain or rigidity.

He was removed to the Fever Hospital, having a rise of temperature
after removal there, but only for a few hours, and six days after the
puncture his temperature was slightly subnormal and remained so. He
slowly recovered strength and is now back at work exhibiting his former
alternating irritable and dull moods. Repeated examinations of his
blood always showed a leucocyte count of under 7000. Repeated
Widal tests were negative.

It is probably certain that cases of delirium during the acute
infectious fevers occur in patients where there is evidence of a
neurotic diathesis. The stronger the predisposition the more
easily will even a mild attack of one of the fevers upset the
mental condition. This man’s predisposition, shown in his
circular attacks of moodiness and irritability, was also apparent
in his having had a mental attack during pneumonia as a
youth.

The difficulty of diagnosing between typhoid and cerebro¬
spinal fever, which made the case so interesting, was a secondary
matter compared with the questions involved in the reception
into an asylum of a case of a disease, which at the time was
causing such alarm in the public mind and regarding the
infectiousness of which so much was in doubt. It was fortunate
that the possibility of an infectious disease was suspected from
the first. The patient was looked after by two male nurses,
who had the supervision, feeding, etc., of about forty patients,
many in bed, and who were also coming in contact with people
outside and inside the Asylum. The usual precautions as
regards stools, urine, etc., were adopted from the moment he
arrived. From the third day the patient’s nose and throat
were regularly disinfected with Izal. The nurses were scrupu¬
lously careful, and latterly all the male staff who in any

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RECENT MEDICO-LEGAL CASES.

737

capacity visited the sick room were persuaded to disinfect their
throats and noses thrice daily. After the case was removed
the throats and noses of all the forty sick-room patients, and
any who had been assisting at meals, etc., were douched with
Izal every alternate day for over a week. The whole of the
clothing and furniture was burned, and the passages and room
disinfected under the supervision of the sanitary authorities.

On reflecting upon some of the acutely delirious cases with
high temperatures which I have seen in the past with typhoidal
appearances but no other symptoms than the raised tempera¬
ture and excitement, I wonder if any of these cases were
undiagnosed mild cerebro-spinal cases admitted at times when
the disease was not being heard of.

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.]

North-eastern Circuit.

The Oiley Murder.

At Leeds, on Saturday, July 18th, before Mr. Justice Bigham, James
Jefferson, 21, labourer, was indicted for the murder of Elizabeth Todd
at Otley on May 5th, 1908. Mr. Bruce Williamson and Mr. C. F.
Lowenthal prosecuted for the Director of Public Prosecutions; and
Mr. A. J. Lawrie represented the prisoner by request of the learned
Judge.

Dr. Edgerley, medical officer of the West Riding County Asylum,
and Dr. Exley were called to show that the prisoner was unfit to plead.
They said that he suffered from insane delusions which filled his mind
and largely impaired his faculty of attention. In answer to the Judge
they conceded that he was able to understand what he was charged
with and the effect of the pleas guilty and not guilty. They said that
his attention was certain to wander during the trial, owing to his pre¬
occupation with insane delusions. His attention at any time could only
be fixed by constantly addressing questions directly to him. Mr. Justice

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RECENT MEDICO-LEGAL CASES.

[Oct.,

Bigham warned the jury against assuming that because a man had
delusions he must be unfit to be tried. He would provide counsel to
look after the prisoner’s interests, and unless they thought that he could
not understand the proceedings on his trial he ought to be tried. The
jury found him fit to plead, and he was accordingly tried for the murder.
He pleaded “Guilty” at first, but at the suggestion of the Judge he
withdrew that plea and pleaded “ Not guilty.”

The facts were not in dispute, except upon the one issue as to the
prisoner’s state of mind. The murder was of an exceptionally horrible
character. The prisoner, a young man of 21 years of age, left New-
castle-on-Tyne on May 4th for Leeds, having just come out of prison,
where he had been serving a sentence under three convictions for arson.
On the following day he appears to have started to walk from Leeds to
Otley. On the way he must have met the murdered woman, Mrs.
Todd. She was 31 years of age, the wife of a shoemaker at Otley, and
she was walking along the Otley road to visit her mother. She was
seen a short distance from the scene of the murder about 4 o’clock.
At about 4.25 p.m. a grocer at Otley named Hellewell was driving
along the Otley road. He saw the prisoner bending over a naked body
by the side of the road; he had a knife in his hand, and had just cut
off the head. Hellewell asked the prisoner what he was doing. The
prisoner looked up and went on hacking the body. Hellewell went off
for help, and got two workmen to return with him. They went to
where Hellewell had left the prisoner with the body; they could not
see either for a moment, but found that he had got over the wall into
the field and taken the body of his victim with him. At this time he
was hacking at the arm of the dead woman, apparently trying to cut it
off. The three men shouted at him to put down the knife; he made
no reply, but on being threatened by one of the three men with a crow¬
bar he threw it down. Hellewell’s two companions then got over the
wall and seized him, and just before they did so he picked up the
woman’s umbrella, corsets, and hat. They made him get back over
the wall on to the road, and he then said, “ I can get 7 s. 6 d. for the
umbrella, 2 s. 6 d. for the corsets, and is. for the hat.” A policeman
then came up and formally took the prisoner into his custody, and
charged him with the murder. He replied, “ I do not know what made
me do it.” The prisoner was then conveyed to Otley, and on the way
he said to the policeman, “ I gave my own brother away. We broke
into a house and robbed a gas meter. I told the police of him, and he
got locked up. I have written to him, but I do not think he has for¬
given me yet.” When he got to the police-station he further said, “ I
do not know the woman. I met her on the road; she turned back
once and then came on again. I robbed her and cut her head off, and
threw her over the wail.”

For the defence it was contended that the prisoner was insane at the
time he committed the crime, and three medical men were called in
support of the contention, Dr. Edgerley, Dr. Exley, and Dr. Exley’s
assistant, Dr. Ellison. They said the prisoner suffered from insane
delusions. He imagined that his brother and other relatives were con¬
spiring together to murder him. He thought his brother was Charles
Peace, and would murder him. He imagined that while he was in

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RECENT MEDICO-LEGAL CASES.

739

Leeds Prison his brother looked through the window at him and
threatened him, though in fact his brother was a convict in Portland
Prison. He heard voices from time to time calling him “Thief” and
other terms of abuse. He thought that the policeman who arrested him
said as he took him to the station, “ Let us kill him now, and he won’t
feel it.” From these and a consideration of the circumstances of the
murder the medical men gave it as their opinion that he was insane.

In answer to the learned Judge, they agreed that he knew he was
killing the woman. But on the question whether he knew he was
doing wrong their answers differed. Dr. Edgerley said he thought that
the prisoner imagined that murdering the woman would be of some
advantage to him, by ridding him of a persecutor, and that this delusion
would probably be so strong in his mind that all idea of right and
wrong would be excluded. Dr. Exley said:—“I think he knew he
was doing wrong, but I think he had no idea how wrong.”

Mr. Justice Bigham directed the jury as follows on the question of
insanity:—If the prisoner knew that he was doing wrong, it does not
matter that he did not know how wrong. If he knew he was doing
wrong, it does not matter that he suffered from delusions or hallucina¬
tions. A man commonly described as a lunatic may be as guilty of
murder as any of you. You have to determine whether he knew he
was doing wrong. It is for the prisoner to satisfy you by his evidence
beyond all reasonable doubt.

A juror.—If there is any doubt, is he not entitled to the benefit of it ?

Mr. Justice Bigham.—No; it is the other way on. He must satisfy
you beyond all reasonable doubt that he did not know he was doing
wrong.

The juror.—If he knew he was doing wrong, but was insane, how
then ?

Mr. Justice Bigham.—If he knew he was doing wrong it does not
matter how insane he was, he is guilty.

The jury, after a retirement of an hour and a half, found the prisoner
Guilty , and he was sentenced to death.— Times , July 20th, 1908.

It is not often nowadays that the formula of the knowledge
of right and wrong is applied with such rigorous strictness of
interpretation as it was by Mr. Justice Bigham in this case.
The circumstances of the murder are alone enough to raise a
strong presumption of insanity in the prisoner at the time of
the crime, and it was not contested that he was insane at the
time of the trial. Yet he was convicted and sentenced.

It is interesting to compare the criterion of responsibility in
this case with the criterion of competence in the case of a tes¬
tamentary disposition or a contract. Either of the latter is
vitiated by the existence of a delusion ad hoc , that is to say a
delusion of such a character as to influence the testator or
contractor in the making of the will or the contract. Here

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RECENT MEDICO-LEGAL CASES.

[Oct,

the evidence of Dr. Edgerley was that the prisoner in committing
the murder was influenced by his delusion. It was a delusion
ad hoc. Yet the prisoner was held responsible. The evidence
of Dr. Exley was particularly interesting. He testified that
the prisoner knew he was doing wrong, but had no idea how
wrong. The judge brushed this consideration on one side, and
said it did not matter that the prisoner did not know how
wrong the act was. In thus ruling, he went counter to the
opinion of his very eminent predecessor, Mr. Justice Stephen,
who attached great importance to the existence of full know¬
ledge on the part of the prisoner.

It is not for me to bandy arguments on points of law with a
judge, but it is certain that very many prisoners have been
found “ guilty but insane ” on much less cogent evidence of
insanity than was adduced in this case ; and it is something of
a shock to us, accustomed as we now are to the liberal, and
what seems to us the enlightened, interpretation given to the
old formula by so many judges, to find that there is still a
judge on the bench capable of interpreting it in its narrowest
and most literal sense. There is, of course, not the slightest
chance of the sentence of death being carried out, and the only
difference that the verdict makes to the prisoner is that he has
had the death sentence, which he probably did not appreciate,
pronounced upon him, before being remitted to Broadmoor,
instead of being sent there without this preliminary*. The
sentencing of acknowledged lunatics to death is becoming less
and less frequent as time goes on, and such a case as this will
be regarded in a few more years in the same light as the public
now regards the sentencing to death of children for stealing
property of the value of forty shillings.

The true moral to be drawn from the case is the unsatis¬
factoriness of the arrangement by which a judge is taken from
a Commercial Court, in which he has gained distinction, to try
criminal cases of which he has had no experience. As long as
this is done miscarriages of justice will occur.

Rex v. James Jefferson (Appeal allowed).

This was an appeal against a conviction for rrturder. The prisoner
was tried at Leeds Assizes for the murder of a woman in circumstances

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of great atrocity, and the proceedings there were reported in The Times
for July 20th last.

Mr. Lawrie appeared on behalf of the appellant; and Mr. Bruce
Williamson and Mr. Lowenthal appeared for the Crown.

Mr. Lawrie, in opening the appeal, said the prisoner had been
through two separate trials at Leeds. The only defence set up being
insanity, there was first an inquiry as to whether he was fit to plead,
and then there was the trial on the main charge. He now appealed on
the ground that, on the medical evidence given at the preliminary
inquiry, the prisoner ought not to have been tried on the main charge
at all.

Mr. Justice Darling.—The Act only gives leave to appeal against a
“conviction”; how can you say that a finding that a prisoner is fit to
plead is a conviction ?

Mr. Lawrie.—I must withdraw the appeal against the finding that
the prisoner was fit to plead, and will confine myself to appealing
against the subsequent conviction.

Mr. Justice Darling.—I want to make that clear as a ruling of this
Court.

Mr. Lawrie then submitted that the Court, on the medical evidence,
ought to find that the prisoner was insane, and order him to be kept in
custody as a criminal lunatic under Section 5 (4) of the Criminal
Appeal Act.

At the conclusion of Mr. Lawrie’s argument,

Mr. Justice Lawrance asked Mr. Bruce Williamson if he was going to
argue that the prisoner, having been found to be sane by the jury, was
in fact sane.

Mr. Williamson said he thought it was his duty to call attention to
the evidence so far as it supported the verdict of the jury: but, having
regard to the very peculiar circumstances attaching to the commission
of the crime and the conduct of the prisoner at the time, he could not
suggest that there was not a serious question to be determined as to
whether this man had a sane mind when he committed this horrible
murder.

Mr. Justice Darling.—It was proved that he cut off the woman’s head
in the presence of witnesses and made no attempt to escape, and also
that he took certain articles of clothing not worth sixpence and brought
them away with him. Some of the doctors at the trial said he was
insane even then.

Mr. Justice Lawrance.—No one here suggests that there was no
evidence to go to the jury. The question is whether their finding was
satisfactory, having regard to all the facts of the case.

Mr. Bruce Williamson.—Having regard to all the facts, we cannot
say that the finding of the jury was satisfactory.

Mr. Justice Lawrance, in giving judgment, said that there was no
doubt that the verdict given was unsatisfactory, and in his judgment it
ought not to stand. He had read the evidence given by the doctors,
and it appeared that there was strong evidence called before the jury
which showed that this man was not in such a state of mind as to make
him responsible for his act. The verdict given being unsatisfactory, he
thought they ought to say that the verdict which the jury should have

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RECENT MEDICO-LEGAL CASES.

[Oct,

returned was that the man was insane when he committed the act. He
hoped the case was not one of those in which the jury returned the
verdict they found because they knew that there was a Court of Appeal
behind them to which recourse might be had. The verdict would be
set aside, and the order would be that the prisoner should be detained
as a criminal lunatic during his Majesty’s pleasure — Ttmcs % July 31st,
1908.

The Court of Criminal Appeal took the only possible course
open to it, but, if it had not existed, the same practical result
would have ensued. Even counsel for the prosecution ad¬
mitted that the finding of the jury was unsatisfactory.
Whether the procedure of the Court of Appeal is on the
whole better than the intervention of the Secretary of State,
must be a matter of opinion. In such a case as this, in which
the miscarriage of justice at the trial was open and palpable,
there is probably not much difference between the two; it is in
cases where the evidence is more evenly balanced that the
difference will come into view. The Court of Appeal, though
less bound by rules than the Assize Court, will not have the
wide discretion in admitting evidence that inheres in the
Secretary of State, but the publicity of proceedings in the
Court will probably be more satisfactory to the public. We
shall watch future cases with much interest.

The inability of the Court of Appeal to review the finding of
the jury in the issue of fitness to plead is of interest, but
perhaps not of much practical value.

Mr. Justice Lawrance said : “ The verdict being unsatisfactory,
he thought they ought to say that the verdict which the jury
should have returned was that the man was insane when he
committed the act.” But this was precisely the verdict which
the jury evidently wished to return, and would have returned
if they had not been forbidden by Mr. Justice Bigham. If the
report is correct, the judgment is very important, for judges
are bound by the deliverances of the Court of Appeal, and in
future it will not be necessary to prove knowledge of right and
wrong, but only insanity of the prisoner at the time of com¬
mitting the crime, in order to secure a verdict of guilty but
insane.

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743

Occasional Notes.

The Annual Meeting.

The Annual Meeting has again demonstrated the steady
increase in the work and organisation of the Medico-Psycho¬
logical Association. To the members who can recall the
meetings of thirty years ago the contrast is indeed striking,
although even at that period the output of energy was great in
comparison with the small numbers of the Association and the
greater difficulties in attending the meetings.

The connection between the present and the past of the
Association was pleasantly and vividly brought to remembrance
by the presentation to the meeting of an album containing the
portraits and autographs of all the past Presidents and Chair¬
men of the Association, to which special allusion is made on
another page.

The address by Dr. Mercier is worthy of the reputation of
the President, and no higher praise or expression of admiration
is necessary. The reputation of the Association is distinctly
enhanced by such a brilliant contribution to its literature.

The work of the meeting extended over three days. The
various Committees dealt with a large number of matters of
great interest, not only to the insane and the Association, but
also to the public. The examination and registration of nurses
and the education of medical men in mental diseases are the
more prominent of these.

In the papers read at the meeting a question of great prac¬
tical interest, “ The Boarding Out of the Insane/’ was raised
by Dr. R. C. Brown. The discussion, however, was postponed
until a later meeting, and the desirability of any action on the
part of the Association will then have to be decided.

The case against dementia praecox, stated by Dr. Robert
Jones, was a very bright challenge to the supporters of this
debated form of insanity, and met with a very ready response.

The battle was, however, not fought out, but also adjourned.
The further discussion, whether at a meeting or in the pages of
the Journal, should be productive of valuable criticism and of
all possible evidence in favour of this alleged form of disease.

Owing to the delay in the issue of the Royal Commission on

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OCCASIONAL NOTES.

744

[Oct,

the Care and Control of the Feeble-minded, Dr. Donkin’s account
of this work could not be communicated.

Lady Henry Somerset’s address on the treatment of inebriates
constituted one of the most striking and valuable communica¬
tions of the meeting. Her practical, common-sense views,
evidencing extensive experience, were stated in a clear, syste¬
matic method that excited general approbation and admiration.

The Annual Dinner was also characteristic of the pro¬
gressive tendency of alienists, and will stand on record as
the first at which ladies who were neither members of the
profession nor of the Association were invited to attend.

The Album of Presidents .

The presentation of an album, containing the portraits of all
the Presidents of the Association, by Dr. Outterson Wood was
a memorable feature of the annual meeting. Following on Dr.
Hack Tuke's sketch of the history of the Association, Dr. Outter¬
son Wood rescued from oblivion the names and dates of our
official members, and the list has been carefully published
every year in the journal. It therefore seemed fitting that
this work should be supplemented by preserving the portraits
of those who have passed the presidential chair. The collection
and arrangement of these has occupied two years; and, contrary
to the most sanguine expectation, the Association has now in
keeping a complete pictorial record from 1841 till 1908 in¬
clusive. This is contained in a handsome book, the preface
of which is reproduced from Conolly’s writings in retirement, a
beautiful and touching account of his later experience of life,
near to Hanwell, full of interest in that great hospital, and,
indeed, in all the asylums of the country. “ When my thoughts
are transferred to nearly forty public institutions for the insane
.... I find a reward for any share I have had in promot¬
ing these things beyond my deserving.”

Following on the preface is the portrait of Dr. Blake, of
Nottingham, chairman in 1841. The others follow in regular
succession. In a panel below each portrait the name and
designation and date of each are clearly given, together with
an extract from his presidental address characteristic of the
address, and an autograph signature. The completeness with

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1908.]

OCCASIONAL NOTES.

745

which the work has been carried out is gratifying, not only to
Dr. Outterson Wood and Dr. Urquhart, with whom he was
associated, but also to the members of the Association gener¬
ally. Much interest was displayed in the album at the Society’s
rooms and also in the ante-room before the annual dinner.
The finely-bound album in purple morocco, displaying the
stamp of the Association, was the work of Mr. John Macgregor,
of Perth, who was deservedly complimented upon his share of
the undertaking.

One cannot turn over the leaves of this album without
awakening a host of kindly and interesting memories. We
have still a link of personal association with Dr. de Vitrfe, of
Lancaster (1842), in Dr. Clouston, who met him during his
service in the Cumberland Asylum. Dr. Thurnam, whose work
in statistics and craniology is still important, is dated 1844
and 1855, having been Chairman and President. By an odd
chance, favoured by the veteran Dr. Brushfield, the silhouette
of Dr. Wintle, of Oxford (1847), was obtained for representa¬
tion. His son, the Rev. F. F. W. Wintle, of Bere Ferrers, Devon,
unfortunately felt unable to be present at the annual meeting,
but he wrote an interesting letter of reminiscences, stating that
Dr. Wintle died at his post; after which bereavement he himself
was appointed secretary to the Warneford, proceeded to medical
studies, and eventually became a clergyman in 1859. Dr.
Wintle died in 1853, leaving five sons and a daughter. In
the Commissioner’s Report of 1847 may be found Dr. Wintle's
remarks on the value of opium in mental disorders, and on his
opposition to blood-letting. He also advocated the use of
creasote. His long service of twenty-six years in the Warne¬
ford was the subject of an appreciation by the Committee, in
which they testified to his devotion, benevolence, and careful
supervision.

We might pursue these biographical details at great length—
indeed, they form part of the history of psychiatry in all their
relations ; and it is to be hoped that an adequate account
of the men who founded and built up the Association will yet
be forthcoming. Conolly’s name is prominent in our records.
Forbes Winslow, Sir Charles Hastings and Sir John Bucknill’s
development of medical organisations is a tempting subject, but
the mere mention of them gives us pause. The materials for a
biography of Sir John Bucknill are in existence and must be

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746

OCCASIONAL NOTES.

[Oct.,

full of interest—we recall him as the first editor of this journal,
as physician to the Devon Asylum, as Lord Chancellors
visitor, but his circle of influence was far wider than the
specialty, and tardy honours were paid to him who conceived
the idea of the Volunteers and gave impetus to his conception
by starting the 1st Battalion of the Devon regiment in 1852.

A glance at the list of Presidents warns us to desist from
these brief notes. The honourable roll is complete, and we
have now a presentation of them as they lived. We would
welcome personal and literary reminiscences of them from
those who know.

Scientific Research Work in Asylums .

The Commissioners in Lunacy, in the supplement to their
report for 1908, have added an account of the clinical and
pathological investigations carried on in asylums and asylum
laboratories.

During the year under review the summary of work thus
recorded proves that an important amount of original investiga¬
tion of a very high character has been produced from these
sources, and is an evidence of the considerable proportion of
scientific workers in the specialty.

This new departure will act as a much-needed stimulus to the
progress of scientific work in asylums, the results of which
will, without doubt, appear in the summaries of succeeding
years. The Commissioners in Lunacy are to be congratulated
on having adopted a procedure which will certainly produce
very beneficial results.

The benefit, however, will not only consist in an added
impetus to scientific investigation, but will strengthen the
standing of the Lunacy Commission both in professional and
popular estimation. Recent Royal Commissions have demon¬
strated how much valuable information can be obtained on any
given subject in a comparatively short period, and the public
will expect that a permanent Commission should yield still
more important results.

The Lunacy Commission in the past, mainly by reason of
its numerical inadequacy to the work thrown upon it, has been
too much limited in its inquiries to the mere care and custody.

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747

the bricks and mortar, bread and butter, water and drain
aspects of insanity. These are of great importance and of
absolute necessity in dealing with the evil results of our faulty
civilisation, but there are larger and more important areas of
work beyond these.

Modern benevolence, however, while not neglecting the end
products of our social errors, is turning its attention more and
more to their prevention. The Lunacy Commission will, no doubt,
not be content to stimulate the study of disease from the point
of view of treatment, but will doubtlessly also urge an inquiry
into the actual modes of production of insanity. To this end a
much more thorough investigation of causation is absolutely
necessary, in order to instruct the public in regard to the
means necessary for the reduction of the mass of insanity
which constitutes so great a blot on our civilisation. The
teaching of the means necessary for the prevention of insanity
should indeed constitute an important, if not primary aim, of
the Commission, and we hail with satisfaction the evidence in
the present report that scientific research in future will not be
without official recognition and encouragement.

Report of the Commission on the Care and Control of the
Feeble-minded .

The report of the Royal Commission, which was appointed
in 1904, has at last been issued, after a laborious and volu¬
minous investigation. The Minutes of Evidence will soon be
given to the public, vols. i and ii relating to England and
Wales, vol. iii relating to Scotland and Ireland, on the original
reference, vol. iv relating to England on the extended refer¬
ence, vol. v appendix papers, vol. vi on medical investiga¬
tions, and vol. vii on the visit of certain commissioners to
America.

The original reference to the Commission was :

“To consider the existing methods of dealing with idiots and
epileptics, and with imbecile, feeble-minded, or defective
persons not certified under the Lunacy Laws ; and, in view of
the hardship or danger resulting to such persons and the com¬
munity from insufficient provision for their care, training and
control, to report as to the amendments in the law or other
LIV. S3

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748

OCCASIONAL NOTES.

[Oct,

measures which should be adopted in the matter, due regard
being had to the expense involved in any such proposals and
to the best means of securing economy therein.”

The following classes of persons were considered :

(i) Idiots, certified and uncertified; (2) epileptics, certified
and uncertified; (3) Imbecile, feeble-minded or defective
persons not certified under the Lunacy Acts.

In November, 1906, there was a further direction :

“To inquire into the constitution, jurisdiction, and working
of the Commission in Lunacy and of other lunacy authorities
in England and Wales, and into the expediency of amending
the same or adopting some other system of supervising the
care of lunatics and mental defectives ; and to report as to any
amendments in the law which should, in their opinion, be
adopted.”

The Commissioners, therefore, proceeded to inquire into the
working of the Central Authorities in England and Wales—
The Lunacy Commission, the Judge and Masters in Lunacy,
and the Lord Chancellor's Visitors in Lunacy. The Report is
signed by all the Commissioners, under the Chairmanship of the
Earl of Radnor. Certain of their number sign under reserva¬
tions and explain their opinions.

Representatives of all classes interested who could assist the
Commissioners by information were examined to the number
of 248. Visits were made to institutions at home and abroad.
The result of this searching inquiry is too widespread and
important to be dealt with fully on this occasion. We would
desire, however, to notice a few of the out-standing recommen¬
dations pending a more thorough examination of this important
Report, and its Appendices.

First of all the Commissioners obtained a report upon the
number of mentally-defective persons to be dealt with, from in¬
vestigations in sixteen typical districts. These may be stated
at 149,628 in England and Wales, or *46 per cent, apart from
the certified insane. It is further estimated that 44*45 per cent.
of these are urgently in need of provision in their own interest
or for the public safety. The total number of mentally-
defective persons, including the certified insane, is, therefore,
271,607, or *83 per cent, of the population.

The Commissioners are compelled to the conclusion that
there is much neglect to the injury of the defective persons

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OCCASIONAL NOTES.

749

themselves and to others, and expenditure wasteful to the com¬
munity. The evidence suggests to them that a settled plan of
action should be established between the existing agencies under
one supervising authority, to ensure permanent care.

Generally, that the mentally defective should have suitable
State protection ; that the ground for such protection is the
mental condition ; that they should be brought into relation
with the local authority ; that care should be continuous so
long as necessary ; that a central authority is required ; that
the property of the mentally defective should be uniformly
protected; that there should be the closest co-operation
between judicial and administrative authorities.

The case for legislation would appear to be strong, and it
must be considered with the Report of the Royal Commission
on the Poor Law and the Departmental Committee on the
Inebriates Acts, both of which are expected to be made public
in the course of this autumn.

The Commissioners find no difference in regard to London
which would lead to a different scheme from that which they
have recommended for England generally.

As regards mentally defective children it would appear that
5*9 per cent . of the total number on the school register require
more suitable provision than at present exists. The Com¬
missioners advise co-operation between the authorities for a
better administration of idiot asylums, and urge that great
changes should be made in law and procedure affecting the
mentally defective in relation with crime, and record their
finding that from 60 to 70 per cent . of drunkards dealt with
under the Inebriates Acts are mentally defective. They
recommend that these persons should be specially provided for.

The Commissioners conclude that all cases of epilepsy should
be provided for by the authorities which they have indicated—
on the ground that the relation of epilepsy with mental defect
is so close.

Recognising the connection between heredity and mental
defect, the Report states that if the mentally defective were
prevented from becoming parents, there would be a diminution
of such persons, but that if surgical or artificial measures to
that end were proposed in legislation, such a course would be
rightly condemned.

The Commissioners discuss the methods by which chronic

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REVIEWS.

[Oct,

and harmless patients can be provided for, setting free
asylum accommodation for the more acute cases : (I) Separate
hospitals ; (2) family colonies ; (3) boarding-out as in Scotland ;
(4) large farm colonies. They also approve of the establish¬
ment of reception wards and the adoption of a temporary
certificate for unconfirmed cases. The Commissioners suggest
that the words lunatic and asylum should be discontinued,
that the persons affected should be considered as persons of
unsound mind, as mentally defective or mentally infirm, and
that asylums should be referred to as hospitals.

Finally, theyestimate the cost of their proposals at £1,175,802
for England and Wales, an increase of the present annual cost
of ^541,492, all of which will not probably be borne by the
public ; and they advise the discontinuation of the 4^. grant

These are far reaching and important proposals which can¬
not be lightly adopted. The cost is enormous and can only
be justified on the ground of necessity. No doubt the Com¬
missioners present a strong case, and it is to be hoped that
certain urgent measures will be adopted soon. It is evident
that the Poor Law will require a drastic revision, and that
we ought to come into line with other countries in dealing
with vagrants, and the unemployed, and the unemployable.
It is certain that inebriates should be more stringently dealt
with. How these great and vital questions are to be con¬
solidated and solved can certainly not be indicated in the
space of this brief note, which is rather meant to inform than
to criticise.

Part II—Reviews.

The Psychology of Alcoholism . By George B. Cutten, B.D.,

Ph.D.Yale. London : The Walter Scott Publishing Co., Ltd.,
1907. 8vo. Price 5*.

Dr. Cutten, from the psychological and religious point of view,
has made this study of alcoholism, which is mainly a rcsum/ of
recent work on the subject. He directs his attention in the first
place towards the alcoholic disturbances of emotional life, of moral,
artistic, and religious sentiments, towards the relief of drunkards by
psychological methods, which he believes to be most appropriate

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and efficacious. The book is the outcome of Dr. Cutten’s theses for
the degrees of Ph.D. and B.D., studies which have been enlarged
for the present-purpose. After an introductory chapter he enters on
a consideration of physiological psychology, illustrated by various
drawings culled from well-known treatises and formulated from
authors whose opinions on the destructive nature of alcohol are
more or less pronounced. The same plan of extensive quotation has
been pursued relative to memory, intellect, will, the emotions and the
senses. It is hardly necessary to follow Dr. Cutten on these familiar
lines. The eighth chapter deals with the psychological aspect of
morals, discussing the question of responsibility. The author enters
into a consideration of physical conditions affecting conduct, and passes
to the effects of mental deterioration, which he has previously estab¬
lished. His conclusion is that an alcoholic person is not responsible,
because his memory is contracted, his will is gone, his emotions are
limited, and his moral nature is warped or destroyed. Further, he
inquires if that person is responsible for becoming alcoholic, and,
having made allowance for hereditary influences, affirms that some
degree of responsibility does exist. A chapter on the relation of
insanity and alcoholism deals with familiar observations and need not
detain us.

That section of the book which points to religious conversion as
a cure emphasises the efficacy of changed associations and the
emotional substitute. Dr. Cutten’s investigations and experience induce
him to believe that religious conversion is the most efficacious cure of
alcoholism. Hypnotism he regards as merely a help to a patient, for
the environment remains unchanged, and there are two conditions of
success not always obtainable—co-operation on the part of the subject
and a hypnotisabie person with which (sic) to deal.

Dr. Cutten’s book is chiefly useful as a fairly well indexed collection
of extracts and references, some of which are authoritative, while others
are of doubtful validity. Professor Trumbull Ladd, in a short preface,
vouches for the indubitable facts of Dr. Cutten’s experience, but
our melancholy impressions lead us to doubt the statements of those
unfortunate alcoholics, whether we appeal to Philip drunk or Philip
sober.

Hypnotism , or Suggestion and Psychotherapy . By Dr.(Med.) August

Forel, formerly Professor of Psychiatry and Director of the
Asylum at Zurich. Translated from the fifth German edition by
H. W. Armit, M.R.C.S., L.R.C.P. London : Rebman, Limited,
1906. 8vo. Price 7 s. 6 d. net.

It is unnecessary to review Professor Forel’s well-known and highly
appreciated treatise. It is convenient in its present form, and will
introduce a philosophical and practical work to a still wider circle of
readers. The fifth edition appeared in 1905, sixteen years after the
first, which represented two years’ experience in the practice of
hypnotism. Semon’s theory of the mneme finds place in the present
edition, that is, the memory as a general law of organic life, and

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Darwin’s recent address further awakens an interest in this subject It
is strange that Dr. Charles Creighton’s work on Unconscious Memory in
Disease has attracted so little attention on the part of those who have
recognised the value of Semon’s interpretation. The opening chapter
on “ Consciousness” forms a most interesting resumi of Professor Forel’s
position, and his mastery of the subject, which occupies most of the
work, is evident on every page.

When we turn to that part dealing with insanity we find it broadly
stated that of all people the insane are the least suggestible, and those
whose mental disturbances are severe are usually absolutely unsug-
gestible. Those suggestions which are directed against delusions act
least of all. As an opponent of the Charcot school, Forel states
emphatically that suggestibility is an absolutely normal characteristic of
the normal human brain. This is in accordance with common experience
—a sane man may be persuaded of his error, but argument is useless
with the insane. Indeed, Forel says that attempts to hypnotise delu¬
sional patients only supplies them with material for delusions. This is
in agreement with the general results observed by those of our colleagues
in this country who have used hypnotism in asylum practice. The
chapter dealing with the forensic danger of hypnotism should have the
most careful study. The restrained, balanced judgment of Professor
Forel is evident throughout his discussion of these real perils. We
commend the book as a credit to the translator and publishers, who
have done good service in producing it.

Psychology. By C. H. Judd. New York : Charles Scribner’s Sons,

1 9 ° 7 -

This volume forms the first of a series of text-books designed to
introduce the student to the methods and principles of scientific
psychology. The second volume of the series, dealing with experi¬
mental psychology, has already appeared.

The author adopts the functional as opposed to the structural or
analytical method of treatment. This point of view, of course, forms
the keynote of one of the most virile schools of modern psycholog)’,
which has done much to bring the science more into touch with life and
reality.

Wherever possible genetic considerations are also taken into account,
and a considerable space is devoted to the physiological correlates of
mind. But the physical, physiological, and psychological are generally
sharply distinguished from one another, and there is but little of that
confusing mixture which one is accustomed to encounter in elementary
text-books.

Space and time are regarded as functional relations between sensa¬
tions. A similar view is adopted concerning the affective aspects of the
mind. “ Feelings are unique phases of experience which depend for
their character upon the congruity or incongruity of the different active
tendencies of any given moment; they are attitudes, never to be confused
with contents.”

The chapter on “ Forms of Dissociation ” is naturally that of most

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753

interest to the alienist, but as the treatment is necessarily sketchy this
part of the book is not very clear or illuminating.

The final chapter deals with the applications of psychology, and con¬
tains much that is suggestive and stimulating.

The book constitutes, on the whole, an excellent presentation of the
general point of view of modern psychology. But owing to the rapid
development of the experimental method the science is inevitably a
good deal in advance of its text-books. Hence we cannot help noticing
certain defects in the present volume. For example, there is no mention
of the researches of Marbe and Biihler on the thought processes, or of
Jung’s work on associations, which are of such importance as to practi¬
cally revolutionise many of the older theories. The immense influence
of the affective side of the mind is only beginning to be recognised,
although it is in this sphere that the alienist may reasonably hope for
assistance from the psychology of the future. Such defects are, how¬
ever, inevitable in a general work dealing with a progressive science,
and cannot in any way be regarded as a reproach.

Bernard Hart.

Psycho-therapy [Zur Psychologic und Therapie Neurotischer Symptome\
By A. Muthmann. Halle a. S : Carl Marhold, 1907.

This work presents the results attained by the application of Freud’s
methods to certain cases in the B&le Clinic.

The preliminary chapters give a resume of Freud’s general principles
and methods. This is followed by certain theoretical considerations con¬
cerning the role of the sexuality in the genesis of the psychoses. The
remainder of the book is occupied by an analysis of several illustrative
cases.

In the process of psycho-analysis Muthmann makes use of hypnosis,
a method which Freud himself no longer employs. The author does
not consider that the objections thereto are altogether sound, and points
out that hypnotism has the advantage of greatly reducing the time
expended on the treatment. Freud estimates that the analysis of
difficult cases requires from six months to three years.

Muthmann refers to Jung’s association experiments, but does not
employ them in his own cases, although it would appear that the
technical difficulties of psycho-analysis may be thereby greatly reduced.

The book is, on the whole, clearly written and easy to understand,
and may be confidently recommended as an excellent introduction to
the subject with which it deals. Bernard Hart.

Jahrlmch fur Sexuelle Zwischenstufen. Edited by Dr. Magnus Hirsch-
feld. Vol. ix. Pp. 664, 8vo. Leipzig: Spohr, 1908. Price
12 m.

This year-book was founded nine years ago for the publication of
studies dealing with the intermediate stages of sexuality, more especially
homosexuality, from the anatomical, physiological, psychological,
historical and social points of view. The large volumes which have

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754

REVIEWS.

[Oct,

ever since been issued year by year have contained contributions, some¬
times by well-known physicians and scholars, which, although they have
now and then betrayed an unduly enthusiastic or eccentric enthusiasm
for the subject discussed, yet, on the whole, reach a high scientific level
and at the same time display extraordinary variety and interest The
Jahrbuck for last year contained, for example, among other monographs,
a lengthy essay on “ The Nature of Love,” by Dr. Hirschfeld, a paper
on the homo-sexual figures in Dante, a long historical sketch of the
history of sexual inversion in the Netherlands by Dr. Van Romer,
psychological studies of Madame Blavatsky and the Emperor Hadrian,
and a psychiatric discussion by Dr. Nacke.

The present issue is not less fresh and varied, though it opens,
indeed, with a contribution to an endless source of discussion in
Germany—the question of removing from the German code the para¬
graph making any homo-sexual act per se a criminal offence. The author,
Dr. Numa Praetorius, a lawyer, wishes to bring the German law into
line with that of Holland and the Latin countries as regards this matter.
Dr. Alfred Kind follows with a paper of more medical character on homo¬
sexuality as complicated by sadism, masochism, or some form of feti-
chism, bringing forward several cases from among one hundred which
he has obtained of such complication. Next comes a study, of entirely
different character, on the painter Sodoma; the writer, Elisar von
Kupffer, evidently possesses a full knowledge of his subject, though his
judgments are sometimes a little uncritical, and his article, which extends
to one hundred pages, is valuable, if only for the numerous well-produced
illustrations of the works of a master by no means easy to see even in
Italy. Sophie Hoechstetter follows with a paper on the early life of
Queen Christina of Sweden. There is little original research here, but
the main facts and probabilities are brought together and the con¬
clusion reached that Christina, though by her sexual functions a woman,
was of “bisexual” organisation with predominantly homo-sexual attrac¬
tions, the sexual life being, however, mainly transformed into psychic
activity and here chiefly revealing its bisexuality.

Two papers deal with homo sexuality in Greece. In the first Kiefer
discusses Socrates, concluding that he was of bisexual constitution, but
that, owing to his strong intellectual and ethical tendencies, sexual impulses
had in him undergone a spiritual transformation. The second is a
lengthy and methodical study of the homo-sexual poems in the Greek
Anthology. To the same group may be said to belong a short paper
by Dr. Nacke in elucidation of the exalted homo-sexual comradeship
customary among the Albanians, since this not only resembles the form
of homo-sexuality we find among the Greeks, but may probably be traced
back to a common root in ancient relationships of race.

Finally, an interesting contribution is furnished by Dr. J. Sadger, of
Vienna, under the title of “ Fragment of Psycho-analysis of a Homo¬
sexual Case.” Sadger is perhaps the ablest and the most enthusiastic
of Freud’s pupils, and he carries out Freud’s methods of investigation
and treatment with an uncompromising thoroughness worthy of his
teacher. This history in its elaborate detail and its penetrating attempts
to reach the emotional core of the morbid condition is entirely in
Freud’s manner. It remains a fragment, for the patient, a young man,

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PHYSIOLOGICAL PSYCHOLOGY.

755

disappeared after thirteen sittings,—a very early stage from the psycho¬
analytic standpoint,—but Sadger believes there was a good prospect of
removing the homo-sexual tendencies. Hypnotic suggestion he con¬
siders has now been proved to be too superficial and temporary in its
effects to be of real use in such cases, # but the psycho-analytic method
he regards as sounder and more fundamental, since it acts by awakening
the latent but repressed normal instincts. Sadger believes that even
the most ordinary people have in them some element of homo-sexuality,
but that this tends to become especially prominent under the influence
of hysteria, obsessional neuroses, and even insanity. Formerly, he
remarks, he knew as little about sexual inversion as other nervous
specialists, and thought it very rare. Now he constantly finds it at the
root of the commonest of the neuroses, hysteria, and with care traceable
back to earliest childhood, while it is not seldom the cause of the
hysterical outbreak.

The concluding two hundred and fifty pages of the volume are
devoted to a full and conscientious critical summary af the recent
literature bearing on the subjects dealt with in the year book. The
space thus occupied is somewhat less than usual, since the task of
reviewing has now to some extent fallen to the new Zcitschrift fur
Sexualwissenschaft , certainly the best and most scientific of the
numerous journals now devoted to topics of sex.

Havelock Ellis.

Part III—Epitome of Current Literature.

i. Physiological Psychology.

Erotic Dreams in Normal Persons [// Sogno Erotico nelPuomo
normale\ (Riv. di PsicoL, Jattuary-February, 1908.) Gualino, L.

The subject of sexual activity during sleep has been touched on by
various psychologists and alienists and studied in detail in a few
individual cases. Gualino appears to be the first to investigate it on a
larger scale, and bases his paper on the experiences of 100 persons
among his acquaintances, doctors, teachers, etc. (apparently all men), to
whom he addressed a series of questions. They had all had experience
of the phenomenon which Gualino regards as entirely normal.

Gualino finds that erotic dreams, with emissions (whether or not
seminal), began somewhat earlier than the period of physical develop¬
ment as ascertained by Marro for youths of the same part of northern
Italy. Gualino found that all his cases had had erotic dreams at the
age of seventeen; Marro found 8 per cent . of youths still sexually
undeveloped at that age, and while sexual development began at
thirteen years erotic dreams began at twelve. Their appearance was
preceded in most cases for some months by erections. In 37 per cent .
of the cases there had been no actual sexual experiences (either
masturbation or intercourse); in 23 per cent . there had been mastur-

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EPITOME.

[Oct,

bation; in the rest some form of sexual contact. The dreams are
mainly visual, tactual elements coming second, and the dramatis
persona is either an unknown woman (27 per cent cases) or only
known by sight (56 per cent.), and in the majority is, at all events in
the beginning, an ugly or fantastic figure, becoming more attractive
later in life, but never identical with the woman loved during waking life.
This, as Gualino points out, accords with the general tendency for the
emotions of the day to be latent in sleep. Masturbation only formed
the subject of the dream in four cases. The emotional state in the
pubertal stage, apart from pleasure, was anxiety (37 per cent.), desire
(17 per cent.), fear (14 per cent.). In the adult stage anxiety and fear
receded to 7 per cent, and 6 per cent, respectively. Thirty-three of the
subjects, as a result of sexual or general disturbances, had had nocturnal
emissions without dreams; these were always found exhausting.
Normally (in more than 90 per cent.), erotic dreams are the most vivid
of all dreams. In no case was there knowledge of any monthly or other
cyclic periodicity in the occurrence of the manifestations. In 34 per
cent, of cases they tended to occur very soon after sexual intercourse.
In numerous cases they were peculiarly frequent (even three in one
night) during courtship, when the young man was in the habit of kissing
and caressing his betrothed, but ceased after marriage. It was not
noted that position in bed or a full bladder exerted any marked
influence in the occurrence of erotic dreams ; repletion of the seminal
vesicles is regarded as the main factor. Havelock Ellis.

Modern “ Speaking with Tongues ” [Das Modeme “ Zungenrcden ”].

(Psychiat.-Neurolog. Wochensch., Nos. 8 and 9, 1908.) Mohr, F

Mohr here studies from the psychiatric standpoint a recent epidemic
of glossolalia in Cassek He traces it back to Wales (Evan Roberts)
and America, and considers that its eruption is specially liable to occur
among emotional and inflammable populations (Welsh, Hessians, etc.)
and is favoured by the pronounced mystic and occult tendencies of the
present day. He compares the phenomenon to katatonic speech, and
also regards it as a hysterical form of speech disturbance. He finds
severe hysteria, dementia pnecox, paranoia, and occasionally epilepsy
among the persons affected by the epidemic.

Havelock Ellis.

The Diagnosis of Homo-sexuality [Die Diagnose der Homosexualitat).

(Neurolog. Chi., April 16 th, 1908.) Nacke, P.

Nacke here returns to his attempts to give greater precision to
the conception of sexual inversion. What is homo-sexuality ?
Nacke answers that “ every feeling aroused by the sight or toudi
of another person of the same sex, whether it becomes actively
sexual or not, is homo-sexual.” He adds that (contrary to Hirsch-
feld) he disbelieves the possibility of such feelings remaining purely
platonic. This feeling is specific. How is its presence to be
recognised ? Nacke does not consider that there are any reliable
objective physical signs. The genitals are usually normal, and (in
agreement with Rohleder) Nacke regards inverts of pronounced
feminine appearance as rare exceptions. He knows only one sure sign

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1908.]

PHYSIOLOGICAL PSYCHOLOGY.

757

of homo-sexuality, and that a purely subjective one—the inverted
character of the sexual dreams. Even that sign, as he cautiously and
truly adds, is not reliable unless it holds good of the dreams generally,
for an isolated homo-sexual dream has no significance. Sexual pre¬
cocity is very common in inverts, but it is by no means diagnostic.
Of more importance is horror femina combined with an enthusiastic
cult of friendship, but horror femina is not, of course, present in
persons with bi-sexual tendencies. Niicke is forced to admit that there
is no certain diagnostic sign, objective or subjective. The heredity,
also, he considers, furnishes little help. Neuropathic conditions are
not specially common, and the stigmata of degeneration not notably
more frequent than in normal hetero-sexual persons, so that Krafft-
Ebing was finally compelled to abandon his earlier conception of
sexual inversion as a degenerative manifestation. Nacke concludes
with some considerations concerning the phenomenon in ancient
Greece, where it certainly involved a very large amount of pseudo-
homo-sexuality. Haveix>ck Ellis.

The Nature of Hallucinations [Nature des Hallucinations ]. (Rev. Phil
June , 1907.) Leroy, />.

Leroy begins by disproving the view of Taine that an hallucination
is an exaggerated normal phenomenon—that is, an unusually strong
mental representation of qualitatively the same kind. He then pro¬
ceeds to argue against the idea of Brierre de Boismont, according to
which hallucinations tend to appear in states of strained attention. He
shows that, on the contrary, it is in states of passivity or semi-passivity
—states that are passive to an abnormal extent—that “ visions” and
“ voices ” tend to be manifested. In such states voluntary attention is
reduced to a minimum. Hallucinations never appear under normal
psychological conditions. Something more, however, is needed than
a state of weakened voluntary attention. This is a state of involuntary
attention, such as may be detected, the author truly points out, in
ordinary hypnogogic visions. There is thus a state of special auto¬
matic attention, and it is possible, Leroy adds, that this phenomenon
of involuntary orientation of the organism plays an important part in
what may be called the state of implicit belief. The author believes
that the combination of this automatic attention with the disturbance of
voluntary attention suffices, if not to explain completely the mechanism
of hallucinations, at all events to differentiate them from other mental
states. Havelock Ellis.

The Definition of Hysteria [Quelques Mots sur la Definition de
fHysterie\ (Arch, de Psychol., October, 1907.) Claparcde, E.

Much of the disagreement concerning the definition of hysteria is
due to the different points of view from which the subject is approached.
Each observer tends unconsciously to frame a definition according to
the therapy which he finds most efficient. It is erroneous to suppose,
however, that perfect definitions must precede every investigation.
The perfect definition of a thing is the crown of its complete study,
and quite different from the preliminary delimitation. The latter

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EPITOME.

758

[Oct,

merely serves to roughly mark out the domain which we propose to
investigate.

The author objects to Babinski’s view that hysteria is characterised
by symptoms which are all the product of suggestion and auto-sugges¬
tion. Suggestion is rather to be regarded merely as one symptom
amongst the others. In any case, this exaggerated suggestibility itself
requires explaining, so that Babinski’s definition does not really take
one very far. Everyone admits the close relationship between hysterical
phenomena and those produced by suggestion, but this does not
necessarily mean that they have the same origin. Now it is precisely
this question of origin which mainly interests us.

Breuer and Freud regard hysteria as due to the suppression by the
personality of memories having a strongly marked unpleasant affective
tone. Now one may throw some light on this hypothesis by consider¬
ing the question biologically. From this point of view the “suppression”
may be conceived as a mode of defence adopted by the personality in
order that the latter may rid itself of certain unpleasant impressions.
According as these are memories, acts, or sensations, so we have
amnesias, paralyses, anresthesias. When the inhibition is total, a
syncopal attack results—homologous with the simulation of death
observed in certain animals. Vomiting, spasm of the oesophagus, etc.,
may be similarly interpreted. In general one may say that from the
biological standpoint a certain number of hysterical symptoms seem to
be the exaggeration of defensive reactions which are only present in a
rudimentary way in the normal individual or which have phylogeneti-
cally altogether disappeared.

We are next led to inquire what is the cause of this tendency to
exaggerated reaction. This is the fundamental question of the
“ hysterical constitution.” No satisfactory solution is forthcoming, but
making use of the conceptions developed above, it may be said that the
hysterical constitution is characterised by a tendency to reversion, to
atavism, to ancient types of reaction.

It is difficult to bring hallucinations and certain other phenomena
into line with the above, and one is compelled to admit that all the
symptoms of hysteria do not originate on the same plane. As Breuer
and Freud remarked, hysteria may be likened to a building consisting
of several stories.

The paper concludes with a plan showing a suggested arrangement
or hierarchy of the symptoms of hysteria, illustrating their mutual
relation to one another. Bernard Hart.

Is Hysteria Curable ? [.Chystirit est-elle curable (Le Prog. Afed.y
January 18 th, 1908.) Terrien .

The accidents of hysteria must be only regarded as external manifesta¬
tions of the neurosis and hot the whole malady. There are hysterics
who have never revealed the state by any accidents, though the latent
disease is there, awaiting only the occasion to display itself. This
hysterical state or diathesis the author considers ingrained and incurable.
He demonstrates clinically how hysterical symptoms may be artificially
reproduced in hypnosis after they have been absent for as many as ten

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PHYSIOLOGICAL PSYCHOLOGY.

759

years. Hypnotic states he regards as purely hysterical phenomena, and
from this standpoint he argues that the production of such states, with
reappearance under suggestion of the accidents, is an indication that
the underlying tendency has remained unchanged during a prolonged
period of apparent freedom from symptoms. H. Devine.

The Psychology of Thought\Tatsachen und Prable me zu einer Psychologie
der Denkvorgdnge , /. Ueber Gedanken ]. Karl Buhler . Leipzig:

Wilhelm Engelmann, 1907.

The author endeavours to analyse the thinking processes by means
of certain experimental methods. “Thinking” has been defined in
various ways, but the majority of authorities have agreed that the content
of thinking is not something specific in itself. It is this conception,
originally developed from Locked sensationalism, which the present
paper contests.

The experimental method adopted is based on that first utilised by
Marbe. The work is divided between an experimenter and an observer.
A question devised by the former is dictated to the latter, who first
answers it, and then describes to the best of his ability the various
processes through which his mind has passed. The questions are of
considerable difficulty so as to exclude the possibility of a comparatively
automatic answer.

If the various examples of thought-processes thus obtained are sub¬
sequently examined one finds that they are composed of the following
elements : (1) An easily-distinguished group of sensory elements—optic,
auditory, verbo-motor, etc.; (2) feelings, and those more neuter tracts of
consciousness, such as doubting, astonishment, reflexion, for which one
may temporarily employ Marbe’s term “ consciousness groundwork ” ;
(3) something of which “clearness,” “liveliness,” “certainty” may be
predicated but which has no sensational content. This we may call
simply thoughts (Gedanke).

Now, if one examines the experimental results it is at once obvious
that the sensory elements only appear fragmentarily and sporadically,
and hence cannot be essential to the thinking process The one indis¬
pensable factor appears to be composed of those “ thought-elements ”
which do not permit of reduction to anything simpler than them¬
selves. It is not denied that thinking is often accompanied by visual
images, inner speech, etc. But as these are not always present they
cannot constitute the essence of the processes in question.

This conception forms the kernel of the author’s position ; the
remainder of his paper is occupied with a consideration of the theories
hitherto in vogue, and with a detailed analysis of the various types of
thought. This portion can hardly be made clear apart from the experi¬
mental results with which it is illustrated, and does not lend itself to a
short epitome. Bernard Hart.

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EPITOME.

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2. Clinical Neurology and Psychiatry.

Hysterical Paralysis Agitans [La Paralysie Agitante Hystirique\ (Gaz.
des Hop ., November *jth, 1907.) Gausset, A.

But little is known as to the relation between Parkinson’s disease and
hysteria, as the two are not commonly associated. The author des¬
cribes in detail an interesting case to demonstrate that the Parkinson
syndrome may be closely reproduced, in each particular, in an hysteric.
The patient, female, aet. 28, had been developing for seven years the
various features of paralysis agitans, tremor, gait, attitude, and sub¬
jective sensations of heat. The hysterical nature of the case is revealed
by a close examination of each individual symptom, the discovery of
stigmata, and a careful search into the previous history. The symptoms
were found to date from an attack of facial paralysis during which she
was confined to hospital. Next to her bed was a patient suffering from
Parkinson’s disease, this close association leading to the subconscious
development of the symptoms in herself. H. Devine.

Chronic Paranoia and Melancholia [Paranoia Chronique et Melancholie\
(Bull, de la Soc. de Med. Ment. de Belg.) Pieters, P.

Delusional melancholic states are usually described as possessing
various features which serve to sharply differentiate them from persecutory
paranoia. In melancholia the delusions are said to be secondary to
the affective disorders and convergent in character, in paranoia they are
primary and divergent. There are many cases, however, in which no
such clear distinctions can be drawn and which are difficult to place
definitely in either category. In a series of observations the author
demonstrates the intimate connection which may exist between the two
forms of mental disorder, arriving at the following conclusions, viz .:

(1) That melancholia may pass into a chronic and progressive
delusional state which merits the name of “ secondary paranoia.”

(2) That sometimes at the decline of melancholia a temporary para¬
noic state is observed together with a certain amount of mental
enfeeblement.

(3) That in the early phases of paranoia affective disorders are
observed which resemble those usually ascribed to anxious melancholia.

(4) That in some cases of anxious melancholia the delusional

interpretations which arise bear characters approximating to those of
chronic paranoia. H. Devine.

A Bulbar Form of General Paralysis ( Vagus syndrome with emotional
crises) [Forme bulbaire de la paralysie generalc (Syndrome du vague
et (Tangoisse) ]. (Le Prog. Med., April 4th, 1907.) Milian.

Klippel has described two bulbar forms of general paralysis, the
glosso-labio-laryngeal and the form with Basedow’s syndrome. The
latter is scarcely legitimately named, as the bulbar origin of Basedow’s
disease is far from being proved. The author describes a third form in
which bulbar symptoms of a different type are prominent He quotes
a case which, in addition to the classical symptoms of general paralysis,
presented functional disorders directly referable to the pneumogastric

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1908.] CLINICAL NEUROLOGY AND PSYCHIATRY. 761

nerve. These were: (a) digestive, alternating, excessive, and dimb
nished salivary secretion, extreme flatulence, vomiting and indigestion;
( b ) cardio-vascular, palpitation and tachycardia (pulse 124 standing, no
lying down); (c) pulmonary, dyspnoea (respirations 38) much increased
by a horizontal position and accompanied by a feeling of constriction of
the throat and intense distress. In addition to this pneumogastric
syndrome he suffered from paroxysmal emotional crises, occurring
chiefly during the night and awaking him with a start from sleep. Such
attacks were identical with those described by Brissaud as occurring in
bulbar affections, and consist of a feeling of impending death, intense
anxiety, and indefinable insecurity with extreme restlessness. The
appearance of the above syndrome indicates a rapidly fatal termination
of the case. H. Devine.

Have the Forms of General Paresis Altered 1 ( Journ . Nerv. and Ment.

Dis ., September , 1907.) Clarke, L. P., and Atwood, C. E.

So far as America is concerned the authors are enabled to speak with
authority on this question, so much discussed of recent years by neuro¬
logists and alienists, owing to the fact that they have made a careful
analysis of 3000 male cases of paresis occurring during the last thirty
years.

Referring to the opinions of others on this subject, they point out
that Paton states that until recently the expansive form included the
majority of cases, but that now only one-tenth to one-fifth are of the
expansive type, while the depressed type forms the majority of all cases,
and the increase of the demented type is apparent only, but unfortu¬
nately his generalisation was based upon comparatively few cases.

On the other hand Brower and Bannister, together with the majority
of clinicians, believe that paresis with excitant and exalted delusions is
still the typical type. Diefendorf holds that the megalomanic type is
becoming less prominent, and now is only encountered in less than one-
fourth of the cases. This is also Kraepelin’s opinion. The latter con¬
siders that the dementing form is now the prevailing type, forming two-
fifths of all cases, whilst the depressed form exists in more than one-fourth
of the cases. He calls attention to the fact that the neurologist sees
more dementing cases of paresis than the alienist on account of the
absence in such cases of the grave mental symptoms which necessitate
asylum care.

As representative of the English view the authors quote Clouston to
the effect that one-third of paresis belongs to the dementing form, and
that all the older asylum physicians hold that this form is increasing at
the expense of the grandiose type. They, however, remark that not a
few English writers fail to diagnosticate paresis in the absence of
euphoria during some stage of the disease, a view they believe to be
largely due to Mickle’s teaching two decades ago.

Italian, French, and Russian alienists make no extended comment
upon the modern views of variation of type in paresis, indeed, the
authors complain that not many writers of to-day in any country make
anything like a genuine attempt to differentiate types or forms of
paresis, which makes their task of a wide geographical interpretation
necessarily somewhat imperfect. They believe that a considerable

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EPITOME.

[Oct.,

number of depressed and simple dementing types of paresis were
formerly classed as melancholics and dements, and that the more
prompt detection of paresis has made it a younger disease ; more cases
occur between twenty and thirty than formerly and fewer occur over the
age of fifty.

In the study of their own cases they divide them into three forms:
grandiose, depressed, and simple dementing, and deduce that paresis is
essentially a disease in which the grandiose type predominates in about
70 per cent, of all cases, the dementing form occurs next in frequency of
20 per cent. , while the depressive form is found in but about 10 per cent.

A. W. Wilcox.

Neurasthenia and General Paralysis [ Neurastenia e paralisi progressiva].
(Riv. Speriment. di Freniat., vol. xxxiii, fasc. ii-iii, 1907.)
Petrazzani.

In an exhaustive and judicious discussion of the literature of the
subject, the author points out that all the symptomatic indications
which have been relied on to establish the differential diagnosis of early
general paralysis from ordinary neurasthenia are utterly fallacious; and
that cases are constantly occurring in practice where the decision as to
which of the two diseases is present has to be left to time. He contends
that this view is indisputable for the more familiar signs—the pupillary
inequality, the affection of memory, the impairment of speech, etc., and
he holds that the value of lumbar puncture is still too uncertain to allow
it to be counted as of more definite significance. On this account he
puts forward the thesis that the so-called neurastheniform period which
so frequently precedes the appearance of the first positive signs of
paretic dementia is in fact nothing else but true neurasthenia. He
believes that the occurrence of neurasthenic symptoms as a pre-paralytic
phase would be found to be extremely frequent, and perhaps constant,
if our clinical histories were more complete. Further, since on the one
hand the symptomatology of the two diseases shows that in both
similar nervous centres are affected, and since, on the other hand,
evidence is accumulating to support the theory that both diseases are
due to some subacute or chronic intoxication of endogenous or exo¬
genous source, he would lean to the opinion that neurasthenia and
general paralysis are intimately related, that in some sort neurasthenia
is the curable stage of general paralysis, or rather that it may be such a
stage, or may be a milder form—owing either to the lesser virulence of
the toxins or to the higher vitality of the nervous elements—of the
same disease. The author indicates the practical inferences that would
follow from this hypothesis, notably with regard to the importance of
prophylaxis and appropriate early treatment of neurasthenia in para-
syphilitic and other patients, the vitality of whose nervous elements has
become impaired. W. Cv Sullivan.

Delirium of Persecution Commencing in the Involutionary Period of Life
\Du delire de persecution survenant a la piriode involutive de la nV].
(Rev. de Psychiat ., May, 1907.) Marchand and Nouet.

This paper contains clinical notes of three cases of persecutory
delirium presenting certain features different from those met with in

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1908.]

TREATMENT OF INSANITY.

763

the general run of cases of d&ire chronique. The patients, whose ages
at the onset of the disease were respectively sixty-three, sixty-four, and
sixty-seven years, were all women. Two of them had strong insane
taint in the stock, but this had not manifested its influence by any
psychic anomalies in earlier life. The unusual features of the three
cases were the extreme brevity of the prodromal period, the early
appearance of megalomania and the very unstable and fugitive nature
of the delusions of exaltation, the presence of some degree of weakness
of memory from the start of the disease, and finally the absence of any
tendency to violent reaction against the supposed persecutors. The
authors attribute these peculiarities to the age of the patients, that is to
say, to the special mode of reaction natural to the senile brain; and
they emphasise the importance of realising that the psychoses of
involution are not exhausted by Kraepelin’s three forms—melancholia,
presenile delirium of suspicion and senile dementia—but that on the
contrary, any form of insanity may be met with at this period, though,
of course, taking a distinctive colour from the organic conditions
which belong to the senium. W. C. Sullivan.

3. Treatment of Insanity.

Epilepsy and Lumbar Puncture . \LEpilepsil et Lombaire Ponction\
(Le Prog. Med., May gt/t, 1908.) Tissot, F.

At first sight epilepsy is a malady which could, to a large extent, be
reduced in severity by lumbar puncture, as the tension of the cerebro¬
spinal fluid is generally increased, especially at the onset of a fit. In¬
creased tension is, indeed, considered a phenomenon of this stage of
epilepsy. In practice,, however, lumbar puncture has not given the
results hoped for, although this is only what might be expected if one
keeps in mind prevalent views and recent histological researches in
regard to the causation of epilepsy. The increased tension of the
cerebro-spinal fluid is a result, not a cause of the disease, and its
signification is of similar value in this respect to the presence of choline
in the cerebro-spinal fluid of epileptics.

Tissot gives details of the results of lumbar puncture in six male
epileptics. In each case punctures were made frequently, over a long
period, and comparisons were made at equal lapses of time before and
after their performance. The results have been completely negative.
Systematic, large and repeated withdrawals of fluid have not in any way
modified the number or quality of the epileptic fits. In conducting
the experiments relatively large quantities of cerebro-spinal fluid were
taken off—rarely less than 40 c.c., and sometimes the amount with¬
drawn at a puncture was 60 c.c., and even 70 c.c. It is pointed out
that, despite this fact, further than a slight headache, which was quickly
dissipated by a rest in bed, evil results seldom followed.

Hamilton C. Marr.

Liv. 54

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EPITOME.

[Oct,

The Needs of our Time in respect of the Surgical Treatment of Insane

Patients [ Ce que Doit fttre d notre Epoque La Chirurgie des Aliinis).

{Rev. de Psychiat. % March , 1907.) Picqul.

The writer’s text is Leroy Broun’s paper, “Preliminary Report of
Gynaecological Surgery in the Manhattan Hospital,” of which a brief
summary was given in the fournal of Mental Science for July, 1907, p.
656. Picqu£ states that whilst he is in certain respects in agreement
with Leroy Broun, his general conception of the surgery of the insane
differs so profoundly from that of the American writer that he wishes to
explain briefly his own views.

Certain surgeons, says Picqu^, have made the extraordinary claim
that it is possible to cure insanity by the removal of healthy organs, such
as the ovaries or the testicles; or by quite unjustifiable operations on the
brain. He feels that it is necessary to protest against such teaching and
practice, the only effect of which can be to arrest the progress of surgery
for the insane. Now, as formerly, Picqud is convinced that the surgeon
is justified in operating on an insane patient only when there exist
formal indications for the operation it is proposed to perform. More¬
over, his investigations on the subject of post-operative psychoses have
shown him that the surgeon, in undertaking an operation in a mentally
afflicted patient, must always take into consideration the possible effects
of his procedure upon the mental state. In a patient apparently sane,
but predisposed to insanity, an operation may induce a post-operative
psychosis; and in a patient already insane an operation may lead to an
aggravation of the mental disorder. He has long maintained that in the
insane and in those predisposed to insanity the question of operation
demands consideration, not from the surgeon only, but from the alienist
as well.

Picqud then speaks of operation for the relief of displacements of the
uterus in cases of mental disorder. Whilst these displacements are
frequently met with in the insane, Picque has found that the patients
are apt to have hypochondriacal ideas and functional troubles altogether
disproportionate to the degree of displacement Many of the patients
demand operation, but in a number of cases the only result of operation
was to aggravate the mental disorder. In these respects the results
obtained by Picqu£ appear to have differed most markedly from those
obtained by Leroy Broun, the latter stating that in fifty-one cases in
which he operated for the relief of uterine displacement the cure of the
mental disorder appeared to be hastened by the operation.

Passing to the consideration of other surgical measures in insane
patients, not concerned with the reproductive organs, Picqu6 points out
that improvement may sometimes follow operation in a manner quite
indirect. For instance, certain patients—melancholics, for example-
need active occupation for the relief of their mental troubles, but this is
rendered impossible by some bone or joint lesion. An orthopaedic
operation, by restoring the use of a limb, may excercise an indisputable,
though indirect, action towards the restoration of mental health.

The surgery of the insane, concludes Picqu£, concerns itself, not
merely with those actually insane and confined in asylums, but also with

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TREATMENT OF INSANITY.

765

those potentially insane (in whom the surgeon has to consider the
possibility of a post-operative psychosis). In those actually insane the
surgeon endeavours—(1) to discover the somatic causes of insanity, that
is, to determine the relations which may exist between surgical lesions
and the diverse forms of mental alienation; (2) to discover the modi¬
fications which the mental state may render necessary in surgical thera¬
peutics, as regards the choice of method and the operative technique;
(3) to study the pathological varieties of disorder most frequently
encountered in insane patients. M. Eden Paul.

Occupation-Therapeutics for Patients suffering from Mental Disorder
[Beschdftigungsiherapie bei Geisteskranken\ ( Psychiat . Neurolog .
Wochenschr ., May nth and 18///, 1907.) Star Unger^ J.

The writer opens by pointing out that it has long been recognised
that work is one of the elementary human needs, without which com¬
plete mental integrity cannot be secured, and that regular occupation
has for many years been recommended and utilised in the treatment of
mental disorder. It is only recently, however, that work has been
systematically employed for therapeutic purposes, and that its immense
importance has been recognised as a part of asylum administration.
At Mauer-Ohling, the institute of which Starlinger is superintendent,
special attention has from the first been devoted to the employment of
the insane, whether curable or incurable. By occupation, in this
relationship, the writer understands any kind of continuous activity,
whether useful or not; and the term embraces not only every kind of
work, but also all amusements to which no contra-indication exists.

Among useful occupations, that is, work in the ordinary sense of the
term, must in the first place be enumerated all kinds of agricultural
operations; every variety of handicraft can also be utilised, whilst for
women every variety of domestic occupation is available. There are
properly fitted rooms for drawing, painting, and other artistic occupa¬
tions. A number of the patients also find employment in the offices
of the institution. Finally, there are many special occupations which
can be utilised in the asylum, such as letter-carrying, driving, road-
making, etc.

Starlinger then passes to consider occupations not directly useful—
amusements and games—which are all of a similar nature to those
utilised in any large English asylum.

The writer lays stress on the importance of interest and continuity in
the occupations allotted.

In the institution under consideration there has never been any
disastrous result from the employment of the patients. Among 1,420
patients, as many as one half will be regularly employed. Notwith¬
standing the great number thus engaged, and notwithstanding the
risky nature of many of the occupations, there has during thirty-two
years never been a serious accident to a patient. Starlinger gives an
interesting table showing the percentage of those suffering from various
forms of mental disorder whom it was found possible to keep regularly
employed:

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EPITOME.

[Oct,

Percentage employed.
66*9

997
53
50
34
52
378
41*8
14*2
544

60
96

Mental disorder.

Congenital idiocy
Congenital imbecility
Melancholia
Mania
Amentia .

Paranoia .

Psychopathia periodica
Dementia

Paralytic dementia .

Insanity with epilepsy
Hysterical mental disorders
Neurasthenic mental disorders
Alcoholism ...

It will be seen that the highest percentage of employable patients is
among those suffering from congenital imbecility and from alcoholism.
This fact is of economic importance, inasmuch as institutions espe¬
cially for the reception of congenital imbeciles and of alcoholic patients
respectively, could be conducted much less expensively than those for
the generality of insane patients, since the majority of the inmates in
the former cases can engage in remunerative occupations. To a less
extent the same is true of the congenital idiots; whilst in the case of
melancholia, mania, paranoia, epilepsy, and neurasthenia, considerably
more than half of the patients are employable.

Contrasting male and female patients, there is little difference in the
number employable, being 55 per cent . in the case of men and 53 per
cent, m the case of women.

Passing to consider the former occupations of the patients in
relation to the possibility of employing them, Starlinger found that the
figures were as follows:

Former occupation.

Percentage employed.

Agricultural labourers .

. • • - 65

Factory hands

. . . . 78

Skilled artisans .

Brain workers

Maid-servants

5 °

More than one-third of the patients in the institution (567 in all) had
previously had no regular occupation; of these one-half were employ¬
able. Striking in the above table is the large percentage of factory
hands found employable, and the small percentage of brain workers.
Of course the occupation followed in the asylum was not necessarily
that in which the patient had been engaged prior to admission.

Starlinger then proceeds to discuss the value of “occupation-
therapeutics/ 1 and summarises his conclusions in the following words:
“ Herein we have a method of treatment which can be utilised systema¬
tically in about 50 per cent, of mixed cases of mental disorder. Its
results, materially and mentally, generally and individually, are so
important that this method is worthy to be placed beside the other
principal elements of the modem management of mental disorder—no
restraint, and treatment by rest in bed. . . . The greatest curse of

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SOCIOLOGY.

767

an asylum/* he continues, “is dulness. . . . We have restored the

insane their liberty, but to allow our patients to loaf about the asylum
is to expose them to the demon of dulness; their freedom must be
rendered useful to them by regular occupation.” M. Eden Paul.

Remarks on the Clinical Effects of Iodine and the Iodides in States of
Stupor and Mental Confusion . {Rev. de Psychiat., November,
1907.) Damaye.

In a number of cases of the type above defined the writer administered
by mouth iodide of potassium or a very dilute Gram*s solution of iodine,
or administered a more concentrated Gram’s solution hypodermically.
Rapid improvement ensued in most of the patients, which was attributed
to the drug thus employed. He considers that iodine acts as a general
stimulant and perhaps as an adjuvant in the struggle of the organism
against infective states. M. Eden Paul.

4. Sociology.

Insanity among fews [Uber die Geistes-Storungen bei den Juden ].

{Neurol. Cbl., April 16 th, 1908.) Sic he l, M.

It is commonly stated that insanity is specially prevalent among Jews,
but usually without proof. Following Pilcz, who has lately investigated
the question among the Jews of Vienna, Sichel here studies it in detail
from the statistics furnished by the town asylum of the ancient Jewish
centre, Frankfurt. He gives his reasons for believing that the results
here obtained are fairly free from fallacy.

In 1906 and 1907 there were 1,953 fresh admissions to the asylum ;
of these 128 (6*5 per cent.) were Jews ; according to sex there were 4*7
per cent. Jews and io*6 per cent. Jewesses. As the proportion of Jews
in the general population of Frankfurt is 6*8 per cent., there seems,
Sichel believes, no excess of Jews in the asylum. (In Vienna Pilcz
found that there was an excess of Jews m the asylum.) When, how¬
ever, insanity of alcholic origin is excluded, a different result is obtained,
and we find 7*6 percent. Jews and 11*5 per cent. Jewesses. Among the
Jewish insane, it will be seen, there is a notably higher proportion of
women ; this is stated to be 49 per cent., while among the non-Jews
there were only 28 per cent, women. (This refers, it must be remem¬
bered, to first admissions.) Sichel proceeds to point out that if epileptic
as well as alcoholic insanity is left out of consideration, in all other forms
there is a definite predominance of Jews over non-Jews. Circular forms
of insanity are very common among Jews. General paralysis is also
more prevalent among Jews than among non-Jews (i2’5 percent, against
8*3 per cent.). Hysteria is decidedly more common, and would have
been, Sichel remarks, still more pronounced if its occurrence in wealthy
Jewish families could be taken into account. Neuropathic heredity was
found in 37*3 non-Jews, in 437 Jews. As regard criminal offences
committed by the Jewish insane, the great majority were, as might be
expected, against property ; offences against the person were rare. In

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EPITOME.

[Oct,

the symptomatology the tendency to ratiocination is the most notable
peculiarity, but Sichel agrees with Pilcz that there is no specific psychosis
judaica .

The paper contains many other interesting details, and a bibliography
of the subject is appended. Havelock Ellis.

Protection against Criminal Lunatics [Die Unschddlichmachung
geisteskranker Verbrecker\ (Psychiat. Neurolog . Wochcnsch .,
April nth , 1908.) Dr . Risch.

The article deals with the manner in which insane and weak-minded
criminals should be treated, and discusses the use of the term “ vermin-
derte Zurechnungsfahigkeit ” (mental incapacity, enfeebled power of
judgment, insufficient psychical resistance). The author's remarks
formed the subject of a leading article in the Frankfurter Zcitung , Nr.
262. After pointing out that feeble-minded criminals, notably those
who have been committed for indecent assault, are set at large after a
shorter or longer term of imprisonment, the author suggests that as soon
as mental defect is proved, such cases should at once be committed to
asylums. Asylum treatment as compared with prison treatment has
these advantages, viz., greater precaution taken to prevent discharge
until recovery is certain, and the possibility of treatment of the mental
condition. The treatment of criminal cases suggested by the author is
rest in bed under observation. On no account must the patient be
placed in a single room. This treatment is correct for all feeble¬
minded persons whose habits make them a danger to the community,
alcoholics, epileptics, hysterical and criminal paranoiacs.

Hamilton C. Mark.

5. Asylum Reports issued in 1908.

Albany Hospital Report for 1907. Mosher, J. M.

The fifth report of Pavilion F of the Albany Hospital is as satisfactory
as in previous years. Pavilion F still claims to be unique in the United
States as the only example of an attempt, in connection with a general
hospital, to treat early mental disease “ under the voluntary relation,
without commitment as insane.”

Nearly twelve hundred cases have now been treated, with most
satisfactory results, as evidenced by the statistics.

The most striking paragraph in the report is the condemnation of
the use of narcotics. Dr. Mosher says, “ the failure to induce natural
sleep by artificial means might be regarded as axiomatic were it not
that these poisons are in almost universal use,” and adds, the first effort
in treatment “ is toward the elimination of noxious substances.”

Henry Rayner.

Some English County and Borough Asylums.

Brighton Borough. —The Committee is considering the question of
making provision for private patients, in a building apart from the

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ASYLUM REPORTS.

76 9

main asylum, the charge proposed being about jQi 5*. Visits have
been made to the Hants and Dorsetshire asylums to inspect similar
accommodation. As a beginning it is determined to adapt the sana¬
torium for receiving twenty females. The action of the Committee, in
affording help at a reasonable rate to a class that can least afford to bear
the cost of insanity, must be highly commended.

We are glad to see that the new statistical tables have been adopted
in their entirety. This was only to be expected from the institution
whose head in former days (Dr. Lockhart Robertson) was a most
active mover in starting the idea of recording in uniform Tables the
facts observed in the practice of the asylum. But we could not have
reasonably looked for such a conscientious observance of principles as
is involved by the recasting of all the averages of the three ways of
calculating recovery-rates, as well as of the death-rates, since the
beginning of the asylum—fifty years save one. Yet this has been done,
though it involved a consideration of every case; and it will always
stand to the credit of the staff at Haywards Heath.

We hope, in a later number, to be able to offer some remarks on such
sets of new tables as may be available, after there has been time to
make a comparison between them.

Carmarthen .—The entry in the visitors’ book made by the Commis¬
sioners harps on the complaints, made so frequently, about the hard¬
ships that are inflicted on the patients in consequence of the “ deplorable
disagreement ” between the authorities who own the asylum. At last
the Commissioners allude to their power of reporting to the Home
Secretary the fact that the authorities concerned have “ failed to provide
adequate asylum accommodation.” Doubtless some difficulties must
exist, though it might be supposed that arbitration would enable these
to be surmounted. But, however this, may be, there can be no excuse
for the members of the committee not carrying out the duty of visitation
which, by accepting office, they take on themselves. In October the
Commissioners note / that two or more visitors have visited only three
times in the year, and none since June. It may be said that the discus¬
sion of these matters is not the business of any but those directly con¬
cerned, but it is not so. We are all concerned in the general advance¬
ment of the treatment of the insane. We are bound to assert that the
-right of patients, jointly and severally, to the best of treatment takes
precedence of all other considerations. No one authority should by its
conduct weaken this principle, which, we are thankful to say, is almost
universally adopted.

London City .—The commissioners advert to the fact that the female
private patients help in the garden and some have small plots of their
own. The private patients now constitute one half of the total popula¬
tion. A rough analysis of the financial statement suggests that out of
the modest sum of jQi is. per week, the staple charge, a very reason¬
able sum has been reserved by way of rent for the excellent accommoda¬
tion offered. With regard to statistics :

“The tables which accompany this report have, as in past years, been
prepared by Dr. Patterson. Though the greatest care has been taken

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770

EPITOME.

[Oct.

to insure accuracy, yet a word of warning is necessary, that in some at
least of these too much stress must not be laid upon the figures given.
The position of this Institution is unique. In the case of most public
asylums the patients are drawn from a defined locality and are of the
same race and social status. At the City of London Mental Hospital
the patients are of many nationalities (see Table I) and from the fact
that half of the total number are of the private class, the social rank is
of varied character. In a public asylum the number of admissions is
an index to the amount of insanity occurring in a certain area, in our
case the private patients come from all parts. Many of the private
patients are sent here from other institutions as being admittedly irre¬
coverable. Many of the rate-paid class also belong to places other than
the City of London. These individuals having wandered into the
City have been sent to Stone, and not infrequently when the patient is
well on the road to recovery he is transferred to the asylum to which he
belongs. During the year, out of 145 admitted, 56 were transferred to
other asylums.”

Derby Borough ,—The asylum is becoming full, indeed it is full, and
extension is called for by Dr. Macphail. Such extension would
appear not only desirable, but likely to be in the end not very expensive.
This is on account of the demand for accommodation for private cases.
This demand cannot be met now, inasmuch as the beds hitherto set
aside for them have to be used for new pauper cases. We note that
the total amount received from private cases in the year was nearly
^1,600, while the “excess” in respect of them handed over to the
building fund was ^700. The great majority of them came from
Derby itself. Of the eighty-four admissions, seventeen were re-admissions.
Of these thirteen had been discharged recovered. The average interval
of relief was nearlv four years. There was an abnormally large pro¬
portion of acute delirious mania among the admissions. This disease
and general paralysis accounted for 40 per cent, of the deaths.

Hertfordshire ,—This asylum, which but a few years ago was the
new one of the day, now requires enlargement, and nearly 250 beds are
to be added. Dr. Boycott has devised a system of statistics of his
own. This, though lacking the advantage of uniformity with a large
amount of material recorded in other asylums, has some merits of its
own. He deals in some of the tables only with new cases, that is, from
the direct admissions he strains off recurring cases. Congenitals, also,
are put on one side. It is somewhat striking that in the first attack
cases, which form just about two-thirds of the 812 direct admissions
received since the opening of the asylum, the proportion of recoveries
is almost identical with that found among the remaining direct cases ,*
this means that the not-first attack cases recovered so frequently that
they made up for the incurability of the congenitals.

Dorset County. —Dr. MacDonald adverts to the malign influence of
influenza as an setiological factor. He admitted several cases of adoles¬
cent insanity following lingering attacks of this disease. The great
prevalence of hereditary predisposition to insanity in his area, in his

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ASYLUM REPORTS.

77 1

opinion, aided the influenza toxin. The recoveries among the private
patients exceeded those among the paupers, as by 54 to 33 per cent.
Here again Dr. MacDonald traces the influence of heredity, the paupers
coming all from a saturated district, while the private cases came from
everywhere. Of twenty-eight recoveries among the female patients the
exceptional number of fifteen had had previous attacks. The new
tables are given in full. Seeing how important a part heredity plays in
this county, we suggest that the optional table, dealing with this great
question, would be of much service to future inquirers.

Canterbury Borough, —About two-fifths of the patients in this asylum
belong to the private class, and they contribute just about half the
income. From this it is apparent that they can only produce a surplus
that would reasonably represent rent and repairs. This is as it should
be. Acute melancholia supplied the large proportion of 30 per cent . of
the admissions.

Nottingham Borough .—A large bound upwards occurred in the
admission-rate during the year—220 against an average of 160. No
special reason could be assigned, but Dr. Powell points out that of this
total 50 per cent, could be written off at once as incurable. On
turning to the statistics, which are conducted on the new system, we
find no out-standing setiological factor, heredity, alcohol, and mental
stress coming at the top of the list; but all were found in quite
moderate proportions. The general paralytics were one-seventh of the
total admissions, while of the males they formed over 20 per cent and
of the females about 8*50 per cent. Apparently none of the 10 female
paralytics showed any evidence of either acquired or congenital syphilis,
this not being recorded in any of the female admissions, while it appears
in 8 out of the 96 male admissions.

We entirely endorse the subjoined remarks. Salus populi , suprema
lex hits many an individual in the asylum very hard.

“A rather unusually large number of patients made their escape, but
they were all re-taken and brought safely back after varying periods of
absence of from a few hours to seven days. Most of them were
employed on the land or in the workshops, where it is easy for anyone
who is so determined to evade the vigilance of the attendant, who, it
must be remembered, is always instructed to work with his patients and
not to act merely as their keeper.

“ I believe it to be for the good of the patients generally to take the
risk of occasional escapes, rather than to err on the side of stringency
in the matter of giving them employment outside the locked doors of
the asylum.”

Salop and Montgomery, —We note that the Committee determined
to take on themselves all risks under the Compensation Acts and have
not insured. There is still much pressure on space. A proposition
has been made that “ one of the workhouses in the county should be
entirely devoted to the purposes of a kind of supplemental asylum.”
This is a somewhat novel idea in England, and no doubt it will receive
much consideration before it is adopted. It should be remembered,

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EPITOME.

[Oct,

however, that Salop has for years past been one of the few counties
that have availed themselves of the provision for boarding-out patients
from the asylum to a workhouse. Apparently this has succeeded to
a certain extent, for there is a proposition to send another ten to join
those who are already in Forden Workhouse. Dr. Rambaut has
adopted the new statistical tables.

Somerset ( Wells). —Here, too, are used the new tables, and, as far as
we have gone, this is the first set that includes the optional heredity
table. Dr. Pope appears to have examined the history in this respect
of each one of the 173 admissions. In all 44 instances were found.
As might be expected, the direct paternal and maternal taint is very
strong, though in as many as twelve cases fraternal taint without other
evidence was found. In relation to what was said about escapes by
Dr. Powell, of Nottingham, one reads much the same here : 44 Escapes:
As regards escapes, seven patients, all males, got away at different
times, all of whom were safely brought back. Five of them have since
been discharged ‘recovered.’ ” If escapes must occur (as, indeed, they
ought to do occasionally), there seems to be scope for art in letting the
right cases get away.

Staffordshire ( Cheddleton ).—Of 202 admissions, Dr. Menzies returns
122 as already chronic, while of the balance of 80 recoverable cases
39 were either alcoholic themselves or had alcoholic parentage. In
another table he shows that alcohol and syphilis, either separately or
jointly, personally or by parentage, entered into aetiology in 112 admis¬
sions, or 55*4 per cent, of the total admissions. Dr. Menzies has, as
noted before, great skill in working out such history, and no doubt he
is right in demonstrating as forcibly as he can the danger of evil habits.
But we cannot follow him in boldly stating that this proportion of cases
were 44 caused by social vice.” That is an exclusion of all other factors
which it is impossible to accept, especially in the question of heredity,
of alcohol, and syphilis. We imagine that were all his carefully taken
histories spread out in the form of the new Table B 8, it would be
found that in some of these cases other suspicious factors would have
to be considered.

We are glad to find that Dr. Menzies’ opinion is that segregation in
special wards of phthisical cases has absolutely no ill mental effect
The possibility of depression resulting was one of the matters urged
against the procedure. The following remarks on tubercle merit
consideration:

44 The observations made during 1904 seem to strengthen the view
that a large proportion of asylum tubercle is present on admission, but
in too early a stage to be suspected; that the conditions of over¬
crowding and want of fresh air in the wards, together with the well-
recognised tendency of the insane towards defective breathing, refusal
of food, poor musculature, sedentary habits, and low immunity ratio,
tend to light up latent foci and spread infection to other cases : that
those who have for some years advocated the maintenance of an arti-
cially high temperature in asylum wards have been helping to promote
the spread ot tubercle; and that lastly, early tubercle is a not uncommon

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ASYLUM REPORTS.

773

cause of primary adult insanity. I hope to continue these observations
during the coming year, and possibly give a practical trial to the serum
method of Professor A. E. Wright.”

East Sussex .—Curiously enough, in the very next report that we take
up for examination the doubt that we expressed above about the exclusive
influence of alcohol and syphilis (including their special heredities) is
strengthened by the way in which such cases stand in the table men¬
tioned (B. 8), the new tables having been used here this year. Dr.
Taylor is very energetic in getting reliable histories, though he only
obtains 75 per cent, of the new cases. In 135 first-attack cases alcohol
was returned as a factor. Heredity is correlated in just half these
cases; but it is mental heredity and not alcoholic or syphilitic heredity.
We cannot help thinking that in the many cases noted by Dr. Menzies
as due to social vice, some must have had mental heredity to thank
for their break-down. We may add that in two other of Dr. Taylor’s
cases senility was also correlated with alcohol. Heredity of insanity
has always been a striking point in this district. It was found in
52 and 65 per cent, of the admissions as to whom a reliable history was
obtained. It relation to this Dr. Taylor writes : 14 It is, of course,
impossible to segregate in an institution or elsewhere patients who have
a family history of insanity until the reproductive period is passed, and
this being so, it would appear that the only alternative is to devote special
care to the education and training of their offspring, who should be
encouraged to take up some occupation which would as far as possible
keep them free from mental stress, excitement, and temptations. Under
the new Education Act the medical examiners should give special
attention to these children. Many of them are preternaturally bright and
precocious, and it is most important that they should not be unduly
forced whilst at school. The fact that a considerable number of the
hereditary cases admitted here break down at or before the period of
adolescence is conclusive evidence of the necessity of attention to this
most important subject.” We note that the inmates of the special
house for idiot children have responded so well to the training that is
undertaken there, that basket and brush making are to be taken in
hand. The possibility of teaching some form of occupation to children,
who otherwise lead a mischievously idle life, is a very solid justification
of the expense entailed in building and furnishing such a department.
We believe that this house was one of those that chiefly commended
themselves to the S. E. Division when it held its pleasant meeting at
Hellingly on the kind invitation of Dr. Taylor. We believe, from what
we have heard, that the whole asylum was highly thought of by those
who inspected it on that occasion.

Suffolk. —Dr. Whitwell likewise attacks the subject of alcohol,
syphilis having but little effect among the factors. He takes a view of
its aetiological importance which differs considerably from that held by
Dr. Menzies. He considers it on the whole to be considerably over-rated.
He gives a map showing the incidence of alcohol in each county, as
revealed by the number of convictions for inebriety. Contrasting this

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774

EPITOME.

[Oct,

with a diagram showing the average rate of alcoholic admissions for all
England, together with the same for Suffolk by itself, he easily demon¬
strates the absence of any comparability between the two criteria-
Suffolk is one of the least alcoholised counties from the police view, and
yet alcohol appears quite up to the average among the assigned causes.
A very suggestive reason for doubting the genuineness of any assignment
of drink as a cause in a given case is supplied.

“It is difficult for any person not engaged in the actual practice of
trying to obtain family histories in the case of mental disease, to
realise the elaborate precautions taken by the relatives in very many
cases, on the one hand, to conceal anything which appears to them
untoward in their family history, and on the other to bring forward,
emphasise, and accentuate the delinquencies and sins of the individual
in order to exculpate the family, and thus attempt to exclude the possi¬
bility of hereditary defect being discovered; thus drink is seized upon
with avidity as apparently a convenient and excellent 4 cause * in many
cases, it which it really is nothing more than an unimportant episode,
and the difficulty of analysis in these cases is very great; hence the
figures indicating alcohol in excess, as a causative factor, are presumably
always in excess of the truth, however carefully examined, as those
indicating * heredity ascertained 1 are always below the mark.”

In binding up the statistics, which are rendered in entire accordance
with the new system, Dr. Whitwell has had tables B. 7 and B. 8 placed
facing each other, instead of in ordinary sequence. Thus the two can
be conveniently read together.

Wiltshire .—We are much surprised to read in the report of this
asylum of complaints being made about its management by the
responsible officials. Reading the report critically year by year, and
critical reading entails a glance at the accounts, we have always looked
upon the Devizes Institution as one of the most evenly and efficiently
conducted in the country. We were therefore not astonished to find
that such complaints have turned out to be quite unfounded. A
special committee of inquiry was appointed, and found no ground for
any adverse allegation. We are glad to see that, as usual, many
deputations of guardians visited and left reports, which are published
with those of the asylum officers. One and all write most highly of the
management, while some specifically traverse the allegation. The
Devizes deputation put the matter really well.

“ As to the general management of the Asylum, regarding which so
much adverse criticism has been heard of late, we wish to assure the
Board that neither by observation nor inquiry could we discover any¬
thing to warrant the complaints referred to. We are of opinion that a
fuller acquaintance with the facts, the difficulties and demands, in some
particulars peculiar to our Asylum, would modify, if not entirely
remove, the dissatisfaction which doubtless to a great extent arises
from a lack of information.”

“ The Medical Superintendent, his staff, and all working under them
are contending with, and controlling, the worst form of human suffering.

“This they are doing at a tremendous cost of bodily and mental strain,
and with the least financial cost consistent with efficiency, and we

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ASYLUM REPORTS.

1908.]

775

consider they deserve our sympathy rather than the harsh criticism by
so-called economists”

A weekly maintenance rate of gs. 2 d. does not suggest extravagance.

Some English Registered Hospitals .

Bamwood , Gloucester .—Dr. Soutar looks with some caution on
causation particulars, as well as on classification, since in both respects
two perfectly competent observers may come to different opinions on
given sets of circumstances. This is true to a certain point, but
undoubtedly there must be some value and some truth in a body of
figures collected year by year from many quarters. The law of averages
tends to rub out the extreme divergencies. He finds considerable
decrease in the recovery-yielding manias and melancholia, while primary
dementia occurs with increasing frequency. As Dr. Soutar {points out,
although we admit, we may say that we know, that heredity plays an
immense part in the production of this epochal disease, yet we are far
from knowing what may be the cause of one member of a family suffering
while all the others, with just the same predisposition, escape.

It is to be noted, with much appreciation, that by devoting part of
the surplus of income over expenditure from time to time to the Pension
Fund, no less a sum than ^48,000 has been accumulated for the
purpose. The statistics are according to the new rigime.

The Warneford, Oxford .—Alcohol as a factor plays a very small part
here. No single one among the first-attack cases is shown. One
occurred in an old man of seventy-six, who had broken down before
and was said to have injured his health by drink in former years.
There was no alcohol in any other of the forty admissions. Heredity
and prolonged mental stress were the principal factors noted. The new
tables have been undertaken.

The Retreat , York .—The new recreation hall and the new residence
for Dr. Bedford Pierce are nearly completed, and the former no doubt
will prove to be a great boon to the patients. Dr. Pierce gives a glaring
instance of the cruelty of practising deception on patients coming for
admission. “An elderly lady with advanced heart disease, and who
could not have long to live, was induced to leave her home under the
impression that she was going to Scarboro’ to see the Channel Fleet.
On arrival at the Retreat one of my colleagues was asked to give a
fictitious name, as she had been told that she would stay with a person
of this name. When he declined to do so the relatives who accompanied
her suddenly disappeared. This deception pained the patient greatly,
and there was no doubt her last days were embittered on this account.
She proved to be a most grateful patient but only lived two months after
admission, and hardly a day passed without her making some reference
to the way in which she had been deceived.”

Dr. Pierce returns to the recommendation that he made last year on
the advisability of allowing recent and curable cases to be admitted into
all asylums, for rich and poor, on no more formality than is required for
the treatment in private houses of acute cases, now practised in Scotland.
We wish him success, and, though there are many difficulties in the way,

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776 EPITOME. [Oct,

the Association might well consider the matter seriously in view of the
changes recommended by the Commission, which has lately reported.
The present would be the best time for taking the matter up warmly, if
it is so determined.

A very interesting communication is published in the report. It con¬
tains some remarks on the condition of the Retreat, and the treatment
used in it, as far back as 1827-1840, by one who is still alive. She was
the daughter of the doctor of the time, and lived in the Retreat, thus
having exceptional opportunities of seeing how things were done. The
principles of administration evidently were as advanced then as they are
now. Mrs. Pumphrey, the writer, asks a question that is perhaps nearer
an answer than it was when it was put, but is not yet answered by
practice as clearly as is desirable. She asks : “ May not such establish¬
ments grow too large ? And is there not still a place for small domestic
homes for the residence of those to whom quiet loving care would be a
great boon ? ”

Some Scottish Royal Chartered Asylums.

Edinburgh ,, Morningside. —The removal of a large quantity of the
City patients to Bangour has left space available for private patients on
reduced terms. Dr. Clouston has been able to say that, except for a
short time, it has been possible to accept every application for private
accommodation, whether for the rich or for the less affluent. It is very
seldom that such an opportunity arises to help the latter classes, who are
altogether too badly provided for throughout the kingdom. We may
feel sure that the best advantage will be taken of the chance. It may
be expected, at least hoped, that several, who have to place their
relatives under treatment, and who would otherwise have to rely on the
rates, will make an effort to find the little extra sum needful to preserve
their independence. Dr. Clouston has reason to look upon influenza
as a disease that has more far-reaching evil effects than any other. He
shows that before it arrived in 1890 the elevated and excited types of
mental disease easily held place against the melancholic and depressed
types. Now this is altered, and in the year under report the reverse
condition was found. Alcohol has not been such a frequent factor in
production, but it has been relatively more prevalent among the women
—a very serious matter.

Of course the impending resignation of Dr. Clouston looms large in
the report. The Managers offer a very full and generous appreciation
of his many years of work. He himself takes leave in a short but
feeling paragraph. We must all wish him years of happy health after
his prolonged work, by which so many have benefited, not least the
members of the Association.

Glasgow , Gartnavel. —Dr. Oswald will probably accept the term
“ manic-depressive ” without much difficulty.

The type of mental disorder was not so markedly one of melancholia as in
former years. The prominent symptom in forty-nine cases was excitement, and
in fifty-two depression; but it is becoming year by year more difficult to draw a
hard and fast line between conditions of excitement and states of depression, for
both may occur in the same patient at different stages of his illness.

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777

The free reception of voluntary cases has formed an increasingly
important feature in the year’s work. As many as one-third of the 145
invalids came for treatment and were taken in simply on permission
of the Board of Lunacy without certificates or order. The equivalent
of this simplicity exists, of course, in England as far as private patients
are concerned, but advantage of it is not taken to anything like this
extent. It is a pity that the same privilege is not extended to pauper
cases and to the entry of private cases into county asylums. These
are points that may well be thought of when the new arrangements are
made in accordance with the Report of the late Commission. We
think that it would be better if, in his statistical tables, Dr. Oswald
could separate the facts concerning these voluntary cases from the other
admissions. It is true that he shows the recovery-rate among these
patients to be greater and the duration shorter than is the case with
the certified admissions. But there are many other points—aetiology,
callings, and so on—that might be studied with benefit. Dr. Oswald
has tried the tent system of treatment, and speaks well of it.

This has been largely practised in some of the large mental hospitals of the
United States, and though the climatic conditions of last summer were very
unfavourable, the results were sufficiently encouraging to justify the experiment
being again made. The accommodation consisted of a large tent pitched in a
pleasant part of the grounds, and receiving from eight to ten beds, which were
either under shelter of the canvas—though freely exposed to currents of air—-or
drawn out in front of the tent. The patients were there in bed, or reclining in
long wicker chairs, during the whole of the daylight, and while the improvement
in some cases might be attributed to the novelty of the surroundings and to the
special diet—which was largely vegetarian, with the addition of milk and eggs—it
was also conduced to by the rest in bed in the fresh air. The calmative effect of
this open-air rest cure on many patients is very marked, and it is often those who,
by reason of restlessness in bed indoors, seem unsuitable for it, in whom most
benefit results.

Perth , The Murray .—Dr. Urquhart has found it necessary to insti¬
tute a new practice for parole patients, which is worth noting.

I have thought it well to give each parole patient two cards—one to be kept at
hand, and the other to be given to the charge nurse or other responsible authority.
As a matter of fact, one of these patients was met in Perth and questioned by an
attendant about his increased liberty. He replied that he had my sanction, which
was unfortunately untrue, and afterwards caused remorse.

It is a curious fact that, after selling a property sixty years ago in
consequence of numbers being reduced, the asylum authorities have
taken an opportunity to buy the same back again because the numbers
are more than the asylum can contain.

The subjoined note is extracted from the Visiting Commissioner’s
entry. We do not find any mention of the subject in either the report
of the Managers or in that of Dr. Urquhart.

The charitable work of the institution, which, in terms of the Charter, is limited
to natives of the County of Perth, continues to be very extensively carried on.
Although the average cost of each patient is about £100 per annum, six are main¬
tained at ^30, three at ^40, one at ^45, twenty-one at £52, one at ^57, eighteen
at ^60, one at £ 63 , three at £ 70 , one at £ 72 , and one at £75. Thus fifty-six
patients are maintained at rates which are unremunerative. Many of these rates
are inclusive of the cost of clothing in addition to that of maintenance. Such a
laudable record as the above deserves recognition, not only because it is in itself

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EPITOME.

77 8

[Oct,

commendable, but in order to direct public attention to the serviceable functions
which are being performed by the institution.

Some Irish District A sy turns.

Down District. —Dr. Nolan notes that influenza has been very viru¬
lent, causing many deaths through an insidious form of pneumonia.
Phthisis, on the other hand, is a decreasing factor, thanks to the
vigorous steps that have been taken for some years in combating its
spread. The same success has attended prophylactic measures devised
against colitis, which was a great scourge at one time. Dr. Nolan
maintains that in the area a lessened occurrence of tuberculosis means
less lunacy, so intimate is the connection of the two diseases in his
view. The following remarks on the inspection of asylum laundries
appear to be appropriate:

The Asylum Laundry has also been inspected by H.M. Inspector of Laundries.
This inspection is necessitated by the extension to asylum laundries of the recent
Factories and Workshop Act. While it is, of course, desirable that even more
than the usual mechanical safeguards should be in use in asylum laundries, it must
be obvious that the general hygienic considerations in an asylum laundry should
not require lay inspection, inasmuch as the employment of the patients is regulated
with a view to their medical treatment and not for profit.

With a maintenance rate of ^22 in, per annum there must be
some skill required to justify the comments of the visiting Com¬
missioner.

In this Asylum, certainly due care appears to be taken that the men's clothing
and their persons generally are properly looked after. This refers not only to the
patients who are able to look after themselves, but also to the helpless and demented.
Amongst the women, efforts are made to minister to the natural pride in their
personal appearance, and so to maintain habits of self-respect.

Special clothing is supplied for wear on Sundays to both male and female
patients, thereby maintaining the customs of their early home life.

In the dining-hall the behaviour of both sexes was excellent. Both men and
women entered and took their seats at their respective tables without confusion,
and left the hall in proper order. The service of the meal was conducted with due
regard to decency and comfort. The dinner was excellent in quality, and appeared
sufficient in quantity, and the provisions which I saw could not be found fault with.

Limerick District .—With the exception of heredity, which was found
in nearly one quarter of the admissions, fright and nervous shock supply
the greatest amount of causation, being returned in eighteen (six male,
twelve female) cases out of 113 admissions. This is quite an unusual
proportion. Intemperance was found in only ten cases, all mala
Active mania accounted for more than two thirds of the admissions,
active melancholia accounting for nearly all the rest. In fact only three
chronic cases were admitted. General paralysis was entirely absent.

For many years past I have repeatedly drawn attention to the fact that insane
prisoners are sent in from the Limerick prison although not belonging to the
Asylum District. Act 38 and 39 Vic., Cap. 67, Sec. 10 entails that persons " from
and after the expiration of sentence must De regarded and treated in all respects as
if admitted to the Asylum as ordinary cases.” The local gaol being the prison for
the Counties of Clare and North Tipperary, lunatics from these counties com¬
mitted here, become, on expiration of sentence, chargeable to the City of Limerick.
Also, lunatics from these districts "found incapable of pleading " at Assizes are
committed. No doubt the cost of maintenance of the latter class is paid for by

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ASYLUM REPORTS.

77 9

1908.]

the Executive, but the accommodation required for the Asylum District is thus
encroached on. ' In January last a strong resolution was passed by the Committee
calling on other asylums similarly circumstanced to take action in the matter. A
copy of the resolution was sent to the affected asylums, the local M.P.’s and the
Irish Party. I would again strongly urge on the Committee the necessity of
seeking redress from this injustice.

Report of the Inspector-General of the Insane, New South Wales, for

the Year 1906.

Dr. Eric Sinclair reports the number of insane under cognisance as
5,525 on December 31st, 1906. These were mostly provided for in
the hospitals of the State, but a few were in licensed houses or South
Australian hospitals. The increase during the year was 248, while the
average annual increase for twenty years was 131. The variation in
these numbers from year to year is difficult to explain. The proportion
of insane to the general population was 1 to 277. Twenty-four were
reported as arrivals from other places to permit of recovery of cost of
maintenance. The recovery-rate was 38*11 per cent., while the death-
rate was 7*51 per cent There were sixty cases of general paralysis,
which is stated to have increased out of proportion to the increase of
population. Phthisis caused sixty-one deaths, although the patients
have been treated by separation in the open air. It is indicated that
suitable buildings for the tuberculous should be erected in the hospitals
for the insane.

Dr. Sinclair reports that further provision is being made for non-
certifiable patients within the grounds of the Reception House at
Darlinghurst. He hopes that the general hospitals of Sydney will, in
time, admit such cases to their wards. It is interesting to observe that
the Metropolitan Reception House, long ago established by the late
Dr. Norton Manning, has fully justified its maintenance, whereas the
house for the smaller district of Newcastle, however useful, is neces¬
sarily expensive in management. Dr. Sinclair deprecates the detention
of these cases in gaols. The scientific work of the department has
made progress and good results have been obtained.

The annual cost of the insane has somewhat increased, but the rate
per head has been lessened, the weekly charge, deducting collections,
having been 8 s. 8 \d.

Report on the Hospital for the Insane, South Australia,for the
Year 1907.

Dr. Clelland reports on the progress of the Parkside Asylum, which
contained private, pauper and criminal patients to the number of 1,019 on
December 31st last. That represents an increase of twenty-five during
the year. Twelve years have elapsed since the total number was 900,
contrasted with four or five years previously required for a similar
increase. Dr. Clelland believes that the latent insanity in the com¬
munity is not increasing, but aged and infirm cases arrive in greater
proportion than formerly. The percentage of recoveries reached the
satisfactory figure of 47*8 per cent., while the deaths represented 8*5
per cent.

LIV. 55

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7 8o

NOTES AND NEWS.

[Oct.

The daily average cost was is. 5 id., the smallest since the year 1900.
We are glad to note that two nurses and one attendant passed the
examination of the Lunacy Department, after a three years’ course of
study and training. The regulations of the Medico-Psychological
Association and their examination papers were adopted.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The sixty-seventh annual meeting of the Medico-Psychological Association was
held in London, at 11, Chandos Street, Cavendish Square, W., on Thursday and
Friday, July 23rd and 24th, 1908.

The proceedings commenced at 11 a.m., and Dr. P. W. MacDonald, the
retiring President, occupied the chair.

Present, the following seventy-six members : S. H. Agar, W. Bevan-Lewis,
G. F. Blandford, C. H. Bond, D. Bower, G. M. P. Braine-Hartnell, J. F. Briscoe,
L. C. Bruce, J. Carswell, J. Chambers, R. H. Cole, H. Corner, M. Craig, W. R.
Dawson, T. Drapes, F. W. Edridge-Green, F. A. Elkins, J. A. Ewan, W. F.
Farquharson, C. H. Fennell, N. J. H. Gavin, B. Hart, W. H. Haslett, H. E. Haynes,
J. W. Higginson, H. G. Hill, R. D. Hotchkis, T. B. Hyslop, T. Johnstone,
Robert Jones, N. T. Kerr, A. B. Kingsford, W. H. C. Macartney, H. C. MacBryan,
O. F. M'Carthy, P. W. MacDonald, T. W. McDowall, A. McDougall, H. J.
Macevoy, E. D. Macnamara, Mary E. Martin, C. Mercier, J. Merson, W. J.
Mickle, J. Middlemass, A. Miller, C. S. Morrison, H. Hayes Newington, F. W.
Nutt, D. Orr, M. E. Paul, Bedford Pierce, E. Powell, R. W. Prentice, D. F.
Rambaut, H. Rayner, W. Rawes, J. M. Rhodes, G. A. Rorie, R. G. Rows, E. F.
Sail, E. H. O. Sankey, G. H. Savage, G. E. Shuttleworth, H. Smalley, R. Percy
Smith, R. H. Steen, J. Stewart, R. J. Stilwell, W. H. B. Stoddart, D. G.
Thomson, A. R. Turnbull, A. R. Urquhart, F. Watson, T. O. Wood, D.
Yellowlees.

Visitors: Drs. H. B. Donkin and G. H. Martin (San Francisco).

Apologies for absence were received from: Drs. B. J. Alcock, J. S. Bolton,
F. StJ. Bullen, H. Clarke, H. G. Cribb, G. Dickson, K. L. Donaldson, C. C.
Easterbrook, G. S. Elliot, C. T. Ewart, F. C. Gayton, E. Goodall, J. T. Hingston,
W. W. Ireland, G. E. Mould, H. C. Marr, M. J. Nolan, W. A. Parker, E. C.
Rogers, H. Roscoe, P. C. Smith, W. R. Watson, H. B. Wilkinson.

The President (Dr. MacDonald) said the minutes of the last annual meeting
had already appeared in the Jourrwl of Mental Science, and it might be the wish
of the meeting to take them as read. This was agreed to, and they were duly
signed.

The next business was the election of Officers and Council for the coming year.
He nominated as scrutineers for the purposes of the ballot Dr. Turnbull, Dr.
Middlemass, Dr. Steen, and Dr. Dawson. In regard to the two representative
members of Council from the Irish Division, it was found that Dr. Nolan and Dr.
Drapes had to retire owing to their having served three years. The Irish Division
wished to substitute for those two gentlemen Dr. W. Graham and Dr. James J.
Fitzgerald.

Agreed to.

On the agenda, under the heading *' Examiners for the Nursing Certificate/'
Dr. Turnbull's name appeared without the qualifying words “for one year."
Owing to the lamented death of Dr. Conolly Norman the vacancy had to be filled

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NOTES AND NEWS.

781

1908.]

for one year, and the Educational Committee asked Dr. Turnbull if he would
carry out that somewhat thankless task for another year. Dr. Turnbull kindly
consented.

Agreed.

The President stated that the scrutineers had announced that the ballot had
been unanimous in favour of the officers and members of Council whose names
appeared on the ballot paper.

Appointment of Auditors.

The President said it was necessary for the meeting to appoint two auditors for
next year. The gentlemen at present filling that office were Dr. Hyslop and Dr.
Thomson. The former retired, and the latter was promoted. The gentleman
appointed should be resident somewhere near London.

Dr. Craig proposed Dr. Steen.

Dr. Thomson seconded, and it was agreed to

Election of Standing Committees.

Parliamentary Committee .—The President then put the list of names to form
the Parliamentary Committee. It was carried as shown on the agenda, with the
addition of the names of Drs. James Chambers and P. T. Hughes.

Educational Committee .—This list of names, as shown on the agenda, was carried
with the addition of the names of Drs. James Chambers, James Middlemass, D. Orr,
R. G. Rows and D. G. Thomson.

Dr. Yellowlbes drew attention to the size of these Committees, which he stated
he believed to be too large and very unwieldy. He thought that a man who did
not attend their meetings ought not to remain on the list.

Dr. Briscoe supported this view.

The President said that no doubt the remarks which had been made would
come under the cognisance of the Nominations Committee next year, and possibly
they would deal with the matter in a more ruthless fashion.

Library Committee .—The four members whose names appeared on the agenda
were elected to form this Committee.

The Treasurer's Report.

The Treasurer said that his Report had been sent round. He regretted that
the last year was not such a good one, financially, as the year before. That was
partly due to the shrinkage of receipts from examination fees, but chiefly in the
miscellaneous expenditure. The major part of the increase had gone in the
preparation of the lithographic stones for printing the sets of tables which had
been circulated round the asylums in connection with the new statistical scheme.
In the present year there was nothing to cause any particular expense. And this
year, as shown by the return he had just received from the Registrar, the number of
candidates for examination had gone up considerably, and the income would no
doubt increase. Every now and then he had made it his custom to give a statement
as to the condition of the Gaskell Prize Fund in addition to his ordinary Treasurer's
Account. That fund was now assuming very large proportions. It began with
^1,000, contributed by the friends of Mr. Gaskell, Commissioner. Those friends
subsequently gave another j&joo, making it up to £1,300 odd of stock. Since
then, out of accumulations, the Association had invested another £300, and there
was now in the hands of the Association a further sum of £167 195. 8 d. t which
would have to be transferred to the Fund at some later time, also a sum of some
£6 as deposit account. That went on from year to year. To-day the Council
had been informed there was again no candidate for the prize provided by the
Fund. At times consideration had been given to the possibility of spending the
money; but the terms of the Trust Deed were rather strict, and it did not seem
possible, without going to Court, to get the provisions altered. So he supposed
the Association must go on laying the money up for no good purpose until such
time as the Council took the matter into more serious consideration and appointed
a committee to decide whether it was worth while to go to the Court, with the

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THE MEDICO-PSYCHOL OGICAL ASSOCIATION- For the Year 1907.

REVENUE ACCOUNT— January ist to December 31st, 1907. _

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Oct., 1908.]

NOTES AND NEWS.

783

THE GASKELL MEMORIAL FUND.

1903-

£ s.

Examination fees (1902)

... 4

July, Balance

•• 94 3

Do. (1903)

... 4

Dec. 31st, Balance...

... 85

£94

£94 3

1904.

July, Examination fees

Jan. 1st, Balance.

85 5

Dec. 31st, Balance

.. 127

Dividends ...

46 0

£13*

£131 5

1905-

March 30th, by purchase of

Jan. 1 st, Balance.

127 I

N. S. Wales 3 per cent.

Dividends.

50 14

Stock .

.. 30°

Cash from Deposit Account

17S 0

Dec. 31st, Balance

• • 5 *

£352 IS

J& 35 2 IS

1906.

Aug., Prize (Dr. Ruther-

Jan. 1st, Balance.

51 17

ford) .

• 35

Dividends.

55 10

Examination Fees...

Medal .

Printers .

Dec. 31st, Balance

. 61

^107

£107 8

1907.

Dec. 31st, Balance

.. 117

Jan. 1 st, Balance.

6l 14

Dividends.

55 10

j£h 7

£”7 5

1908.

July 23rd, Balance

.. 167 19

Jan. 1st, Balance.

i *7 5

Dividends.

50 14

£167 19

Since the Annual Meeting £150 of the balance, reported above, has been placed
in the Deposit Account.

The funds of the Gaskell Memorial Trust are represented on October 1st,
1908, by—

New Zealand 3^ per cent. Stock ... ...£1380 14 3

New South Wales 3 per cent. Stock ... ... 337 11 o

Deposit Account at Bank ... ... 156 1 5

In the hands of the Association ... ... 17 19 8

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7 « 4

NOTES AND NEWS.

[Oct,

sanction of the friends of Mr. Gaskell, for permission to adopt some more
favourable scheme. He laid the Report on the table, also the account books and
bank pass book, in case any member wished to inspect them.

Dr. Clouston asked whether it would be competent for him to move a resolu¬
tion to the effect that the Educational Committee be requested to take into con¬
sideration the question of the re-arrangement of the terms on which the Gaskell
Prize was at present awarded.

The President said it would be quite in order.

Dr. Clouston said he desired a recommendation on the subject to go from
that meeting to the Council. He saw no object in delaying the matter indefinitely.
Apparently there was at present a large sum of money of the Fund unused, and
at the Council there had ensued a discussion on a means of exciting interest and
stimulating assistant medical officers of asylums to do more work than some of
them at present seemed inclined to do. As there could be no reason for delay, he
moved “ That the Educational Committee be requested to consider, and if thought
fit, bring forward a scheme in regard to, the Gaskell Prize Fund.” He was willing
to put the resolution into the terms most likely to result in carrying out what was
desired.

Dr. Stewart seconded, and it was carried.

Dr. Craig asked whether those terms would empower the Committee to go to
counsel for opinion and guidance. That was really the difficulty, because nothing
could be done in the matter without legal advice. It was necessary for the
Educational Committee to receive authority to obtain legal advice.

Dr. Stewart suggested that Dr. Clouston should add to his motion the words
“ With power to consult counsel, if necessary.”

Dr. Craig said he thought that was the Treasurer’s view also.

Dr. Clouston said he would be very happy to accept the suggestion.

The resolution, with this addition, was then put and carried.

Auditors’ Report.

Dr. D. G. Thomson said his colleague (Dr. Hyslop) and himself spent some
time in going over the accounts, and found them to correspond with the state¬
ment which had been presented by the Treasurer.

The Report or the Editors.

The Editors have no special matters to report in connection with the publication
of the Journal beyond the fact of a further increase in the number of copies printed
to noo. This increase was considered to be desirable from the advance in the
number of members, the greater number of changes in membership, and some
indication of a greater demand for back numbers, the stock of back numbers for
some years having been exhausted.

The grievous loss sustained by the Editors by the death of Dr. Conolly Norman
has already been dwelt on in the Journal. No adequate expression of our
appreciation of Dr. Norman, as a co-worker or of his services to this Journal, could
be conveyed within the limits of this report.

The Editors have again to express their thanks to Dr. Lord for his valuable aid
in connection with the “ Epitome,” which is yearly increasing in interest.

Henry Raynkr.

A. R. Urquhart.

James Chambers.

Dr. Urquhart, in the temporary absence of Dr. Rayner, submitted the Editors'
Report. He moved its adoption, which was seconded by Dr. Craig and carried.

REPORTS OF THE THREE STANDING COMMITTEES.

Report of Educational Committee.

The President reminded the members that this report had been circulated
among them, but he believed Dr. Craig desired to make a correction and some
additions.

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1908 .] NOTES AND NEWS.

785

Report of the Principal Work of the Educational Committee since
the Annual Meeting, 1907.

The following is a brief account of the work done by this Committee up to, and
including, the last May meeting:

The Educational Committee have held the usual number of meetings during
the year, and have had several important matters under consideration. Amongst
other subjects the following have been dealt with:

They make the following recommendation re the Nursing Certificate Examina¬
tion :

Recommendation re Nursing Certificate, to be Confirmed by the
Annual Meeting.

At the Annual Meeting, 1906, the Educational Committee made a proposal
that the Nursing Examination be divided into two parts, to be taken at different
times in the period of training. The idea of such a division was agreed to in
principle, and the scheme was referred back to the Educational Committee for
elaboration and detail. The Educational Committee, in November, 1906, re¬
appointed the original Sub-Committee, and gave it instructions to draw out a
scheme as requested by the Annual Meeting.

The Sub-Committee made their report, and it was printed and privately issued
to all members of the Educational Committee. The report was fully considered
by the Educational Committee at their meetings in May, July and November,
1907, and in May, 1908, and several important amendments were made.

It is recommended :

(а) That a candidate shall be eligible for the First Examination after twelve

months of training and attendance on one course of at least twelve
lectures.

(б) That a candidate who has passed the First Examination shall not be

eligible for the Final Examination until after completing three full years
of training and having attended three courses of lectures of not less than
twelve in each course, and that at least one course of lectures shall be
taken subsequently to passing the First Examination.

( c ) Any candidate who has been referred back in either of the examinations

shall not be admitted for re-examination until he or she has attended a
further course of practical or other instruction.

( d ) That a candidate for the First Examination shall be examined in:

(1) Anatomy and Physiology; (2) First Aid.

(1 e) That a candidate for the Final Examination shall be examined in :
(1) Bodily Diseases and Disorders; (2) Sick Nursing and Hygiene;
(3) Mental Diseases and Mental Nursing.

(/) That each examination consist of a written and vivd voce portion.

{g) That the vivd voce in each examination be divided into an Oral and a
Practical portion ; and that the vivd voce examination should be not less
than ten minutes in length. This should be extended, if necessary, in
order to make it thorough. Candidates must show a competent know¬
ledge in both the Oral and the Practical portions.

( h) That the Written and the vivd voce portions of the Examination be
regarded as separate, and candidates must satisfy the Examiners in both.

The Educational Committee consider that the present system of reporting
candidates as “ passed ” or “ failed ” in both the vivd voce and the Written portions
of the Examination is the only practical way of marking. Nevertheless, for the
instruction of the Examiners of the Written and vivd voce portions, it should be
understood that no candidate should be reported to the Registrar as “ passed ”
unless the candidate has obtained the equivalent of 50 per cent . in general
accuracy in answering in each branch.

The Educational Committee consider that the present style of questions is
satisfactory, but it is decided that no question in the written portion of the
examination should be on any subject that is not referred to in the Handbook,
and that the questions should be framed in such a way as to bring out whether or
not that candidate has a proper understanding of the subject asked.

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786

NOTES AND NEWS.

[Oct,

The Educational Committee recommend that in Rule 9, sub-section (g), of the
Nursing Rules the words “ a senior ” be deleted and replaced by “ an/’ and in the
following line the word “ five ” be replaced by “ three ”; so that the Rule will run
as follows:

“ The Coadjutor shall be the present or past Superintendent, or the Acting
Superintendent of another Institution, or in the event of the inability or
refusal of any of these to act, an Assistant Medical Officer of not less
than three years* standing who is a member of the Medico-Psychological
Association, and in all cases must be approved by the President cf the
Association.”

It is further recommended that these Rules be not put into force until the
revised edition of the Handbook is published.

It is recommended that all candidates coming up for re-examination for the
Nursing Certificate should pay a fee of 5 s. t as at the First Examination.

The whole subject of the remuneration of the Examiners for the Nursing and
the Professional Certificate has been under review, and important changes are
recommended. It is considered advisable that the Examiners for the Nursing
Certificate should be paid a fixed sum, and not per paper examined, as is the case
at present; and it is recommended that this sum be Twenty Guineas per annum
for each Examiner.

It is recommended that for the Professional Examination each Examiner shall
receive Two Guineas per examination in which he takes part.

The Sub-committee, who have been preparing the new Handbook, have made
good progress with their work, and most of the book is already in print.

A Sub-committee has been sitting to consider "the advantages arising from
examining candidates, in the Final Examination for medical degrees, in mental
diseases.” No report has yet been received, but it is hoped that it will be ready
to bring before the Annual Meeting.

It has been decided by the Council on the recommendation of the Educational
Committee to publish, in pamphlet form for sale, one hundred questions selected
from the Nursing Examination papers set during recent years.

The Registrar reported that 148 candidates entered for the Nursing Examina¬
tion in November, 1907, and that 100 passed.

The percentage of failures in the Written portion of the Examination was 18
per cent., and for the Practical portion 9 per cent.

The Registrar reported that 669 candidates entered for the Nursing Examina¬
tion in May, 1908.

The percentage of failures in the Written portion of the Examination was
22 per cent., and for the Practical portion 18 per cent.

(Signed) Charles Mkrcier, Chairman .

Maurice Craig, Han. Sec.

Dr. Craig said that he desired that the paragraph dealing with the work of the
Committee upon criminal procedure should be deleted. The latter was a special
committee and their report would appear separately. He added that the Registrar
reported that 669 candidates presented themselves for the nursing examination in
May last, and of this number 434 passed, 223 failed, and 12 withdrew (66 per cent.
passed, 34 per cent, failed). He reported that there were 8520 certificates on the
register. Eight candidates entered for the medico-psychological certificate, all of
whom passed. One essay was received for the bronze medal, and it has been
awarded to Dr. Carlisle Howard, Assistant-Physician Perth District Asylum.

The Handbook Sub-committee handed in the following report, which was
received and adopted:

"The Handbook Sub-committee regrets that it cannot lay the completed
work on the table, but it is able to report that the whole of it is in print
with one or two minor exceptions, such as the index. The Sub-committee
have used the funds allowed to it by the Council in order to have a
literary revision and an index prepared, and, further, an authoritative
opinion has been obtained on some debatable points.”

He concluded by moving the adoption of the report.

Dr. Milsom Rhodes seconded.

Dr. G. Thomson asked what was to be inferred from paragraph 5, page 3, of
the Report: A sub-committee has been sitting to consider “ the advantages arising

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NOTES AND NEWS.

787

1908.]

from examining candidates in the final examination for medical degrees in mental
diseases .” No report has yet been received , but it is hoped that it will be ready to
bring before the annual meeting . Was it intended to bring that before the
meeting now ?

Dr. Craig replied that that matter had been considered. The report which had
been sent in by the sub-committee was a very excellent one, but the content of it
was regarded as of such importance that the Educational Committee wished to
consider it further before making any recommendation upon it.

The President asked for any further comments, and, as there were none, he
put the motion for the adoption of the Report, and it was carried.

Parliamentary Committee.

Report for the Year 1907-1908.

The Parliamentary Committee has met four times this year. It has been chiefly
occupied in trying to advance the appointment of a “ Minister of Public Health,”
but its endeavours have met with little success at present. The British Medical
Association, and all examining bodies in England, Scotland, and Wales, have
been communicated with, but none have exhibited any disposition to act in the
matter.

The Commissioners’ circular relating to the Factory Acts was also considered
and reported on to the Council at the May meeting.

(Signed) David Bower, Chairmnn.

June 20th, 1908. H. Wolseley-Lewis, Secretary .

The President said that a meeting of this Committee had been held the
previous day, but he was not sure whether there was anything to add to this report,
which had already been circulated.

Dr. Bond said there was one other point which arose at the Parliamentary
Committee's meeting of the previous day, namely, consideration of the present
position of pensions. The matter had been the subject of correspondence between
the Parliamentary Committee and the Asylum Workers Association, and allusion
was made to certain asylum officials who had recently, on taking up their appoint¬
ments, been asked to sign an undertaking that they waived their claim to a pension.
A sub-committee had been appointed by the Parliamentary Committee to consider
how far that was legal.

Dr. Briscoe said he desired to point out an error in the Parliamentary Com¬
mittee’s report. He saw it was stated that the British Medical Association had not
exhibited any disposition to act in the matter concerning the appointment of a
Ministry of Public Health. The fact was that the British Medical Association
took it up in 1904, and it was discussed at meetings of the Southern Branch. He
was Chairman of the Winchester Division of the Southern Branch, and he
naturally took a good deal of interest in the subject. He had heard from the
Secretary of the British Medical Association that that Association leaned very
strongly towards the 1 ; appointment of a Public Health Officer. He would like to
read to the meeting a very short minute of the British Medical Association-

The President : What is it you complain of in this report P

Dr. Briscoe : It is incorrect.

The President-. In what respect is it incorrect?

Dr. Briscoe stated it was incorrect in saying that the British Medical Associa¬
tion had not exhibited any disposition to act in the matter. He did not remember
having received any communication from the Medico-Psychological Association on
the matter, although Dr. Bower called upon him once, and he explained the matter
to him. There was a memorandum published by the British Medical Association,
and if the President or the Secretary of the Medico-Psychological Association
would write for a copy it would be sent. It stated: “ It is therefore considered
that the co-ordination and central administration concerning matters of public
health would best be effected by entrusting all duties of the kind to the Local
Government Board.” He apologised for interrupting.

The President said that was the very point which he thought Dr. Briscoe was
coming to. The British Medical Association did not view the matter from the
same standpoint as did their own Association. The former wished to place it
under the Local Government Board, but their own Association asked for a special
Minister of Public Health, quite outside the Local Government Board.

Digitized by L^ooQle

788

NOTES AND NEWS.

[Oct.

Report of Library Committee.

This was as follows :

Books Added.

Barr .—Mental Defectives . 1905.

Clouston .—Hygiene of Mind . 1906. (Presented by Author.)

Jones, R .—Mental Nursing. 1908. (Presented by Author.)

Report of the Royal Commission on the Feeble-minded. 1908.

Tredgold, A. F .—Mental Deficiency. 1908. (Presented.)

Wilson.— Education , Personality , and Crime. 1908.

Ziehen.— Psychiatry. 1908.

Also the usual journals, exchanges, and review copies sent here by the editors of
The Journal of Mental Science.

The Library has been well used both for reference and for home reading.

H. Rayner.

R. H. Cole.

T. Outterso.n Wood.

The report was adopted.

Report of the Council.

The number of members—ordinary, honorary, and corresponding—on December
31st, 1907, was 690, which is an increase of five as compared with the corresponding
figure for the previous year.

The following table shows the membership during the past decade:

Members.

1898

li »99

1900

1901

190a

1903

1904

1905

>gc*

1907

Ordinary

540

550

568

580

586

597

620

641

638

645

Honorary

3 2

Corresponding

12 !

1 >0

15!

Total

590

598 1

616

628

635

64s

670

688

68 S

690

From this it will be seen that the ordinary membership has increased by seven,
the honorary members are less by two, while the number of corresponding members
remains unchanged.

The number of new members continues very satisfactory, as many as thirty-nine
having been registered during last year, while the names of two former members
were replaced.

The Council regrets to have to chronicle the deaths of three honorary members—
Dr. Charles 'Fhrh, Sir William T. Gairdner, K.C.B., and Dr. A. E. MacDonald,
and of four ordinary members—Drs. J. Forsyth, A. T. Abbot, F. R. Dickson, and
R. A. L. Graham.

The usual quarterly meetings were held in February, May, and November. That
in February was, by the courtesy of Dr. Miller, held at Warwick County Asylum.
The standard of the papers read has been well maintained and the attendance
unusually good.

Eleven Divisional meetings were held.

The possibility of a change in the future accommodation of the Association and
its library was again reported upon at the last annual meeting. The special Com¬
mittee dealing with this matter was re-appointed, with power to negotiate. Since
then no action has been necessary.

The Workmen’s Compensation Act Committee at the last annual meeting issued
a valuable report embodying numerous points of useful information.

Following the action against a member of the Association, a Criminal Procedure

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NOTES AND NEWS.

1908.]

789

Committee was appointed last July to consider the present practice in relation to
the question of the alleged insanity in accused persons and other allied matters.
Its three sub-committees have held meetings, and the Committee, as a whole, are
reporting to the present annual meeting.

The Factory and Workshops Act of 1907 was the subject of discussion at the
February meeting, and a resolution was passed to the effect that in the opinion of
the Association it was undesirable that asylums should be brought under the
provisions of the Factory Acts.

The Educational Committee, under the chairmanship of Dr. Mercier, presents
its report. Its work, which has included the revision of the regulation for the
nursing certificate, has been very heavy.

The Parliamentary Committee, now under the chairmanship of Dr. Bower—Dr.
Ernest White having resigned after three years’ service as chairman—also presents
its report.

The question of the most convenient week-day in which certain of the Associa¬
tion’s meetings should be held has been under consideration, and after a general
referendum it was resolved that the majority of the meetings, including the May
meeting, should be held on Tuesdays. In this connection the thanks of the Associa¬
tion are due to the Treasurer for much time spent in endeavouring to secure better
terms from the railway companies.

The Journal continues much appreciated and its circulation satisfactory. Its
editorship has sustained a severe loss in the lamented death of Dr. Conolly
Norman.

The Library Committee’s useful work continues.

The finances of the Association remain in a sound position under the able and
vigilant administration of the Treasurer.

The number of entries for the nursing certificate was again slightly less than the
past two years. But the Registrar’s duties continue very heavy, and as heretofore,
to him, to the Divisional Secretaries (who have assiduously promoted the success
of their respective divisions), and other officers, the hearty thanks of the Association
are due.

The General Secretary read the report and moved its adoption.

Dr. Stewart said he had much pleasure in seconding the motion for adoption,
and took the opportunity of remarking how great was the obligation which ordinary
members of the Association were under to the Council and the Committees for the
work they had done. It was obvious that a good deal of time must be spent in
connection with all the details, and those who did not work on those Committees
perhaps did not take sufficient cognisance of the self-sacrifice shown by the
members of those Committees. He wished to allude to one matter which had
been brought to his notice by some members who had not the courage of their
convictions. He had. There were many men, like himself, who had long been
members of the Association, and having contributed something like forty guineas
to the Association by paying their guinea each year, some consideration should be
given by the Council to the question of whether a life-membership should not be
established as was the case in other associations, such as the Medical Society of
London. He asked that the Council would consider the suggestion before the
next annual meeting.

The report was then put, and agreed to.

REPORTS OF SPECIAL COMMITTEES.

Report of Criminal and Civil Procedure Sub-Committee.

The respective Sub-Committees for Great Britain and Ireland appointed re
criminal and civil procedure have held several meetings and have collected
together much valuable material, but it has been impossible yet to formulate any
definite opinions or to make any recommendations. It is therefore desirable that
these Sub-Committees should be re-appointed with power to co-opt to their
numbers. They further ask that a sum not exceeding £25 should be granted to
meet any expenses that they may incur in the matter of printing and circulating
reports, etc.

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790 NOTES AND NEWS. [OcL,

Dr. Craig submitted this report, and moved that it be received and adopted.

Dr. Milsom Rhodes seconded the motion, and drew attention to a flagrant case
which took place last week in the Leeds murder case. A man killed a woman by
chopping her head off and was surprised in the act of cutting off her right arm,
another man threatening to kill him with a crowbar if he did not desist. The
murderer then turned quietly round, lit a cigarette, and began smoking it. He
then picked up the woman’s corsets and said he could sell them for half-a-crown,
picked up her umbrella and said it would fetch 7s. 6 d. At the trial three mental
experts were called, and they said he was insane. Yet the jury found—and the
judge appeared to agree with them—that he was guilty of wilful murder, and the
man was now lying under sentence of death. It was monstrous that such a thing
should be possible in this country at the present time, and he urged upon the
Committee not only to consider what they were doing, but to go to the Home
Office to see if some alteration could be made. The Lunacy Commissioners had
drawn attention to it, as had several other people, and he declared that our
criminal law as it at present stood was a disgrace to the Statute Book.

Dr. Urquhart, in supporting the motion, said he would like to explain in a few
words the actual state of matters. Some ten years ago the Association had a very
important committee to consider that question, and after two years’ work and long
debates the net result was that, although they did not approve of the state of the
law, they had, at that time, no suggestion to make for its amendment. But in the
course of last year another committee was appointed, and it was thought well to
have it representative of all three Divisions of the Kingdom, as the law was so
different in those Divisions. After a year’s work they found themselves unable to
report at great length to-day, and they had requested re-appointment for another
year, before those very important and intricate legal matters could be fully
considered.

The report was then put and adopted.

Motions Involving the Expenditure of Funds.

The President said he had been informed by the Treasurer that there were no
such motions.

Fixing Dates of Annual and Quarterly Meetings.

The President said a suggestion had been made that the meeting provisionally
fixed for Tuesday, November 24th, should be altered to Thursday, November 19th.
That came before the Council, and they recommended the alteration. This and
the other dates were then agreed to.

Dr. Thomson said that arising out of Section F, fixing the date of the annual
meeting, he would like to offer a suggestion.

The President said that was usually left to the Council.

Dr. Thomson said he would like to suggest that it be an instruction to the
Council that, if possible, next year the meetings of the Association should not clash
with the opening meeting or with other meetings of the British Medical Association.
Not being Jekyll and Hyde, he could not be in two places to-morrow, and therefore
he felt a great sense of disappointment that he could not attend both the present
annual meeting and the meeting of the British Medical Association. He put it
forward as a suggestion to the Council.

The President said he could sympathise with Dr. Thomson, but unfortunately
it arose "bwing to the fact that the representative meeting of the British Medical
Association fixed up two or three days more than it used to do for its annual
meeting. So the Medico-Psychological Association would have to go either
backwards or forwards ten days if its annual meeting was to escape that of the
other Association.

Dr. Thomson said it needed only an alteration of one day.

The President said he felt sure that the President-elect, when he succeeded to
the office, would bear the suggestion in mind.

Dr. Thomson thanked the President, remarking that that was all he wished.

Dr. Mercier said he was somewhat responsible for the situation, owing to an
attempt to get particular speakers for the dinner.

Digitized by L^ooQle

1908.]

NOTES AND NEWS.

791

Ballot for New Members.

A ballot was then taken for the following ten gentlemen who had been proposed
for election as members of the Association. They were unanimously elected :—
Anderson, James Richard Sunner, M.B., Ch.B.Glasg., Senior Assistant Medical
Officer, Cumberland and Westmorland Asylum, Carlisle (proposed by W. F.
Farquharson, G. F. Barham, and C. Hubert Bond) ; Blandy, Gurth Swinnerton,
M.B., Ch.B.Edin., Assistant Medical Officer, Middlesex County Asylum, Napsbury,
Herts (proposed by T. O’C. Donelan, R. H. Steen, and C. Hubert Bond) ; Ellison,
Arthur, M.R.C.S., L.R.C.P.Lond., Deputy Medical Officer, H.M. Prison, Leeds;
120, Domestic Street, Holbeck, Leeds (proposed by John Exley, T. S. Adair, and
Harold R. Cross); Geale, William James, L.R.C.S.&P.Edin., L.F.P.S.Glasg.,
Assistant Medical Officer, Scalebor Park, Burley-in-Wharfdale, Yorks (proposed
by J. R. Gilmour, G. F. Barham, and C. Hubert Bond); Inglis, J. P. Park, M.B.,
Ch.B.Edin., Assistant Medical Officer, Borough Asylum, Canterbury (proposed by
E. F. Sail, N. Navarra, and R. H. Steen) ; Litteljohn, Edward Salteme, M.R.C.S.,

L. R.C.P.Lond., Assistant Medical Officer, London County Asylum, Hanwell, W.
(proposed by Percy J. Baily, H. Hayes Newington, and C. Hubert Bond); Morton,
John Hall, M.D., B.Ch., B.A.O., Univ. Dubl., Assistant Medical Officer, Hatton
Asylum, Warwick (proposed by Alfred Miller, Arthur W. Wilcox, and W. F.
Samuels) ; Rodgers, Frederick Millar, M.B., Ch.B.Vict., D.P.H., Senior Assistant
Medical Officer, Lancashire County Asylum, Winwick (proposed by Alexander
Simpson, G. F. Barham, and C. Hubert Bond) ; Rolleston, Charles Ffrance, B.A.,

M. B., B.Ch., B.A.O., Univ. Dubl. (Assistant Medical Officer, County of London
Manor Asylum), Horton Manor, Epsom (proposed by W. J. Donaldson, G. F.
Barham, and C. Hubert Bond); Tattersall, John, M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, London County Asylum, Hanwell, W. (proposed by
Percy J. Baily, H. Hayes Newington, and C. Hubert Bond).

Dr. Thomson’s Motion.

Dr. Thomson formally proposed the following resolution, of which he had given
notice, and which appeared on the agenda:

“That for the more efficient teaching and training of the coming
generation of alienists in psychiatry, the Medico-Psychological Associa¬
tion—in the first instance through its Education Committee—consider
some scheme for post-graduate teaching and training, with or without
the imprimatur of a diploma given after such a course (with or without
examination) with a view to its being brought before the Universities and
other qualifying and teaching bodies.”

He said he did not think there was any need to take up much of the time of the
meeting by any remarks on the motion because it had been twice before the
majority of the members in abstract, printed among abstracts of papers. Further,
the Editors of the Journal had kindly published an expurgated edition of his short
paper in the July issue. He wished to add, however, that three months’ further
consideration of the subject had convinced him more than ever of the importance
of taking some action on the motion. In the discussion he would like the question
of asylum administration to be kept out as much as possible because that was not
quite the point touched on, and its consideration would come later on. The whole
point of his motion was that they should catch their men young, and train them
properly at that stage, just as other specialists were trained, such as medical
officers of health, military and naval men, and so on. The rest would follow. He
mentioned that, because at the discussion on his paper, which was reported in the
July Journal, speakers went into details concerning the co-existence of adminis¬
trative capacity with purely medical capacity. He aid not regard that as germane
to the subject at all. Members of that Association were primarily specialists in
mental disorders, and he maintained that they ought to be trained as such. He
moved the motion standing in his name.

Dr. Clouston said he had great pleasure in seconding Dr. Thomson’s motion.
As yet the idea foreshadowed by Dr. Thomson was somewhat vague, but all
present understood what he meant, and it was certainly worth while to refer it to
the Educational Committee to have it thoroughly thrashed out, and have the great

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792

NOTES AND NEWS.

[Oct,

question of the special study of psychiatry among assistant medical officers of
asylums taken into consideration, and if possible, some concrete scheme submitted
to the Association. No doubt there were many difficulties in the matter, and he
imagined that the chief one was that there existed already quite enough difficulty
in getting assistant medical officers, whether trained or untrained ; and if anything
were added to the qualifications required of them probably the market for such
assistants would still further decline and they would not be able to get assistant
medical officers at all. However, Dr. Thomson, both in his speech and in his
paper, rather foreshadowed that it should not be a kind of qualifying examination
for the admission of asylum medical officers, but a course of study which they
should take up after being assistant medical officers of an institution. Probably
that would be by far the better mode of tackling the subject. (Hear, hear.)
There could be no doubt of the need of instilling into everybody who entered
asylum service the scientific spirit. The only possible means by which our
reputation as a nation for the study of psychiatry would be advanced would
be to get our young men keenly interested in that subject. It was beyond doubt
that there was plenty of ability. And that being so, why should they not
proceed to train it on the right lines in their own specialty ? He did not wish to
occupy much of the time of the meeting. Everybody was convinced—as he was
himself—that it would be a very good thing if a practical scheme could be
administered. It was known that the Army allowed the medical officers in the
Indian Medical Service time for special study, and the same thing could probably
be arranged for in institutions if assistant medical officers were allowed to go to a
medical school for three months in the summer once in two or three years for post¬
graduate study. It could not fail to add enormously to their usefulness and
efficiency.

Dr. Lewis Bruce wished to support Dr. Thomson’s motion, as he thought it
a most desirable thing that the younger men of the specialty should have a chance
of being educated and being capable of doing good work in such a tremendous 6eld
as that of psychiatry. He did not agree with Dr. Clouston’s view that if men were
better trained for the work there would be a greater difficulty in getting assistant
medical officers for asylums. He knew from personal experience, and from talking
with young men who had been in asylum service and left it, that they left it because
there was a lack of interest in the service; they saw no chance of advancemenL
That state of affairs could not be improved because, on the average, only one of
four assistants got promoted to a medical superintendency. What, therefore, was
to become of the other three ? They must become what were known as " chronics”
in asylum service, which was not desirable; or else they must be in a position to
acquire knowledge which would help them in other branches. That was where
Dr. Thomson’s scheme would come in so well; it would make the service much
more attractive than at present. If a man, after taking two or three years of
asylum service, left that service after acquiring a store of knowledge, not necessarily
a knowledge of psychiatry, but such as would enable him to devote himself to
clinical work of various sorts, he would be a very much more valuable man and
more likely to obtain a billet outside the specialty than a man who had been three
or four years in an asylum and did nothing to improve his knowledge, who did
nothing but go his rounds, and allowed his medical knowledge to rust. He could
speak, also, from the experience of men who had been with him, who went in for
the Indian Medical Service and passed well, merely in consequence of the work
they had done off their own bat in an institution.

Dr. Bevan Lewis said he had the greatest appreciation for the motion and the
way it had been framed and advocated by Dr. Thomson, as well as for the manner
in which the meeting had received it. And in criticising it he hoped he would
not be regarded as captious, nor as regarding with pessimism the great difficulties
which stood in the way. Until those difficulties had been removed he did not think
much advance would be made. Why was it that at present they had, by implica¬
tion, to charge our asylums with a certain degree of stagnation in the medical spirit?
He could indicate two, perhaps three, difficulties which were present and accounted
for that stagnation. First, there was the passing of the clinical assistant—a very
important matter. Again, he would indicate the extension—and the very large
extension—of the medical curriculum, and the overwhelming amount of work which
the assistant had to take in hand. The third point, and one of very great difficulty.

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1908.]

was the paucity of those institutions which would afford their young men what he
looked upon as the absolutely essential foundation for their study as psychiatrists,
namely, their attendance at hospitals for general mental and nervous diseases, such
as that at Queen Square. That, above all things, formed an essential element in
the education of the alienist physician. With regard to the passing of the clinical
assistant, he would refer to the resident assistant who had been in asylum service
for nine, twelve, or eighteen months. At Wakefield, as probably many knew, under
Sir James Crichton Browne, his successor, Dr. Herbert Major, and himself, there
had been a constant passage through the wards of men who, though doubly qualified
and unpaid, took up the post of clinical assistant, and assisted the staff right man¬
fully, who enjoyed the work, and benefited by it, gaining an enormous and excellent
experience, yet who were unpaid. It might be asked how that was possible. It
was possible in those days, and at present many of those men held eminent posi¬
tions in the specialty, in England, Scotland, Ireland, and the Colonies. That day
seemed to have passed away. Perhaps it was a pessimistic view of the case to take
when speaking of the passing of the clinical assistant. He trusted there would be
a resurrection ere long. What was the special utility of that state of things?
Surely it was that those men he referred to brought in an enormous stimulus to
the permanent staff of the asylum. The senior assistant would take them in hand
and follow up the teaching; and the circumstances seemed to require that he should
keep abreast of the times. He, Dr. Lewis, deplored the passing of the clinical
assistant. It was due, he thought, to the very keen competition for existence.
Coupled with that was the prolongation of studies. Then there was also the very
important fact that the clinical assistant had very great attractions in other paths.
A very important one was the locum tenens physician. The remuneration for a
locum tenens used to be about two guineas a week. He was now paid from three
to five guineas. Of course one could not expect a clinical assistant to take a posi¬
tion in an asylum who had an opportunity of serving as locum tenSHs at three to
five guineas a week outside. His remedy was to offer more prizes to applicants
for office in asylums, and in that way perhaps there would be brought about the
resurrection he desired. Then, all would agree as to the over-burdening of the
medical curriculum, especially in the fifth year of the graduate’s existence. At
the present time it was almost impossible for a man to take out a resident course
of studies in an asylum. An attempt was being made at Wakefield, and he hoped
it would succeed. There would be considerable difficulty with the university and
teaching authorities generally in bringing that about. What was required was a
longer period of residence in the asylums, also an oral examination in mental
diseases.

Dr. Thomson said he was sorry to interrupt Dr. Bevan Lewis, but did so on a
point of order. His motion had reference entirely to post-graduate teaching.
There was no question of overburdening the medical student in it, and a great deal
of what Dr. Lewis suggested was a matter for the Committee.

Dr. Bevan Lewis, continuing, said he thought he fully conceived the tendency
of Dr. Thomson’s remarks. He thought the development of post-graduate tuition
depended to a great extent on the very great interest of the profession in psychiatric
medicine, and if residents at asylums could get courses at the great institutions
which taught general nervous diseases, he thought that would be securing a great
deal of what was wanted. He did not mean as a substitute for what Dr. Thomson
proposed, but as a strong accessory to the same end.

The President said that if no one else wished to discuss the motion, he would
suggest that the question be referred to the Educational Committee to consider
and report.

Agreed.

The meeting was then adjourned for lunch.

AFTERNOON MEETING.

On resuming, Dr. Macdonald welcomed to the meeting Dr. George Henry
Martin, of San Francisco, whom he was sure all would be pleased to have amongst
them.

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NOTES AND NEWS.

[Oct,

Thanks to the President and Officers.

Dr. Blandford said he had much pleasure in proposing a vote of thanks, in
which he was quite sure all present would cordially concur. It referred to the Presi¬
dent and Officers of the Association for their work during the past year. He was
sure it was quite unnecessary to enlarge upon the merits of the President or of
the officers, who thoroughly deserved the members* thanks.

Dr. Percy Smith seconded the proposal, remarking that only those who had
gone through the mill of the various offices knew how great an amount of work
was entailed, and how it increased from year to year. Members had heard the
President’s expressions of sympathy with the medical student on account of the
amount of work he was expected to get through, and the same might be said of
the Association’s officers. The amount of work was on the increase, as those
serving the offices knew.

The motion was carried by acclamation.

The President (Dr. Macdonald), in thanking the mover and seconder and the
meeting generally for the vote of thanks, said he felt as if he must put himself in
the background, for whether in that Association or any other, the real success
depended on the permanent officials. He thought the Association was fortunate
in its permanent officials. No president could know that better than he did himself.
If he began with the General Secretary, it was because he had a large share of the
work to do; and he assured the meeting that from no man could he have received
greater help than he had had from Dr. Bond. Another officer who had a
tremendous amount of work to do was the Registrar, and that he knew now more
than he had ever known before. He thought very few members realised the amount
of work which Dr. Miller had to do, and therefore the special thanks of the
Association were due to him also. They were all glad to see that most necessary
and important officer, the Treasurer, among them again. Long might he be spared
to occupy his usual seat at the meetings. During his year of office he, the
President, had made it a point to try and go round the divisions, and it had been
a source of the greatest satisfaction to him to see the amount of interest which was
being taken in the work of the Association, and what was more, to see on the spot
the amount of good and useful work being carried out. He therefore wished to
thank the officers of the divisions for the interest they were taking in the work of
the Association. Having said that there yet remained one other department of
the Association's activity, which was well known, namely the Journal. Members
knew with what care and earnestness the Editors looked after the Journal, and so
long as it retained the Editors now controlling it he thought it was likely to con¬
tinue its present high standard, and, indeed, to go upwards in influence and
reputation. He had one further word to say. It was a late date to do what
should have been done twelve months ago, namely, to return to members his very
grateful thanks for the honour they did him by placing him in the presidential
chair. It had been to him a most happy year of office, and that had been due to
the great kindness and consideration which he had received from everybody. In
conclusion he returned grateful thanks on behalf of the officers of the Association.

Induction of Dr. Mercier as the new President.

The President said the last duty remaining to him as President was not by any
means the least pleasant. He viewed it as a distinct honour that it should have
fallen to his lot to induct into the chair Charles Mercier. If he had felt called
upon to use any words in doing so, he did not know what words he should choose,
but he felt that any words would be an impertinent superfluity. In placing around
the neck of the new President the medallion of office he wished him a very pleasant
year in his new sphere.

Dr. Mercier then took the chair.

The President, in returning thanks, said he supposed there was no position
more grateful to a man who had worked for a number of years at one particular
specialty among a large number of colleagues scattered all over the country than
to be elected, by the suffrages of his fellows to the chair of that Association. He
need scarcely say how very highly he appreciated the great honour his fellow mem-

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NOTES AND NEWS.

1908.]

795

bers had done him, and how much indebted he was to his predecessor for the
graceful words with which he introduced him.

He announced that the Association’s Bronze Medal had been awarded to Dr.
S. Carlisle Howard, Assistant Physician of the Perth District Asylum for an essay
on “The Systematic Estimation of the Leucocytes in certain Cases of Insanity,
with Special Reference to the Toxsemic Theory.” Dr. Howard was not present,
but the medal would be forwarded to him, and he expressed the Association’s
congratulations to the recipient. Unfortunately, as the Treasurer intimated in the
morning, the Gaskell Prize had not been awarded. It was a matter of great regret,
and he could not allow the present occasion to pass without expressing his sorrow
that the very handsome and splendid provision which was made by Mr. Gaskell’s
relatives was not more appreciated, and that there was not more competition for
that Prize. It had been several times suggested that other prizes should be offered
by the Association for scientific work done in asylums; but as long as the Gaskell
Prize remained unawarded it would be, he thought, futile to encourage work by
those means. The fund was now increased, owing to lapses, so that by the aid of
judicious investments it was now 50 per cent . greater, and whoever gained the
award would receive a very handsome one. It consisted of a gold medal with a
sum of money, and it was matter for regret that it was not more sought after.

Another pleasant duty which he had was to ask the Association to accept an
extremely handsome present which had been made to it by a past president, Dr.
Outterson Wood, who had been associated with Dr. Urquhart in the matter, and
had succeeded, after the expenditure of infinite time and labour, in unearthing the
portraits of every president of the Association, from its inception to the present
day. Those had been combined in an album, and that album Dr. Outterson Wood
would now present to the Association.

PRESENTATION OF ALBUM OF PORTRAITS
OF PAST PRESIDENTS.

Dr. Outterson Wood said it afforded him very great pleasure to lay before his
fellow members an album containing portraits of past Presidents of the Association.
It contained fifty-eight such portraits, with the name, date, and qualification of
each, together with a characteristic sentence from their writings. The first annual
meeting of the Association, as many might remember, was held at the Nottingham
County Asylum in 1841. The chairman of that meeting was Dr. Blake, who was
then visiting physician to that institution. Fortunately, he had been able to obtain
his portrait with which to commence the series, and the likeness of each successor
was continued in an unbroken line down to to-day. The labour had, admittedly,
been considerable, but he assured his hearers it had been a labour of love, and he
could scarcely express the extent to which they were all indebted to the indomitable
perseverance and energy of their esteemed colleague Dr. Urquhart for the enormous
trouble he had taken in unearthing the records of the past in order that the value
of the album might be enhanced by a characteristic sentence from the writings
of each president. There was something from every one of them ! Acting also
upon Dr. Urquhart’s suggestion, there had been added to the book a “foreword ”
or preface, in the beautiful words of their esteemed predecessor, Conolly, in which
he gave expression to his feelings on leaving Hanwell Asylum. As they were very
brief he craved permission to quote them : “No longer residing in the Hanwell
Asylum, and no longer superintending it, or even visiting it, I continue to live
within view of the building and its familiar trees and grounds. The sound of the
bell that announces the hour of the patients’ dinner still gives me pleasure, because
I know it summons the poorest creature there to a comfortable, well-prepared, and
sufficient meal; and the tone of the chapel bell, coming across the narrow valley
of the Brent, still reminds me, morning and evening, of the well-remembered and
mingled congregation of the afflicted who are then assembling, humble, yet hopeful
and not forgotten, and not spiritually deserted. The contemplation of the vast
exterior of the wings of the Asylum still deepens the happy impression that through

uv. 56

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796 NOTES AND NEWS. [Oct.

all that extent of ward and gallery kindness and watchfulness ever reign. And
when my thoughts are transferred from this, my home asylum, with its 1,000
patients, to nearly forty institutions for the insane in this great country, in which
there are more than 13,000 patients to whom similar comforts are afforded, and
throughout which the same system prevails, 1 find a reward for any share I have
had in promoting these things beyond my deserving, a consolation in years of
comparative inactivity, and a happiness far overbalancing the pains and troubles
incidental to my life as to that of all mortal men.” Dr. Outterson Wood said he
thought any further remarks of his own were unnecessary, and he now confided
the album to their keeping, with the hope that in the days that are to come othvs
may be found to continue the work which he and Dr. Urquhart had ventured to
begin. I n conclusion he begged the Association to accept the album as a gift from
himself and as a small recognition of the pleasant memories connected with his
membership of the Association for so manv years.

Dr. Yellowlers said he thought the Association should not be content with
the expression of gratitude from the chair only, but that as an Association they
should say how very highly they appreciated the beautiful gift by Dr. Outterson
Wood, and the infinite trouble and pains which he and Dr. Urquhart took in the
matter, and how much it was valued. There should be a very special vote of
thanks. Without Dr. Urquhart’s research into the remoter ages even Dr. Wood's
patience would not have sufficed.

Dr. Urquhart said he did not know that it was necessary for him to offer any
remarks, except to acknowledge the very kind words which had fallen from the
President and from Dr. Yellowlees for the two years’ work which had been put
into the Album. Dr. Wood naturally could not say what he had done to carry out
that work, which he long ago began by placing before the Association a complete
record of the history of the chairmen and presidents, working over the whole
chronology of the Association in the admirable introduction to each volume, which
showed how they stood year by year. It was a great pleasure to him that Dr.
Wood’s gift had been so acceptable to members, and any help which he.
Dr. Urquhart, had been able to give had been a source of great gratification to
himself. The most impressive part of the little ceremony just performed was the
reading of Conolly’s eloquent words. Sir John Bucknill used to say to him that
he would have every man who practised amongst the insane read every word that
Conolly ever wrote; and it was, perhaps, only when one returned to Conolly after
many years and re-read what he wrote that one fully appreciated the power, the
influence, and the extraordinary facility which he had in guiding opinion in this
country. It was a great pleasure to be able to insert that preface, because he was
sure that amongst those presidents who had retired from more active administra¬
tive duties, those words of Conolly must find an echo in their hearts. And that
was an encouragement to those who were not yet upon the shelf.

The President said the Album would now be deposited among the archives.
It would be for all time a record of the personal appearance of every past president
of the Association. He supposed there was no other medical society in London
which had the same privilege of referring to so intimate a personal image of its
previous directors.

The President then delivered his Address (see p. 619).

Dr. Clouston said the Association had just listened to an unique address, and
from an unique origin. He thought members had that day seen and heard Dr.
Mercier at his very best. It was not always that a man when promoted to the
presidential chair appeared and spoke his best. He was very well aware that to
thank a man for a magnificent address like that just delivered was always so much
of an anticlimax that the speaker was anathematised by those who listened to him.
But they could not pass over that address without at all events expressing their
warmest appreciation of the pleasure which it had given, and conveying their warm
congratulations to the President, not only for the address itself, but for the way in
which it had been delivered. (Cheers.) The subtlety of the address had been
great. First, members had an experience of Mercier the wit, in the introduction,
and then they saw Mercier the metaphysician and the philosopher. Then he got
as far as the psychology. Then, with a touch of physiology thrown in, he
got at last to the physician. And those portions were so delightfully put together
that his audience were taken in, as it were, and the transition from the one phase

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NOTES AND NEWS.

797

1908.]

to the other was imperceptible. He believed that the old philosopher of the most
cast-iron mind would have accepted Dr. Mercier’s general proposition. But
Mercier himself began with the ego, the consciousness, the will, and told them
that everything depended upon that, especially the great things of the mind—
desire, love, hate. That would satisfy the physician absolutely and he would not
want anything more ; he would have said that all the rest was mere addition to
that main proposition. But Dr. Mercier gradually led his audience in his subtle
way through those psychological regions, and so adroitly that he did not think
anyone would fail to agree with him. Probably when they got home they would
disagree with several of his main propositions, but they did not do so then. Dr.
Mercier was wise enough not to begin in the ordinary commonplace way of the
psychologist of the present day by explaining mind in its relationship to reflex
action as it occurred in the lower creatures, and working upwards. He hit out
from the shoulder and attacked the main problem of the ego of consciousness, and
from that he worked down, as they had heard. The Association must feel proud
of itself, and he could tell the President he had not only made a brilliant
appearence, but what he had done had brought good to the Association over which
he was presiding. (Cheers.)

Dr. G. Savage, in seconding the vote of thanks, said he felt, with Dr. Clouston,
that it was a very good thing indeed that Dr. Mercier had presented such a paper;
it was altogether out of the common, and he was happy to say it was not intensely
practical. One felt the greatest respect for the workers of the world—for the
practical men ; but the men who prided themselves on being practical were so often
nothing else, and in many cases their practicality was rather doubtful. One was
also pleased to find that Dr. Mercier was getting older; it was a pleasure to find
that softening influence which age was supposed to bring. He often thought of an
aged French physician coming round with him at Bethlem Hospital many years
ago, and whom he asked whether he believed in a number of things. The reply
was: “ When I was young I believed all sorts of things about all sorts of things,
but now 1 am old I believe nothing about nothing.” He was inclined to feel that
the President was subject to that healthy agnosticism, that capacity for receiving
fresh impressions and absorbing them, that feeling that there was something beyond
the definite, that, in fact, our knowledge must depend upon our growth. He
thought that one of the most impressive things to him for many years was the way
in which Mr. Balfour, at a meeting of the British Association, pointed out that science
was so self-satisfied, and yet he asked what science was ? It was the measure of
experience, of things occurring in the outer world. What were those things
measured by? By the very instruments which those impressions made. Eyes
were used to measure and gauge light and sight; yet they were created by impres¬
sions. And for a scientific man to say he could only believe what he saw and heard,
and was not prepared to accept anything beyond that, simply meant that he did
not recognise that there were other forces and other things which we had not yet
attained to, and that our attempt to explain what mind was must depend, in each
age, upon the advance which we had made towards its knowledge. He was sure
that such an address as that just given by Dr. Mercier helped members distinctly
to feel what they would like to know. The way in which Dr. Mercier had referred
to desire on the one hand, while throwing in healthy doubt, was very helpful.
The President pointed out that we had grounds for believing in a very definite
relationship between mind and matter. When he spoke so eloquently as he did
upon desire and its relationships, one could not help feeling that there was in
Nature, as exhibited by desire, almost a chemical action, and he, Dr. Savage, was
in the habit of thinking—if not of saying—that desire, affection, and the rest
were, after all, glandular; that they were, to a very great extent, dependent
upon the attraction of something towards the self. And, as Dr. Mercier had
pointed out, it was an entirely organic thing, which could be explained. He had
said quite enough to show how fully he appreciated the address which had been
given, and he was sure all would agree that it deserved their heartiest thanks.

The resolution was carried by acclamation.

The President said he would express his acknowledgment of the vote in few
words. Dr. Clouston had surpassed himself in eulogy, and he could only say—
much exaggerated. He thanked the meeting for its kind appreciation.

The President then invited a discussion on Dr. Cunyngham Brown’s paper

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798 NOTES AND NEWS. [Oct.,

upon “The Boarding-out of the Insane in Private Dwellings.” (The paper had
already been published in the Journal for July this year.)

Following a resumi of the paper by Dr. Brown, a good discussion was elicited,
in which Drs. Milsom Rhodes, Elkins, Clouston, McDowall, Rayner, San key,
Hayes Newington, Dawson, Bond, and Robert Jones took part.

The President pointed out that there was as yet no seconder to the resolution
embodied in the paper. He suggested that Dr. Brown might bring the matter up
again the following morning, having in view the appointment of a committee and
their exact terms of reference.

SECOND DAY.

The President, Dr. Mercier, was in the Chair.

The President expressed regret that Dr. Cunyngham Brown was unable to be
present, as he had hoped he would have had this opportunity to reply to the
discussion on his paper, and to submit terms of reference if it were decided to
appoint a Committee.

Dr. Rayner then proposed the formation of a committee, indicating its member¬
ship, and was seconded by Dr. Drapes.

After considerable discussion, in which Drs. Dawson, Rayner, Bedford Pierce,
Yellowlees, Rhodes, Hayes Newington, Robert Jones, P. W. MacDonald, Bower,
and the President took part, it was resolved, having in view the forthcoming
report of the Royal Commission upon the Feeble-minded, to adjourn the con¬
sideration of the matter until November.

“The Case against Dementia Prsecox” was the title of a paper which was then
read by Dr. Robert Jones (see p. 651).

A very lively discussion ensued, in which the President, Drs. Stoddart, Drapes,
Percy Smith, Bevan-Lewis, T. Johnstone, Clouston, and Bower took part.

As several other members were desirous of joining in the discussion, but were
prevented from lack of available time, it was resolved, in view qf the importance
of the subject, to adjourn the discussion until the November meeting, and further,
that as the subject was complicated and difficult, it would be better that the
adjourned discussion take the form of a set symposium by those who were willing
to take part.

Afternoon Meeting of Second Day.

Dr. Alan McDougall read a paper entitled “ On the Principles of the Treat¬
ment of Epilepsy ” (see p. 718).

The President having remarked that the true title of the paper would seem to
be “The Treatment of Epileptics,” Dr. Savage opened an interesting discussion,
which was continued by Drs. Milsom Rhodes, Rayner, Shuttleworth, Yellowlees,
Robert Jones, Clouston, Briscoe, Paul, Orr, Bond, and the President.

Dr. McDougall replied.

The President said the Association was honoured that afternoon by the
presence of Lady Henry Somerset, who had promised to communicate some of
her great experience on the treatment of inebriety.

Lady Henry Somerset then gave an instructive and highly interesting address,
entitled, “ Some Aspects of Inebriety ” (see p. 704).

It was followed by a full and animated discussion, in which the President, Drs.
Stewart, Clouston, Yellowlees, Milsom Rhodes, Hayes Newington, Bedford Pierce,
and Rayner took part.

The proceedings were terminated by a paper read by Dr. Elkins. Its title was,
“ Asylum Officials: Is it Necessary or Advisable for so many to Live on the
Premises P ” (see p. 691).

Owing to the lateness of the hour and the obvious importance of the paper it
was agreed that the discussion on it should take place at the November meeting,
the paper in the meantime to appear in the Journal.

Annual Dinner.

The annual dinner was held in the evening of the second day at the Criterion
Restaurant. The occasion was unique in the history of the Association, as it was
the first time that the presence of ladies graced the dinner. About fifty members
and thirty guests were present.

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1908.]

NOTES AND NEWS.

799

IRISH DIVISION.

The Spring Meeting of the Division was held at St. Edmundsbury, Lucan, on
Thursday, April 30th, 1908, by the courtesy of Dr. Leeper, who entertained the
members at luncheon after first escorting them round the institution.

At the meeting afterwards the chair was occupied by Dr. Leeper, and there were
also present—Drs. T. Drapes, James J. Fitzgerald, H. M. Cullinan, J. O’C.
Donelan, M. J. Nolan, John J. Fitzgerald, H. M. Eustace, J. A. Oakshott, and
W. R. Dawson (Hon. Sec.). Letters regretting inability to attend were received
from the President of the Association and Drs. P. O’Doherty and J. Patrick.

A resolution expressing the sense of the loss sustained by the Association in the
death of Dr. Conolly Norman, and of sympathy with Mrs. Norman, was unani¬
mously passed.

The minutes of the previous meeting were read, confirmed, and signed.

A letter was read, acknowledging a copy of a resolution passed at last meeting,
recommending the proposals o? the Irish Asylum Officials Superannuation Com¬
mittee to the favourable notice of the Chief Secretary for Ireland.

A letter was read from one of the Hon. Secretaries to the Conolly Norman
Memorial Committee, asking for the sympathy and support of the members of the
Division. The project of establishing a memorial to the late Dr. Norman was
unanimously approved.

Dr. James F. Fitzgerald, Assistant Medical Officer, District Asylum, Clonmel
(proposed by Drs. B. C. Harvey, J. O’C. Donelan, and W. R. Dawson), and Dr.
Richard R. Kirwan, Assistant Medical Officer, District Asylum, Castlebar (pro¬
posed by Drs. F. C. Ellison, E. Fleury, and W. R. Dawson), were after ballot
declared unanimously elected ordinary members of the Association.

Dr. W. R. Dawson was elected Divisional Secretary, and Drs. M. J. Nolan and
T. Drapes, Representative Members of Council, for the ensuing year.

The following dates were fixed on for the meetings of the Irish"Division in the
ensuing session: Saturday, November 7th, 1908; Thursday, April 22nd, and
Thursday, July 1st, 1909.

It was left to the Hon. Secretary to arrange a place for the Summer Meeting of
the Division.

The report of a Committee of the Division appointed at last meeting to consider
the best method of promoting increased interest in the work of the Association
amongst the Assistant Medical Officers was received and adopted. It was
suggested (1) To try to secure reduced rates from the railway companies; (2) To
offer a medal or prize for competition by Assistant Medical Officers, subject to the
approval of the Association ; (3) To invite the Assistant Medical Officers to join in
collective investigations; (4) That offers of hospitality should be secured for
Assistant Medical Officers ; (5) That Resident Medical Superintendents should
try to allow their Assistants to attend one meeting in the year; (6) That the
Autumn Meeting should be set apart for considering the reports of collective
investigation.

The Secretary called attention to the circumstances connected with the election
of a Resident Medical Superintendent to Carlow Asylum, the committee of which
were endeavouring to appoint the Assistant Medical Officer, though not legally
qualified either by length of time registered or in the asylum service, and had been
threatened with a mandamus. After some discussion a resolution was unanimously
passed expressing satisfaction that the Executive were enforcing the legal require¬
ments.

Dr. John J. Fitzgerald read a paper entitled, “ Twelve Months' Experience of
the Treatment of One Thousand Cases of Insanity, without the Employment of
Chemical or Mechanical Restraint, or Seclusion.” It was discussed by the Chair¬
man and Drs. Drapes, Donelan and Oakshott, and Dr. Fitzgerald replied.

A letter from Dr. W. Graham was read, calling attention to the report of a trial
in the course of which it appeared that His Honour, Sir Francis Brady, had
animadverted on the making of wills by asylum patients, and said that he would not
uphold such wills. After a general discussion it was decided to suggest to the

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NOTES AND NEWS.

800

[Oct.,

Lord Chancellor that it might be desirable for him to issue specific directions
respecting will-making by lunatics.

The meeting terminated with a cordial vote of thanks to Dr. Leeper for his kind
hospitality.

The Summer Meeting of the Divbion was held at Waterford District Asylum,
by the courtesy of Dr. Oakshott, on Thursday, July 2nd, 1908.

After a visit to the Asylum in the morning the members enjoyed a very pleasant
trip down the harbour to Dunbrody Abbey and the new Barrow Bridge, in a steam
launch kindly lent by J. N. White, Esa., M.R.I.A. They were then entertained at
lunch by Dr. Oakshott, who occupied the chair at the subsequent meeting, there
being also present :—Drs. T. Drapes, R. R. Leeper, James J. Fitzgerald, John J.
Fitzgerald, A. Fitzgerald, H. M. Eustace, G. F. West, O. F. McCarthy and W. R.
Dawson (Hon. Sec.). Dr. MaryS. P. Strangmanattended as a visitor. Apologies
were received from the President of the Association and from Drs. W. Graham,
O’Neill, Nolan, Bond, Redington, Allman, Donaldson, Steen, Burrell, Cullinan,
Rutherford, Pierce, Lawless, Martin, Revington and Rainsford.

The minutes of last meeting were read, confirmed, and signed, and the Hon.
Secretary reported on various matters arising out of them, stating amongst other
things that a conditional mandamus had been obtained to compel the Committee
of Carlow Asylum to appoint a properly qualified Medical Superintendent.

A letter from Mrs. Conolly Norman was read, thanking the members for the
resolution of condolence passed at last meeting.

A letter from the Registrar in Lunacy was read, stating that the Lord Chan¬
cellor could not lay down definite rules as to will-making by lunatics.

The following was unanimously elected an Ordinary Member of the Associa¬
tion :—William Douglas Sammon, L.R.C.P.I., L.M., L.R.C.S.I., Assistant Medical
Officer, Richmond Asylum, Dublin. Proposed by Drs. J. O’C. Donelan, J. M.
Redington, and D. F. Rambaut.

Drs. W. Graham and James J. Fitzgerald were unanimously elected Represen¬
tative Members of Council for the ensuing session, to replace Drs. Nolan and
Drapes, who were found to be ineligible by reason of having held the post for the
last three years consecutively.

It was decided to hold the Autumn Meeting of the Division at the Royal College
of Physicians, Dublin.

The following were appointed a Committee of the Division to watch legislation
in the interests of the insane, in view of the impending Irish Poor-Law Amend¬
ment Bill, viz.: Drs. Donelan, Dawson, Graham, Nolan, James Fitzgerald, Leeper,
Drapes, and Oakshott.

The Chairman, having called attention to the fact that the expenses of the Hon.
Divisional Secretary in attending meetings were not paid, it was unanimously
resolved, on the proposal of Dr. Leeper, seconded by Dr. Drapes, to ask the
Council to consider the matter with a view to making a grant towards the Secre¬
tary’s expenses in attending the London meetings.

Dr. Oakshott contributed some “ Notes on Waterford District Lunatic
Asylum ” :—

The Waterford Asylum was erected in 1833, and opened in July, 1835, with
accommodation for 100 patients, fifty of each sex. The original building con¬
sisted of a central administrative Block with Clock Tower on top, and corridors
right and left, so arranged that both sleeping and day rooms faced the east.

The building was from the design of a Mr. Wm. Murray, whose plans seem to
have had the approval of the then Board of Control, as a number of asylums were
erected in Ireland about the same time on a similar plan.

It was more like a prison or penitentiary than a hospital for sick people with its
long, vaulted, flagged corridors and single rooms with small windows placed high
up from the ground. It appears strange with all the advantages the site possesses
that the plan was not so arranged that the inmates could have the benefit of the
sunlight and beautiful view available from the south and west aspects.

Whatever may have been the drawbacks to this building it must have been a
vast improvement on the accommodation provided previously for the lunatic
poor of the city, as it appears that before it was opened the only place of refuge

Digitized by L^ooQle

1908.]

NOTES AND NEWS.

801

for them was the “ House of Industry” which they shared with tramps and disso¬
lute characters of both sexes. An insight into the character of those confined
there can be gathered from a note taken from ‘ Ryland’s History of Waterford/
published in 1827. “This institution (House of Industry) has derived great
benefit from the introduction of a tread-mill.” It is to be hoped that this bene¬
ficent instrument of discipline was not used as a mode of treatment for the poor
lunatic.

The prison-like character of the old building can still be seen in a few places,
altered though it has been from time to time, but in 1835 it must have been
dreary in the extreme with its long, badly lighted, cold, cheerless corridors, with
flagged floors, whitewashed walls, and small windows, only admitting the minimum
quantity of light and air, and its dismal airing courts surrounded by high walls.

When the Asylum was first opened, and for twenty-eight years afterwards, the
Superintendent, or Manager as he was then styled, was a layman. The first
Manager was a Major Rowan, who only held the position for a few years, and was
succeeded by Capt. Dobbs. They were assisted by a Visiting Physician, who at
first was not expected to visit daily.

On the retirement of Capt. Dobbs on pension in 1863, Dr. Thomas Crowe
Burton was appointed the first Resident Medical Superintendent, Waterford being
the last asylum to be placed under the care of a resident physician. From the
time of Dr. Burton’s appointment a great improvement appears to have been
made in the condition of both patients and staff, as the discipline must have been
very lax previously if one can judge from the frequent reports and dismissals of
attendants during his short time of office, extending only for two years, when he
was transferred to Castlebar Asylum. Dr., now Sir Francis, MacCabe was
appointed early in 1866, and continued the work of improving the condition of
the establishment. He was after six years good service promoted to the impor¬
tant position of Governor of Dundrum Central Criminal Asylum. The vacancy
created by Dr. MacCabe’s promotion was filled by Dr. R. V. Fletcher, the late
respected Resident Medical Superintendent of Ballinasloe Asylum, to which he
was transferred after about two years service, when he was succeeded by Dr.
Pierse Connolly, who had been for many years previously Visiting Physician to
the Asylum. He also only held the position for two years, dying in November,
1877.

On his death an interregnum of three months occurred, the Asylum in the
meantime being managed by the Visiting Physician and the Clerk. It was not
until February, 1878, that the late Dr. Ringrose Atkins was appointed. He held
the position for exactly twenty years, dying in 1898.

It is hardly necessary to remind the members of this Association of the late
Dr. Atkins. He was well known as an alienist and a writer and lecturer on
various subjects. His memory is still revered here, where he endeared himself to
all classes and creeds by his amiable and charitable disposition.

By his early and unexpected death, the writer of these notes was selected to fill
the vacancy, being the last but one Superintendent in Ireland to be appointed
before the Local Government Act (Ireland) 1898 came into force. As already
stated the Asylum was originally constructed to contain 100 patients, but as the
space provided shortly became insufficient the Asvlum was enlarged from time to
time, at first by internal structural alterations and afterwards by additions built to
the parent Asylum, the most extensive of these being the red-brick building
erected in 1895 at the south side, which raised the accommodation to 484 beds.
The space thus provided having again become insufficient for the wants of the
district the Committee, in 1903, after long and careful consideration, decided to
further enlarge the institution by erecting two detached pavilions for 60 patients of
each sex to act as hospitals for the sick and infirm, to alter certain rooms on the
first floor of the oldest part and convert them into four large dormitories and a
dayroom, enlarge the windows at the back and front of these rooms, heat a number
of wards with hot pipes, build a house for the Resident Medical Superintendent
and convert his old dwelling, part into quarters for the Assistant Medical Officer,
and part into apartments for attendants, and utilise a room made available by
these changes for the meetings of the Committee.

These additions and alterations raised the accommodation to 605 beds and
provided separate sleeping rooms for the attendants, as heretofore they had to
sleep in the dormitories with the patients.

Digitized by {jOoq le

802

NOTES AND NEWS.

[Oct.,

All the changes in the original design of the institution clearly show the marked
improvement in the style of buildings of the present day from the dreary prison-
like structure of over seventy years ago. It is interesting to note on going over
the records the anxiety of the Governors to provide for and ameliorate, if passible,
the condition of the lunatic poor of the district; this is characteristic of the people
of Waterford, who are remarkable for their charitable disposition. A stranger
coming to live among them cannot help being struck by the number of charitable
institutions in the city and by the generous help always afforded to the deserving
poor.

Dr. Mary S. P. Strangman, introduced by the Chairman, read a paper
entitled, “ The Atropin Treatment of Morphinomania and Inebriety,'* which was
discussed by the Hon. Secretary and Drs. Leeper, Eustace, James Fitzgerald, and
West (see page 727).

Hearty votes of thanks were unanimously passed to Dr. Oakshott for his conduct
in the chair and his kind hospitality; to J. N. White, Esq., M.R.I.A., for kindly
lending his steam-launch for the use of the members; and to Dr. Strangman for
her paper; and Dr. Oakshott having replied for himself and Dr. Strangman. the
meeting terminated.

COMPLIMENTARY.

THE PRESENTATION OF THE FREEDOM OF KIRKWALL TO
DR. CLOUSTON.

The freedom of the Royal Burgh of Kirkwall in far Orkney has been conferred
on Dr. Clouston, who was surrounded by his family and friends on that auspicious
occasion. Provost Slater said that the list of distinguished men on the Burgess’
Roll was honourable because each of them had been a man of outstanding distinc¬
tion in the country. Dr. Clouston had conferred distinction on the county, of
which Kirkwall was the chief town, and came of an old Orkney family who have
held lands there for very many years. Provost Slater proceeded to sketch Dr.
Clouston’s career, with which we are all familiar ; and referred to his kindness
and hospitality, specially to Orcadians; his help and his influence had been a
boon and a blessing to many. Provost Slater handed the burgess ticket to Dr.
Clouston. It was engrossed as follows:

Kirkwall, the twenty-eighth day of August, one thousand nine hundred and
eight.—Which day the Magistrates of the Royal Burgh of Kirkwall admitted
Thomas Smith Clouston, Esq., M.D., LL.D.Edinburgh, a Burgess and Guild
Brother of the said Burgh, with all the privileges and immunities thereto
belonging, on the occasion of his first visit since his recent retirement from the
arduous duties of Medical Superintendent of the Royal Edinburgh Asylum after a
service of thirty-five years, in recognition of his very distinguished professional
career, of his world-wide reputation as an authority on mental diseases, of the
additions he has made to the literature of his profession, and of the deep interest
he has always taken in his native county of Orkney. This Burgess and Guild
Brother Ticket was directed to be prepared and delivered to him, the said Thomas
Smith Clouston, by acceptance hereof, becoming solemnly bound to discharge
every civil duty incumbent by law on a true and faithful Guild Brother of the said
Burgh. A memorandum of which admission, written upon stamped paper, is
enrolled among the records of the said Burgh.—In witness whereof, these presents
are subscribed by the said Magistrates and by the Town Clerk, and the seal of the
Burgh is impressed hereon.

Jas. Slater, Provost.

Wm. B. Baikie, Senior Bailie.

Wm. F. White, Junior Bailie.

Wm. J. Heddle, Town Clerk.

Provost Slater in handing the burgess ticket to Dr. Clouston remarked, amid
cheers, that he had great pleasure in doing so on behalf of the citizens of the
Royal Burgh.

Digitized by L^ooQle

NOTES AND NEWS.

803

1908.]

Dr. Clouston, in acknowledging the honour conferred upon him, said that he was
never so pleased with anything in his life. Being an Orcadian, bearing a name
which is absolutely Orcadian, and a name found nowhere else but when borne by
Orcadians and descendants of Orcadians, it was specially gratifying that he
should be asked to receive the greatest honour which the Town Council of Kirk¬
wall could confer on any citizen. There had been comparatively few men within
the last hundred years who had received this great distinction, and so it was
doubly welcome and doubly appreciated. Dr. Clouston referred to the work of
his life, and indicated that statesmen should turn their attention to the sons of
Orkney and Shetland to reinvigorate the race. Dr. Clouston then signed the
Burgess Roll, and was afterwards entertained to a banquet in the Kirkwall Hotel,
where the proceedings were enthusiastic and cordial. We feel sure that Dr.
Clouston’s many friends will compliment him upon this new honour which has
been so kindly conferred upon him. They best know how well deserved it was.
We need only add our congratulations to Dr. Clouston, and express our best
wishes.

DR. MAGNAN.

Dr. Magnan’s jubilee has been honoured in Paris by a concourse of distin¬
guished friends. For forty years he has been physician to the admission block of
St. Anne’s Asylum, and his former fellow-student, Dr. Bouchard, presided at the
festival. Dr. Magnan was presented with a beautiful plaque, the work of Professor
Richer of the Institute; and the subscribers are to receive replicas in the form of
medals. Well-known colleagues were present, Dr. Ritti, representing the Medico-
Psychological Society; Drs. Briand and S^rieux, speaking in the name of former
pupils ; Dr. Ladame for Switzerland ; and Dr. Bagenof for Russia. Dr. Mierze-
jewsky had been chosen by his friends to represent them, had journeyed to Paris
for the purpose, but the calamity of his sudden and fatal disease occurred on the
very day of the ceremony.

Dr. S&ieux said, My dear master, observer, investigator, incomparable clinician,
you have upheld the glorious traditions of French psychiatry, and it is to you we
owe the present position of our branch of medicine. We cannot forget that you
are also a teacher and the benefactor of your patients. I hardly see anyone here
who has not been your pupil, directly or indirectly. Teacher you certainly are,
not only by way of formulae, but also by your good deeds and the thorough
performance of your daily duty. Devoted to duty not only in the advancement of
science but also in the care of your patients—finding words of comfort for them
and combatting the coalition of routine with ignorance—we find to have been an
education of the best. We have not only had our preference for mental patho¬
logy developed, but have found it revivified by your published works. Your
influence has permeated France, and spread throughout the world where your
pupils are scattered. Your life has been a valuable lesson on which to meditate—
une excitation k bien penser et k bien faire. You have lived among your patients,
disdaining publicity, taking no account of popularity, which some so often use to
conquer. You require much of your colleagues, but are still more exacting of
yourself. I have seen you late at night calming one patient and comforting
another. I have heard them pour forth their troubles to you while I was lost in
admiration. Your ardour is unabated after forty years of work here. Here is your
life and the unity of it is splendid. Without your personal influence what preju¬
dices would yet live, how many unfortunate patients would yet wear strait-
waistcoasts in absolute isolation ? We bow to-day before the master and bene¬
factor.

CONOLLY NORMAN MEMORIAL FUND.

The Honorary Treasurers of this Fund will be greatly obliged if all intending
subscribers will forward their contributions at an early date.

Digitized by L^ooQle

804

NOTES AND NEWS.

[Oct,

THE HANDBOOK FOR NURSES.

It is hoped that this Handbook will be published early in November, 1908, by
Messrs. Bailli&re, Tindall and Cox.

COMPILATION FORMS AND EXPANSION TABLES.

The Compilation Forms and Expansion Tables, which have been found very
necessary in the preparation of Asylum Statistics on the new system sanctioned
by the Association, have been in general use during this year. A few errors and
inconveniences have been reported. If any member has found any particular
inconvenience he can kindly send a note of it either to Messrs. Adlard and Son
or to the General Secretary.

OBITUARY.

Dr. John Cameron.

We regret to record the death of Dr. John Cameron, Medical Superintendent
of the Argyll and Bute Asylum at Lochgilphead. He was born in Killin 67 years
ago, and qualified at Edinburgh University. His first appointment was to Crich¬
ton Royal Institution, Dumfries, from which he went to the Argyll and Bute
Asylum in 1874, in succession to Dr. James Rutherford. He was at one time an
ardent volunteer, and retired from the Argyll and Bute Artillery with the rank of
Lieutenant-Colonel. About three months ago Dr. Cameron went to Edinburgh,
where he died, suffering from an internal malady, no hope being then entertained
of his recovery.

NOTICES BY THE REGISTRAR.

Examination for the Nursing Certificate.

List of the successful candidates at the examination for the Nursing Certificate
held in May, 1908.

England.

Birmingham City {Rubtry Hill). —Males: George Hy. Cushan, George T.
Mason.

Bethlem Hospital. —Male: Edward Cole. Females: Eva F. Scott, Isabella
Evans, Harriett Mann, Alice M. Fosbery.

Canterbury Borough. —Male: Frederick T. Stannard. Female: Hilda J.
Thornycroft.

Caterham. —Males: Harold J. Edwards, James Payne, Albert Atkins. Females:
May Pringle, Mary McConnell.

Hull City. —Males: Thomas France, Arthur W. Legard, Albert Clabby.
Females: Rose Stott, Lydia Thornton, Mary M. Moore, Hephzibah Harp.

Leavesdtn. —Males: Ashley A. Haseldine, George Roberts, Frederick Rhodes.
Females : Mary E. Norwell, Mary Sullivan.

Newcastle City. —Females : Louisa Denham, Grace Thompson.

Notts City. —Male : Walter E. Cooper.

Retreat , York. —Females: Eliza J. Brearley, Ethel Gordon Dunbar, Geraldine
S. McKew.

Sunderland Borough. —Male: Fred. A. McCullagh.

Storthes Hall. —Female : Gertrude Green.

Scalebor Park. —Males : William Atkinson, Frederick C. Horton, Harry Gilder,
George Cawood, John Henry Cawood. Females: Mary Jane Stewart, Mary
Charlotte Walls.

Digitized by L^ooQle

1908.]

NOTES AND NEWS.

80S

St. LukYs Hospital. —Female: Esther H. Savage.

Private nurse examined at Long Grove. —Female : Helen Armstrong.

Private nurse examined at Claybury. —Male : John Mahony.

Bristol City. —Males: Timothy Rowan, Frederick W. Holland, Arthur Legg,
Henry Castle. Females: May Jackson, Helen F. Wigglesworth, Florence E.
Button.

Cumberland and Westmorland. —Male: Sidney Hill. Females: Edith Hayden,
Mary Farquhar, Gertrude Jamison.

Derby County. —Male: Thomas Gamble. Female; M. H. O’Bieme.

Devon County. —Males: Edwin Harding, Frederick S. Eager, George
Whitehouse. Females: Beatrice Edworthy, Elizabeth A. Morgan, Ada Saunders,
Bessie Simons.

Essex County. —Females: Frances Lily Penny, Anna M. Lewsey, Alma Bale,
Maria J. Jones.

Herts County. —Male: Ernest J. Haywood. Female: Annie Alden.

Kent County {Maidstone ).—Males: Percy F. Laming, Frank Neve, Guy K.
Knight, Jesse Collar, Donald P. White. Females: Susanna Shaw, Rose Kemsley,
Emily Mankelow, Alice M. Franklin, Ellen McCormick.

Tooting. —Females : Elizabeth Jordan, Ethel Wicks.

Salop County. —Female : Elizabeth A. Haywood.

Lancaster. —Males: David G. Edmonds, Herbert Ordish, James H. Paxton,
Charles Tiplady, Joseph Lomax, Robert Parkin, William Power. Females: Annie
Towlson, Lily Ada Tidyman, Mary Hurtley, Margaret Norris, Frances M.
Parkinson, Mary Preston, Julia Brough, Mary Keating.

Lancaster County {Winwick). —Males: William E. Milligan, John Thompson,
James William Scaling, Martin Meehan. Females: Jane Elizabeth Forbes,
Edith A. Bennison, Annie Duckett, Annie R. Laurie.

Lancaster County ( Whittingham). —Males : Edward Seed, Ernest Pittaway,
James Fisher, Arthur Hy. Fann, Charles Dean, Frederick Coupe, Charles
Broadley, Gill Akroyd, Albert Sutcliffe, George E. Gillett, William Allison, Willie
Riley, John Richardson, Louis C. Patmore, Arthur L. Packer, Thos. Wm. Nelson,
R. Hy. Holding, John Farrington. Females: Mary McGann, Jessie Fisher, Clara
Smith, Marion Snow, Bridget Regan, Rose Owen, Louisa S. Gibson, Mary J.
Harkin, Ellen Annie Cox.

Middlesex County ( Napsbury). —Male : Robert Morris. Females: Ada Gamble,
Jeanie Dumble, Margaret McCarthy, Frances M. Simmonds, Florence E. Pettit,
A. A. E. McKnight.

Norfolk County. —Male: Henry Nobbs. Females: Sarah A. Fisher, Henrietta
M. Gallant, Winifred Jones.

Somerset and Bath {Wells). —Male : Samuel J. Heath.

Staffs County {Cheddleton). —Females: Sarah C. Achurch, Maud E. G. R.
Smith.

Suffolk County {Melton). —Males: Charles Addison, Henry Fuller, Cornelius
Courtney. Female: Rosetta Clare.

Surrey County {Brookvaood). —Males: Rodger Howard, John D. Howden,
William Marshall. Female: Margaret Hiney.

Sussex County {Chichester). —Females: Winifred B. Brooks, Winifred M.
Brown, Ada H. Frith, Florence E. Godfrey, Esther Johnson, Laura L. King, Edith
M. Yeadon.

Sussex County {Hellingly). — Males : James Marks Braids, Septirrfus C.
Somerville, William M. Fells.

Three Counties {Hitchin). —Males: James Moore, William Parsons. Females:
Dorothy B. Brown, May Ludford, Lucy Lambert.

Barnsley Hall. —Male: Joseph Grundy. Females : Mary Healey, Annie Best.
Yorks {Wakefield). —Males: Francis L. Jackson, George Hutchinson, Henry T.
Lilliman. Females: Annie Quickfall, Nellie Corridon, Lily Scales, Christiana
Powles, Annie Tennant, Alice M. Astbury, Emma Hasker.

Yorks {Wadsley). —Female: Clara Vaughan.

London County {Bexley). —Males : Alfred Doidge, James Spittles. Females:
Jennie E. Crombie, Jane L. Hunter, Eliza Johnson, May Seaward.

London County {Cane Hill). —Male: James Dye.

London County {Claybury). —Males: William James Hall, Charles C. Saye,

Digitized by L^ooQle

8o6

NOTES AND NEWS.

[Oct,

James William White. Females: Kate Brenton, Ellen Walsh, Anna Tinnej,
Lucy M. M. Gale, Frederica Doyle, Elizabeth Peglar, Florence E. Thorpe,
Margaret Mewitt, Louisa Hamilton, Elizabeth Todd, Kathleen Mary Nelson,
Charlotte E. Briody.

London County {Colney Hatch). —Females: Annie Vile, Daisy J. Monday, Eva
Steele, Emma Ayling, Kate Hobbs, Lily E. Williams, Lizzie E. Humphreys,
Agnes E. Hope, E. G. Bradley, Ada M. A. Dodd, Ada A. Drayton, Emily E.
Newell, Sarah Ralph, Emma E. Robertson, Elizabeth V. Rose, Elizabeth Clarke,
Louisa Moore, Hilda Wood, Louisa B. Adlington, Sarah L. Wheatley, Edith A.
Edwards, Annie Groves, Alice L. Child, Florence Hampson, Jane E. Frost,
Elizabeth A. Emerson, Hannah Hills, Amy Davies.

London County {Hanwell ).—Females: Kate Williams, Sophia Farr, Ossie
Gollidge, Nora E. Wooster, Grace Eyre.

London County {Horton). —Males: Hugh Johnston, William G. Randall,
James Staddon, Adam S. Calder, Ernest S. Dean, Michael J. Oliver. Females:
Agnes Kelly, Margaret A. Morrison, Florence Boulch, Euphemia Percival, Annie
Newman, Eliza A. Johnston.

London County {Long Grove). —Males: Bertram H. Mitchell, Ernest R. Webber,
Donald C. Clark, Frank M. M. Hardy, Samuel J. Coleman. Females: Beatrice
Cawthron, Elizabeth Randle, Margaret Baird.

Private nurse examined at Bicton {Salop). —Female : Margaret K. Sim moods.
Kent County {Chartham). —Male: Frederick Howlett. Females: Maud M.
Mullins, Annie G. J. Easterbrook.

Chester County. —Males: Arthur Pritchard, Ernest A. Jones, Edward Owen,
John Smith, Thomas Henry Newport, John P. Schofield. Females: Alice M.
Glover, Catherine Valentine, E. M. Hargreaves, Daisy McIntosh, Harriet Valen¬
tine.

Warwick County. —Males : Austin Keen, Clarence Henry Lane. Females: Amy
Sharp, Teresa Power.

Wales.

Glamorgan. —Males: Richard Jenkins, John R. Elmslie, Davie J. Thomas.
Females: Elizabeth M. Davies, Margaret James, Blodwin Lewis, Sarah Lewis,
Charlotte Missinden, Florence E. M. Skey, Mary Ann Owen.

Newport Borough. —Males: Albert Davenport, James R. Cook, Harry Bailey.
Female : Evelyn H. Nigh.

Brecon and Radnor. —Male : W. G. Franklin.

Scotland.

Aberdeen Royal. —Males: George Heron, James Duncan. Female: Mary Helen
Minty.

Ayr District. —Male: Patrick McBarron. Female : Mary Lindsay.

Crichton Royal. —Male: Adam Lothian. Females: Jeannie Fordyce, Christina
Reid, Annabella Black, Mary Cameron, Elsie Macpherson.

Edinburgh Royal. —Females : Isabel J. K. Dott, Isabel K. Craigs, Annetta M. L-
Ingram, Helen Hepburn, Margaret Alexander.

Fife and Kinross. —Males: John Adamson, Peter Scott Brown. Females: Annie
Main, Margaret H. Sharp.

Glasgow District {Lenzie). —Females: Haslett Margaret, Mary Jenkins Smith,
Jeanie G. Park, Mary McWilliam, Margaret Fleming, Mary M. Black, Margaret
Symon.

Glasgow District {Gartloch). —Male: Temple C. Cormack. Females: Mary
Pansy Allan, Marion K. Stevenson, Mary A. Wilson, Elizabeth Richardson, Ellen

A. Cleary.

Glasgow District {Gartnavel). —Males : Alexander Ewing, Louis Tenner, Walter

B. Lynas. Females : Isabella A. Helen, Bessie W. Thomson, Elizabeth Swanson,
Margaret C. Robertson.

Govan District. —Male: Alexander Murdock. Female: Nettie S. McNish.
Inverness District. —Male: John M. Munro. Female : Agnes MacIntyre.
Kingseat. —Female : Elizabeth Robertson.

Lanark District. —Male: William Strachan. Females: Christina W. Greenhorn,
Annie Bradley, Mary McNeil Weir, Jeanie Jackson.

Digitized by L^ooQle

1908.] NOTES AND NEWS. 807

Montrose. — Males: John A. Thomson, John Nicoll. Females: Alice McKenzie,
Annie C. Milne, Cecilia Fullerton, Annie Chapman, Charlotte Buchan.

Perth District. —Females : Ella MacKenzie, Annie F. Dewar, Margaret C. Boyd.
Riccartsbar. —Male : James Simpson.

Roxburgh District. —Females: Helen McFarlane, Mary A. Jarvie.

Stirling District. —Males: Martin Scanlan, John T. Mowat. Females: Alice E.
Forster, Janet W. Marshall, Margaret Wards, Annie E. Mulholland, Margaret
Lippiatt.

Ireland.

BalUnasloe. — Males: William Hickey, Marks Kilalea, Timothy Churchill.
Females: Mary Gorman, Nora Cullinan, Mary A. Finnerty.

Clonmel. —Males: Patrick Harding, James Grady. Females: Mary Maher,
Mary Milton.

Cork District. —Males: Denis Mahony, John Coughlan, John Keane. Females :
Annie Murphy, Minnie Reardon, Ellie O’Brien, Nora Motherway, Mary A.
Sullivan, Anna Gould, Julia Lordon, Kate Twomey.

Downpatrick. —Males: John Barry, John Murtagh, Patrick King, William James
McConvey, William James Tuft, William James Hanna, Joseph Hodgson.
Enniscorthy. —Male: James Nolan. Female : Annie Walsh.

Londonderry. —Females : Margaret Jacob, Kathleen Murphy.

Monaghan. —Males: William Haine, Arthur Graham, Peter Murphy, Joseph
Johnston, Owen Connolly, Joseph Morrow, John Stewart, Patrick McKenna
Females: Eliza Jane Clarke, Mary Ann McAdam, Mary Anne Boyle, Bridget
Holland.

Portrane. —Females: Mary Kieran, Mary McGuirk, Anne Maria Orr, Kate
Henneberry, Sarah Jane Taylor, Mary F. Nolan, Mary Phelan.

Richmond. —Males: John Pallis, John Brennan, Lawrence Murray, Michael
Boland, John Quinn, William McDonald. Females: Edith Casey, Mary Aungier,
Helena K. O’Beirne, Mary A. Breen, Margaret Alice Hartford, Maria McGuiness,
Elizabeth O’Callaghan.

Waterford. —Males: James McDonald, Thomas J. Dunn. Females : Catherine
Maher, Mary B. O’Toole.

St. Patrick’s Hospital. —Female: Katherine S. D. Graham.

The following is a list of the questions which appeared on the paper:

1. What is meant by reflex action ? Give three examples.

%. What points should a nurse attend to in the general management of a
patient suffering from heart disease ?

3. Describe the mental features seen in “ epileptic insanity.”

4. What are the special risks in cases of senile insanity, and how should they
be guarded against P

5. A patient spits bright red blood. Where is it likely to come from, and how
would you treat the patient till the doctor comes ?

6. Describe the performance of artificial respiration.

7. What is a convulsion ? In what diseases are convulsions most likely to
occur ?

8. What are the precautions to be observed in nursing patients suffering from
consumption ?

9. What are the principal conditions that lead to a progressive loss of weight P

10. What would lead you to believe that a patient suffers from hallucinations
of hearing? Illustrate your answer by the signs observed in two patients known
to you. Why are hallucinations of grave importance in many cases P

NURSING CERTIFICATE.

The next examination for the Nursing Certificate will take place on Monday,
the 2nd November, 1908.

Digitized by L^ooQle

8o8

NOTES AND NEWS.

[Oct, 1908.

NOTICES OF MEETINGS.

Quarterly Meeting. —The next meeting will be held at 11, Chandos Street,
Cavendish Square, on Thursday, November 19th, 1908.

South-Western Division. —The Autumn Meeting will be held at Bath on Friday,
October 30th, 1908.

Northern and Midland Division. —The Autumn Meeting will be held on Thurs¬
day, October 22nd, 1908.

Scottish Division. —The Autumn Meeting will be held on Friday, November
20th, 1908.

Irish Division. —The Autumn Meeting will be held on Saturday, November 7th,
1908.

APPOINTMENTS.

Anderson, J. Theo., L.R.C.P., L.R.C.S., Senior Assistant Medical Officer to the
Hospital for the Insane, Perth, West Australia.

Gayton, F. C., M.R.C.S., M.D.Aber., Medical Superintendent to the Surrey
County Asylum.

Reid, W., M.A.St.And., M.B.Edin., Senior Assistant Medical Officer to Stafford¬
shire County Asylum, Burntwood, near Lichfield.

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INDEX TO VOL. LIV.

Part I.—GENERAL INDEX.

Etiology, 416

^Etiology of status epilepticus, 94
After-care Association, the, 393
Agglutinins in blood of the insane, 59
Album of portraits of past Presidents, 744

„ „ „ „ presentation of, 795

Alcoholism, 136, 750
Alkalinity of blood in epilepsy, 598
Amentia and dementia, 1, 264, 433

„ „ general summary of, 445

Amnesia due to arrest of development, 595
Amsterdam international congress, 195
Anaesthesia, general, acute mania following, 118
Annual meeting, 743
Anthropology, criminal, 70
Aphasia and apraxia, left-sided, 149
Appointments, 201, 431, 618, 808
Arson in hysterical somnambulism, 152
Asylum officials, 691

„ reports issued in 1907, 158

„ „ „ „ 1908, 768

Asylum Workers’ Association, 580
Asylums, clinical work in, 122
„ research work in, 746

Atropin treatment of morphinomenia and inebriety, 727
Auto-intoxication in mental confusion, 603

Babinski’s conception of hysteria, 186

„ symptom, absence of, in hemiplegia, 150
Bacillus coli in mania, 220
Balance sheet, 782
Biometrics and national eugenics, 71
Blake, William, 141
Blindness as a cause of dementia, 277
„ . mental, localisation «f, 148
Blood, changes in, in insanity, 59, 227, 600
Boarding out of the insane, 532

Cakebread, Jane, 705
Cameron, Dr. J., 804
Carious teeth and mania, 218

Cerebral under-development in dementia paralytica, 48
„ wasting in dementia paralytica, 41
„ „ in senile dementia, 15

Chorea, maniacal, 153
Classification of dementia paralytica, a, 50

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8io

INDEX.

Clinical neurology and psychiatry, 151, 593, 760
„ psychiatry, 417

„ results following injection of tuberculin, 344
„ types of dementia paralytica, 49

„ work in asylums, 122

Clouston, Dr., presentation of freedom of Kirkwall to, 802
„ „ retirement of, 388, 405

Colney Hatch Asylum, notes on history of, 606
Cortex cerebri, its volume and nerve-fibres, 143
Cretinism, a case of, 570
Crime, prevention of, 307
Crimes and offences, 82

„ and petty offences, statistics of, 85
Criminal anthropology, 70

„ law in relation to free will and responsibility, 77
„ lunacy in the Punjab, 362

„ lunatics, protection against, 768

„ „ sequestration of, 419

„ physiognomy, 69

„ responsibility, test of, 289

Criminology, 582

Deafness as a cause of dementia, 277

Death-rates in mental diseases (including and excluding dementia paralytica), 32
Degeneracy, 72

M of cerebral vessels and senility, 4, 12

Degeneration in families, 396
Delusional disorders in the aged, 505
Dementia, 151

„ amentia and, 1, 264, 433
„ excess of intra-cranial fluid in, 13
„ following epilepsy, 434
„ following sense deprivation, 269
„ paralytica, 22

,, „ bacillus paralyticans in, 24

M „ cerebral under-development in, 48

M „ classification of, 50

„ „ heredity in, 26

„ „ juvenile, 51

M „ morbid anatomy of, 37

M „ syphilis as cause of, 6

„ prsccox, 661
„ „ the question of, 651

M „ and mental degeneracy in Syria, 511

•> progressive and secondary, 2

„ „ senile, 10

„ special varieties of, 265, 434
Desire, physical basis of, 629
" Diaschisis,” 147
Digestion in mania, 219
Divisional meetings, 180, 424, 606, 799
Dreams, erotic, 755
Dualism, 620

Education in mental disease, 578
Epilepsy, alkalinity of blood in, 598
,, late, 151

„ lumbar puncture in, 703

Epileptic fits, thrombotic origin of, 638
Epileptics, insane, treated under hospital principles, 518
Erotic dreams, 755

Eugenics, national, and biometrics, 71

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INDEX

8l I

Female suffrage, 579

Feeble-minded, report of Commissioners on, 747
Free will, criminal law in relation to, 77
Frontal gyrus, cases of destruction of, 597

Gaskell Memorial Fund, 783
General paralysis, 22

„ „ a bulbous form of, 760

„ „ Have the forms altered ? 761

„ „ in father, mother, and son, 562

„ „ influence of morbid heredity in, 461

„ „ without mental symptoms, 54

Glossolalia, 590, 756

Haematogenous lesions of the spinal cord, 561
Hallucinations, nature of, 757
Hallucinations, visual, in hemianopsia, 154
Hebephrenia, 654

Heredity, morbid, in general paralysis, 416
Homo-sexuality, 588, 753

„ diagnosis of, 756

Hyoscine hydro-bromide in status epilepticus, 98, 100
Hypnotism and psycho-therapy, 751
Hysteria, Babinski’s conception of, 186
„ definition of, 757

„ Is it curable P 758

Hysterical paralysis agitans, 760

Idiocy, paralytic amaurotic, 420
Incipient insanity, treatment of, 119
Indirect action of toxines, 3
Industrial drinking, 137
Inebriety, some aspects of, 704
„ treatment of, 710, 732

Inquisition in lunacy, an, 575
Insanity and allied neuroses, 134
,, increase of, in England, 123
„ „ in Ireland, 128

„ „ in Scotland, 125

„ in Jews, 528
Insane, boarding out of, 532

„ epileptics treated under hospital principles, 518
„ menstruation in, 116
International Congress, Amsterdam, 195
Intra-cranial fluids in dementia, excess of, 13
Iodides in stupor, 767

< ahrbuch fur sexuelle zwischenstufen, 753
' ews, insanity in, 528, 767
] udicial and penal reform, 320
jurisprudence and penology, 313
uvenile dementia paralytica, 51
„ general paralysis, three cases of, 112

Katatonia, 654

Language, mechanism of, 272

Lesions of central nervous system, loss of function following, 146
Leucocytosis in acute mental disorders, 669
Life of asylum officials, 691
Longitudinal inferior bundle, 144

liv. 57

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INDEX.

Si 2

Lucretius, epicurean and poet, 138
Lumbar puncture, 587, 599, 763
Lymphogenous lesions of the cord, 560

Magnan, Dr., 803

Mania, acute, following general anaesthesia,. no

,, acute, furious, in cerebro-spinal meningitis, 734
„ bacillus coli and, 220
„ the blood in, 227
„ carious teeth and, 218
,, circulatory system in, 220
,, symptoms and aetiology, 207
Maniacal attacks in the aged, 501
„ chorea, 153

Manual for nurses, 395 c

Maudsley, Dr., and the metropolitan hospital for mental diseases, 389

Mechanism of language, 272
Medico-legal cases:

King, William Henry, an inquisition in lunacy, 575
Otley murder, the, 737
Rex v. James Jefferson, 740
Thaw case, 372

Medico-Psychological Association :

Presidential address, 619
Report of meetings, 179, 422, 604, 780
Melancholia, onset of, 357
Memory, physical basis of, 622
Menstruation in the insane, 116
Mental disease, education in, 578

„ disorder in advanced life, pathology and treatment ot 500
„ recreations of the mental nurse, 490

„ therapeutics, 391

Mercier, Dr., induction of, as President, 794
Migraine, psychical phenomena in, 595
Mind, physical basis of, 619
Ministry of national health, 120
Moorcroft, a short account of, 181
Monism, 620
Morison lectures, 207

„ „ summary of, 226, 244, 260

Morphinomania, treatment of, 727
Motor apparatus, double, in the brain, 144
Multiple sclerosis, early diagnosis of, 151

Narcolepsy, a case of, 107
„ literature of, 109
National health, ministry of, 120
Neurasthenia and general paralysis, 762
Neurology, 143

Neologisms in nomenclature, 657, 667
New Zealand, nursing examination in, 428

„ „ report on mental hospitals of, 199

Norman, Dr. Conolly, 203, 387

„ „ „ memorial, 582,803

Notices of meetings, 200, 431,617, 808
„ by the registrar, 429, 804
Nursing certificate, recommendation re, 785
„ examination in New Zealand, 428

Obituary.—Cameron, Dr. John, 804
Norman, Dr. C., 203, 387
Macleod, Dr., 425
Wilson, Dr. G. R., 426

Digitized by L^ooQle

INDEX.

813

Obituary, references, 605

Occupation therapeutics in mental disorder, 765

Onset of melancholia, 357

Open-air rest treatment of insanity, 105

Opsonic index to various organisms in control and insane cases, 57
Optic tract, entrance of, into cortex, 146
Organic change and feeling, 589
Orientation, reversed, a case of, 594

Paranoia, chronic, and melancholia, 760
Pathology of insanity, 420, 598

„ „ progressive senile dementia, 12

Pellagra and psychosis, 409
Penal reform, summary of, 318
„ systems in relation to recidivism, 291
Persecution, delusions of, 762
Philosophy of psychiatry, a, 473
Phthisis in the insane in Ireland, 130
Physical basis of mind, 619
Physiological psychology, 150, 588, 755
Physiognomy, criminal, 69
Pituitary body, tumour of, 153
Pleasure and pain, 635

Post-operative insanity, emotional factor in, 418

Prefrontal cortex, 448

Presidential address, 619

Prison systems on the Continent, 303 et seq.

„ „ in Great Britain and Ireland, 293

„ „ „ United States of America, 299

Progress of psychiatry:

America, 399
Belgium, 405
France, 407
Germany, 410
Italy, 412
Spain, 415

Progressive and secondary dementia, 2
„ senile dementia, 10

„ „ „ pathology of, 12

„ „ „ symptomatology of, 19

Psychasthenia and delusions, 593
Psychical rigor, 358
Psychiatry, a philosophy of, 473

„ clinical, 417

„ teaching of, 550

Psychology, 752

„ of alcoholism, 750
„ of folk lore, 150
„ of thought, 759
Psycho-therapy, 489, 753
Pulse rate in mania, 221
Punjab asylum, criminal lunacy in, 362

Quantitative psychology, 591

Recidivism, 68, 289

„ aetiology of, 290
„ causation of, 73
„ its relation to lunacy, 91
„ penal systems in relation to, 291
Reports, asylum, issued in 1907, 157 et seq.

„ u „ 1908, 768 „

„ of the Commission on Care of the Feeble-minded, 747

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814 INDEX

Reports of the Commissioners in Lunacy for England, 123

of the General Board of Commissioners for Scotland, 125
” of the inspectors of lunatics (Ireland), 128
” on mental hospitals (New Zealand), 199

„ of Special Committees, 789

„ of Standing Committees, 784

„ Treasurer’s, 781

Research work in asylums, 746
Resistances in brain work, 592
Responsibility, 155
Rest treatment of acute insanity, 105
Reversed orientation, 594
Rheumatism and insanity, 59, 209
Rutherford, Dr., retirement of, 389

School hygiene, second international congress on, 426
Senile dementia, regions of cerebral wasting in, 16
Senility and degeneration of cerebral vessels, 4
Sensation, physical basis of, 624
Sexual aetiology of neuroses, 588
„ hygiene in France, 155
Sociology, 155, 767

Somnambulism, hysterical, arson in, 152
“ Speaking with tongues,” 756
Spirochaeta pallida, 23

Spinal cord, histology of some toxic lesion of, 560
„ fluids in nervous diseases, 599
Statistical notes on criminal lunacy in the Punjab, 362
Statistics, note on, 581

Status epilepticus and its treatment, 94, 5 22 » 5 2 4
Surgical treatment of the insane, 764
Syphilis as a cause of dementia paralytica, 6
Syria, dementia praecox and mental degeneracy in, 511

Tabetic general paralysis, 53
Teaching of psychiatry, 550
Test of criminal responsibility, 289
Thaw case, 372, 403

Thomson’s, Dr., motion re teaching of psychiatry, 791
Thought, physical basis of, 625
„ psychology of, 759
Thrombotic origin of epileptic fits, 638
Toxines, indirect action of, 3

„ vascular and neuroglial changes following action of, 5
Tic, 587

Timidity in psycho-neuroses, 592

Treasurer’s report, 781

Treatment of insanity, 105, 119, 418, 763

Trinitrine in mental disorder, 418

Tuberculin, clinical results following injection of, 344

Unity of insanity and its bearing on classification, 328

Will, 626

Xenoglossia, 591

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INDEX.

815

Part II.—ORIGINAL ARTICLES.

Baird, Dr. H., some observations on insanity in Jews, 528

Baugh, Dr. L. D. H., observations on insane epileptics treated under hospital
principles, 518

Bolton, Dr. J. S., amentia and dementia: a clinico-pathological study, 1, 264, 433
Brown, Dr. R. D., a case of narcolepsy, 107

Brown, Dr. R. C., the boarding out or the insane in private dwellings, 532
Bruce, Dr. L. C., the symptoms and aetiology of mania : the Morison lectures, 207,
227, 245

Drapes, Dr. T., the unity of insanity and its bearing on classification, 328

East, Dr. G. R., acute mania following general anassthesia, 118
„ „ a case of cretinism, 570

Hart, Dr. B., a philosophy of psychiatry, 473

Jones, Dr. R., the mental recreations of the mental nurse, 490
„ „ the question of dementia praecox, 651

Leeper, Dr. R. R., of the onset of melancholia, 357

McDougall, Dr. A., on the principles of the treatment of epilepsy, 718
McDowall, Dr. C. F. F., three cases of juvenile general paralysis, 112
„ „ general paralysis in father, mother and son, 562

„ „ leucocytosis: its relation to and significance in acute

mental disorders, 669

Mackenzie, Dr. T. C., menstruation in the insane, 116

Mercier, Dr. C., the presidential address, on the physical basis of mind, 619

Norman, Dr. Conolly, obituary of, 204

Orr, D., and Rows, R. G., Drs., some points in the histology of lymphogenous and
hematogenous toxic lesions of the spinal cord, 560

Raffle, Dr. A. B., some notes on status epilepticus and its treatment, 94
Robertson, Dr. A., observations on the less severe forms, pathology and treatment
of mental disorder in advanced life, 500

Robertson-Milne, Major C. J., statistical notes on criminal lunacy in the Punjab
asylum, 362

Shaw, Dr. C. J., clinical results following the injection of tuberculin, 344
„ „ observations on the opsonic index to various organisms in control

and insane cases, 57

Somerset, Lady H., some aspects of inebriety, 704

Strangman, Dr. Mary S. r., the atropine treatment of morphinomania and
inebriety, 727

Sturrock, Dr. J. P., acute furious mania in cerebro-spinal meningitis, 734
Sutherland, Dr. J. F., recidivism regarded from the environmental and psycho-
pathological standpoints, 68, 289

Thomson, Dr. D. G., the teaching of psychiatry, 550
Thwaites, Dr. H., dementia praecox and mental degeneracy in Syria, 511
Turner, Dr. J., some further observations bearing on the supposed thrombotic
origin of epileptic fits, 638

Urquhart, Dr. A. R., dementia praecox, 661

Wigglesworth, Dr. J., on the treatment of cases of acute insanity by rest in bed in
the open air, 105

Digitized by L^ooQle

816

INDEX.

Part III.—REVIEWS.

Bateman, Sir F. f and Rye, W., The history of the Bethel hospital at Norwich, 395
Cutten, G. B., The psychology of alcoholism, 750

Denny and Camus, P., Drs., The intermittent psychoses. Maniacal De pr e ss ive
Insanity, 585

Forel, Dr. A., Hypnotism or suggestion and psycho-therapy, 751
HirscMeld, Dr. M., Jahrbuch fur sezuelle zwischenstufen, 753

J ones, Dr. R., A text-book of mental and sick nursing, 393
udd, C. H., Psychology, 752

ung, C. G., The physiology of dementia praecox, 584
Lange, Dr. Fr., Degeneration in families, 396

Lannois and Porot, Drs., Recent therapeutics in nervous diseases, 587

Masson, Dr. ]. M., Lucretius, epicurean and poet, 138

Morel, Dr. J., Manual for nurses in hospitals for mental diseases, 395

Muthmann, A., Psycho-therapy, 753

de Quiros, Senor C. B., Las nuevas teorias de la criminalidad, 582

Report of the Commissioners in Lunacy for England for 1906, 123

„ of the General Board of Commissioners for Scotland for 1907, 125
„ of the Inspector of Lunatics (Ireland) for 1906, 128
Royer, Dr. M., De l'absolue n6cessit£ de ('assistance des enfants anormaux, 397

Savage, Dr. G. H., Insanity and allied neurosis, 134
Sullivan, Dr. W. C., Alcoholism, 136
Symons, A., William Blake, 141

Ziehen, von, Dr. Th., Die erkennung und behandlung der melancholie in der
praxis, 143

Part IV.—AUTHORS REFERRED TO IN EPITOME.

Adamkiewicz, 144
Antheaume, A., and
Mignot, R., 417
Arnaud, F., 593
Awtokratow, P. M., 596

Ballet, etc., 155
Blrillon, Damoglou, etc.,
592

Buhler, K., 759
Burr, C. W., 154
Bychowski, 150

Claparfede, E., 757
Clarke, L. P., and Atwood,
C. E., 761
Cullerre, 152

Damaye, 767

Finney, J. Magee, 153
Forli, 595
Fornaca, 416
Friedl&nder, A., 588

Galdi, 600
Gausset, A., 760
Gualino, L., 755

Henkel, 599

Janet, P., 594

Kaes, T., 143
Kurschman, 151

La-Salle-Archambault,

144

L6al, Foveau de Cour-
melles, etc., 155
Leroy, B., 757
Liepmann, 597
Lombard, E., 590

Maas, O., 149
Marchand, L., and Monet,
H., 151

Marchand and Nouet, 762
Masselon, R., 151
Mayendorf, E. N., 146
Milian, 760
Mohr, F., 756
Mosher, J. M., 768

N&cke, P., 419, 588, 756

Petrazzani, 762

Picqu£, 764
Pieters, P., 760
Prunier, Andrfc, 603

Rlmond and Voivenel,
418

Rieger, C., 592
Riklin, 150
Risch, 768

Rothmann, Max, 146

Sanna Salaris, 418
Schaffer, 420
Schuster, 153
Shepard, J. F., 589
Sichel, M., 767
Starlinger, J., 765

Terrien, 758
Tissot, F., 763
Tolone, J., 598

Van Biervliet, 591

Wehrli, 148
Witmer, Lightner, 595

Digitized by L^ooQle

INDEX.

817

ILLUSTRATIONS.

Plates to illustrate Dr. Bolton’s article on “ Amentia and Dementia,” 17, 47
Diagrams to illustrate Dr. Sutherland's article on " Recidivism,” 86, 92
Charts to illustrate Dr. Raffle's article on “ Status Epilepticus,” 97, 99, 102, 103
Photograph of Dr. Conolly Norman, to face page 203

Charts to illustrate Dr. Bruce's article on “ Symptoms and iEtiology of Mania,' 1
209, 215, 216-219, 221, 223-225, 230-238, 240-243, 254-259
Plates to illustrate same, 218

Tables to illustrate Dr. Drapes' article on " Unity of Insanity,” 342, 343
Plate to illustrate Drs. Orr and Rows’ article on “ Histology of Lymphogenous
and Haematogenous Toxic Lesions of the Spinal Cord,” 560
Charts to illustrate Dr. Turner’s article on " The Thrombotic Origin of Epileptic
Fits,” 644-646, 649

ADLARD AND SON, IMPR. LONDON AND DORKING.

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