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I _ THE JOURNAL 

OF 

MENTAL SCIENCE. 


EDITORS: 

J. R. Lord, C.B.E., M.B. Henry Devine, O.B.E., M.D. 

G. Douglas McRae, M.D. 


VOL. LXVIII. 




LONDON: 


J. & A. CHURCHILL, 

7, GREAT MARLBOROUGH STREET. 

mdccccxxm. ; ».■ 


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" In adopting our title of the Journal of Mental Science , published by authority 
of the Medico-Psychological Association , we profess that we cultivate in our pages 
mental science of a particular kind, namely, such mental science as appertains 
to medical men who are engaged in the treatment of the insane. But it has 
been objected that the term mental science is inapplicable, and that the term 
mental physiology or mental pathology, or psychology, or psychiatry (a term 
much affected by our German brethren), would have been more correct and ap¬ 
propriate ; and that, moreover, we do not deal in mental science, which is pro¬ 
perly the sphere of the aspiring metaphysical intellect. If mental science is 
strictly synonymous with metaphysics, these objections are certainly valid; for 
although we do not eschew metaphysical discussion, the aim of this Journal is 
certainly bent upon more attainable objects than the pursuit of those recondite 
inquiries which have occupied the most ambitious intellects from the time of 
Plato to the present, with so much labour and so little result. But while we 
admit that metaphysics 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. t F.R.S. 



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THE 

M ED ICO-PSYCHO LOGICAL ASSOCIATION 
OF GREAT BRITAIN AND IRELAND. 

THE COUNCIL AND OFFICERS, 1921-22. 


president. —CHAS. HUBERT BOND, C.B.E., D.Sc., M.D., F.R.C.P. 
president elect.— G. M. ROBERTSON, M.D., F.R.C.P.Edin. 
ex-presidbnt. —W. F. MENZIES, M.D., F.R.C.P. 
treasurer.— JAMES CHAMBERS, M.A., M.D. 

/J. R. LORD, C.B.E., M.B. 

H. DEVINE, O.B.E., M.D., F.R.C.P. 
kditors OF journal q D0 UGLAS McRAE, M.D., F.R.C.P.Edin. 

».W. R. DAWSON, O.B.E., M.D., F.R.C.P.IreL 

DIVISIONAL SECRETARY FOR SOUTH-EASTERN DIVI8ION. 

J. NOEL SERGEANT, M.B. 

DIVISIONAL SECRETARY FOR SOUTH-WESTERN DIVI8ION. 

G. N. BARTLETT, M.B. 

DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION. 

J. R. GILMOUR, M.B. 

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION. 

W. M. BUCHANAN, M.B. 

DIVISIONAL SECRETARY FOR IRISH DIVISION. 

RICHARD R. LEEPER, F.R.C.S.Irei. 

GENERAL SECRETARY. 

R. WORTH, O.B.E ., M.B. 

CHAIRMAN OF PARLIAMENTARY COMMITTEE. 

R. H. COLE, M.D., F.R.C.P. 

SECRETARY OF PARLIAMENTARY COMMITTEE. 

W. BROOKS KEITH, M.C., M.D. 

CHAIRMAN OP EDUCATIONAL COMMITTEE. 

JOHN KEAY, C.B.E., M.D., F.R.C.P.Edin. 
vice-chairman.— M. A. COLLINS, O.B.E., M.D. 

SECRETARY OF EDUCATIONAL COMMITTEE. 

A. W. DANIEL, B.A., M.D. 
registrar.— ALFRED MILLER, M.B. 


RBPRB8BNT AT1VB. 

J. BRANDER ^ 

F. H. EDWARDS I c 

J. G. PORTER PHILLIPS P 
R. H. STEEN J 

T. 8. GOOD U 

J. G. SOUTAR P 

T. STEWART ADAIR ) T 

R. R.KIRWAN P 

j. h. McDonald u 

C. J. SHAW P 


MEMBERS OF COUNCIL. 

1VB. REPRESENTATIVE. 

^ J.C. MARTIN ) lR _ 

U.E. Div. H * C * RUTHERFORD f ARB 

'®f NOMINATED. 

J A. HELEN A. BOYLE. 

IS.W. Div. J- KEAY. 

> Sir F. W. MOTT. 

tN&M Div M. J. NOLAN, 

j- in., u iv. BEDFORD PIERCE. 

I o G. W. SMITH. 

[Scotland. d g XIIOMSON. 

[Tlie above form the Council.] 


|Ireland 


EXAMINERS. 

England! J - G * P0RTER PHILLIPS, M.D. 

ENGLAND | E g p ASM0RE> M.D. 

a<wrl „ f J. H. C. OUR, M.D. 

SCOTLAND | D0NALD R0SS( M.B. 

Ireland ! P* E - HAINSFORD, B.A., M.D. 

Ireland | j O’CONOR DONELAN, L.R.C.P.&S.Irel. 

Examiners for the Nursing Certificate of the Association : 

Final. —T. C. MACKENZIE, M.D.; J. MILLS, M.B.; G. E. PEACHELL, M.D. 
Freliminary.—J. BRANDER, M.B.; P. O’DOHERTY, B.A., M.B.; 

D. K. HENDERSON, M.D. 

Mental Defectives ; Final. —E. B. SHERLOCK, M.D.; R. D. CLARKSON, BJSc.^ 
M.D., F.R.C.S.Edin.; F. E. RAINSFORD, B.A., M.D. 


C. F. F. McDOWALL, M.D. 


AUDITORS. 


C. M. TUKE, M.R.C.S. 


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PARLIAMENTARY 

T. STEWART ADAIR. 

Sir R. ARMSTRONG-JONES. 

G. N. BARTLETT. 

FLETCHER BEACH. 

J. SHAW BOLTON. 

D. BOWER. 

A. HELEN A- BOYLE. 

W. M. BUCHANAN. 

R. B. CAMPBELL. 

J. CHAMBERS. 

R. H. COLE. 

M. A. COLLINS. 

Sir M. CRAIG. 

A. W. DANIEL. 

J. F. DIXON. 

R. EAGER. 

J. W. GEDDES. 

J. R. GILMOUR. 

D. K. HENDERSON. i 

J. KEAY. ! 

W. BROOKS KEITH. | 

R. R. KIRWAN. 

R. L. LANGDON-DOWN. j 

R. R. LEEPER. J 

EDUCATIONAL 

Sir R. ARMSTRONG-JONES. 
FLETCHER BEACH. 

J. SHAW BOLTON. 

D. BOWER. 

A. HELEN A. BOYLE. 

R. B. CAMPBELL. 

JAMES CHAMBERS. 

R. H. COLE. 

M. A. COLLINS. 

T. P. COWEN. 

Sir M. CRAIG. 

A. W. DANIEL. 

W. R. DAWSON. 

J. F. DIXON. 

R. EAGER. 

J. W. GEDDES. 

B. HART. 

D. K. HENDERSON. 

R. D. HOTCHKIS. 

J. KEAY. 

R. R. KIRWAN. 

LIBRARY 

FLETCHER BEACH. 

A. HELEN A. BOYLE. 

M. A. COLLINS. 

H. DEVINE. 

B. HART. 

T. B. HYSLOP. 

RESEARCH 

T. 8TEWART ADAIR. 

J. SHAW BOLTON. 

C. H. BOND. 

J. CHAMBERS. 

M. A. COLLINS. 

H. DEVINE. 

E. GOODALL. 

J. KEAY. 

J. R. LORD. 


COMMITTEE. 

J. R. LORD. 

H. C. MACBRYAN. 

T. C. MACKENZIE. 

G. DOUGLAS McRAE. 

W. F. MENZIES. 

A. MILLER. 

W. F. NELIS. 

L. R. OSWALD. 

E. S. PASMORE. 
BEDFORD PIERCE. 
NATHAN RAW. 

G. M. ROBERTSON. 

J. NOEL SERGEANT. 

G. E. SHUTTLEWORTH. 
J. H. SKEEN. 

R. PERCY SMITH. 

J. G. SOUTAR. 

R. H. STEEN. 

R. C. STEWART. 

F. R. P. TAYLOR. 

D. G. THOMSON. 

E. W. WHITE. 

J. R. WHITWELL. 

H. WOLSELEY-LEW1S. 

COMMITTEE. 

H. C. MACBRYAN. 

T. C. MACKENZIE. 

G. DOUGLAS McRAE. 

W. F. MENZIES. 

J. MIDDLEMASS. 

A. A. MILLER. 

Sir F. W. MOTT. 

W. F. NELIS. 

J. G. PORTER PHILLIPS. 
L. R. OSWALD. 

BEDFORD PIERCE. 

G. M. ROBERTSON. 

E. B. SHERLOCK. 

J. H. SKEEN. 

G. W. SMITH. 

R. PERCY SMITH. 

J. G. SOUTAR. 

R. H. STEEN. 

F. R. P. TAYLOR. 

D. G. THOMSON. 

J. R. WHITWELL. 

COMMITTEE. 

J. KEAY (ex officio). 

E. MAPOTHER. 

H. RAYNER {Chairman). 
R. H. STEEN ( Secretary ). 
W. H. B. STODDART. 

D. G. THOMSON. 

COMMITTEE. 

Sir F. W. MOTT. 

W. M. OGILV1E. 

D. ORR. 

FORD ROBERTSON. 

R. G. ROWS. 

R. PERCY SMITH. 

R. H. STEEN. 

D. G. THOMSON. 

W. J. TULLOCH. 


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LIST OF CHAIRMEN. 

1841. Dr. Blake, Nottingham. 

1842. Dr. de Vitre, Lancaster. 

1843. Dr. Conolly, Han well. 

1844. Dr. Thuruam, York Retreat. 

1847. Dr. Wintle, Warneford House, Oxford. 

1851. Dr. Conolly, Hanwell. 

1852. Dr. Wintle, Warneford House. 


LIST OF PRESIDENTS. 

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

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

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

1857. Forbes Winslow, 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. Win. 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., Sandywell Park, Cheltenham. 

1869. T. Laycock, M.D., Edinburgh. 

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

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

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

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

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

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

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

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

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

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

1880. G. W. Mould, M.R.C.S., Royal Asylum, Cheadle. 

1881. D. Hack Tuke, M.D., London. 

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

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

1884. Henry Rayner, M.D., County Asylum, Hanwell. 

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

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

188T. Sir Fred. Needham, M.D., Barnwood House, Gloucester. 

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

1889. H. Hayes Newington, F.R.C.P., Ticehurst, Sussex. 

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

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

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

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

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

1895. David Nicolson, C.2?., M.D., State Criminal Lunatic Asylum, Broadmoor. 

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

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

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

1899. J. B. Spence, O.B.E., M.D., Burntwood Asylum, nr. Lichfield, Stafford¬ 

shire. 

1900. Fletcher Beach, M.B., 79, Wimpole Street, W. 1. 

1901. Oscar T. Woods, M.D., District Asylum, Cork, Ireland. 

1902. J. Wiglesworth, M.D., Rainhill Asylum, near Liverpool. 


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1903. Ernest W. Wliite, C.B.E. , M.B., Betley House, nr. Shrewsbury. 

1904. R. Percy Smith, M.l)., 36, Queen Anne Street, Cavendish Square, 

London, W. 1. 

1905. T. Outtersou Wood, M.D., 40, Margaret Street, Cavendish Square, 

London, W. 1. 

1906. Sir Robert Armstrong-Jones, C.B.E., M.D., Claybury Asylum, Woodford 

Bridge, Essex. 

1907. P. W. MacDonald, M.D., County Asylum, Dorchester. 

1908. Clias. A. Mercier, M.D., 34, Wimpole Street, London W. 1. 

1909. W. Bevan-Lewis, M.Sc., L.R.C.P., late Medical Director, West Riding 

Asylum, Wakefield. 

1910. John Macpherson, M.D., Commissioner in Lunacy, 8, Darnaway Street, 

Edinburgh. 

1911. Wm. R. Dawson, O.B.E., M.D., Inspector of Lunatic Asylums, Dublin 

Castle, Dublin. 

1912. J. Greig Soutar, M.B., Barn wood House, Gloucester. 

1913. James Chambers, M.D., The Priory, Roeharapton, S.VV. 

1914-18. David G. Thomson, C.B.E. y M.D., County Asylum, Thorpe, Norfolk. 

1918. John Keay, C.B.E. , M.D., Bangour Village, Uphall, Linlithgowshire. 

1919. Bedford Pierce, M.D., The Retreat, York. 

1920. William F. Menzies, ‘ M.D., Staffordshire County Mental Hospital, 

Cheddleton, near Leek. 

1921. C. Hubert Boud, C.B.E., M.D., Commissioner of the Board of Control, 

England. 


LIST OF MAUDSLEY LECTURERS. 

1920. Sir J. Crichtou-Browne, LL.D., D.Sc., M.D., F.R.S. 

1921. Sir F. W. Mott, K.B.E., LL.D., M.D.. F.R.C.P., F.R.S. 

1922. Sir M. Craig, C.B.E ., M.A., M.D., F.R.C.P. 


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Honorary and Corresponding Members . 


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HONORARY MEMBERS. 

1896. Allbutt, Sir T.Clifford, K.C.B., D.L., LL.D., M.D.Camb., F.R.C.P.Lond., 
F.R.S., Regius Professor of Physic, Univ. Carnb., St. Radegund's, 
Cambridge. 

1918. Bevan-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Lond., 22, 
Cromwell Road, Hove. (President, 1909-10.) 

1907. Bianchi, Prof. Leonardo, Manicomio Provinciale di Napoli. Musee N. 3, 
Naples, Italy. (Corr. Mem., 1896.) 

1900. Blumer, G. Alder, M.D., L.R.C.P.Edin., Butler Hospital, Providence, 
U.S.A. ( Ord. Mem., 1890.) 

1900. Bresler, Johannes, M.D., Sanitafcsrat, Director of the Provincial Mental 
Hospital, Kreuzburg, Oberschlesien, Germany. (Editor of the 
Ptychiatrisch-neurologi&che Wochenschrift.) ( Corr. Mem. 1896.) 
1902. Brush, Edward N., M.D., Sheppard and Enoch Pratt Hospital, Towson, 
Maryland, U.S.A. 

1920. Colin, Dr. H., Secretaire General de la Soci6te Medico-Psycliologique de 

* « Paris, 26, Rue Vanquelin, Paris (V e ), France. 

1917. Colles, John Mayne, LL.D.Dubl., K.C., J.P., 35, Kensington Terrace, 
^ ^ B Hyde Park, Leeds. 

1909. 50 Collins, Sir Win! Job, K.C.V.O., D.L., B.Sc., M.D., M.S.Lond., F.R.C.S. 

Eng., 1, Albert Terrace, Regent's Park, N.W. 1. 

1912. Considine, Thomas Ivory, P.R.C.S., L.R.C.P.Irel., Inspector of Lunatic 
Asylums, Ireland, Office of Lunatic Asylums, Dublin Castle, Dublin. 

1918. Cooke, Sir Edward Marriott, K.B.E. , M.D.Lond., Commissioner in 

Lunacy, 43, Colherne Court, South Kensington, S.W. 5. 

1902. Coupland, Sidney, M.D., F.R.C.P.Lond., Commissioner of the Board of 
^ Control, “Plas Gwyn,” Frognal, Hampstead, London, N.W. 3. 
1876. Crichton-Browne, Sir J., LL.D., D.Sc., M.D.Edin., F.R.S., Lord 
Chancellor's Visitor, Royal Courts of Justice, Strand, London, 
W.C. 2., and 45, Hans Place, London, S.W. 1. (President, 1878.) 
1911. ^ Donkin, Sir Horatio Bryan, M.A., M.D.Oxon., F.R.C.P.Lond. (Medical 
Adviser to Prison Commissioners and Director of Convict Prisons), 
28, Hyde Park Street, London, W. 2. 

1895. Ferrier, Sir David, LL.D., M.D., F.R.C.P.Lond., F.R.S., 34, Cavendish 
Square, London, W. 1. 

1872. Fraser, John, M.B., C.M., F.R.C.P.Edin., Formerly Commissioner in 
Lunacy, 54, Great King Street, Edinburgh. 

1909. Kraepelin, Dr. Emil, Professor of Psychiatry, The University, Munich. 

1910. Macpherson, John, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8, 

Darnaway Street, Edinburgh. (President, 1910.) ( Ordinary 

Member from 1886.) 

1921. Maudsley, Sir Henry Carr, K.C.M.G ., C.B.B., M.D., F.R.C.P., Lecturer 

on Medicine, University of Melbourne. 

1889. Needham, Sir Frederick, M.D.St. And., M.R.C.P.Edin., M.R.C.S.Eng., 
Formerly Commissioner of the Board of Control, Imperial Hotel, 
Bournemouth. (President, 1887.) 

1909. Obersteiner, Hofrat Prof. Dr. Heinrich, Wien, XIX, Krottenbachstr. 3, 
Vienna. 

188J. Peeters, M., M.D., Gheel, Belgium. 

Seinelaigne, Rene, M.D.Paris, Secretaii’e des Seances de la Society 
Medico-Psycliologique de Paris, 59, Boulevard de Montmorency, 
Paris, XVI, France. ( Corresponding Member from 1893.) 

1901. Toulouse, Dr. Edouard, Directeur du Laboratoire de Psychologie experi¬ 
mental k l'Ecole des Hantes Etudes, Paris. 

1910. Trevor, Arthur Hill, Esq., B.A.Oxon., of the Inner Temple, Barrister at 
Law, Commissioner of the Board of Control, 4, Albemarle Street, 
London, W. 1. 


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CORRESPONDING MEMBERS. 

1911. Boedeker, Prof. Dr. Justus Karl Edmund, Privafc Docent and Director, 
Fichtenhof Asylum, Schlaclitensee, Berlin. 

1897. Busclian, Dr. G., Stettin, Germany. 

1904. CoroletS, Wilfrid, Manicomio de Las Corts, Barcelona, Spain. 

1896. Cowan, F. M., M.D., 109, Perponcher Straat, The Hague, Holland. 

1911. Falkenberg, Dr. Wilhelm, Sanit&tstrat, Direktor der Berliner, Torenan- 
stalt, Herzberge, Berlin-Lichtenberg. 

1907. Ferrari, Giulio Cesare, M.D., Director of the Manicomio Provinciale, 
Imola, Bologna, Italy. 

1911. Friedlander, Prof. Dr. Adolf Albrecht, Haus Sonnblick, Littenweiler, bei 
Freiburg i/Baden, Germany. 

1901. Gommes, Dr. Marcel, 5, Rue Parrot, Paris XII. 

1909. Moreira, Dr. Julien, Directeur General de V Assistance aux S. American 
Alienes, Prava da Sandara 288, Rio de Janeiro, Brazil. 

1909. Pilcz, Dr. Alexander, VIII/2 Alserstrasse 43, Wien, Austria. 


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Members of the Association , 


vii 

MEMBERS OF THE ASSOCIATION. 

Alphabetical List of Members of the Association on December 31 st, 1921, with 
the year in which they joined . 

1900. Abbott, Henry Kingsmill, B.A., M.D.Dubl., D.P.H.Irel., Medical Superin. 
tendon t. The Knowle, Fareham. 

1891. Adair, Thomas Stewart, M.D., C.M.Edin., F.R.M.S., Medical Superin. 

tendent, Storthes Hall Asylum, Kirkburton, near Huddersfield. 
{Son. Sec. N. and M. Division , 1908-20.) 

1910. Adam, George Henry, M.R.C.S., L.R.C.P. Lond., Manager and Medical 
Superintendent, West Mailing Place, Kent. 

1868. Adams, Josiah O., M.D.Durli., F.R.C.S.Eng., J.P., 117, Cazenove Road, 
Stamford Hill, London, N. 16. 

1921. Adamson, James Weeden Woodhams, M.D.Durh.,M.R.C.S.Eng., L.R.C.P. 

& L.S.A.Lond., Senior Neurologist, Ashhurst Hospital (Ministry of 
Pensions) ; Ashhurst Hospital, near Oxford. 

1919. Adey, J. K., M.B., C.M.Melb., Receiving House, Royal Park, Melbourne, 
Australia. 

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

1921. Aidan, G dr don Wemyss Thomson, M.B., Ch.B.Glas., Asst. Med. Officer, 
Glasgow Royal Asylum, Gartnavel, Glasgow. 

1899. Alexander, Hugh de Maine, M.D., C.M.Edin., Medical Superintendent, 
Kingseat Mental Hospital, Newmachar, Aberdeen. 

1899. Allmaun, Dorah Elizabeth, M.B., B.Ch.R.U.l., Assistant Medical Officer, 
District Asylum, Armagh. 

1908. Anderson, James Richard Sumner, M.B., Ck.B.Glasg., Senior Assistant 
Medical Officer, Cumberland and Westmorland Mental Hospital, 
Garlands, Carlisle. 

1898. Anderson, John Sewell, M.R.C.S., L.R.C.P.Lond., Senior Assistant 
Medical Officer, Hull City Asylum, Wilier by, near Hull. 

1921. Anderson, William, M.B., Ch.B.Aberd., Senior Assistant Physician, 
Royal Asylum, Aberdeen. 

1918. Anderson, William Kirkpatrick, M.B.,Ch.B.Glasg.,Dykebar War Hospital, 
Paisley; 2, Woodside Crescent, Glasgow. 

1912. Annandale, James Scott, M.B., Ch.B.Aberd., Wadsley Asylum, nr. 
Sheffield. 

1912. Apthorp, Frederick William, M.R.C.S.Eng., L.R.C.P.Edin., M.P.C., 
Senior Medical Officer, Mulgrave, Burgess Hill. 

1904. Archdale, Mervyn Alex., M.B., B.S.Durh., Medical Superintendent, 

County Mental Hospital, Cambridge. 

1905. Archdall, Mervyn Thomas, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., L.S.A. 

Loud., Brynn-y-Nenadd Hall, Llanfairfechan, N. Wales. 

1918. Archibald, Alexander John, M.B., Ch.B.Glasg., 245, Langlands Road, 
Go van, Glasgow. 

1918. Archibald, Madeline, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., 245, Lang¬ 
lands Road, Go van, Glasgow. 

1882. Armstrong-Jones, Sir Robert, C.B.E ., D.Sc.Wales, M.D., B.S., 
F.R.C.P.Lond., F.R.C.S.Eng., 105, Harley Street, W. 1 (and Plls 
Dinas, Carnarvon, North Wales). (Gen. Secretary from 1897 to 

1906.) (President, 1906-7.) Lord Chancellor’s Visitor-in- 
Lunacy. (Lect. on Ment. Die. St. Barth. Hosp.) 

1910. Auden, G. A., M.A., M.D., B.Ch.Camb., F.R.C.P.Lond., D.P.H.Camb., 
F.S.A., School Medical Officer, Education Office, Council House, 
Margaret Street, Birmingham. 

1891* Aveline, Henry T. S., M.D.Durh., M.R.C.S., L.R.C.P.Lond., M.P.C., 
Medical Superintendent, County Asylum, Cotford, near Taunton, 
Somerset. {Son. Sec. for S. W. Division , 1905-11.) 

1909- Bain, John, M.A., M.B., B.Ch.Glasg., Medical Superintendent, Mental 
Hospital, Rowditch, Derby. 


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viii Members of the Association . 

1913. Bainbridge, Charles Frederick, M.B., Ch.B.Edin., Assistant Medical 
Officer, Devon County Mental Hospital, Exmintter. 

1906. Baird, Harvey, M.D., Ch.B.Edin., Periteau, Winchelsea, Sussex. 

1878. Baker, H. Morton, M.B., C.M.Edin., 7, Belsize Square, London, N.W. 3. 
1888. Baker, Sir John, M.D., C.M.Aberd., 18, Nettlecombe Avenue, 
Southsea. 

1904. Barham, Guy Foster, M.A. f M.D., B.Cb.Camb., M.R.C.S., L.R.C.P.Lond., 
Medical Superintendent, Clayburj Mental Hospital, Woodford 
Bridge, Essex. 

1919. Barkas,Mary Rusliton, M.Sc.N.Z., M.B.Lond., M.R.C.S., L.R.C.P.Lond., 

National Hospital, Queen Square, London, W.C. 

1913. Barkley, James Morgan, M.B., Ch.B.Edin., Senior Medical Officer, 
Bracebridge Asylum, Lincolnshire. 

1910. Bartlett, George Norton, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., 
Medical Superintendent, City Mental Hospital, Exeter. 

1901. Baskin, J. Lougheed, M.D.Brux., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., 

Ashhurst War Hospital, Littlemore, Oxford. 

1902. Baugh, Leonard D. H., M.B., Ch.B.Edin., The Pleasaunce, York. 

1874. Beach, Fletcher, M.B., F.R.C.P.Lond., 5, De Crespigny Park, Denmark 

Hill, S.E. 5. ( Secretary Parliamentary Committee , 1896-1906. 
General Secretary ♦ 1889-1896. Pbbsidbkt, 1900.) 

1892. Beadles, Cecil F., M.R.C.S., L.R.C.P.Lond., Gresham House, Egham Hill, 
Egham. 

1921. Beaton, Thomas, O.B.E., M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond., 
Senior Assistant Physician, Bethlem Royal Hospital, London, S.E. 1. 

1913. Bedford, Percy William Page, M.D., Ch.B., Dipl. Psych. Edin., West 

Riding Asylum, Wakefield, Yorks. 

1909. Beeley, Arthur, M.Sc.Leeds, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond., 
D.P.H.Camb. (Assistant Medical Officer , E. Sussex Educational 
Committee), Windybank, King Henry's Road, Lewes. 

1914. Bennett, James Wodderspoon, M.R.C.S., L.R.C.P.Lond., Marsden, 

Babbacombe Road, Torquay. 

1912. Benson, Henry Porter D'Arcy, M.D., C.M., F.R.C.S., M.R.C.P.Edin., 
Farnham House, Finglas, Dublin. 

1914. Benson, John Robinsou, F.R.C.S.Eng., L.R.C.P.Lond., Resident 
Physician and Proprietor, Fiddington House, Market Lavington, 
Wilts. 

1899. Beresford, Edwyn H., M.R.C.S., L.R.C.P.Lond., Medical Superintendent, 

Tooting Bee Mental Hospital, Tooting, London, S.W. 17. 

1912. Berncastle, Herbert M., M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Croydon Mental Hospital, Warlingham, Surrey. 

1920. Birch, W. S., M. C., M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, 

Stone House, Dartford, Kent. 

1894. Blachford, James Vincent, C.B.E., M.D., B.S.Durh., M.R.C.S., L.R.C.P. 

Lond., M.P.C., City Asylum, Fishponds, Bristol. (Lect. on Ment. 
Dis. Univ. of Bristol.) 

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

1919. Blake, Stanley, L.R.C.P.&S.Irel., Assistant Medical Officer, Portrane 
Asylum, Donabate, Ireland. 

1919. Blakiston, Frederick Cairns, M.R.C.S., L.R.C.P.Lond., Medical Super¬ 

intendent, Isle of Man Asylum. 

1897. Blandford, Joseph John Guthrie, B.A.Camb., M.R.C.S., L.R.C.P.Lond., 
D.P.H.Camb., Hotel St. George, Liverpool. 

1918. Blandford, Walter Folliott, B.A.Camb., M.R.C.S., L.R.C.P.Lond., 
Devonshire Club, S.W. 1. 

1904. Bodvel-Roberts, Hugh Frank, M.A.Camb., M.R.C.S., L.R.C.P.Lond., 
L.S.A., Napsbury Mental Hospital, near St. Albans, Herts. 

1920. Boland, J. J., M.B., B.Ch.N.U.I., Assistant Medical Officer, House of 

St. John of God, Stillorgan, Co. Dublin. 

1900. Bolton, Joseph Shaw, D.Sc., M.D., B.S., F.R.C.P.Lond., Medical Super¬ 

intendent, West Riding Asylum, Wakefield. (Prof, of Ment. Dis. 
Univ. of Leeds.) 


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1892. Bond, Charles Hubert, C.B.E., D.Se., M.D., C.M.Edin., F.R.C.P.Lond., 

M.P.C., Commissioner of the Board of Control, 66, Victoria Street, 
London, S.W.l. (Mon. General Secretary, 1906-12.) (President.) 
1920. Bowen, Tudor David John, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Napsbury Mental Hospital, Napsbury, St. Albans. 

1918. Bower, Cedric William, L.M.S.S.A., Joint Medical Officer, Springfield 

House, near Bedford. 

1877. Bower, David, M.D., C.M.Aberd., Springfield House, Bedford. ( Chairman , 
Parliamentary Committee , 1907-1910.) 

1917. Bowie, Edgar Ormond, L.A.H., D.P.H.Dubl., Dip. Grant Med. Coll. 

Bombay; County and City Mental Hospital, Burghill, near 
Hereford. 

1900. Bowles, Alfred, M.R.C.S., L.R.C.P.Lond., 10, South Cliff, Eastbourne. 
1896. Boycott, Arthur N., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical 
Superintendent, Herts County Mental Hospital, Hill End, St. 
Albans, Herts. (Mon. Sec. for S.-E. Division , 1900-05.) 

1898. Boyle, A. Helen A., M.D.Brux., L.R.C.P.&S.Edin., 9, The Drive, Hove, 
Brighton. 

1891. Braine-Hartnell, George M. P., M.R.C.S.,L.R.C.P.Lond., Medical Super¬ 
intendent, County and City Mental Hospital, Powick, Worcester. 

1911. Brander, John, M.B., C.B.Edin., Deputy Medical Superintendent, London 

County Mental Hospital, Bexlev, Kent. 

1919. Branthwaite, Robert Welsh, C.B., M.D.Brux., M.R.C.S., L.R.C.P., 

D.P.H.Lond., Commissioner of the Board of Control, 66, Victoria 
Street, London, S.W. 1. 

1905. Brown, Harry Eger ton, M.D., Ch.B.Glasg., M.P.C., c/o Digby S. Brown, 
106, Hope Street, Glasgow. 

1908. Brown, Robert Cunyngliam, C.B.E.. M.D., B.S.Durh., Ministry of 
Pensions, Westminster, London, S.W. 1. 

1908. Brown, R. Dods, M.D., Ch.B., F.R.C.P., Dipl. Psych., D.P.H.Edin., 
Medical Superintendent, The Royal Asylum, Aberdeen. 

1912. Brown, William, M.D., C.M.Glasg., M.P.C., District Medical Officer, 

Adviser in Lunacy to Bristol Magistrates, 1, Manor Road, Fish¬ 
ponds, Bristol. 

1916. Brown, William/D.Sc.Lond., M.A., M.D., B.Ch.Oxon., Wilde Reader in 
Mental Philosophy, Univ. Oxford; 13, Welbeck Street, W. 1. 

1893. Bruce, Lewis C., M.C., M.D., F.R.C.P.Edin., M.P.C., Medical Superinten¬ 

dent, District Asylum, Druid Park, Murthly, N.B. (Co-Editor of 
Journal 1911-1916; Mon. Sec. for Scottish Division , 1901-1907.) 

1913. Brunton, George Llewellyn, M.D., Cli.B.Edin., Senior Assistant Medical 

Officer, North Riding Asylum, Clifton, Yorks. 

1920. Bryce, William Henderson, M.B., C.M.Edin., Medical Superintendent, 

Kenlaw House, Colinsburgh, Fife. 

1912. Buchanan, William Murdoch, M.B., Ch.B.Glasg., Kirklands Asylum, 
Bothwell, Lanarkshire. (Mon. Sec. for Scottish Division from 1920.) 
1908. Bullmore, Charles Cecil, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Medical 
Superintendent, Flower House, Catford, London, S.E. 6. 

1912. Burke, J. D. G., M.B., B.Cb.R.U.!., St. Audry’s Hospital, Melton, 
Suffolk. 

1921. Butcher, Walter Herbert, M.A., M.B., B.Ch.Oxon., M.R.C.S., L.R.C.P. 

Lond., Assistant Medical Officer, City Mental Hospital, Humber- 
stone, Leicester. 

1921. Buzzard, Edward Farquhar, M.A., M.D.Oxon., F.R.C.P.Lond., Physician 
to St. Thomas's Hospital and to the National Hospital for the 
Paralysed, Queen Square, W.C.; 78, Wimpole Street, London, W. 1. 

1891. Caldecott, Charles, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical 
Superintendent, Royal Earlswood Institution, Redhill, Surrey. 
1921. Caldicott, Charles Holt, M.B.E., M.B.Lond., M.R.C.S., L.R.C.P.Lond., 
Grantbourne, Chobham. 

1894. Campbell, Alfred Walter, M.D., C.M.Edin., M.P.C., Macquarie Chambers, 

183, Macquarie Street, Sydney, New South Wales. 


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1009. Campbell, Donald Graham, M.B., C.M.Edin., “ Auchinellan,” 12, Reid- 
haven Street, Klgiu. 

1914. Campbell, Finlay Stewart, M.D., C.M.Glasg., Deputy Director of Medical 

Services, Ministry of National Service, Ayr, Scotland. 

1897. Campbell, Robert Brown, M.D., C.M., F.R.C.P.Edin., Stirling District 
Asylum, Larbert. (Secretary for Scottish Division, 1910-20.) 
1905. Carre, Henry, L.R.C.P. & S.lrel., Woodilee Asylum, Lenzie, 
Glasgow. 

1891. Carswell, John, F.R.F.P.&S.Glasg., L.lt.C.P.Edin., J.P., Commissioner, 

Board of Control, Scotland, 25, Palmerston Place, Edinburgh. 
1874. Cassidy, D. M., D.Sc.Edin., M.l)., C.M.McGill, F.R.C.S.Edin., Medical 
Superintendent, County Asylum, Lancaster. 

1888. Chambers, James, M.A., M.D.R.U.I., M.P.C., The Priory, Roehampton, 
London, S.W. 15. ( Co-Editor of Journal 1905-i.914, Assistant 
Editor 1900-05.) (President, 1913-14.) ( Treasurer since 1917.) 
(Lect. on Ment. Dis. Middlesex Hosp.) 

1911. Chambers, Walter Duncanon, M.A., M.D., Ch.B.Edin., M.P.C., Murray 
House, Perth. 

1865. Chapman, Thomas Algernon, M.D.Glnsg., L.R.C.S.Edin., F.R.S., F.Z.S., 
Be tula. Re i gate. 

1915. Clieyne, Alfred William Harper, M.B., Ch.B.Aberd., Assistant Medical 

Officer, Royal Asylum, Aberdeen. 

1917. Chisholm, Percy, L.R.C.P. & S.Edin., L.R.F.P. & S.Glasg., Assistant 
Medical Officer, Stirling District Asylum, Larbert. 

1907. Chislett, Charles G. A., M.B., Ch.B.Glasg., Medical Superintendent, 
Stoneyetts, Chryston, Lanark. 

1921. Cholmeley, Mountague Adye, M.R.C.S., L.R.C.P.Lond., Ministry of 
Pensions Hospital, Orpington, Kent. 

1880. Christie, J. W. Stirling, L.R.C.P.&S.Edin., 21, St. Matthew’s Gardens, 
St. Leonards-on-Sea. 

1878. Clapham, Win. Crochley S., M.D., F.R.C.P.Edin., M.R.C.S.Eng., F.S.S., 
The Five Gables, Mayfield, Sussex. (Hon. Sec . N. and M. 
Division , 1897—1901.) 

1920. Clark, R. M., M.B., C.M.Edin., Medical Superintendent, Whittingham 

Asylum, Lancashire. 

1907. Clarke, Geoffrey, M.D.Lond., Medical Superintendent, London County 
Mental Hospital, Bexley, Kent. 

1907. Clarkson, Robert Durward, B.Sc., M.D., C.M.Edin., F.R.C.P.Edin. 

(Medical Officer, Scottish National Institute for the Education of 
Imbecile Children), The Park, Larbert, Stirling. 

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

Street, London, W. 1. (Secretary of Parliamentary Committee , 
1912-21, Chairman since 1921.) (Lect. ou Ment. Dis. St. Mary’s 
Hosp.) 

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

1900. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Kent County Mental Hospital, Barming Heath, Maid¬ 
stone. 

1903. Collins, Michael Abdy, M.D.,B.S.Lond.,M.R.C.S.,L.R.C.P.Lond., 

Medical Superintendent, Kent Mental Hospital, Chartham Downs, 
Kent. (Hon. General Secretary , 1912-18.) 

1910. Conlon, Thomas Peter, L.R.C.P.&S.Irel., Resident Medical Superin¬ 
tendent, District Asylum, Monaghan. 

1921. Connell, Ernest Henry,M.B., Ch.B.Edin., Clinical Assistant, Morningside 

Royal Asylum, Edinburgh. 

1920. Connell, O. G., M.C., L.R.C.P.&S.Irel., Senior Assistant Medical 
Officer, Norfolk County Mental Hospital, Thorpe, Norwich. 

1914. Connolly, Victor Lindley, M.C., M.B., B.Ch.Belf., Assistant Medical 
Officer, Long Grove Mental Hospital, Epsom, Surrey. 

1910. Coombes, Percival Charles, M.R.C.S., L.R.C.P.Lond., Medical Superin¬ 
tendent, Netherne House, Coulsdon, Surrey. 


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Members of the Association. 

192J. Cooper, Alexander, M.A., M.B., Ch.B.Aberd., Junior Assistant Medical 
Officer, Aberdeen Royul Asylum, Aberdeen. 

1905. Cooper, K. D., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., c/o Leopold & Co. 
Apollo, Bunder, Bombay. 

1903. Cormac, Harry Dove, M.B., B.S.Madras, Medical Superintendent, 
Parkside House, Macclesfield. 

1891. Corner, Harry, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C., 37, Harley 
Street, London, W. 1. 

1917. Costello, Christopher, M.B., B.Cli.N.U.I., Assistant Medical Officer, 

Portrane Asylum, Ireland. 

1897. Cotton, William, M.A., M.D.Ediu., D.P.H., M.P.C., 231, Gloucester Road, 
Bishopston, Bristol. 

1910. Couplatid, William Henry, L.R.C.S.&P.Edin., Medical Superinten¬ 

dent, Royal Albert Institution, Albert House, Haverbreaks, 
Lancaster. 

1913. Court, E. Percy, M.R.C.S., L.R.C.P.Lond., Severalls Mental Hospital, 
Colchester. 

1893. Cowen, Thomas Philip, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond., 
Medical Superintendent, County Asylum, Rainhill, Lancashire. 
(Lect. on Ment. Dis. Univ. of Liverpool.) 

1911. Cox, Donald Maxwell, M.R.C.S., L.R.C.P.Lond., 2, Royal Park, Clifton, 

Bristol. 

1918. Cox, The lit. Hon. M. F., LL.D., M.D.R.U.I., F.R.C.P.lrel., Physician, St. 

Vincent’s Hospital, Dublin; Lord Chancellor’s Consulting Visitor in 
Lunacy for County and City of Dublin; 26, Merrion Square, 
Dublin. 

1893. Craig, Sir Maurice, C.B.K, M.A., M.D., B.Ch.Camb., F.R.C.P.Loud., 

M.P.C., 87, Harley Street, Loudon, W. 1 . (Hon. Secretary of 
Educational Committee , 1905-8; Chairman of Educational Com¬ 
mittee 1912-19.) (Lect. on Psychol. Med. Guy’s Hosp.) 

1921. Creagh, Pierce Nagle, L.R.C.P.&S.I., Deputy Commissioner, Mediral 
Services (Neurological), Ministry of Pensions; 142, Lexham 
Gardens, London, W. 8. 

1897. Cribb, Harry Gifford, M.R.C.S., L.R.C.P.Lond., Medical Superintendent, 
Winterton Asylum, Ferryhill, Durham. 

1911. Crichlow, Charles Adolphus, M.B., Ch.B.Glasg., Roxburgh District 
Asylum, Melrose. 

1917. Crocket, James, M.D.Edin., D.P.H., Medical Superintendent, Colony of 
Mercy for Epileptics, Consumption Sanatoria of Scotland, Craigielea, 
Bridge of Weir. 

1904. Cross, Harold Robert, L.S.A.Lond., F.R.G.S., Storthes Hall Asylum, 
Kirkburton, near Huddersfield. 

1915. Crostlnvaite, Frederick Douglas. M.B., Ch.B.Edin., D.P.H., Assistant 
Physician, Pretoria Mental Hospital, South Africa. 

1919. Cuthbert, James Harvey, M.B., Ch.B.Edin., Senior Assistant Medical 

Officer, 63, Eastwood Road, Goodmayes, Essex. 

1907. Daniel, Alfred Wilson, B.A., M.D., B.Ch.Camb., M.R.C.S., L.LLC.P.Lond., 
Medical Superintendent, London County Mental Hospital, Hanwell, 
London, W. 7. ( Secretary of Educational Committee since 1920.) 
1896. Davidson, Andrew, M.D., C.M.Aberd., M.P.C., c/o A. Fraser, Esq., J.P., 
Forres, Scotland. 

1921. Davies-Jones, Charles William Saunderson, M.B., Ch.B.Edin., Ashhurst 
Hospital, Littlemore, Oxford. 

1891. Davis, Arthur N., L.R.C.P.&S.Edin., Medical Superintendent, County 
Asylum, Exminster, Devon. 

1894. Dawson, William R., O.B.E. , B.A., M.D., B.Ch.Dubl., F.R.C.P.lrel., 

M.P.C., D.P.H., Inspector of Lunatics in Ireland, 7, Ailesbury Road, 
Dublin. (Hon. Sec. to Irish Division , 1902-11; Presidbnt, 1911- 
12; Co-Editor of the Journal since 1920.) 

1920. Dawson, William Siegfried, M.A., M.B., B.Ch.Oxon., M.R.C.P.Lond., 

Assistant Medical Officer, Hanwell Mental Hospital, Southall. 


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1901. De Steiger, Ad&le, M.D.Lond., Essex County Mental Hospital, Brent¬ 

wood, Essex. 

1905. Devine, Henry, O.B.E., M.D., B.S., F.R.C.P.Lond., M.R.C.S.Eng., 

M. P.C., Medical Superintendent, Borough Mental Hospital, Milton, 
Portsmouth. ( Co-Editor of the Journal since 1920; Assistant 
Editor 1916-20.) 

1904. Devon, James, F.R.F.P. A S.GIasg., L.R.C.P. A S.Edin., 11, Rutland 

Square, Edinburgh. 

1921. Dick, Alexander, M.C., M.B., Ch.B.Glasg., Assistant Medical Officer, 
Glasgow District Mental Hospital, Woodilee, Lenzie. 

1915. Dillon, Frederick, M.B., Ch.B.Edin., Assistant Medical Officer, 
Northumberland House, Green Lanes, Finsbury Park, London, 

N. 4. 

1909. Dillon, Kathleen, L.R.C.P.AS.Irel., Assistant Medical Officer, District 

Asylum, Mullingar. 

1905. Dixon, J. Francis, M.A., M.D., B.Ch.Dubl., M.P.C., Medical Suptr- 

intendent. Borough Mental Hospital, Humherstone. Leicester. 

1879. Dodds, William J., D.Sc., M.D., C.M.Edin., 15, Marina Road, Prestwick, 
Ayrshire. 

1889. Donaldson, William Ireland, B.A., M.D., B.Ch.Dubl., 2, Ahbeylands, 
Killiney, Co. Dublin. 

1892. Donelan, John O’Conor, L.R.C.P.AS.Irel., M.P.C., St. Dymphna’s, North 
Circular Road, Dublin (Med. Supt., Richmond Asylum, Dublin). 
(Lect. on Ment. Dis. Uuiv. of Dublin.) 

1910. Downey, Michael Henry, M.B., Ch.B.Melb., L.R.C.P. A S.Edin., 

L. R.F.P. A S. Glasg., Medical Superintendent, Parkside Asylum, 
Adelaide, South Australia. 

1919. Drake-Brockman, Henry George, F.R.C.S.Edin., M .R.C.S., L.R.C.P.Lond., 

The Mental Hospital, Middlesbrough. 

1916 Drummond, William Blackley, M.D., C.M.Edin., F.R.C.P.Edin., Medical 
Superintendent, Baldovan Institution, Dundee. 

1921. Drury, Kenneth Kirkpatrick, M.C., M.D., B.Ch.Dubl., Senior Assistant 
Medical Officer and Deputy Superintendent,County Mental Hospital, 
Stafford; “Swift Brook/’ Corporation Street, Stafford. 

1907. Dryden, A. Mitchell, M.B., Ch.B.Edin., Senior Assistant Medical Officer, 
Woodilee Mental Hospital, Lenzie. 

1902. Dudgeon, Herbert Wm., M.D., B.S.Durh., M.R.C.S., L.R.C.P.Lond., 

Medical Superintendent, Khanka Government Asylum, Egypt. 
1899. Dudley, Francis, L.R.C.P.AS.Irel., Medical Superintendent, County 
Asylum, Bodmin, Cornwall. 

1920. Duncan, Jessie Galloway, M.B., Ch.B.Glasg., D.P.H.Camb., Visiting 

M. O., South Side Home for Mental Defectives, Streatham; 33, 
Heybridge Avenue, Streatham, London, S.W. 16. 

1921. Dunlop, George William Cunningham, M.B.,Ch.B.Edin., Senior Assistant 

Medical Officer, District Asylum, Inverness. 

1903. Dunston, John Thomas, M.D., B.S.Lond., Commissioner of Mental 

Disorders and Defective Persons, South Africa, and Medical Super¬ 
intendent, West Koppies Mental Hospital, Pretoria, South Africa. 

1899. Eades, Albert I., L.R.C.P.AS.Irel., Medical Superintendent, North 
Riding Asylum, Clifton, Yorks. 

1906. Eager, Richard, O.B.E. , M.D., Ch.B.Aberd., M.P.C., Assistant Medical 

Officer, The Devon County Mental Hospital, Exminster. 

1891. Earls, James Henry, M.D., M.Ch.R.U.I., L.S.A., D.P.H.Lond., M.P.C., 
Barrister-at-Law, Fenstanton, Christchurch Road, Streatham Hill, 
London, S.W. 2. 

1921. East, Guy R., B.Hy., M.D., B.S., D.P.H.Durh., Medical Superintendent, 
Northumberland County Asylum, Gosforth. 

1907. East, Wm. Norwood, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C., H.M. 

Prison,Liverpool; 95, King’s Avenue, Claphaui Park, S.W. 

1895. Easterbrook, Charles C., M.A., M.D., F.R.C.P.Edin., M.P.C., J.P., 
Physician Superintendent, Crichton Royal Institution, Dumfries. 


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xiii 

1895. Edgerlev, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superinten- 
deut, West Hiding Asylum, Menston, nr. Leeds. 

1897. Edwards, Francis Henry, M.D.Brux., M.R.C.S., M.R.C.P.Lond., Medical 
Superintendent, Camberwell House, London, S.E.5. 

1919. Eggleston, Henry, M.B., B.S.Durh., M.P.C., Ministry of Pensions 
Hospital, Rotherfield Court, Henley-on-Thames. 

1901. Elgee, Samuel Charles, O.-B.F., L.R.C.P.&S.Irel., Medical Super¬ 
intendent, Cane Hill Mental Hospital, Coulsdon, Surrey. 

1889. Elkins, Frank Ashby, M.D., C.M.Edin., M.P.C., Waingroves Cottage, 
121, Rickmansworth Road, Watford, Herts. 

1912. Ellerton, John Frederick Heise, M.D.Brux., M.R.C.S.Eng., L.R.C.P. 
Edin., Rotherwood, Leamington Spa. 

1917. Ellis, Vincent C., M.B., B.Ch.Dubl., Assistant Medical Officer, Richmond 

Asylum, Grangegorman, Dublin. 

1908. Ellison, Arthur, M.R.C.S., L.R.C.P.Lond., Deputy Medical Officer, H.M. 

Prison, Leeds; 10, Sholebroke Avenue, Leeds. 

1899. Ellison, F. C., B.A., M.D., B.Ch.Dubl., Resident Medical Superintendent, 
District Asylum, Castlebar. 

1901. Erskiue, Wm. J. A., M.D., C.M.Edin., Medical Superintendent, County 
Mental Hospital, Wliitecroft, Newport, I. of W. 

1895. Eurich, Frederick Wilhelm, M.D., C.M.Edin., 8, Morniugton Villas, 
Maningham Lane, Bradford. 

1894. Eustace, Henry Marcus, B.A., M.D., B.Ch.Dubl., M.P.C., Medical 
Superintendent, Hampstead and Highfield Private Asylum, 
Glasneviu, Dublin. 

1909. Eustace, William Neilson, L.R.C.S. & P.Irel., Lisronagh, Glasnevin, 

Co. Dublin. 

1918. Evans, A. Edward, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., D.P.H. 

Liverp. (Inspector, Board of Control), 3, Rotherwick Court, Golders 
Green, London, N.W. 4. 

1918. Evans, Tudor Benson, M.B., Ch.B.Liverp., 184, Upper Warwick Street, 
Liverpool. 

1891. Ewan, John Alfred, M.A. St. And., M.D., C.M.Edin., M.P.C., Greylees, 
Sleaford, Lines. 


1894. Furquharson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬ 
tendent, Cumberland and Westmorland Mental Hospital, Garlands, 
Carlisle. 

1921. Farran-Ridge. Clive, M.B., Cli.M.Syd., D.P.M.Lond., Assistant Medical 
Officer, County Mental Hospital, Stafford. 

1907. Farries, John Stothart, L.R.C.P.&S.Ediu., L.R.F.P.&S.Glasg., The 

Cottage, Hetliersgill, Carlisle. 

1903. Fennell, Charles Henry, M.A., M.D.Oxon, M.R.C.P.Lond., 5, Pembridge 
Place, London. W. 2. 

1906. Fielding, Saville James, M.B., B.S.Durh., Medical Superintendent, 
Bethel Hospital, Norwich. 

1873. Finch, John E. M., M.A., M.D.Camb., M.R.C.S.Eng., L.S.A.Lond., 
Homedale, Stoneygate; Leicester. 

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

1906. Firth, Arthur Harcus, M.A., M.D., B.Ch.Edin., Deputy Medical Super¬ 
intendent, Worcestershire County Mental Hospital, Bromsgrove, 
W orcestershire. 

1903. Fitzgerald, Alexis, L.R.C.P.&S.Irel., Medical Superintendent, District 

Asylum, Waterford. 

1908. Fitzgerald, James Francis, L.R.C.P.&S.Irel., Assistaut Medical Officer, 

District Asylum, Clonmel, co. Tipperary, Ireland. 

1921. Fleming, Gerald William, M.R.C.S.Ene., L.R.C.P.Lond., Assistant 
Medical Officer, Sunderland Mental Hospital, Ryhope, Sunderland. 

1904. Fleming, Wilfrid Louis Remi, M.R.C.S., L.R.C.P.Lond., Suffolk House, 

Pirbright, Surrey. 


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xiv Members of the Association. 

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

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

1911. Forrester, Archibald Thomas William, M.D., B.S.Lond., M.R.C.S., L.R.C.P. 

Loud., Senior Assistant Medical Officer, Leicester and Rutland 
Counties Mental Hospital, Narhorough. 

1916. Forsyth, Charles Wesley, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Senior 
Assistant Medical Officer, llubery Hill Mental Hospital, near 
Birin iughaui. 

1913. Forward, Ernest Lionel, M.R.C.S., L.R.C.P.Lond., Ministry of Pensions, 
5, Millbank, S.W.; E&stburv House Hotel, North wood, Middlesex. 
1913. Fotbergill, Claude Francis, B.A., M.B., B.Ch.Cnmb., M.R.C.S., L.RC.P., 
Loud.; “Carncsa!!,” Chorley Wood, Herts; and 150,Harley Street, 
W. 1. 

1920. Fox, J. Tylor, M.A., M.D., B.Ch.Camb., Medical Superintendent, 

Lingfield Epileptic Colony; The Homestead, Lingfield, Surrey. 

1881. Fraser, Donald, M.D., C.M.Glasg., F.U.F.P. & S.Glas., Connel, Cothal, 
nr. Aberdeen. 

1919. Fraser, Kate, B.Sc., M.D., Cb.B.Glasg., D.P.H., Deputy Commissioner, 
General Board of Control, Scotland; 25, Palmerston Place, Edin¬ 
burgh. 

1921. Fuller, Hugh Hercus Cavendish, M.B., Ch.B.Edin., Medical Officer, 

Malvern College; “ Oakdale,” Priory Road, Great Malvern. 

1902. Fuller, Lawrence Otway, M.R.C.S., L.R.C.P.Lond., Medical Super¬ 
intendent, Three Counties’ Meutal Hospital, Arlesey, Beds. 


1906. Gane, Edward Palmer Steward, M.D.Durh., M.R.C.S., L.R.C.P.Lond., 
The Coppice, Nottingham. 

1912. Garry, John William, M.B., B.Ch.N.U.I., Assistant Medical Super¬ 
intendent, Clare County Asylum, Ennis, Ireland. 

1912. Gavin, Lawrence, M.B., Ch.B., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., 
Superintendent, Mullingar District Asylum, Ireland. 

1806. Geddes, John W. t M.B., C.M.Edin., Medical Superintendent, Mental 
Hospital, Middlesbrough, Yorks. 

1892. Geunnel, James Francis, M.B., C.M.Glasg., Tarbat Ness Lodge, Port- 
mahamack, Fearn, Ross-shire. 

1919. Gifford, John, B.A.Cape, M.B., Ch.B.Edin., Senior Assistant Medical 

Officer, Derby County Asylum, Mickleover, Derby. 

1921. Gilfillau, John Aitken, M.B., Ch.B.Glasg., D.P.M., Assistant Medical 
Officer, London County Mental Hospital, Long Grove, Epsom. 

1899. Gilfillau, Samuel James, M.A.,M.B„ C.M.Edin., Medical Super¬ 

intendent, London County Mental Hospital, Colney Hatch, Loudon, 
N. 11. 

1889. Gill, Stauley A., B.A.Dubl., M.D.Durh., M.R.C.S., M.R.C.P.Lond., 
Shaftesbury House, Formby, Liverpool. 

1904. Gillespie, Daniel, Jf.C., M.D., B.Ch., D.P.M.R.U.I., Wadsley Asylum, 
near Sheffield. 

1921. Gillespie, Robert Dick, M.B., Ch.B.Glasg., Junior Assistant Physician, 
Royal Asylum, Gartnavel, Glasgow. 

1920. Gill is, Kurt, M.B., Ch.B.Edin., Assistant Physician, Mental Hospital, 

Bloemfontein,. O.F.S., South Africa. 

1897. Gilmour, John Rutherford, M.B., C.M., F.lt.C.P.Edin., M.P.C., Medical 
Superintendent, West Riding Asylum, Scalebor Park, Bnrley-in- 
Wharfedale, Yorks. ( Hon . Sec. N. and M. Division from 1920.) 

1906. Gilmour, Richard Withers, M.B., B.S.Dm h., M.R.C.S., L.R.C.P.Lond., 
Homewood House, West Meon, Hants. 

1878. Glendinning, James, M.D.Glasg., L.R.C.S.Edin., Lyndhurst, Avenue 
Road, Abergavenny. 

1897. Good, Thomas Saxty, M.R.C.S., L.R.C.P.Lond., Medical Superin¬ 
tendent, Ashhurst Mental Hospital, Littlemore, Oxford. 


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1889. Goodall, Edwin, C.B.E ., M.D., B.S., F.Il.C.P.Loud., M.P.C., Medical 
Superintendent, City Mental Hospital, Cardiff. 

1918. Goodfellow, Thomas Ashton, B.Sc., M.D.Lond., M.R.C.S., L.R.C.P.Lond., 
60, Palatine Road, West Didsbury, Manchester. 

1920. Gordon, George, M.B., Cli.B.Glasg., Neurolagist, Ministry of Pensions; 

c/o Holt & Co., 3, Whitehall Place, London, S.W. 1. 

1899. Gordon, James Leslie, M.D., C.M.Aberd., Karaissi, Caterliam, Surrey. 
1901. Gostwyck, C. H. G., M.B., Ch.B., F.R.C.P.Edin., M.P.C., Dipl. Psych., 
Stirling District Asylum, Larbert. 

1914. Graham, Norman Bell, M.C., B.A.R.U.I., M.B., B.Ch.Belf., D.P.H., 
Assistant Medical Officer, Villa Colony, Purdysburn, Belfast. 

1894. Graham, Samuel, L.R.C.P.Lond., Resident Medical Superintendent, 
District Asylum, Antrim. 

1918. Graham, Samuel John, L.R.C.P.&S.Edin., L.ll.F.P.&S.Glasg., Resident 
Medical Superintendent, Villa Colony Asylum, Purdysburn, Belfast. 

1908. Graham, William S., M.B., B.Ch.R.U.I., Senior Assistant Medical 

Officer, Somerset and Bath Asylum, Cotford, near Taunton. 

1921. Grant, Alastair Robertson, M.B., Ch.B., Assistant Medical Officer, 

County Asylum, Wliittinghara, near Preston. 

1015. Graves, T. Chivers, B.Sc., M.D., B.S.Lond., F.R.C.S.Eng., Medical Super¬ 
intendent, llubery Hill Mental Hospital, nr. Birmingham. 

1916. Gray, Cyril, L.R.C.P.&.S.Edin., L.R.F.P.&S.Glasg., Newcastle City 
Mental Hospital, Gosforth, Newcastle-on-Tyne. 

1921. Gray, Joseph Anthony Wenceslaus Pereira, M.D.Brux., M.R.C.S., 
L.R.C.P.Lond., Medical Officer, Exeter Poor Law Institution; 
Surgeon, Exeter Police; Visitor of Licensed Houses under Lunacy 
and Mental Deficiency Acts; 3, Northernhay Place, Exeter. 

1909. Greene, Thomas Adrian, L.R.C.S.&P.lrel., J.P., Medical Superintendent, 

District Asylum, Carlow. 

1901. Grills, Galbraith Hamilton, M.D., B.Ch.R.U.I., Dipl. Psych., Medical 
Superintendent, County Mental Hospital, Chester. 

1916. Grimbly, Alan F., M.A., M.D., B.Ch.Dubl., Assistant Medical Officer, 
Severalls Mental Hospital, Colchester, Essex; 168, Rock Avenue, 
Gillingham, Kent. 

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

1894. Halsted, Harold Cecil, M.D.Durh., M.R.C.S., L.R.C.P.Lond., Manor 
Road, Selsey, Sussex. 

1920. Hancock, Allen Coulter, M.C., M.R.C.S., L.R.C.P.Lond., Assistant 
Medical Officer, Cane Hill Mental Hospital, Coulsdon, Surrey. 

1920. Harding, Edward Palmer, L.R.C.P.&S.Irel., Assistant Medical Officer, 
East Riding Mental Hospital, Beverley, Yorks. 

1920. Harper, R. Sydney, M.ll.C.S., L.R.C.P.Lond., F.R.M.S., Neurologist in 
Charge Psycho-Therapeutic Clinic,Ministry of Pensions, Brighton; 
4, Adelaide Crescent, Hove, Sussex. 

1904. Harper-Smith, George Hastie, M.A., M.D.Camb., M.ll.C.S., L.R.C.P. 

Loud. (Senior Assistant Medical Officer, Brighton County Mental 
Hospital, Haywards Heath), Fir Cottage, Haywards Heuth, Sussex. 
1898. Harris-Liston,L., M.D.Brux., M.R.C.S., L.R.C.P.Lond., L.S.A., Middleton 
Hall, Middleton St. George, Co. Durham. 

1905. Hart, Bernard, M.D.Lond., M.R.C.S., L.R.C.P.Lond., 81, Wimpole 

Street, London, W. 1, and Northumberland House, Finsbury Park, 
London, N. 4. (Lect. on Ment. Dis. Univ. Coll. Hosp.). 

1886. Harvey, Bagenal Crosbie, L.It.C.P.&S.Edin., L.A.H.Dubl., Resident 
Medical Superintendent, District Asylum, Clonmel, Ireland. 

1892. Haslett, William John H., M.R.C.S., L.R.C.P.Lond., M.P.C., Resident 
Medical Superintendent, Halliford House, Sunbury-on-Thames. 
1890. Hay, J. F. S., M.B., C.M.Aberd., Inspector-General of Asylums for New 
Zealand, Government Buildings, Wellington, New Zealand. 

1900. Haynes, Horace E. t M.R.C.S.Eng., L.S.A., J.P., Littleton Hall, Brent¬ 
wood, Essex. 


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xvi Members of the Association. 

1920. Haynes, Horace Guy Lankester, M.R.C.S., L.R.C.P.Lond., Littleton Hall, 
Brentwood, Essex. 

1920. Heal, James Gordon Freeman, M.D., C.M., Dalhousie, L.M.S., N. Scotia, 
Guysborough, Nova Scotia, Canada. 

1911. Heffernan, P., I.M.S., B.A., M.B., B.Ch.C.U.I., Range moor, Bakewell, 

Derby. 

1920. Henderson, Cyril John, M.B.Durh., Assistant Medical Officer, The 
Royal Albert Institution for the Feeble-Minded, Lancaster. 

1916. Henderson, David Kennedy, M.D., Ch.B.Edin., F.R.F.P.&S.Glasg., 
17, Wbittingbam Drive, Kelvitiside, Glasgow. 

1905. Henderson, George, M.A., M.B., Ch.B.Edin., 25, Commercial Road, 
Peckham, London, S.E. 15. 

1877. Hetherington, Charles E., B.A., M.B., M.Ch.Dubl., St. Lawrence Hill, 
Londonderry, Ireland. 

1877. Hewson, R. \V. f L.R.C.P.&S.Edin., Medical Superintendent, Coton Hill, 
Stafford. 

1914. Hewson, R. W. Dale, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Coton Hill 
Hospital, Stafford. 

1912. Higson, William Davies, M.B., Ch.B.Liverp., 21, Walton Park, 

Liverpool. 

1882. Hill, H. Gardiner, M.R.C.S.Eng., L.S.A., Pentiliie, Leopold Road, 
Wimbledon Park, London, S.W. 19. 

1920. Hills, T. W. S., M.A., B.Ch.Camb., L.S.A., Woodside, Kings Langley, 
Herts. 

1914. Hills, Harold William, B.Sc., M.B., B.S.Lond., M.R.C.S., M.R.C.P.Lond., 
D.P.M., The Rittle House, Gerrards Cross, Bucks. 

1909. Hodgson, Harold West, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Severalls Mental Hospital, Colchester. 

1908. Hogg, Archibald, M.B., Ch.B.Glasg., 54, High Street, Paisley, N.B. 
1900. Hollander, Bernard, M.D.Freib., M.R.C.S., L.R.C.P.Lond, 57, Wimpole 
Street, London, W. 1. 

1920. Hooper, Reginald Arthur, M.B., B.S.Durh., Assistant Medical Officer, 
Netlierne Mental Hospital, Coulsdon, Surrey. 

1903. Hopkins, Charles Leighton, B.A., M.B., B.Ch.Camb., Medical Superin¬ 

tendent, York City Asylum, Fulford, York. 

1914. Horne, Laura Katherine, M.B., Ch.B.Edin., Public Health Dept., St. 
James’ Street, Burnley, Lancs. 

1918. Horton, Wilfred Winnall, M.D., C.M.Edin., Medical Superintendent, Wye 
House, Buxton. 

1894. Hotchkis, Robert D., M.A.Glasg., M.D., B.S.Durh., M.R.C.S., L.R.C.P. 

Lond., M.P.C., Renfrew District Asylum, Dykebar, Paisley, N.B. 
1912. Hughes, Frank Percival, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,The 
Grove, Pinner, Middlesex. 

1900. Hughes, Percy T., M.B., C.M.Edin., D.P.H., Medical Superintendent, 
Worcestershire County Mental Hospital, Barnesley Hall, Broms- 
grove. (Lect. on Ment. Dis. Univ. of Birmingham.) 

1904. Hughes, William Stanley, M.B., B.S.Lond., M.ll.C.S., L.R.C.P.Lond., 

Medical Superintendent, Salop County Asylum, Bicton Heath, 
Shrewsbury. 

1897. Hunter, David, M.A., M.B., B.Ch.Camb., L.S.A., Medical Superintendent, 
The Coppice, Nottingham. (Secretary for S.E. Division 
1910-1913.) 

1912. Hunter, George Yeates Cobb, I.M.S ., M.R.C.S., L.R.C.P.Lond., M.P.C., 
c/o Messrs. Grindlay & Co., 54, Parliament Street, London, 
S.W. 1. 

1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., Three Counties 
Mental Hospital, Arlesey, Beds. 

1911. Hutton, Isabel Etnslie, M.D., Ch.B.Edin., “ Sir Tristrams,” Park Road, 
Camberley; and Forum Club, 6, Grosvenor Place, S.W. 

1888. Hyslop, Theo. B., M.D., C.M.Edin., M.R.C.P., L.R.C.S., F.R.S.Edin.,, 
M.P.C., 5, Portland Place, London, W. 1. 


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1915. Ingall, Frank Ernest, F.R.C.S.Eug., L.R.C.P.Lond., D.P.H., Public 
Health Offices, Clarence Street, Southend-on-Sea. 

1908. Inglis, J. P. Park, M.B., Ch.B.Edin., Assistant Medical Officer, 
Caterham Mental Hospital, Caterham, Surrey. 

1906. Irwin, Peter Joseph, L.R.C.P.&S.Irel., Medical Superintendent, District 

Asylum, Limerick. 

1920. Jackson, John Luke,M.B.,B.Ch.Belf., Senior Assistant Medical Officer and 

Deputy Superintendent, Hants County Asylum, Knowle, Fareham. 

1914. James, George William Blomfield, Jf.C., M.D., B.S.Lond., Moorcroft 

Cottage, Hillingdon, Uxbridge. 

1921. Jardine, Maurice Kirkpatrick, M.B., Ch.B.Edin., Assistant Medical 

Officer, Fife and Kinross District Asylum, Cupar, Fife. 

1908. Jeffrey, Geo. Rutherford, M.D., Ch.B.Glasg., F.R.C.P.Edin., M.P.C., 

F.R.S.Edin., Medical Superintendent, Bootham Park, York. 

1893. Johnston, Gerald Herbert, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., Brooke 
House, Upper Clapton, London, N. 5. 

1905. Johnston, Thomas Leonard, L.R.C.P.&S.Edin., L.R.F.P&.S.Glasg., 
Medical Superintendent, Bracebridge Asylum, Lincoln. 

1912. Johnstone, Emma May, L.R.C.P. & S.Edin., L.R.F.P.&S.Glasg., M.P.C., 
D.P.M.Camb,, University Club for India, 2, Audley Square, W. 1. 

1878. Johnstone, J. Carlyle, M.D., C.M.Glasg., Stourton Hall, Stourbridge. 
1903. Johnstone, Thomas, M.D., C.M.Edin., M.R.C.P.Lond., Annandale, 

Harrogate. 

1921. Jones, Ernest William, M.D.Lond., M.R.C.S., L.R.C.P., The Manor 
House, Aldridge, Walsall, Staffs. 

1879. Kay, Walter S., M.D., C.M.Edin., M.R.C.S.Eng., The Grove, Starbech, 

Harrogate. 

1886. Keay, John, C.B.E., M.D., C.M.Glasg., F.R.C.P.Edin., Medical Super¬ 
intendent. Bangour Village, Uphall, Linlithgowshire. (President, 
1918.) (Lect. on Ment. Dis. Sch. of Med. Roy. Coll. Edinburgh.) 

1909. Keith, William Brooks, M.C., M.D., Ch.B.Aberd., M.P.C., Senior Assistant 

Medical Officer, The Orchard, Knaphill, Surrey. ( Secretary Parlia¬ 
mentary Committee from 1921.) 

1907. Keene, George Henry, M.D., B.Ch.Dubl., 14, Palmerston Park, Dublin. 
1899. Kennedy, Hugh T. J., L.R.C.P.&S.Irel., Medical Superintendent, District 

Asylum, Enniscorthy, Co. Wexford. 

1920. Kerr, Felix Arthur, M.B., Ch.B.Glasg., Assistant Medical Officer, Rubery 
Hill Mental Hospital, Birmingham. 

1897. Kerr, Hugh, M.A., M.D.Glasg., Medical Superintendent, Bucks County 
Mental Hospital, Stone, Aylesbury, Bucks. 

1902. Kerr, Neil Thomson, M.B., C.M.Edin., J.P., Medical Superintendent, 

Lanark District Asylum, Hart wood, Lanarkshire. 

1920. Key, Gordon James, M.B., Ch.B.Aberd., Assistant Physician, Mental 
Hospital, Pretoria, Transvaal, South Africa. 

1897. Kidd, Harold Andrew, C.B.E., M.R.C.S., L.R.C.P.Lond., Medical 
Superintendent, Graylingwell Mental Hospital, Chichester. 

1920. Kimber, William Joseph Teil, M.R.C.S., L.U.C P.Lond., Senior Assistant 

Medical Officer, Herts County Mental Hospital, Hill End, St. Albans. 

1903. King, Frank Raymond, B.A.Camb., M.R.C.S., L.R.C.P.Lond., Medical 

Superintendent, Peckham House, Peckham, London, S.E. 

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

shire. 

1915. Kirwan, Richard R., M.B., B.Ch.R.U.I., Assistant Medical Officer, West 

Riding Asylum, Menston, Leeds. 

1921. Kitchen, John Edward, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Second 

Assistant Medical Officer, Storthes Hall Asylum, Kirkburtou, near 
Huddersfield. 

1919. Knight, Mary Reid, M.A., M.B., Ch.B.Glasg., Assistant Medical Officer, 
Paisley District Asylum. Riccartsbar, Paisley, Scotland. 

1903. Kough, Edward Fitzadam, B.A., M.B., B.Ch.Dubl., Senior Assistant 

Medical Officer, County Asylum, Gloucester. 

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xviii Members of the Association. 

1898. Labey, Julius, M.R.C.S., L.R.C.P., L.S.A.Lond., Medical Superin- 
ten dent, Public Asylum, Jersey. 

1902. Langdon-Down, Percival L., M.A., M.B., B.Ch.Camb., Normansfield, 
Hampton Wick, Middlesex. 

1896. Langdon-Down, Reginald L., M.A., M.B., B.Ch.Camb., M.R.C.P.Lond., 
Normansfield, Hampton Wick. 

1919. Langton, Peregrine Stephen Brackenbnry, M.B., B.S., M.R.C.S., 
L.R.C.P.Lond., Assistant Medical Officer, York City Asylum, 
Fulford, York. 

1914. Ladell, R. G. Macdonald, M.B., Ch.B.Yict., Goldiealie, Wylde Green, 

Birmingham. 

1919. Latham, Oliver, M.B., C.M.Syd., Pathologist, Lunacy Department, 

University, Sydney, N.S.W. 

1902. Laval, Evariste, M.B., C.M.Edin., The Guildhall, Westminster, London, 
S.W. 1. 

1898. Lavers, Norman, M.D.Brnx., M.R.C.S., L.R.C.P.Lond., Medical Super¬ 

intendent, Bailbrook House, Bath. 

1892. Lawless, George Robert, F.R.C.S., L.R.C.P.Irel., Medical Superin¬ 
tendent, District Asylum, Armagh. 

1870. Lawrence, Alexander, M.A., M.D., C.M.Aberd., 26, Hough Green, 
Chester. 

1883, Layton, Henry A., M.R.C.S., L.R.C.P.Edin., 26, Kimbolton Road, 
Bedford. 

1915. Leech, H. Brougham, B.A., M.D., B.Ch.Dubl., Senior Assistant Medical 

Officer, County Asylum, Hatton, Warwick. 

1909. Leech, John Frederick Wolseley, B.A., M.D., B.Ch.Dubl., Assistant 
Medical Officer, Wilts County Asylum, Devizes. 

1899, Leeper, Richard R., F.R.C.S., L.R.C.P.Irel., M.P.C., Medical Super¬ 

intendent, St. Patrick’s Hospital, Dublin. (Hon. Sec . to the 
Irish Division since 1911.) 

1883. Legge, Richard J., M.D.R.U.I., L.R.C.S.Edin., 8, Bath Place, Chelten¬ 
ham. 

1906. Leggett, William, B.A., M.D., B.Ch.Dubl., Smithston Asylum, Greenock, 
Scotland. 

1916. Lewis, Edward, L.R.C.P.&S.Edin., F.R.F.P.&S.Glasg., Drymma Hall, 

Skewen, nr. Neath, Glamorgan. 

1920. Lilley, George Austen, M.D.Camb., M.R.C.S., L.R.C.P.Lond. Assistant 

Medical Officer, London County Mental Hospital, Hanwell, W. 7. 
1908. Litteljohn, Edward Salteine, M.R.C.S., L.R.C.P.Lond., Medical Super¬ 
intendent, Manor Cert. Institution for Mental Defectives, Epsom. 

1921. Livesay, A. W, B., Surg.-Cdr. R.N., M.B., C.M.Edin., F.R.C.S.E., Royal 

Naval Mental Hospital, Great Yarmouth. 

1920. Lloydd-Dodd, E. H. H., L.R.C.P.&S.Irel., Assistant Medical Officer, 
Leavesden Mental Hospital; Woodside, Leavesden, Watford, 
Herts. 

1898. Lord, John R., C.B.E., M.B., C.M.Edin., Medical Superintendent, 
Horton Mental Hospital, Epsom. ( Co-Editor of Journal since 1911; 
Assistant Editor of Journal , 1900-11.) 

1906. Lowry, James Arthur, M.D., B.Ch.R.Ud., Medical Superintendent, 
Surrey County Asylum, Brookwood. 

1904. Lyall, C. H. Gibson, L.R.C.P.&S.Edin., City Mental Hospital, Humber- 
stone, Leicester. 

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


1920. McAlister, William, M.A., M.B., Ch.B.Edin., Assistant Physician, Royal 
Asylum, Morningside, Edinburgh. 

1906. Macarthur, John, M.R.C.S., L.R.C.P.Lond., Deputy Medical Superin¬ 
tendent, Colney Hatch Mental Hospital, London, N. 11. (Lect. 
on Psychol. Med. N.E. Lond. Post-Grad. Coll.) 

1880. MacBryan, Henry C., L.R.C.P.&S.Edin., Kingsdown House, Box, 
Wilts. 


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1900. McCHntock, John, L.U.C.P.&S.Edin., Resident Medical Superintendent, 

Grove House, All Stretton, Church Stretton, Salop. 

1920. McCowan, Peter Knight, M.B., Ch.B.Edin., Assistant Medical Officer, 

Caue Hill Mental Hospital, Coulsdon, Surrey. 

1921. McCutcheon, Archibald Muun, M.B., Ch.B.Glasg., Resident Medical 

Officer, Monyhull Colony, King’s Heath, Birmingham. 

1901. MacDonald, James H., M.B., Ch.B. t F.lt.F.P.&S.Glasg., Govan District 

Asylum, Hawkhead, Paisley, N.B. (Lect. on Psychol. Med. Univ. 
of Glasgow.) 

1884. MacDonald, P. W., M.D., C.M.Aberd., Grasmere, Radipole, Weymouth. 

(First Hon. Sec. S. W. Div. 1894 to 1905.) (Pbbsident, 1907-8.) 
1911. MacDonald, Ranald, M.D., Ch.B.Edin., Assistant Medical Officer, London 
County Mental Hospital, Coluey Hatch, New Southgate. 

1905. MacDonald, William Fraser, M.B., Ch.B.Edin., M.P.C., 96, Pol worth 
Terrace, Edinburgh. 

1905. McDougall, Alan, M.D., Ch.B.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.D., B.S.Durli., Medical Superin¬ 

tendent. Ticehurst House, Ticehurst, Sussex. 

1870. McDowall, Thomas W., M.D., L.R.C.S.Edin., “Burwood,” Wadhurst, 
Sussex. (President, 1897-8.) 

1895. Macfarlane, Neil M., M.D., C.M.Aberd., Deputy Principal Medical 
Officer, Maseru, Basutoland, South Africa. 

1921. McGrath, Mathew Joseph, M.B., B.Ch., D.P.M., Assistant Medical 
Officer, West Riding Asylum, Waketield; 12, Lansdowne Terrace, 
Wakefield. 

1902. McGregor, John, M.B., Ch.B.Edin., Senior Assistant Medical Officer, 

County Asylum, Bridgend, Glam. 

1917. Mclver, Colin, I.M.S., M.R.C.S., L.R.C.P.Lond., c/o Messrs. Grindlay & 
Co., Post Box 93, Bombay, India. 

1921. McKail, Robert Buchanan Forbes, M.B., Ch.B.Glasg., Senior Assistant 
Medical Officer, “ Calderstones ” Certified Institution for Mental 
Defectives, Whalley, near Blackburn. 

1914. Mackay, Magnus Ross, M.D., Ch.B.Edin., Newport Borough Mental 
Hospital, Caerleon, Mon. 

1917. Mackay, Norman Douglas, B.Sc., M.D., Ch.B., D.P.H.St. And., Dall- 
Avon, Aberfeldy, Perthshire. 

1911. Mackenzie, John Cosserat, M.B., Ch.B.Edin., Burntwood Mental Hospital, 
near Lichfield. 

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

1903. Mackenzie, Theodore Charles, M.D., Ch.B., F.R.C.P.Edin., M.P.C., 

Medical Superintendent, District Asylum, Inverness. 

1921. Mackie, George, M.B., Ch.B.Edin., Assistant Medical Officer, Scalebor 
Park, Burley-in-Wharfedale. 

1920. McLachlan, Jessie Brown, M.B., Ch.B.Glasg., D.P.H.Carab., Assistant 

Medical Officer, Stirling District Asylum, Larbert, N.B. 

1921. Macleod, Neil, M.B., Ch.B.Edin., Assistant Physician, Royal Edinburgh 

Asylum (Craig House), Morningside Drive, Edinburgh. 

1904. Macnamara, Eric Danvers, M.A., M.D., B.Ch.Camb., F.R.C.P.Lond., 87, 

Harley Street, London, W. 1. (Lect. on Psychol. Med. Charing 
Cross Hosp.) 

1910. MacPhail, Hector Duncan, M.A., M.D., Ch.B.Edin., Assistant Medical 
Officer, City Asylum, Gosforth, Newcastle-on-Tyne. 

1882. Macphail, S. Rutherford, M.D., C.M.Edin., New Saughton Hall, Polton, 
Midlothian. 

1901. McRae, G. Douglas, M.D., C.M., F.R.C.P.Edin., J.P., Medical Super¬ 
intendent, Glengall House, Ayr, N.B. (Co-Editor of the Journal 
since 1§2>0\ Assistant Editor 1916-20). 

1894. McWilliam, Alexander, M.A., M.B., C.M.Aberd., Waterval, Odiham, 
Winchfield, Hants. 


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Members of the Association . 

1908. Mapother, Edward, M.D., B.S.Lond., F.R.C.S.Eng., M.R.C.P.Lond., 
Deputy Medical Superintendent, Long Grove Mental Hospital, 
Epsom. 

1903. Manian, John, B.A., M.B., B.Ch.Dubl., Medical Superintendent, County 
Asylum, Gloucester. 

1896. Marr, Hamilton C., M.D., C.M., F.R.F.P.AS.Glasg., M.P.C., Commis¬ 
sioner in Lunacy (10, Succoth Avenue, Edinburgh). (Hon. See. 
Scottish Division , 1907-1910). 

1905. Marshall, Robert Mactiab, M.D., Ch.B.Glasg., M.P.C., 2, Clifton Place, 
Glasgow. 

1908. Martin, Henry Cooke, M.B., Ch.B.Edin., Assistant Medical Officer, 
Newport Borough Asylum, Caerleon. 

1896. Martin, James Charles, L.R.C.S. k P.Irel., J.P., Assistant Medical Officer 
District Asylum, Letterkenny, Donegal. 

1908. Martin, James Ernest, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., 
Assistant Medical Officer, London County Mental Hospital, 
Han well, W. 7. 

1907. Martin, Mary Edith, L.R.C.P.&S.Edin., L.R.F.P.&S.Glos., L.S.A.Lond., 
M.P.C., 11, The Drive, Hove. Sussex. 

1914. Martin, Samuel Edgar, M.B., B.Ch.Edin., Barrister-at-Law, Medical 

Officer, Fisherton House, Salisbury. 

1911. Martin, William Lewis, 0.3.E ., M.A., B.Sc., M.B., C.M., D.P.H.Edin., 
M.P.C., Dipl. Psych., Certifying Physician in Lunacy, Edinburgh 
Parish Couucil, 56, Bruntsfield Place, Edinburgh. 

1921. Masefield, William Gordon, M.R.C.S., L.R.C.P.Lond., Deputy Medical 
Superintendent, Severalls Mental Hospital, Colchester. 

1911. Mathieson, James Moir, M.B., Ch.B.Aberd., Assistant Medical Officer, 

Woodvale. South Yorks Asylum, Sheffield; 172, Whithaui Road, 
Broomhill, Sheffield. 

1912. Melville, William Spence, M.B., Ch.B.Glasg., National Bank of Scotland, 

37, Nicholas Lane, E.C. 

1890. Menzies, William F., B.Sc., M.D.Edin., F.R.C.P.Lond., Medical Superin¬ 
tendent, Stafford County Mental Hospital, Cheddleton, near Leek. 
(Pbesident, 1920-21.) * 

1877. Merson, John, M.A., M.D., C.M.Aberd., Medical Superintendent, Borough 
Asylum, Hull. 

1893. Middlemass, James, M.A., B.Sc., M.D., C.M., F.R.C.P.Edin., M.P.C., 
Medical Superintendent, Sunderland Boro’ Mental Hospital, Ryhope. 
(Lect. on Psychol. Med. College of Medicine, Univ. of Durham.) 

1910. Middlemiss, James Ernest, M.R.C.S., L.R.C.P.Lond.; 131,North Street, 

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

1912. Miller, Richard, M.B., B.Ch.Dubl., Stock, Ingatestone. 

1893. Mills, John, M.B., B.Ch., D.M.D., R.U.I., Medical Superintendent, 
District Asylum, Ballinasloe, Ireland. 

1911. Moll, Jan. Marius, Doc. in Arts and Med, Utrecht Univ., L.M.S.SJL 

Lond., M.P.C., Box 2587, Johannesburg, South Africa. 

1921. Monahan, Robert Vincent, M.B., B.Ch., N.U.I., Assistant Medical Officer, 
Northumberland County Asylum, Morpeth. 

1910. Monnington, Richard Caldicott, M.D., Ch.B., D.P.H.Edin., D.P.M.* 
Neurologist, Ministry of Pensions, 33, New Street, Salisbury. 

1915. Monrad-Krohn, G. H., B.A., B.S.Christiania, M.R.C.S., M.R.C.P.Lond.* 

M.P.C., Lecturer in Neurology at the University aud Physician 
to the Neurological Section of Rikshospitalet, Christiania, Norway. 
1899. Moore, Wm. D., M.D., M.Ch.R.U.I., Medical Superintendent, Holloway 
Sanatorium, Virginia Water, Surrey. 

1917. Morris, Bedlington Howel, M.B., B.S.Durh., Inspector-General of 
Hospitals, South Australia; Pembroke Street, College Park, 
St. Peter’s, S. Australia. 

1896. Morton, W.B., M.D., M.R.C.S., L.R.C.P.Lond., Medical Superintendent* 
Wonford House, Exeter. 


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Members of the Association. 

1896. Mott, Sir Frederick W., K.B.TS., LL.D.Edin., M.D., B.S., F.R.C.P.Lond., 
F.R.S., Pathologist to the Loudon County Mental Hospitals, 25, 
Nottingham Place, Marylebone, London, W. 1. 

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

Yorks. 

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

Manchester. 

1914. Moyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds. Tue Brook Villa, 
Liverpool, E. 

1919. Mules, Annie Shortridge, M.R.C.S., L.R.C.P.Lond., House Physician, 
Devon and Exeter Hospital; Court Hall, Kenton,near Exeter. 

1907. Mules, Bertha Mary, M.D., B.S.Durh., Court Hall, Kenton, S. 
Devon. 

1911. Muncaster, Anna Lilian, M.B., B.Ch.Ediu., 8, Craylockhart Terrace, 
Edinburgh. 

1917. Munro, Robert, M.B., Ch.B.Aberd., Assistant Medical Superintendent, 

Essex Hall, Colchester. 

1919. Murnane, John, L.R.C.P. AS.Irel. & L.M., Portroe, Nenagh, Co. 

Tipperary. 

1916. Murray, Jessie M., M.D., B.S.Durh., 14, Endsleigh Street, Tavistock 
Square, London, W.C. 1. 

1909. Myers, Charles Samuel, M.A., D.Sc., M.D., B.Ch.Camb., M.R.C.S., 

L.R.C.P.Lond., F.R.S., Gonvilie aud Cains College, Cambridge. 

1903. Navarra, Norman, M.R.C.S., L.R.C.P.Lond., City of Loudon Mental 
Hospital, near Dartford, Kent. 

1910. Neill, Alex. W., M.D., Ch.B.Edin., Warneford Mental Hospital, Oxford. 
1903. Nelis, William F.,M,D.Durh.,L.R.C.P.Edin.,L.R.F.P.&S.Glasg.,Medical 

Superintendent, Newport Borough Mental Hospital, Caerleon, Mon. 

1920. Nicol, William Drew, M.R.C.S., L.R.C.P.Lond., Assistant Medical 

Officer, London County Mental Hospital, Han well, London, W. 7. 

1921. Nicoll, James, M.D.Edin., D.P.H.Lond., Medical Superintendent, 

Fountain Mental Hospital, Tooting Grove, S.W. 17. 

1869. Nicolson, David, C.B., M.D., C.M.Aberd., M.R.C.P.Ediu., F.S.A.Scot., 
Blythewood, Camberley, Surrey. (Pbesidbnt, 1895-6.) 

1920. Nix, Sidney, M.D., B.S.Durh., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., 
Senior Assistant Medical Officer, Graylingwell Mental Hospital, 
Chichester. 

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

1913. Nolan, James Noel Green, B.A., M.D., B.Ch.Dubl., Hellingly Mental 
Hospital, Sussex. 

1909. Norman, Hubert James, M.B., Ch.B., D.P.H.Edin. (Assistant Medical 

Officer, Camberwell House Asylum, Peckham Road, London, S.E. 5), 
51, Crystal Palace Park Road, Sydeubam, London, S.E. 26. 

1920. Novis, Rupert Stanley, B.Sc., M.R.C.S., L R.C.P.Lond., Fountain 
Mental Hospital, Tooting Grove, S.W. 17. 

1903. O'Doherty, Patrick, B.A., M.B., B.Ch.R.U.I., District Asylum, Omagh. 

1918. Ogilvie, William Mitchell, M.B., C.M.Aberd., Medical Superintendent, 

Ipswich Mental Hospital, Ipswich. 

1901. Ogilvy, David, B.A., M.D., B.Ch.Dubl., Medical Superintendent, London 

County Mental Hospital, Long Grove, Epsom, Surrey. 

1911. Oliver, Norman H., M.U.C.S., L.R.C.P.Lond., Barrister-at-Law, Officer 

in Charge, No. 4 Special Hospital for Officers, Latch mere, Ham 
Common, Surrey. 

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

1920. O’Neill, Arthur, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, 
Napsbury Mental Hospital, Napsbury, St. Albans. 

1902. Orr, David, M.D., C.M.Edin., M.P.C., Deputy Medical Superintendent, 

County Asylum, Prestwich, Lancs. 

1910. Orr, James H. C., M.D., Ch.B.Edin., Midlothian Asylum, Rosslyn Castle. 


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xxii Members of the Association . 

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

1914 Osburne, Johu C., M.B., B.Ch.N.U.l., Assistant Medical Officer, Lindville, 
Cork.. 

1890. Oswald, Landei R., M.B., C.M.Glasg., M.P.C., Physician Superin¬ 

tendent, Royal Asylum, Gartnavel, Glasgow. (Ltct. on Ins. Univ. 
of Glasgow.) 

1916. Overbeck-Wright, Alexander William, M.D.,Ch.K.Aberd., M.P.C., D.P.H., 
Superintendent, Asylum House, Agra, U. P., India. Address 12, 
Rubislaw Terrace, Aberdeen. 

1905. Paine, Frederick, M.D.Brux., M.R.C.S., M.R.C.P.Lond., Claybury 

Mental Hospital, Woodford Bridge, Essex. 

1898. Parker, William Arnot, M.B., C.M.Glasg., M.P.C., Medical Super¬ 
intendent, Gartloch Asylum, Gurtcosh, N.B. 

1920. Parkin, George Gray, M.B., Cli.B.Vict, Deputy Medical Superintendent, 
Cheshire County Mental Hospital, Parkside, Macclesfield. 

1920. Parnis, Henry William, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, London County Mental Hospital, Colney Hatch, N. 11. 

1898. Pasmore, Edwin Stephen, M.D., M.R.C.P.Lond., Chelsham House, 

Warlingham, Surrey. 

1916. Patch, Charles James Lodge, M.C. , Capt. I.M.S., L.R.C.P.&S.Edin., 

L. R.F.P.&S.Glasg., c/o Messrs. King, King & Co., P.O. Box 110, 
Bombay, India. 

1899. Patrick, John, M.B., Ch.B.R.U.I., Medical Superintendent, District 

Asylum, Omagh, Ireland. 

1907. Peachell, George Ernest, M.D., B.S.Loml., M.R.C.S., L.R.C.P.Lond., 

M. P.C., Medical Superintendent, Dorset County Mental Hospital, 
Herrison, Dorchester. 

1910. Pearn, Oscar Phillips Napier, M.R.C.S., L.R.C.P., L.S.A.Lond., Cane 
Hill Mental Hospital, Coulsdon, Surrey. 

1915. Pennant, Dyfrig Huws, D.S.O. , M.R.C.S., L.R.C.P.Lond., Penydre, 
Saundersfoot, Pembrokeshire. 

1913. Penny, Robert Augustus Greenwood, M.R.C.S., L.R.C.P.Lond., Devon 
County Asylum, Exminster. 

1920. Penson, John Frederick, M.A., M.B., B.Ch.Oxon., M.R.C.S., 

L. R.C.P.Lond., Assistant Medical Officer, Long Grove Mental 
Hospital, Epsom. 

1893. Perceval, Frank, M.R.C.S., L.R.C.P.Lond., Medical Superintendent 
County Asylum, Prestwich, Manchester. 

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., Mont Estoril, 
Belle Vue Road, Paignton. 

1908. Phillips, John George Porter, M. 1)., B.S.Lond., M.R.C.S., M.R.C.P.Lond., 

M. P.C., Resident Physician and Superintendent, Bethlem Royal 
Hospital, Lambeth, London, S.E. 1. (Leet. on Ment. Path., London 
School of Med. for Women.) (Secretary of Educational Committee , 
1913-20.) 

1910. Phillips, John Robert Parry, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
* Officer, City Asylum, Fishponds, Bristol. 

1906. Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬ 

tant Medical Officer, County Asylum, Abergavenny, Monmouthshire. 
1905. Phillips, Norman Routh, M.D.Brux., M.H.C.S., L.R.C.P.Lond., Senior 
Assistant Medical Officer, St. Andrew’s Hospital, Northampton. 

1921, Phillips, Philip Gordon, L.R.C.P.&S.Edin., L.R.F.P.AS.Glasg., Medical 

Superintendent, Ministry of Pensions Neurological Hospital, 
Oulton Hall, Woodlesford, near Leeds. 

1891. Pierce, Bedford, M.D., F.R.C. P.Lond., York. (Hon. Secretary N . and M. 

Division 1900-8.) (President, 1919.) 

1888. Pietersen, J. F. G., M.R.C.S., L.R.C.P.Lond., Ash wood House, Ivingswin- 
ford, near Dudley, Stafford. 

1896. Planck, Charles, M.A.Camb., M.R.C.S., L.R.C.P.Lond., Medical Super¬ 
intendent, Brighton County Mental Hospital, Haywards Heath. 


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1912. Plummer, Edgar Curnow, M.R.C.S., L.R.C.P.Lond., Assistant Medical 

Officer, Resident Licensee and Acting Medical Superintendent, 
Bailbrook House, Bath. 

1889. Pope, George Stevens, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Heigham 
Hall, Norwich. 

1913. Potts, William A., M.A.Camb., M.D.Edin.&Birm., M.R.C.S., L.R.C.P. 

Lond., Medical Officer to the Birmingham Committee for the Care 
of the Feeble-minded , 118, Hagley Road, Birmingham. 

1876. Powell, Evan, M.R.C.S.Eng., L.S.A., Medical Superintendent, City 
Asylum, Nottingham. 

1810. Powell, James Farquharsou, M.R.C.S., L.R.C.P., D.P.H.Lond., M.P.C., 
Assistant Medical Officer, Mental Hospital, Caterhatn, Surrey, 

1916. Power, Patrick William, L.R.C.P.&S.Irel., Senior Assistant Medical 
Officer, County Mental Hospital, Chester. 

1921. Poynder, Ernest George Thornton, M.R.C.S., L.R.C.P.Lond., Fourth 
Assistant Medical Officer, Long Grove Mental Hospital, Epsom. 
1908. Prentice, Reginald Wickham, L.M.S.S.A.Lond., Beauworth Manor, 
Alresford, Hants. 

1918. Prideaux, John Joseph Francis Engledue, M.R.C.S., L.R.C.P.Lond^ 
Pathological Laboratory, Cambridge. 

1901* Pngh, Robert, M.D., Ch.B.Edin., Medical Superintendent, Brecon and 
Radnor Asylum, Talgarth, S. Wales. 

1899. Rainsford, F. E., B.A., M.D.Dubl., L.R.C.P.Irel., L.R.C.P.&S.Edin., 
Resident Physician, Stewart Institute, Palmerston, co. Dublin. 
1894. Rambaut, Daniel F., M.A., M.D., B.Ch.Dubl., Medical Superintendent, 
St. Andrew’s Hospital, Northampton; Priory Cottage, Northampton. 
1889. Raw, Nathan, C.M.£., M.D., B.S., L.S.Sc.Durh., F.R.C.S.Edin., 
M.R.C.P.Lond., M.P.C., M.P., 58, Harley Street, W. 1. 

1870. Rayner, Henry, M.D.Aberd., M.R.C.P.Edin., Upper Terrace House, 
Hampstead, Londou, N.W. 3. (President, 1884.) ( General 
Secretary , 1877-89.) ( Co-Editor of Journal 1895-1911.) 

1913. Read, Charles Stanford, M.D., M.R.C.S., L.R.C.P.Lond., 31, Wimpole 

Street, London, W. 1; and 16, Downshire Hill, Hampstead. N.W.3. 

1920. Read, Walter Wolfe, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Medical 

Superintendent, Berkshire County Asylum, Wallingford. Berks. 

1921. Reardou, Arthur Francis, L.M.S.S.A.Lond., Deputy Medical Superin¬ 

tendent, County Mental Hospital, Cambridge. 

1899. Redington, John, F.R.C.S., L.R.C.P.Irel., Deputy Medical Superinten¬ 
dent, llivagb. Salt Hill, Galway. 

1911. Reeve, Ernest Frederick, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., 
Senior Assistant Medical Officer, County Asylum, Rainhill, Lancs. 
1911. Reid, Daniel McKinley, M.D., Ch.B.Glasg., Hawkhead Mental Hospital, 
Cardonald, Glasgow. 

1910. Reid, William, M.A.St. And., M.B., Ch.B.Edin., Senior Assistant Medical 

Officer, Burntwood Mental Hospital, near Lichfield. 

1899. Rice, David, M.D.Brux., M.R.C.S., L.R.C.P.Lond., D.P.H., Medical 
Superintendent, City Asylum, Hillesdon, Norwich. 

1897. Richard, William J.,M.A., M.B.,Ch.M.Glasg., Merry flats. Go van, Glasgow. 
1899. Richards, John, M.B., C.M., F.R.C.S.Edin., Medical Superintendent, 
Joint Counties Mental Hospital, Carmarthen. 

1920. Rickman, John, M.A., M.B., B.Ch.Camb., 22, Rose Hill, Dorking, Snrrey. 

1921. Riddel, Donald Olson, D.S.O., M.B., Ch.B.Aberd., Assistant Medical 

Officer, County Asylum, Whittingham, Preston. 

1911. Roberts, Henry Howard, M.D., Ch.B.Edin., D.P.H.Glasg., Ennerdale, 

Haddington, Scotland. 

1921. Roberts, Edward Douglas Thomas, M.R.C.S., L.R.C.P.Lond., Assistant 
Medical Officer, Herts County Mental Hospital, Hill End, 
St. Albans. 

1914. Roberts, Ernest Theophilus, M.D., C.M.Edin., F.R.F.P.&S.Glasg., D.P.H. 

Camb., M.P.C., Hawkstone, 68, South Brae Drive, ,Jordanhil1, 
Glasgow. s 


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xxiv Members of the Association. 

1903. Roberts, Norcliffe, O.B.E., M.D., B.S.Durh., Medical Superintendent, 
Ministry of Pensions Hospital, Ewell. 

1887. Robertson, Geo. M., M.D., C.M., F.R.C.P.Edin., M.P.C., Physician- 

Superintendent, Royal Asylum, Morningside, Edinburgh; Tipperlin 
House, Morningside Place, Edinburgh. (Prof, of Psychiatry, 
Univ. of Edinburgh.) (Pbbsidbnt-Elect.) 

1908. Robertson, George Dunlop, L.R.C.S.&P.Edin., Dipl. ’Psych., Assistant 
Medical Officer, District Asylum, Hartwood, Lanark. 

1895. Robertson, William Ford, M.D., C.M.Edin., Pathologist, Scottish 
Asylums, 60, Northumberland Street, Edinburgh. 

1900. Robinson, Harry A., M.D., Ck.B.Vict., 140, Edge Lane, Liverpool. 

1920. Robinson, William, M.B., Ch.B., D.P.M.Leeds, Medical Superintendent, 
Essex County Mental Hospital, Brentwood. 

1911. Robson, Capt. Hubert Alan Hirst, M.R.C.S., L.R.C.P.Lond., Punjaub 

Asylum, India. 

1914. Rodger, Murdoch Mann, M.D., Ch.B.Glasg. (The Anchorage, Both well, 

Scotland); Lunatic Asylum, Abbassia, Cairo, Egypt. 

1908. Rodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.H., Senior Medical 
Officer, County Asylum, Win wick, Lancs. 

1895. Rolleston, Lancelot W., C.B.E., M.B., B.S.Durh., Medical Super¬ 

intendent, Middlesex County Mental Hospital, Napsbnry, near St. 
Albans. 

1920. Roscrow, Cecil Beaumout, L.R.C.P.&.S.Edin., Medical Superintendent, 
City Mental Hospital, Winson Green, Birmingham. 

1888. Ross, Chisholm, M.D.Syd., M.B., C.M.Edin., 151, Macquarie Street, 

Sydney, New South Wales. 

1910. Ross, Donald, M.B., Ch.B.Edin., M.P.C., Medical Superintendent, Argyll 
and Bute Asylum, Lochgilphead; Tigh-ma-Linne, Lochgilphead, 
Argyll. 

1899. Rotherham, Arthur, M.A., M.B., B.Ch.Camb., Commissioner under 
Ment. Defec. Act, Board of Control, 66, Victoria Street, West¬ 
minster, London, S.W. 1.; Lauesand, Ashtead, Surrey. 

1906. Rowan, Marriott Logan, B.A., M.D.R.U.I., Medical Superintendent, 
. Derby County Asylum, Mickleover. 

1883. Rowland, E. D., M.B., C.M.Edin., 71, Main Street, George Town, 
Demerara, British Guiana. 

1902. Rows, Richard Gundry, C.B.E ., M.D.Lond., M.U.C.S., L.R.C.P.Lond. 

(Director, Section of Mental Diseases), Tooting Neurological 
Hospital, Church Lane, Tooting, S.W. 

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

1912. Russell, John Ivison, M.B., Ch.B.Glasg., M.P.C., Assistant Medical 

Officer, West Riding Asylum, Wakefield. 

1915. Russell, William, M.C., M.D., Ch.B., Dip.Psych., D.T.M.Edin., Senior 

Assistant Physician, Mental Hospital, Bloemfontein, S. Africa. 
1912. Rutherford, Cecil, M.B., B.Ch.Dubl., Assistant Medical Officer, Holloway 
Sanatorium, Virginia Water, Surrey. 

1997. Rutherford, Henry Richard Charles, F.R.C.S., L.R.C.P.Irel., D.P.H., 
St. Patrick's Hospital, James's St., Dublin. 

1896. Rutherford, James Mair, M.B., C.M.,F.R.C.P.Edin., M.P.C., Brislington 

House, Bristol. 


1902. Sail, Ernest Frederick, M.R.C.S., L.R.C.P.Lond., Medical Superinten¬ 
dent, The Mental Hospital, Canterbury. 

1908. Samuels, William Frederick, L.M.&S.Dubl., S. Dymphna’s, Tanjong, 
Rambutan, F.M.S. 

1894. Sankey, Edward H. O., M.A., M.B., B.Ch.Camb., Resident Medical 
Licensee, Boreatton Park Licensed House, Baschurcb, Salop. 

1854. Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Road, 
Oxford. 

1906. Scanlan, John J., L.R.C.P. & S.Edin., L.R.F.P. & S.Glasg., D.P.H., 
80, Royal Hospital Road, Chelsea. 


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Members of the Association. 

1889. Scowcroffc, Walter, M.R.C.S.Eng., L.R.C.P.Irel., Medical Superintendent 
Royal Lunatic Hospital, Cheadle, near Manchester. 

1911. Scroope, G., M.B., B.Cli.Dubl., Assistant Medical Officer, Central Asylum, 

Dundrum. 

1880. Seccombe, George S., M.R.C.S., L.R.C.P.Lond., c/o Messrs. H. S. King 
and Co., 65, Cornliill, London, E.C. 3. 

1912. Sergeant, John Noel, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical 

Superintendent, Newlands House, Tooting Bee ‘Common, London, 
S.W. 17. ( Secretary South-Eastern Division since 1913.) 

1921. Severn, Adolphe Gladstone Millott, M.D.Brux., M.R.C.S., L.R.C.P. 
Lond., F.C.S., Jesus College, Cambridge. 

1913. Shand, George Ernest, M.D., Ch.B.Aberd.; (Senior Assistant Medical 

Officer, City Mental Hospital, Winson Green, Birmingham). 
Permanent address : 307, Gillott Road, Edgbaston, Birmingham. 
1901. Shaw, B. Henry, M.D., B.Ch.R.U.l., Medical Superintendent, County 
Mental Hospital, Stafford. 

1905. Shaw, Charles John, M.D., Ch.B., F.R.C.P.Edin., Medical Superinten¬ 
dent, Royal Asylum, Montrose. 

1917. Shaw, John Custance, M.R.C.S., L.R.C.P.Lond., Medical Superin¬ 
tendent, West Ham Borough Asylum, Goodmayes, Essex. 

1904. Shaw, Patrick, L.R.C.P.&S.Ediu., Medical Superintendent, Hospital for 

Insane, Ballarat, Victoria, Australia. 

1909. Shaw, William Samuel J., Major I.M.S., M.D.Belf., M.B., B.Ch.R.U.l., 
c/o Messrs. Grindlay & Co., 54, Parliament Street, S.W. 1. 

1920. Shearer, Christina Hamilton, M.B., Ch.B.Glasg., Visiting Physician, 

Lady Chichester Hospital, 11, The Drive, Hove, Sussex. 

1909. Shepherd, George Ferguson, F.R.C.S., L.R.C.P.Irel., D.P.H., 9, Ogle 

Terrace, South Shields. 

1900. Shera, John E. P., M.D.Brux., L.R.C.P.&S.Irel., Medical Superintendent, 

Somerset County Asylum, Wells, Somerset. 

1914. Sherlock, Edward Burball, B.Sc., M.D., D.P.H.Lond., Medical Superin¬ 

tendent, Darenth Industrial Colony, Dartford. 

1914. Shield, Hubert, M.C., M.B., B.S.Durh., Assistant Medical Officer, 
Archbold Terrace, Jesmoud, Newcastle-on-Tyne. 

1877. Shuttleworth, George E., B. A.Lond., M.D.Heidelb., M.R.C.S. and L.S.A. 
Lond., 36, Lambolle Road. Hampstead, London, N.W. 3. 

1901. Simpson, Alexander, M.A., M.D., C.M.Aberd., Medical Superin¬ 

tendent, County Asylum, Winwick, Wallington, Lancashire. 

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

Beverley, Yorks. 

1888. Sinclair, Eric, M.D., C.M.Glnsg., Inspector-General of Insane, Richmond 
Terrace, Deraain, Sydney, N.S.W. 

1891. Skeen, James Humphry, M.B., C.M.Aberd., M.P.C., Medical Super¬ 
intendent, Fife and Kinross District Asylum, Cupar, N.B. 

1921. Skene, Leslie Henderson, M.B., Ch.B., Dipl.Psych.Edin., Medical Super¬ 

intendent, Criminal Lunatic Department, Perth; “ Glenpark,” 
Edinburgh Road, Perth. 

1914. Slaney, Chas. Newnham, M.R.C.S., L.R.C.P.Lond., The Elms, Parkhurst, 
I.W. 

1901. Slater, George N. O., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant 
Medical Officer, Essex County Mental Hospital, Brentwood. 

1910. Smith, Gayton Warwick, M.D.Lond., B.S.Durh., M.R.C.S., L.R.C.P. 

Lond., D.P.H., Assistant Medical Officer, Springfield Mental 
Hospital, Tooting, London, S.W. 17. 

1905. Smith, George William, M.B., Ch.B.Edin., Chiswick House, Chiswick. 
1907. Smith, Henry Watson, M.D., Ch.B.Aberd., Medical Superintendent, 
Lebanon Hospital for the Insane, Asfuriyeh, near Beyrout, 
Syria. 

1899. Smith, John G., M.D., C.M.Edin., Medical Superintendent, County and 
City Mental Hospital, Burghill, near Hereford. 

1920. Smith, Maurice Hamblin, M.A.Camb., M.D.Durh., M.R.C.S., L.R.C.P. 
Lond., H.M. Prison, Birmingham. 


Digitized by 


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xxvi Members of the Association. 

1886. Smith, II. Percy, M.D., B.S., F.R.C.P.Lond., M.P.C., 36, Queen 

Anne Street, Cavendish Square, London, W. 1. ( General Secretary, 
1896-7. Chairman Educational Committee, 1899-1908.) (PRESI¬ 
DENT, 1904-5.) 

1918. Smith, Thomas Cyril, M.B., B.Ch.Edin., County Asylum, Gloucester. 

1911. Smith, Thomas Waddelow, F.R.C.S.Eng., L.R.C.P.Lond., M.P.C., Assis¬ 
tant Medical Officer, City Asylum, Nottingham. 

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

Victoria. 

1914. Smith, Walter R. H., B.A., M.D., B.Ch.Dubl., Senior Assistant Medical 
Officer, County Asylum, Shrewsbury. 

1920. Smyth, Geoffrey Norman, L.R.C.P.&S.Irel., Assistant Medical Officer, 

St. Edmundsbury, Lucan, Co. Dublin. 

1921. Smyth, John Francis, M.B., B.Ch., B.A.O., N.U.I., Assistant Medical 

Officer, Gateshead Mental Hospital, Stannington. 

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

1913. Somerville, Henry, B.Sc., M.R.C.S., L.R.C.P.Lond., F.C.S., Harrold, 

Sbarnbrook, Bedfordshire. 

1885. Soutar, Janies Greig, M.B., C.M.Ediu., M.P.C., 20, Royal Parade, 

Cheltenham. (President, 1912-18.) 

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

London County Mental Hospital, Banstead, Surrey. 

1875. Spence, J. Beveridge, O. B.E., M.D., M.Ch.Q.U.L, L.A.H.Dubl., Medical 
Superintendent, Burntwood Mental Hospital, near Lichfield. 
(First Registrar, 1892-1899; Chairman Parliamentary Committee, 
1910-12.) (President, 1899-1900.) 

1920. Staley, Mildred Ernestine, M.B., B.S.Lond., Assistant Medical Officer, 
Stafford County Mental Hospital, Burton-on-Trent; Rosliston 
Rectory, Burton-on-Trent. 

1891. Stansfield, T. E. K., C.B.E., M.B., C.M.Edin., Southmead, Wimbledon 
Park, London, S.W. 19. 

1901. Starkey, William, M.B., B.Ch.R.U.I., Medical Superintendent, Borough 
Asylum, Blackudon, Ivy bridge, S. Devon. 

1907. Steele, Patrick, M.D., Ch.B., M.B.C.P.Edin., Medical Superintendent, 

The Hermitage, Melrose. 

1898. Steen, Robert H., B.A.R.U.I., M.D., M.R.C.P.Lond., Medical Super¬ 

intendent, City of London Mental Hospital, Stone, Hartford. 
(Hon. Sec. S.E. division, 1905-10; Acting Oen. Sec. and Qen. 
Sec. 1915-19.) (Prof, of Psychol. Med. King's College Hosp.) 

1914. Stephens, Harold Freize, M.R.C.S., L.R.C.P.Lond., 9, Belmont Avenue, 

Palmer's Green, Middlesex. 

1909. Steward, Sidney John, D.S.O., M.D., B.Ch.Camb., M.R.C.S., L.R.C.P. 

Lond., Assistant Medical Officer, Langton Lodge, Farncombe, 
Surrey. 

1868. Stewart, James, B.A.Q.U.I., F.R.C.P.Edin., L.R.C.S.Irel.,“ Donegal,” 32, 
Kingsmead Road, London, S.W. 2. 

1887. Stewart, Rothsay C., M.R.C.S.Eng., L.S.A.Lond., Medical Superinten¬ 

dent, County Mental Hospital, Narborough, near Leicester. 

1914. Stewart, Roy M., M.B., Ch.B.Edin., D.P.M., Assistant Medical Officer, 
County Asylum, Wliittingham, Preston. 

1905. Stilwell, Henry Francis, L.R.C.P.AS.Edin., Hayes Park, Hayes, Middlesex. 

1899. Stilwell, Reginald J., M.R.C.S., L.R.C.P.Lond., Moorcroft House, Hil¬ 

lingdon, Middlesex. 

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

Eng., M.P.C., Harcourt House, Cavendish Square, London,W. 1. 
(Hon. Sec . Educational Committee, 1908-1912.) (Lect. on Ment. 
Dis. St. Thomas's Hosp.) 

1909. Stokes, Frederick Ernest, M.D., Ch.B.Glasg., D.P.H., Assistant Medical 
Officer, Boro' Mental Hospital, Portsmouth. 

1903. Stratton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., York Lodge, Cliff 
Cottage Road, Bournemouth. 


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1885. Street, C. T., M.R.C.S., L.R.C.P.Lond., Haydock Lodge, Ashton, 

Newton-le-Willows, Lancashire. 

1909. Staart, Frederick J., M.R.C.S., L.R.C.P.Lond., Medical Superintendent, 

Northampton County Asylum, Berrywood* 

1900. Sturrock, James Prain, M.A.St.And., M.D., C.M.Edin., 25, Palmerston 
Place, Edinburgh. 

1886. Suffern, Alex. C., M.D., M.Ch.R.U.I., Glen-y-Mor, Hillhead, Fareham, 

Hants. 

1921. Suffern, Canning, M.A.Camb., M.R.C.S., L.R.C.P.Lond., Junior Assis¬ 
tant Medical Officer, City Mental Hospital, Nottingham. 

1894. Sullivan, William C., M.D., B.Ch.R.U.I., State Criminal Lunatic Asylum, 
Broadmoor, Crowthorne, Berks; 

1920. Sutcliffe, John, M.R.C.S., L.R.C.P.Edin., Medical Superintendent, 

Cheadle Royal, Cheadle, Cheshire. 

1918. Sutherland, Francis, M.B., Ch.B.Edin., D.P.H., Assistant Medical Officer, 

District Asylum, Inverness. 

1919. Suttie, Ian D.,M.B., Ch.B., F.R.F.P.&S.Glasg. (Assistant Medical Officer, 

Royal Asylum, Glasgow), 1055, Great Western Road, Glasgow. 
1916. Suttie, Jane I., M.B„ Ch.B.Glasg., 4, Grauville Street, Glasgow. 

1908. Swift, Eric W. D., M.B.Lond., Medical Superintendent, Mental Hospital, 
Bloemfontein, S. Africa. 

1908. Tattersall, John, M.D.Lond., M.R.C.S., M.R.C.P.Lond,, Deputy 
Medical Superintendent, London County Mental Hospital, Hanwell, 
London, W. 7. 

1910. Taylor, Arthur Loudoun, B.Sc., M.B., Cli.B., M.R.C.P.Edin., Craigend 

Neurasthenic Hospital, Craigend Park, Liberton, Midlothian. 

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

Lond., Medical Superintendent, East Sussex Mental Hospital, 
Hellingly. 

1921. Thomas, Cyril James, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, 

County Asylum, Lancaster. 

1920. Thomas, Frederic Percival Selwyn, M.B., Ch.B.Viet.; Neurological 

Pensions Medical Board, Potteries Area; Ranelagh, Chesterton, 
Newcastle, Staffs. 

1921. Thomas, George Nathaniel William, M.B., Ch.B.Edin., of the Middle 

Temple and South Wales Circuit, Barrister-at-Laiv; Assistant 
Medical Officer, Napsbnry Mental Hospital, Napsbury, St. Albans. 
1908. Thomas, Joseph D., B.A., M.B., B.C.Camb., Northwoods House, Winter¬ 
bourne, Bristol. 

1911. Thomas, William Rees, M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond., 

M.P.C., Rampton State Institution, near Retford, Notts; Gray 
Ridges, Woodbeck, Retford, Notts. 

1921. Thompson, James Arthur, B.A., M.B., B.Ch.Dub. (T.C.D.), Surgeon- 
Cdr. R.N., Royal Naval Hospital, Hasiar; 47, Victoria Road North, 
Southsea. 

1921. Thomson, Aidan Gordon Werayss, M.B., Ch.B.Glasg., Assistant Medical 
Officer, Glasgow Royal Asylum, Gartnavel, Glasgow. 

1880. Thomson, David G., C.B.E ., M.D., C.M.Edin., Medical Superintendent, 
County Mental Hospital, Thorpe, Norfolk. (President, 1914-18.) 
1903. Thomson, Herbert Campbell, M.D., F.It.C.P.Lond., Assist. Physician 
Middlesex Hospital, 34, Queen Anne Street, London, W. 1. 

1920. Thomson, William George, M.A., M.B., Ch.B.Aberd., D.P.H., Assistant 
Medical Officer, County Mental Hospital, Cheddleton, Leek. 

1901* Tiglie, John V. G. B., M.B., B.Ch.R.U.I., Medical Superintendent, 
Gateshead Mental Hospital, Stannington, Northumberland. 

1914. Tisdall, C. J., M.B., Ch.B.Edin., Tue Brook Villa, Liverpool. 

1903. Topham, J. Arthur, B.A.Camb., M.R.C.S., L.R.C.P.Lond., Kent County 
Mental Hospital, Chartham Downs, Kent. 

1896. Townsend, Arthur A. D., M.D., B.Ch.Birm., M.R.C.S., L.R.C.P.Lond., 
Medical Superintendent, Barnwood House, Hospital for Insane, 
Gloucester. 


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Digitized by 


Members of the Association. 

1904. Treadwell, Oliver Fereira Naylor, M.R.C.S.Eng., L.S.A.Lond., 8, 
Trebovir Road, Earl’s Court, S.W. 

1903. Tredgold, Alfred F., M.D., F.R.S.Edin., M.R.C.P.Lond., M.R.C.S.Eng., 

“ St. Martins,” Guildford, Surrey. 

1908. Tuach-MacKenzie, William, M.D., Ch.B.Aberd., Medical Superintendent, 

Royal and District Asylums, Duudee; Westgreen, Dundee. (Lect. 
on Ment. Dis. St. And. Univ.) 

1881. Tube, Charles Molesworth,M.R.C.S.Eng., Chiswick House,Chiswick,W.4. 
1906. Turnbull, Peter Mortimer, M.C ., M.B., B.Ch.Aberd., Tooting Bee 
Mental Hospital, Tooting, London, S.W. 17. 

1909. Turnbull, Robert Cyril, M.D.Lond., M.R.C.S., L.R.C.P.Lond„ Medical 

Superintendent, Essex County Mental Hospital, Colchester. 

1889. Turner, Alfred, M.D., C.M.Edin., Plympton House, Plympton, S. Devon. 
1906. Turner, Frank Douglas, M.B.Lond., M.R.C.S., L.R.C.P.Lond., Medical 

Superintendent, Royal Eastern Counties Institution, Colchester. 

1890. Turner, John, M.B., C.M.Aberd., South Street, Rochford, Essex. 

1917. Vevers, Oswald Henry, M.R.C.S., L.R.C.P.Lond., Norton Vicarage, 
Evesham. 

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

St. Ann’s Asylum, Port of Spain, Trinidad, B.W.I. 

1894. Vincent, William James N., C.B.E., M.B., B.S.Durh., M.R.C.S., 

L.R.C.P.Lond., Medical Superintendent, Wadsley Asylum, near 
Sheffield. (Lect. on Psychiatry Univ. of Sheffield.) 

1914. Vining, Charles Wilfred, M.D., B.S., M.R.C.P.Lond., D.P.H., M.P.C., 
Assistant Physician, Leeds General Infirmary, 31, Park Square, 
Leeds. 

1913. Walford, Harold R. S., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical 

Officer, Kent County Mental Hospital, Harming Heath, Maidstone. 
1920. Walker, James, M.B., Ch.B.Vict., D.P.H., M.P.C., Senior Assistant 
Medical Officer, City of Cardiff Mental Hospital, Whitchurch, 
near Cardiff. 

1914. Walker, Robert Clive, M.B., Ch.B.Edin., West Riding Asylum, Menston, 

near Leeds. 

1908. Wallace, John Andrew Leslie, M.D., Ch.B.Edin., M.P.C., Mental 
Hospital, Callan Park, Sydney, N.S.W. 

1912. Wallace, Vivian, L.R.C.P. AS.Irel., Assistant Medical Officer, District 
Asylum, Mullingar. 

1920. Wanklyn, William McConnel, B.A.Camb., M.R.C.S., L.R.C.P.Lond., 
D.P.H., Principal Assistant in the Public Health Department of the 
London County Council, 2, Savoy Hill, London, W.C. 2. 

1889. Warnock, John, C.M.G., B.Sc.,M.D., C.M.Edin., Medical Superintendent, 
Abbasiyeh Asylum, nr. Cairo, Egypt. 

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

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

1891 Watson, George A., M.B., C.M.Edin., M.P.C., Lyons House, Rainhill, 
Liverpool. 

1908. Watson,H. Ferguson, M.D., Ch.B.Glasg., L.R.C.P.&S.Edin., L.R.F.P.&S. 

Glasg., Northcote, Edinburgh Road, Perth, 

1911. Webber, Leonard Mortis, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Netherne Mental Hospital, Coulsdon, Surrey. 

1919. Westrup, Joseph Perceval, M.R.C.S., L.R.C.P.Lond., Medical Officer, 
Fisherton House Mental Hospital, Salisbury. 

1919. Wheeler, Frederic Francis, M.R.C.S., L.R.C.P.Lond., 5, Egleston Road, 
Putney, S.W. 15. 

1911. White, Edward Barton C., M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Dorset Mental Hospital, Charminster. 

1884. White, Ernest William, C.B.E ., M.B., M.R.C.P.Lond., Betley House, 
nr. Shrewsbury. (Hon. See. South-Eastern Division , 1897-1900.) 
(Chairman Parliamentary Committee , 1904-7.) (Pbbsidbbt 
1903-4.) 


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1921. Whitelaw, William, M.B., B.Ch.Glasg., Director Western Asylums 
Research Institute; 10, Clay thorn Road, Glasgow, W. 

1905. Whittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond., 
1, Eaton Gardens, Hove, Sussex. 

1889. Whitwell, James Richard, M.B., C.M.Edin., Medical Superintendent, 
St. Audry’s Hospital, Melton, Suffolk. 

1913. Wilkins, William Douglas, M.B., Ch.B.Vict., M.R.C.S., L.R.C.P. 

Lond., County Mental Hospital, Cheddleton, Leek, Staffs. 

1900. Wilkinson, H. B., M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, 
Plymouth Borough Asylum, Blackadon, Ivybridge, South Devon. 
1887. Will, John Kennedy, M.A., M.D., C.M.Aberd., M.P.C., Fisher ton House, 
Salisbury. 

1914. Williams, Charles, L.R.C.P. & S.Edin., L.S.A.Lond., The Vicarage, 147, 

Hornsey Road, Holloway. N, 

1907. Williams, Charles E. C., M.A., M.D., B.Cb.Dubl.; Branksome Chine 
House, Branksome Park, Bournemouth. 

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

1920. Wilson, James Leitch, M.B., Ch.B.Edin., Assistant Medical Officer, 

Brooke House, Clapton, E. 5. 

1916. Wilson, Marguerite, M.B., Ch.B.Glasg., c/o Messrs. Wilson & Baird, 

372, Scotland Street, Glasgow. 

1912. Wilson, Samuel Alexander Kinnier, M.A., B.Sc., M.D.Edin., F.R.C.P. 

Lond., Registrar, National Hospital, Queen’s Square, 14, Harley 
Street, London, W. 1. 

1899. Wolseley-Lewis, Herbert, M.D.Brux., F.R.C.S.Eng., L.R.C.P.Lond., 

Medical Superintendent, Kent County Mental Hospital, Barming 
Heath, Maidstone. ( Secretary Parliamentary Committee, 1907-12, 
Chairman , 1912-21.) 

1921. Wood, Bertram William Francis, M.B., B.S.Univ. Leeds, c/o P.M.O., 

K&duna, Northern Provinces, Nigeria. 

1869. Wood, T. Outterson, M.D.Durh., M.R.C.P.Lond., F.R.C.P., F.R.C.S. 

Edin., “ Lodore,” Chelston Road, Torquay. (President, 1905-6.) 
1912. Woods, James Cowan, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond., 
45, Weymouth Street, W. 1. (Lect. on Ment. Dis. St. George’s 
Hosp. and London Hosp.) 

1885. Woods, J. F., M.D.Durh., M.R.C.S.Eng., 7, Harley Street, Cavendish 
Square, London, W. 1. 

1912. Wootton, John Charles, M.R.C.S., L.R.C.P.Lond., Hay dock Lodge, 
Newton-le-Willows, Lancs. 

1900. Worth, Reginald, O.B.E., M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond., 

Medical Superintendent, Springfield Mental Hospital, nr. Tooting, 
S.W. 17. ( General Secretary since 1919.) 

1917. Wright, Maurice Beresford, O.B.E., M.D., C.M.Edin., 4, Devonshire 

Place, London, W. 1. 

1921. Yellowlees, David, M.B., Ch.B.Glasg., 5, St. James Terrace, Glasgow, W. 
1914. Yellowlees, Henry, O.B.E. , M.D., Ch.B.Glasg., F.R.F.P.&S.Glasg., 
Medical Superintendent, The Retreat, York. 

Ordinary Members . 631 

Honorary Members . 25 

Corresponding Members .. ... 10 

Total ... ... ••• ... 666 

Members are particularly requested to send changes of address , etc., to The 
General Secretary, Springfield Mental Hospital, Tooting, London, 
S. W . 17, and in duplicate to the Printers of the Journal , Messrs. 
Adlard Sf Son Sf West Newman, Ltd., 23, Bartholomew Close y 
London , E.C. 1. 


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xxx Members of the Association. 


OBITUARY. 

Members . 

1913. Black, Robert Sinclair, M.A.Edin., M.D., C.M.Aberd., D.P.H., 

Medical Supt., Pietermaritzburg Mental Hospital, Natal, South 
Africa. 

1899. Harmer, W. A., L.S.A., Redland Private Asylum, Tonbridge, Kent. 

1917. Bruce, Alexander Niniun, D.Sc., M.D., F.R.C.P.Edin., Lecturer on Neuro¬ 
logy, University of Edinburgh, 8, Ainslie Place, Edinburgh. 

1893. Kershaw, Herbert Warren, M.R.C.S., L.R.C.PiLond., 1, Stanhope Road, 
Darlington. 

1913. Molyneux, Benjamin Arthur, B.A., M.D., B.Cb.Dubl., St. Helens 
House, St. Helens, Hastings. 

1873. Savage, Sir Geo. H., M.D., F.R.C.P.Lond., 26, Devonshire Place, 
London, W. 1. (Late 'Editor of Journal.) (Pbbsidbkt, 1886.) 

1862. Yellowlees, David, LL.D.Glasg., M.D.Edin., P.R.P.P.AS.Glasg.,«Grange- 
neuk, ,> Fountainhall Road, Edinburgh. (PRESIDENT, 1890.) 

1910. Younger, Edward George, M.D.Brux., M.R.C.S., M.R.C.P., L.S.A.Lond., 
D.P.H., Physician to the Finsbury Dispensary, 2, Mecklenburgh 
Square, London, W.C. 1. 


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2 DIASTASE-CONTENT OF URINE IN MENTAL DISORDER. [Jan., 


urine; he showed that there is normally a certain amount of diastase in 
the blood, and that the same quantity is excreted by the kidneys. 
Provided the kidneys are functionally unimpaired, an increase of 
diastase in the blood is accompanied by a corresponding increase in 
the amount of diastase in the urine. MacKenzie Wallis states that the 
slightest damage to the renal epithelium leads either to a diminution or 
an increase of urinary diastase, depending upon the permeability of the 
kidney. MacLean and Russell, however, ( s ) state that a high diastatic 
value is in nearly every case an indication of efficient renal action. 
According to MacKenzie Wallis, there seems to be no doubt that a 
high diastase-value of the urine is in favour of pancreatic disease, 
whereas, with a normal pancreas, normal or low values are obtained. 

The method adopted in this inquiry was that of Wohlgemuth, in 
accordance with which varying strengths of urine are added to a given 
amount of starch, and the mixture digested for thirty minutes at 
body-heat. 

The tubes containing the various strengths of urine from 0-5 c.c. to 
*oi c.c., made up in each case to i c.c. with distilled water, were placed 
in a water-bath at body-heat for fifteen minutes. To each tube were 
then added 2 c.c. of a 1 per 1,000 starch solution (starch dissolved in 
10 per cent, sodium chloride and kept as a 2 per cent, stock solution), 
commencing with the highest tube; in practice ten tubes are usually 
sufficient, the tenth containing '05 c.c. of urine. The contents were 
mixed by agitation, and the tubes replaced in the water-bath at body- 
heat for thirty minutes. They were then removed and placed in a 
beaker of cold water for three minutes to cool. The tubes were then 
placed in the test-tube stand in order, commencing with the 0 5 tube. 

Commencing with tube 1, one drop of 1 in 50 normal solution of 
iodine was added by a specially-made pipette, delivering always the 
same quantity. If the colour produced rapidly faded, another drop was 
added to each tube. The tube in which the starch had been digested 
as far as the dextrin stage—the first tube from No. 1, showing a reddish 
colour, with no tinge of blue—was taken as the limit, tube. The 


formula d 


3i° 

30 


expresses in units the amount of a o'i percent, solution of 


starch which 1 c.c. of urine is able to digest, at the temperature named, 


in half an hour. The normal average value is given by different writers 


as from 5-20, from 6-30, and from 10-33-3 units. 


As regards diet taken by the patients, the subjects of these observa¬ 
tions, at the outset of the work they were given a diet of milk, eggs, 
rice pudding, and bread and butter, on which they subsisted in bed for 


forty-eight hours, the urine being collected over the second twenty- 
four-hour period. Later many of the same patients and a fresh batch 
pf cases were kept in bed for twenty-four hours (during which the 


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1922 .] BY EDWIN GOODALL AND H. A. SCHOLBERG. 


3 


urine was collected) on the ordinary diet of mental hospitals, consisting 
of bread and margarine for breakfast and tea; meat, fish or soup, with 
bread (occasionally an addition—to fish or soup—of cheese, or bread and 
currant pudding), for dinner; and 2 J pints of fluid (tea 2 pints, water £ 
pint). The difference in diet made no difference in the results obtained. 
A specimen from the twenty-four-hour urine was examined in each case. 
Rigid precautions were taken to prevent contamination of the urine by 
saliva or otherwise. The utensil was kept away from the patient until 
required. Urine, as passed, was poured into a bottle containing toluol. 

A record was kept in each case of the quantity of urine passed, its 
specific gravity, reaction, and the presence or otherwise of albumen and 
sugar. 

As regards the kinds of mental disorder, the patients examined may 
be classified as follows : Delusional insanity, 20; secondary dementia, 
21 ; recent melancholia, 17 ; dementia praecox, 10; recent mania, 9; 
congenital mental defect, 9; acute confusional state, 8 ; dementia para¬ 
lytica (demented type), 7; dementia paralytica (maniacal type), 1 ; in 
sanity with epilepsy, 6 ; congenital defect with epilepsy, 3 ; alcoholic 
delusions, 2; alcoholic confusion, 1 ; hypochondriasis, 2; chronic 
mania, 1 ; acute hallucinatory state, 1; primary dementia (? dementia 
praecox), 1. 

In respect of general bodily condition, 81 were in good, 11 in fairly 
good, 28 in reduced condition. 

As regards ages in decennial periods, the cases were distributed thus 

17 cases between the ages of 17 years and 26 years inclusive, 28 
between 27 and 36, 28 between 37 and 46, 26 between 47 and 56, 

18 between 57 and 66, 3 between 67 and 76. 

With very few exceptions the urine was examined at least twice at 
intervals, and in many cases from three to seven times. Out of a total 
of 120 patients examined (324 total urine examinations), a low diastase 
value, in the absence of all evidence of kidney disease (as afforded by 
the usual clinical urine tests, including the urea concentration test), was 
found in only 6 cases (2 secondary dementia; 2 general paralysis of 
the insane, demented form; 1 recent melancholia; 1 recent mania). 
A high diastase value—kidney disease similarly excluded—was found 
in only one case (recent delusional insanity). The diastase figure in 
this case was 200. The patient was discharged; he relapsed, and 
during the relapse the figure was 50. 

In only one of the cases dealt with was there evidence of kidney 
disease (mental disorder associated with arterio-sclerosis), and in this 
the diastase figure was 66 6 on one occasion (sp. gr. urine 1,012; 
albumen ; urea concentration, 1 43 per cent.). On a second occasion, 
about seven weeks later, the diastase figure was 6 6; urine (twice) sp. 
gr. 1,018-1,020; no albumen. 


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4 DIASTASE-CONTENT OF URINE IN MENTAL DISORDER. [Jan., 

In all other cases than those above referred to (excluding the case 
of kidney disease) the diastase value was within the normal limits. 

Since only a high diastase value is in favour of pancreatic disease, 
there is evidence of such disease—as far as this test is concerned—in 
only one case of the number examined. 

Conclusion. —Out of 120 cases of various kinds of mental disorder, as 
seen in a public institution, there was no evidence, excluding one 
possible case, of pancreatic disease, as indicated by the urinary-diastase 
test. 

In the course of this investigation our attention has been drawn to 
the wide variations in the amount of urine passed by patients—a 
condition noted by my colleagues and myself in the course of previous 
investigations involving the collection of urine. We know that wide 
variations occur under normal conditions. MacLeod (Physiology and 
Bio-chemistry in Modern Medicine , third edition) states the amount of 
urine passed in twenty-four hours as 1,000-1,800 c.c. On a constant 
diet with constant fluid intake (2,070 c.c.) the urine excreted by 20 
individuals varied from 1,013 to I >7 12 c.c. (35 to 60 oz.) in twenty-four 
hours. Whether these patients were up and about or in bed is not 
stated, and no mention is made of the meteorological conditions. 
We have kept 49 patients (of whom 26 were chronic, healthy, 
working cases, and 23 recent and acute cases) in bed for three 
successive periods of twenty four hours, upon a fixed diet and fixed 
amount of fluid, and collected the urine for three periods of twenty-four 
hours each, taking the average quantity passed in twenty-four hours. 
The diet consisted of a fixed quantity of bread and margarine for 
breakfast and tea, and of a fixed amount of meat, vegetables and bread 
for dinner, with 2\ (in some cases 3) pints of fluid per diem. The 
following table shows respectively for the months of March, April, 
May and June the average amount of urine passed per twenty-four hours, 
the average maximum and mean temperatures, and the average per¬ 
centage humidity (i.e., the average of the temperatures and humidity for 
each case in the group concerned). 


Numbers 

Average 

Average 

Average 

Average 
humidity. 
(Ptr cent.) 

amount 

maximum 

mean 

of cases. 

passed, 
in ounces. 

temperature. 

(°F.) 

temperature. 

(°F.) 



March-April. 



26 chronic cases , 

■ 47'3 

53‘87 

467 

78^0 



March-April. 



5 recent cases 

■ 3 i '4 

5576 

4702 

79-2 



May. 



6 recent cases 

. 25 0 

62*6 

53’6 

69*3 



June. 



12 recent cases 

• 258 

698 

6o‘2 2 

628 


The slight difference in temperature and humidity between the 


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1922 .] BARIUM SULPHATE MEAL IN DEMENTIA PRAECOX. 5 

period in March-April, when the acute and recent cases were dealt 
with, and the period in the same months when the chronic cases were 
taken, does not account for the lesser amount (by nearly 16 oz. per 
twenty-four hours) of urine passed by the recent cases. It happened 
that only five of these cases occurred during March and April, the rest of 
the recent cases occurring in May and June, when, as the table shows, 
the average maximum and mean temperatures were higher and the 
average humidity less, accounting, presumably, for a fall in the amount 
of urine passed. Nevertheless, the amounts passed in May and June 
(25 and 25-8 oz. per twenty-fours) are very low. Some of these patients 
passed an average of only 19, 18 and 13 oz. in the twenty-four hours. 

The subject is worthy of more extensive inquiry, with the safeguard 
of controls in normal persons, which, however, we have found it hitherto 
not feasible to obtain, having regard to the somewhat irksome conditions 
involved, with the exception of 3 cases of fractured femur (2) and 
patella (1), otherwise healthy persons, patients in King Edward VII’s 
Hospital, Cardiff". These were kept under precisely the same conditions, 
as regards bed and diet, as the mental cases. Their average (three 
days) 24-hour urine amounts were respectively 57, 38 and 34 oz., as 
against 33, 24, 18, 28 and 23 oz. in recent and acute mental cases at 
about the same dates in the month of May, or an average of 43 oz. as 
against 25 oz. 

(The discussion which followed will be found on p. 524 , vol. Ixvii, 1921 .) 

( l ) Brit. Med. Journ., August 21 st, 1920 . 

(*) Lancet, June 19 th, 1920 . 


The Passage of a Barium Sulphate Meal in ten Cases of Dementia 
Prcecox.Q) By R. V. Stanford, M.Sc., Ph.D. (Cardiff City 
Mental Hospital), and Edwin Goodall, C.B.E., M.D., B.S., 
F.R.C.P.Lond. (Cardiff City Mental Hospital), with the advice 
and co-operation of Robert Knox, M.D.Edin., Hon. Radiologist, 
King’s College Hospital, etc. 

The investigation of which the ten cases here dealt with constitute 
the early stage was undertaken in connection with an inquiry, still in 
progress, into the gastric digestion of a test-meal in cases of dementia 
praecox. Incidentally, Sir Arbuthnot Lane includes dementia praecox 
amongst the conglomeration of diseases which, according to him, are 
traceable to coprostasis. 

The lantern-slides here exhibited illustrate the passage of a barium 
sulphate meal through the gastro-intestinal tract in ten cases of 
dementia praecox. The intention to include some other cases was 
frustrated by the resistance offered by the patients, but the inquiry is 
being pursued. 

(*) A paper read at the Annual Meeting held in London, July 12th, 1921. 


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6 BARIUM SULPHATE MEAL IN DEMENTIA PR^COX. [Jan., 


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The radiograms from which the slides were made were taken by 
Dr. R. V. Stanford, M.Sc., Ph.D., Research Chemist, Cardiff City 
Mental Hospital, in the X-Ray Department of the Hospital. All the 
radiograms are “instantaneous” pictures, so that no blurring due to 
peristalsis is met with. These rapid exposures were obtained by using 
duplitised films, which have a sensitive emulsion on both sides, and 
two intensifying screens, one on each side. The actual time of exposure 
was not more than one quarter of a second. 

Throughout this work we have had the great advantage of the advice 
and co-operation of Dr. Robert Knox, Hon. Radiologist, King’s College 
Hospital, etc., to whom our thanks are due. The reduced photos were 
submitted to him, and the observations now made are summaries of 
his statements concerning each case. 

The radiograms were taken under standard conditions. To clear the 
bowels preliminarily each patient was given a dose of castor oil thirty-six 
hours before the barium meal, and had no food after tea the evening 
before the day upon which the meal was given, this being given about 
io a.m. The barium sulphate (4 oz.) was given, well mixed with 
arrowroot, cornflour, and dried milk, with cocoa as a flavouring material. 

Radiograms were taken as follows: At o hours (/.*., immediately 
after the meal), 1 hour, 4 hours, 7 hours, 24 hours, and, in some cases, 
48 hours; in one case 72 hours. They were taken with the patient in 
the upright position, the tube being placed behind the patient. 

The following notes indicate the clinical condition of the patients: 


Case i.—C. J—, set. 28. Duration, about one year. Demented; apathetic; 
sits or stands in one place; neglects himself; unemployable; degraded facial 
expression. (Hebephrenic type.) 

Case 2. — C. H—, set. 17. Duration, about years. Demented; foolish 
expression and smile ; stands in same place; explosive laughter ; complete apathy 
and loss of affection ; dirty in habits. (Hebephrenic type.) 

Case 3.—W. G. N —, set. 32. Duration, three years. Demented; dirty in 
habits; resistive; has a fixed (demented) facial expression; no spontaneity ; 
stands or lies in one place without moving; rigidity of limbs; cyanosis. (Kata- 
tonic type.) 

Case 4.—L. R. J—, set. 22. Duration, one year or rather more. Demented; 
smiles fatuously; grimaces and blinks ; is impulsive in actions, and sometimes 
strikes; unclean; somewhat resistive; no spontaneity; completely apathetic; 
stands or sits in one place. (Hebephrenic type.) 

Case 5 -—R- D. P—, set. 18. Duration, about ii years. Demented ; apathetic; 
no attention-power; stands in one place; stops in the middle of actions; no 
volition. (Hebephrenic type.) 

Case 6.—S. A. T—, set. 27. Duration, 2* years. Marked stupor; loss of 
expression; bursts of laughter without known cause; requires feeding; neglects 
herself ; stands or sits in same place ; very cyanosed. (Hebephrenic type.) 

Case 7.—J. B—, set. 21. Duration, eight to twelve months. Demented, silly 
expression and laughter; impulsive acts; mucus dropping from nose; cyanosed ; 
wet; stands or sits in one place; no spontaneity; loss of regard for others. 
(Paranoidal type.) Has had persecutory delusions, but now more of the Hebe¬ 
phrenic type. 

Case 8.—D. V. M—, set. 21. Duration, eight months. Face lacking in expres¬ 
sion ; stands or sits in the same place ; pays no attention, and makes no response ; 


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1922 .] BY R. V. STANFORD AND EDWIN GOODALL. 7 

wets the bed; requires dressing; is fed by hand, and resists feeding; starts doing 
a thing and leaves it. (Hebephrenic type.) 

Case 9.—B. W. E—, aet. 26. Duration, at least three years. Loss of facial 
expression ; listless ; untidy; occasionally wets himself; laughs, and makes impul¬ 
sive movements, pushing people or striking them ; sits unoccupied. (Hebephrenic 
type.) 

Cask 10.—J. R. O’B—, aet. 19. Duration, about fourteen months. Demented; 
face lacking in expression; much mental confusion; considerably resistive; dis¬ 
posed to be sudden and impulsive; completely disorientated in time and place ; 
wet and dirty in habits; no reply to questions; grins foolishly; sits smiling to 
himself. (Hebephrenic type.) 

The following is a summary of Dr. Knox’s observations upon the 
radiograms: 

Cask i.—T his case shows considerable deformity of the duodenal cap (1 
hour) and (24 hours) the first portion of the transverse colon is looped 
towards the caecum ; there is some delay in the evacuation of the latter and slight 
spasticity of the transverse colon. The deformity of the duodenal cap may be 
due to (a) incomplete filling of a normal bulb, (h) pressure of spine, (c) adhesions, 

( d ) “extrinsic” spasm—reflex from gall-bladder, appendix, etc., (e) “ intrinsic” 
spasm, associated with ulceration. Further examination of this patient is 
indicated. 

Case 2.—The stomach and small intestine are hypermotile. There is no 
abnormality to note. 

Cask 3.—The stomach is of normal size, but is situated to the left of the normal 
position. The stomach and small intestine are hypermotile. The transverse colon 
is ptosed. 

Case 4.—This is possibly a spasmodic hour-glass stomach. There is delayed 
evacuation of the ccecum and marked spasticity of the transverse colon. The films 
at 48 and 72 hours show delayed evacuation of the ascending and transverse 
colons with rectal accumulation. 

Case 5.—The 24 hours’ radiogram shows delayed evacuation of the caecum 
and the transverse colon somewhat spastic , but in 48 hours there is complete 
evacuation. 

Case 6.—The stomach is situated to the left of the mid-line, but there is no 
abnormality in contour, size or motility of stomach and intestine. 

Case 7.—Lower pole of the stomach is dilated and situated to the right of the 
normal position. Very small duodenal cap (? incomplete filling). The transverse 
colon is looped back in the line of the ascending colon. This obliquely-placed 
colon may be due to adhesions. There is delayed evacuation of the transverse and 
descending colons with rectal accumulation. 

Case 8.—In this case there is spasticity and delayed evacuation of the colon, but 
there is no abnormality of contour, size or position. 

Case 9.—The stomach is placed rather obliquely. The first portion of the 
transverse colon seems to be curved back to the line of the ascending colon, and 
at the lower corner a break is to be seen in the shadow, which (7 hours) dis¬ 
appears owing to the increased intra-colonic pressure. The transverse colon 
ascends obliquely from right iliac fossa (? due to adhesions), and there is spasticity 
of the colon and (48 hours) rectal and colonic retention. 

Case 10.—The stomach is large, dilated, and hypo-tonic; it empties rapidly, 
but there is no evidence of other abnormality; the meal passes rapidly through 
the small intestine and colon. 

In six out of ten cases there is delayed evacuation of, or retention of 
faeces in, the large bowel; in one case ptosis of the large bowel. The 
question of adhesions arises in two of the six cases. 

In five out of ten there is spasticity of the colon. 

The spasticity of involuntary muscle-fibre is interesting in view of 
the like condition (rigidity or rigid immobility) noted in respect of 
voluntary muscle in some cases (katatonic) of dementia praecox. 


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8 


BACTERIAL INFECTION IN DEMENTIA PRSECOX. [Jan., 


Chronic Bacterial Infection in Cases of Dementia Preecox. By W. 
Ford Robertson, M.D., Pathologist to the Scottish Asylums^ 1 ) 

I have to present the results of an inquiry into the possible im¬ 
portance of chronic bacterial infection as a factor in the causation of 
dementia prsecox. My conclusions are based chiefly upon the study of 
thirty-two early cases in which it has been possible to make a sufficiently 
complete examination. I have also investigated by the same methods 
thirty cases of other forms of acquired insanity, and over 300 cases of 
nervous and other disorders in persons among the general population. 
I have to describe the chronic infections I have found in the cases of 
dementia prsecox, and to endeavour to estimate their relation to the 
malady. 

The bacteriological methods that I have employed consist especially 
in the use of haemoglobin agar media of various degrees of acidity, and 
the regular subjection of the cultures to incubation under anaerobic as 
well as under aerobic conditions. My criteria of identification of species 
are those laid down in my book on therapeutic immunisation, which do 
not differ in very many particulars from those of the standard text-books 
of bacteriology, although in several instances they go beyond them. 

Every case of dementia prsecox that I have investigated has been 
found to be suffering from severe bacterial infections, involving especially 
the intestinal tract. No one of these infections is special to this malady. 
They may be found in cases of acute insanity and of manic-depressive 
insanity, and not infrequently among the general public. On the 
ground of the observations I have made in cases outside asylums, it may 
be stated as an incontrovertible conclusion that the bacterial infections 
from which the subjects of dementia prsecox suffer are quite incom¬ 
patible with health. 

Whilst the chronic infective disorders of cases of dementia prsecox 
are always multiple, three main types can be recognised, each with its 
dominating form of infection. These may be termed respectively the 
pneumococcus, the neurotoxic diphtheroid bacillus, and the anaerobic 
streptothrix types. The most important associated infections are by 
Streptococcus pyogenes , Streptococcus anginosus, the Bacillus Friedldttder, 
staphylococci, influenza bacilli, and anaerobic strains of Micrococcus 
catarrhalis. 

In order to be able to estimate the significance of these chronic 
infections in dementia prsecox and other forms of insanity, it is of the 
utmost importance to understand what effects they produce when they 
occur in persons outside asylums. I shall therefore take each of the 
three dominating infective agents in turn, and state what I believe can 
be said to be known about its pathogenic action. 

Pneumococci are among the most important of the many bacteria 
(') A paper read at the Annual General Meeting, London, July 14 th, 1921 . 


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BY W. FORD ROBERTSON, M.D. 


9 


that attack the human subject. It is now recognised that they form a 
group containing numerous species, each more or less distinct in its 
pathogenic action. Pneumococci have been studied chiefly as they 
attack the respiratory tract. Comparatively little attention has hitherto 
been paid to their occurrence in the alimentary tract. In my experience 
chronic pneumococcus infection of the intestine is a fairly common and 
extremely important cause of ill-health. It is chiefly this action of the 
pneumococcus as a chronic infective agent in the intestine that concerns 
us in regard to dementia prsecox, and we therefore require to know 
what symptoms it produces when it occurs in patients whose treatment 
is in the hands of the general practitioner. 

I have records of twenty-seven cases of this kind. For reasons that 
it is hardly necessary to explain, I have excluded all cases of pernicious 
anaemia with intestinal pneumococcus infection. A symptom or group 
of symptoms present in all of these twenty-seven cases was neurasthenia- 
I believe it is clearly established that chronic intestinal infection by 
pneumococci is one of the several bacterial toxic causes of this malady. 
There are, however, commonly added other symptoms, especially attacks 
of diarrhoea, abdominal pain, or discomfort, loss of weight and anaemia 
The following are five examples of cases observed : 

A captain in the Army had suffered for three years from neurasthenia and 
symptoms suggesting bacillary dysentery. It had been ascertained, however, that 
his stools did not contain the specific bacteria. I found that he had a severe infec¬ 
tion of the intestine by pneumococci. There were no complicating infections. 
Under therapeutic immunisation the patient made a good recovery. 

A gentleman, set. 63, had for over two years suffered from attacks of diarrhoea, 
alternating with severe constipation. He had lost weight, and was very neuras¬ 
thenic. The intestinal flora showed about twenty streptococcus colonies to one 
coliform bacillus colony. On further investigation, about 70 per cent, of the 
streptococci were found to give the reactions of a pneumococcus, and 30 per cent. 
those of Streptococcusfcecalis hcemolyticus. Therapeutic immunisation was carried 
out against these two streptococci and against an aberrant type of Bacillus coli 
communis . Under this treatment the patient made a rapid and complete recovery, 
and re-examination of the stools four months later revealed a normal flora. 

A girl, aet. 2j, had suffered for many weeks from attacks of diarrhoea, which 
were followed by severe constipation, anaemia, and general malaise. Examination 
showed a pneumococcus infection of the intestinal tract. Under therapeutic 
immunisation the child made a complete recovery. 

A working man, past middle age, had suffered for several years from slowly- 
increasing paraplegia. He had become completely bedridden. Cultures made 
from the stools showed about two hundred pneumococcus colonies to one colony 
of Bacillus coli communis . I believe that, in this case, the chronic intestinal 
infection was the actual cause of the paralysis, but I have not time to go into the 
reasons for this conclusion. 

A nurse suffered from neurasthenia and anaemia of so severe a nature that she 
became unfitted for work. An intestinal examination revealed evidence of infec¬ 
tion by pneumococci. She was treated by therapeutic immunisation, and made a 
complete recovery. She has now remained well for several years. 

These cases, and many others that might be cited, show that pneumo 
coccus infections of the intestine are commonly attended by distinct 
signs of neurotoxic action. Comparatively rarely, pneumococcus in¬ 
fections of the respiratory tract may be observed to cause special 


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IO BACTERIAL INFECTION IN DEMENTIA PRiECOX. [Jan., 


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nervous disturbances. I have studied several cases of this kind, and 
have seen the symptoms disappear under therapeutic immunisation. 

The second form of chronic infection that I have specially to 
consider, as it occurs in members of the general population, is that by 
neurotoxic types of diphtheroid bacilli. The subject is a vast one, and 
for details concerning it I must refer to what I have recently written 
elsewhere. I would say here that there is incontrovertible evidence, 
drawn from all sides, that in the very large group of aerobic and anaerobic 
diphtheroid bacilli there are many species that are powerfully neuro- 
toxic. The evidence includes the results of cultural observations 
extending over many years, of experimental work upon lower animals, 
and of therapeutic immunisation in some hundreds of cases. These 
neurotoxic actions are quite commonly exhibited among the general 
population. The respiratory, genito-urinary and alimentary tracts are 
each liable to attack. Chronic intestinal infection by anaerobic diph¬ 
theroid bacilli is the chief toxic cause of neurasthenia, but there are 
aerobic species that are equally or even more highly neurotoxic. The 
following are a few examples: 

A young lady suffered from symptoms of neurasthenia, complicated by tremor 
and inco-ordination of movement, affecting especially the lower limbs. A diagnosis 
of disseminated sclerosis had been made by one specialist whom she had consulted. 

I found that she had what may be termed a diphtheroid cystitis. The urine was 
loaded with anaerobic diphtheroid bacilli, and the centrifuge deposit showed a large 
number of polymorphs. Under therapeutic immunisation she made a complete 
recovery in the course of about six months, and after a year she remains well. The 
bacilli have disappeared from the urine. 

An elderly lady had suffered for several weeks from insomnia and aggravation 
of neurasthenic symptoms, to which she had long been subject. I found that the 
intestinal tract was loaded with anaerobic diphtheroid bacilli. Under therapeutic 
immunisation against these she steadily improved, and in the course of a few weeks 
was restored to her usual health. 

A young lady employed in an office had suffered for over a year from neuras¬ 
thenic symptoms and almost complete insomnia. I found that she had evidences 
of intestinal infection by Streptococcus pyogenes , Staphylococcus pyogenes , and 
anaerobic diphtheroid bacilli. I have never observed any case in which insomnia 
could be attributed to chronic infection by Streptococcus pyogenes or by Staphy¬ 
lococcus pyogenes , and this symptom must, I believe, be attributed in this case to 
the action of the diphtheroid bacillus. Under therapeutic immunisation against 
these infections all of the distressing symptoms gradually disappeared, and within 
three or four months the patient was completely restored to health. 

An officer had been discharged from the Army on account of neurasthenia and 
tachycardia, which was associated with slight enlargement of the thyroid gland. 
I found that his stools and urine were loaded with aerobic diphtheroid bacilli. 
He displayed great sensitiveness to a corresponding vaccine, but gradually improved, 
and in the course of a year lost nearly every symptom of neurasthenia and the 
tachycardia. 

A young lady suffered from neurasthenia and exophthalmic goitre. The stools 
and urine were loaded with anaerobic diphtheroid bacilli. The patient was at first 
intensely sensitive to a corresponding vaccine. After a course of therapeutic 
immunisation the signs and symptoms of her malady had almost completely 
disappeared. 

Numerous cases of exophthalmic goitre that I have investigated have 
shown similar intestinal anaerobic or aerobic diphtheroid bacillus in- 


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fections, hypersensitiveness to minute doses of an autogenous vaccine 
and gradual recovery under continued therapeutic immunisation. 

I could cite scores of other cases illustrating the neurotoxic action 
of diphtheroid bacilli among members of the general population as 
distinguished from asylum patients, but these must suffice here. 

The third form of chronic infection I have to notice, as it occurs 
in members of the general public, is one by a group of anaerobic 
streptothrices, that may be found especially in the intestine. My 
attention was first directed to them in the course of the bacteriological 
investigation of the intestinal flora in a case of diabetes mellitus. In 
19 consecutive cases of this disease I have found the stools to be loaded 
with a bacterium of this kind. There are, I think, sufficient grounds, 
including the evidence of animal experiment, for the conclusion that 
this streptothrix is the cause of diabetes, and that it acts by injuring a 
particular area in the bulb. If a streptothrix of this kind can thus 
injure one portion of the nervous system, there is a presumption that it 
is capable also of damaging other portions. The further I have in¬ 
vestigated the matter the more important has it seemed to become. 
A large amount of evidence has now accumulated that supports the 
conclusion that there is a group of anaerobic streptothrices that are 
highly neurotoxic bacteria, responsible for a very large amount of 
serious nervous disease, the cause of which has hitherto been entirely 
obscure. Apart from typical diabetes mellitus, intestinal infections by 
anaerobic streptothrices are fairly common in patients outside asylums. 
I have observed fourteen cases. All of the patients suffered from nervous 
disorders, on account of which they sought advice. These disorders 
included severe types of neurasthenia, neuritis, paralysis agitans and 
paraplegia. Several of the patients were very anaemic, and most of 
them had lost weight and were very thin. All in whom the point could 
be investigated had glycosuria. The following are some examples : 

The wife of a doctor had a history of having been operated upon twelve years 
before for appendicitis, which was followed by much trouble on account of peri¬ 
toneal adhesions. Recently the patient had become extremely neurasthenic. 
She was steadily losing weight, and no turn for the better had occurred after many 
months. I was asked to investigate. The special interest of the case to me lies in 
the fact that it is the only one in which I have found uncomplicated chronic infec¬ 
tion by an anaerobic streptothrix. The intestine was loaded with an organism of 
this kind. The patient had the usual glycosuria. I advised therapeutic immunisa¬ 
tion against the streptothrix and against Bacillus coli communis , as it seemed 
probable that this bacterium was acting as a secondary infecting agent. The 
doctor has reported to me that under this treatment the patient is now steadily 
improving. 

A gentleman of middle age suffered from neurasthenia and anaemia, on account 
of which pernicious anaemia was suspected. An investigation of the intestinal 
flora showed that he had an infection of some portion of the gastro-intestinal 
tract by Streptococcus pyogenes and also an intestinal infection by an anaerobic 
streptothrix. There was a large amount of sugar in the urine. This patient is 
under treatment, but I have had no report of the result. 

A girl of about sixteen years of age suffered from neurasthenia, anaemia and 
cardiac weakness, on account of which she had for many months been unable to 


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attend school. I found that the intestinal flora was very abnormal. There was 
great excess of streptococcus colonies, which were ascertained to consist of 
pneumococci and Streptococcus fatcalis heemolyticus in about equal proportions. 
Anaerobic cultures yielded profuse growths of a streptothrix. The urine contained 
a considerable amount of sugar. Under therapeutic immunisation against these 
and some other minor infections of the gums the patient steadily improved, and 
made a perfect recovery in the course of about six months. 

A lady between thirty and forty years of age had suffered for over three years 
from intense neurasthenia, complete insomnia, requiring the constant use of 
hypnotics, and latterly from mental depression and confusion. The intestinal 
anaerobic flora consisted almost wholly of colonies of a streptothrix and of 
diphtheroid bacilli. The urine was full of sugar. This is a recent case, and 
treatment has not yet been carried out. 

The remaining ten cases of anaerobic streptothrix infection were so 
complicated by other chronic infections that their testimony is of less 
value. I have, however, obtained striking evidence of the neurotoxic 
action of these streptothrices from animal experiment. Rats fed with 
strains isolated from cases of diabetes mellitus have developed not only 
glycosuria but also a state of profound lethargy and stupidity; some 
showed extraordinary choreic movements and inco ordination. In 
spite of liberal supplies of food they became greatly emaciated, and, in 
some of them, death was preceded by a prolonged state of uncon¬ 
sciousness suggestive of diabetic coma. In the human subject, the 
constant association of infection by these streptoth rices with nervous 
disorders, and the very great preponderance of such infection in asylum 
patients as compared with the general population, are facts that also 
testify to the neurotoxic action of the group. 

Having thus laid the foundations for the superstructure that I wish to 
build, I pass to the consideration of the chronic infective conditions 
found in the 32 cases of dementia praecox that I have specially in¬ 
vestigated. Seven of them were of the pneumococcus type, 9 of the 
neurotoxic diphtheroid bacillus type, and 13 of .the anaerobic streptothrix 
type. Only 3 could not be put in any of these categories. Mixed 
types were almost the rule, and I have classified the cases merely in 
accordance with what seemed the predominating infection. In all 
there were other chronic infections, generally of a severe nature. I 
have accepted the physician’s diagnosis of dementia praecox. An 
endeavour was made, as far as possible, to select early cases. The 
following are some examples : 

A female patient in Roxburgh District Asylum, who was thin and anemic, was 
found to have an intestinal flora which in aerobic cultures showed about one 
hundred streptococcus colonies to one coliform bacillus colony. The normal 
proportion is just the converse. These streptococcus colonies, on further 
investigation, were found to consist of pneumococci, Streptococcus pyogenes and 
Streptococcus feecalis heemolyticus , in about equal proportions. The coliform 
bacillus was exclusively the bacillus of Friedlander. The gums, which were 
intensely inflamed, yielded profuse growths of aerobic and anaerobic strains of 
Streptococcus pyogenes and Micrococcus catarrhalis. The urine was loaded with 
anaerobic diphtheroid bacilli and pneumococci. From the nasal passages profuse 
growths of the bacillus of Friedlander were obtained. The main fact in this case 
was the intestinal infection by pneumococci; the other most important infective 


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agents were, I think, Streptococcus pyogenes in the gums and intestines, the 
bacillus of Friedl&nder and anaerobic diphtheroid bacilli. 

A young lady, somewhat recently admitted to one of the Royal Asylums, was 
also found to be suffering from very complex infections. The state of her gums 
was satisfactory, but there was severe chronic catarrh of the tonsils and pharynx. 
From the fauces I obtained profuse growths of aerobic and anaerobic strains of 
Streptococcus pyogenes and Micrococcus catarrhalis ; the nasal, passages contained 
a threading diphtheroid bacillus. The urine yielded abundant colonies of an 
aerobic diphtheroid. The stools in aerobic culture showed great excess of 
streptococcus colonies, which were found to consist in about equal proportions 
of pneumococci and Streptococcus pyogenes. The coliform bacillus was the bacillus 
of Friedl&nder. Anaerobic cultures yielded profuse growths ofjdiphtheroid bacilli. 
Here again the leading infection was that of the intestine by pneumococci. 
The chief complications were infections by Streptococcus pyogenes , anaerobic 
diphtheroid bacilli and the bacillus of Friedl£nder. This is one of the cases 
I shall presently refer to as having responded satisfactorily to therapeutic 
immunisation. 

Another female patient in Roxburgh District Asylum showed an extremely 
abnormal intestinal flora. Anaerobic cultures yielded profuse growths of diph¬ 
theroid bacilli, and the only coliform bacillus present was the bacillus of 
Friedl&nder. The urine was loaded with aerobic and anaerobic diphtheroids, and 
there was a chronic infection of the naso-pharyngeal region by Streptococcus 
anginosus. This is an example of the diphtheroid type. This patient, like the 
previous one, did well under therapeutic immunisation. 

A young man in the same asylum was found to have stools and urine loaded 
with anaerobic diphtheroid bacilli. There was chronic catarrh of the naso¬ 
pharyngeal region, which was found to be associated with infection by Strepto¬ 
coccus pyogenes , which developed in profuse growths in cultures made from a 
swab. This patient also responded well to treatment by therapeutic immunisation. 

These must suffice as examples of the pneumococcus and diphtheroid 
bacillus types, and I pass on to the anaerobic streptothrix type. 

One of the first cases of this kind observed was that of a boy, aet. 17 , in 
Roxburgh District Asylum. In anaerobic cultures from the stools profuse 
growths of a streptothrix were obtained. In the naso-pharynx there were 
infections by Staphylococcus pyogenes aureus, and the bacillus of Friedl&nder. 
Therapeutic immunisation was applied by Dr. Steele aud Dr. Crichlow. I am 
informed that the patient improved, and had to be discharged because he was 
so well. 

A man, aet. 29 , in Rosslynlee Asylum, showed intense chronic congestion of the 
nasopharynx. Cultures from this region yielded profuse growths of Streptococcus 
pyogenes . The urine contained a large amount of sugar; no bacteria of importance 
were obtained from it. In aerobic culture the intestinal flora was normal; in 
anaerobic culture it yielded very abundant colonies of a streptothrix and of 
diphtheroid bacilli. 

Another case of dementia praecox in the same asylum, submitted to me for 
examination on the same day by Dr. James H. C. Orr, was found to have a 
pathogenic flora almost identical with that of his fellow patient. The only 
difference was that profuse growths of anaerobic diphtheroid bacilli and Strepto¬ 
coccus pyogenes were obtained from the urine. 

A gentleman in one of the Royal Asylums, who was selected as a typical case 
of early dementia praecox, was found to have a large amount of sugar in his 
urine. There was a Streptococcus pyogenes infection of the gums and fauces. 
The stools showed, in aerobic culture, great excess of colonies of Streptococcus 
fcecalis fuemolyticus , and, in anaerobic culture, very abundant growths of a 
streptothrix. No bacteria of importance were obtained from the urine. As the 
other infections did not seem to be very severe, this was an almost uncomplicated 
case of anaerobic streptothrix infection. 

A lady patient in another Royal asylum had suffered for over two years from 
paranoid dementia. I was asked to investigate the case, and found that there 


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were evidences of severe infection of the intestine by an anaerobic streptothrix; 
the only coliform bacillus present was the bacillus of Fried lender. Profuse growths 
of Streptococcus pyogenes were obtained from a throat-swab. This case is now 
being treated by immunisation against these infections, and, if her defensive 
forces are capable of adequate response, I expect to hear of a good result having 
been obtained. 

The last case that I shall describe is one in which pneumococcus, 
diphtheroid bacillus and streptothrix infections were combined. 

The patient is a youth of eighteen in one of the Royal Asylums. I found that 
his fauces, which were much inflamed, were the seat of chronic infections by 
Streptococcus pyogenes and Micrococcus catarrhalis. The stools, in aerobic culture, 
yielded colonies of diphtheroid bacilli, pneumococci and staphylococci, in addition 
to the normal Bacillus coli communis. In anaerobic culture they showed very 
abundant growths of a streptothrix, and of diphtheroid bacilli. The urine contained 
a large amount of sugar, and was loaded with anaerobic diphtheroids. 


The three cases that could not be placed in any of the main 
categories I have distinguished all suffered from very severe chronic 
infections. They were among the earliest cases in which anything 
like a complete examination was attempted, and it is more than 
probable that some important anaerobic intestinal infections were 
missed. 

It may seem to many that I have asked them to take a great deal 
on trust, but it must be apparent to all that these things can be 
demonstrated only in the laboratory. All those who are interested in 
the matter will be welcomed at the Laboratory of the Scottish Asylums, 
where, I am confident, a six months’ course of practical bacteriology 
will cure them of all symptoms of scepticism regarding the importance 
of bacterial infection as a factor in the pathogenesis of the acquired 
forms of insanity. 

I hold that the results I have described have at least shown that 
extremely severe chronic infective conditions occur in cases of dementia 
prsecox, and that they include attack by bacteria, the action of which is 
known to be neurotoxic. 

What is the relation of these chronic infections to the mental disorder 
in dementia praecox ? If there is any one who has formed the con¬ 
clusion that they are the result of the mental disorder let him bring 
forward his evidence. If there is any one who holds that these chronic 
infections and the mental disorder are entirely independent phenomena, 
let him also bring forward his evidence ; but let me tell him two things 
in advance : the first is that the only evidence that would be relevant 
would be observations showing either that dementia prsecox can develop 
in persons free from chronic bacterial infections, or that in cases 
without permanent brain damage suppression of chronic infections does 
not result in any improvement in the mental condition ; and the second 
is that, in regard to this point, there is already weighty testimony that 


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just the converse is the case, namely, that suppression of the chronic 
infections in early cases is attended by benefit to the patient’s mental 
health. 

In my judgment these chronic bacterial infections are the most 
important of several factors that determine the mental disorder. They 
are the direct cause of the morbid process in the brain that destroys its 
efficiency as a mechanism, and leaves it incapable of many normal 
motor, sensory and psychical reactions. Among the other important 
factors are the special inherent reactive qualities of the patient and 
psychic traumatism. We have to explain why only some persons 
suffering from such chronic infections become insane. It is really not 
very difficult to do so. Every form of bacterial infection shows a wide 
range of effect in any group of individuals. In other words, individual 
differences in power of resistance colour the clinical picture produced 
by every form of bacterial attack. In the victims of dementia prsecox 
we have to recognise a special type of inherent defective resistance to 
the action of bacterial toxins. This defective resistance would appear 
to be especially on the part of the nerve-cells of the most highly 
developed areas of the brain, namely, the association centres. In other 
words, these unfortunate people have a predisposition to fix certain 
toxins in their higher cortical nerve-cells, and when they suffer from 
severe neurotoxic infections their association centres quickly become 
damaged instruments that can respond to the play of the environment 
only by more or less discordant notes. 

How are we to prove whether these possibilities are in accord with 
fact or not? We cannot settle the matter by simply multiplying 
bacteriological investigations in the sane and in the insane, for it is not 
a question of a specific infection causing dementia prsecox. Animal 
experiments will not help us very much. Nevertheless, I believe the 
problem is capable of solution. The most direct and satisfactory plan 
is simply to employ therapeutic immunisation against the existing in¬ 
fections in a series of early cases before the brain is irretrievably 
damaged, and to observe if, in addition to benefiting the physical health, 
as in persons outside asylums, we can arrest the ordinary progress of 
the mental disorder. 

It has been impossible for me, as yet, to pursue this part of the 
inquiry very far. It was essential that much should first be known 
about the infective conditions before therapeutic work was attempted 
on any large scale. Such observations as have, however, been made 
for me, and the few that I have been able to carry out myself, have 
given results that are very encouraging. 

I would mention a series of cases treated at Roxburgh District 
Asylum, first by Dr. Carlyle Johnstone, and later by the present Medical 
Superintendent, Dr. Patrick Steele, and their assistant, Dr. Charles 


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Crichlow, to whom I am greatly indebted for his keen practical interest 
in the matter. 

Distinct improvement has been noted in at least 7 cases in the 
series, and 4 of these have been discharged from the asylum as 
recovered. A case of the diphtheroid type, complicated by chronic 
infections by Bacillus influenza and Streptococcus pyogenes , treated by 
Dr. Orr at Rosslynlee Asylum, made a remarkable recovery, and was 
discharged. Distinct improvement has also been reported in several 
cases treated for me by Dr. Campbell and Dr. Gostwyck at Larbert 
Asylum. A case of the pneumococcus type under the care of Prof. 
George Robertson, to whom I am indebted for permission to carry out 
therapeutic immunisation, steadily improved from the first dose, and 
now, after only six weeks’ treatment, instead of showing all the typical 
signs of a grave case of hebephrenia, is bright, active, responsive in 
conversation, says she feels ever so much better, and, to an ordinary 
observer at least, seems quite rational. A case of the streptothrix type, 
also under the care of Prof. George Robertson, and treated at the 
same time as the other patient, has certainly improved. He has become 
bright instead of dull, has lost his delusions, talks more rationally, and 
has repeatedly stated that he feels much better in health. I am 
encouraged also by the result obtained in the case of a young man 
whom I had known for over a year to be curiously dull mentally. I 
found that his urine contained sugar, and that he had well-marked 
anaerobic streptothrix and diphtheroid infections of the intestine. After 
ten weeks’ immunisation against these bacteria the state of his health 
has been completely changed. He is now bright and alert, converses 
freely and intelligently, and is himself well aware that he has benefited 
in a remarkable way from the injections. When he called recently for 
his tenth and last immunising dose, I asked him to tell me in his own 
words what was the chief difference he felt, and he replied, “ I feel that 
something has gone that was oppressing me.” This case teaches, I 
think, the great importance of diagnosing and treating these neurotoxic 
infections at an early stage. 

In concluding, I would say that it is my conviction, founded upon 
years of practical study of the problems presented by the pathology of 
insanity, that it is along such lines that we shall in course of time 
succeed in exercising an important measure of control over the large 
group of the acquired forms of mental disease, which includes dementia 
praecox, acute insanity and the affective psychoses. 

It is my duty to make acknowledgment of the help I have received 
from those who have given me facilities for examining not only the 
cases dealt with in this paper, but also many other cases, the study of 
which has led up to this later series. I am greatly indebted not only 
to those who have already been named, but also to Dr. J. H. Skeen, 


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and his assistant, Dr. Jardine, Dr. C. C. Easterbrook, Dr. Neil T. Kerr, 
and Dr. Dunlop Robertson, as well as to assistant physicians at the 
Royal Edinburgh Asylum, including Dr. Henry Yellowlees, Dr. William 
McAlister, Dr. E. M. Johnstone, Dr. Bell Emslie and Dr. Neil McLeod. 

(The discussion which followed will be found on pp. 543-6, vol. 
lxvii, October, 1921.) 


The Oxford Clinic .(«) By T. S. Good, M.R.C.S.Eng., L.R.C.P. 

Lond., Medical Superintendent, Ashhurst Hospital, Littlemore, 

Oxford. 

The Oxford Clinic for Nervous Disorders first came into official being 
ih the beginning of 1918, when the Committee of the Radcliffe Infirmary 
did Dr. W. McDougall and myself the honour of appointing us as Phy- 
sicians-in-Charge of this department, and asked us to organise and run it. 
It was started with an out-patient department one afternoon a week and 
was entitled the Department for Nervous Disorders. This term was 
chosen as it was hoped that it would induce all classes of nervous cases 
to apply for treatment. Particularly for those cases which show mental 
symptoms was this title chosen, in the hope that such patients would 
come to the clinic without feeling they were being specially branded as 
“ mental.” Opportunity would be given for treatment, and possibly 
improvement or even cure might be effected, and thus certification, 
which every one of these cases most dreads, could be avoided. 

A case-sheet was designed and carefully discussed, then printed on the 
loose-leaf system. Dr. McDougall and I considered a case-sheet 
essential in order that records should be kept of all physical changes in 
the nervous system. This was more especially necessary, we felt, in 
that we were hoping to deal with physical and psychic cases, and though 
in mental cases it is perhaps impossible to design a case-sheet to cover 
all signs and symptoms, this is not so as regards the physical. The 
sheet is so arranged that a routine examination of all motor and sensory 
signs is recorded, both negative and positive, commencing at the head 
and proceeding systematically through the body, with spaces for family 
history, past and present, and personal history of the patient. We felt 
that as we were dealing with mixed cases, in which the diagnosis is often 
difficult as regards whether the disorder is functional or organic, or both, 
that it was absolutely imperative to have a record not only of positive 
but of negative symptoms, and also to ensure, as far as possible, that a 
routine examination should be conducted in every case. I think we 
were greatly influenced in this respect by what I may perhaps call the 
“ omissions ” which had come under our notice on case-sheets of such 

(') A paper read at the Annual Meeting held in London, July 13th, 1921. 

LX VIII. 


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[Jan., 

patients during the war. We often found that only certain reflexes and 
signs were recorded, no mention being made as to whether others were 
present or not. For instance the knee-jerks might be mentioned, but 
the plantar reflexes were not unless they were extensor. 

It is, in our opinion, absolutely essential to record as accurately as 
possible the state of all reflexes, both superficial and deep, whether 
normal or abnormal, as it appears probable that many cases which were 
labelled “ functional ” might later prove to have some organic basis. Early 
cases of disseminated sclerosis and tabo-paresis, for instance, often in 
the initial stages show very little, if any, organic change. At first sight 
they present all the symptoms of a purely functional nature, but they do 
not clear up under psycho-therapy. Thus it would appear imperative 
that careful records should be kept, not only for the reasons already 
advocated, but also with the idea of helping to solve the question as to 
whether prolonged functional disorders may eventually develop into 
organic. A careful examination is also, I believe, in many cases, a great 
psychic help in obtaining the co-operation of the patient in his 
treatment. 

The Oxford Clinic is held at the County Hospital, and there are 
many and great advantages in being attached to a general hospital: 

(1) Borderland or more advanced mental cases do not object to 
presenting themselves, or their friends do not mind bringing them for 
advice; whereas they will shun anything of the nature of a mental 
institution until so ill that to go there appears the only course left 
open to them. 

(2) At a general hospital there is easy access to every other depart¬ 
ment, such as eye, ear, V.D., electrical, and massage, and the opinion 
of another specialist is therefore not only available, but the department 
now under survey is br'ought into close touch with other branches of 
medicine and surgery to their mutual advantage. I feel that in the past 
there has been too great a cleavage between the mental and organic 
sides of medicine, to the detriment of both. 

(3) It enables team work to be carried out. Many cases in the clinic 
•of a partly organic and partly functional nature would appear to improve 
more rapidly under two specialists working in unison than under one 
department: for instance V.D. cases often develop mental symptoms 
which psycho-therapy will relieve, or orthopaedic surgery may be assisted 
in the after-treatment or vici versa. In fact with proper collaboration 
there are hardly any departments which cannot be of mutual help. The 
-importance, too, of having access to a V.D. department is immense, and 
I venture to think a Wassermann blood test might be adopted as a 
routine in every case in which there is the least suspicion of nervous 
■disorder. 

The question of in-patients at the clinic has been considered, and the 


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original plan was to have had about twenty beds allotted at an extension 
of the Radcliffe Infirmary at Headington. Up to the present, however, 
owing to lack of funds these beds have not materialised. This question 
of beds attached to a nervous-disorders clinic is a difficult one. In 
many of the cases in-patient treatment is not only unnecessary, but in 
my opinion even harmful. 

In the neuroses there is always an unconscious reason, i.e. t some 
decision the sufferer fears to make and wishes to avoid, and the illness 
is an attempt at adjustment: they fear their own psychic death, their 
symptoms are an unconscious question. Therefore it would appear 
that in most cases to take such patients into a hospital would be likely 
to increase their malady, for the reason that by this step their unspoken 
question is being answered and confirmed by the physician, i.e., if they 
are ill enough to be taken into a hospital it must be as they feared, and 
they are in danger of psychic death, and that the doctor has agreed with 
this because he has admitted them to hospital. Also unconsciously 
they have thus avoided for a time making any decision or effort—the 
very thing which was the primary cause of the illness. 

Out-patient treatment for these cases is, to my mind, and in my small 
experience, the best. As an out-patient the case has at once one 
question answered, “ The doctor does not think me hopeless.” This 
immediately strengthens the transference, and then analysis may un¬ 
ravel the mental tangle and the patient may be possibly improved or 
even cured. 

As an illustration of the great possibilities of out-patient treatment of 
a case with suicidal tendencies, I may mention I have recently treated 
a young school mistress who was brought to me by her father and sister, 
and who, I was told, had made ah attempt at suicide, and was threatening 
suicide, they said, at the time I first saw her.- The father maintained 
that she needed to be under control. I risked the suicide and treated 
the case as an out-patient by analysis, which proved that the suicidal 
threats were an unconscious attempt at a solution of her conflict, which 
was the fear of death, both physical and psychical, the latter being 
insanity. This started as a child with fear of the mother’s fits of rage, 
and the idea that her mother was mad. The father, for whom she 
consciously had a great attachment, she despised unconsciously 
because of his domination by the mother. Fear of her mother forced 
the girl to withhold all questions on the various sexual problems of a 
growing girl, which consequently she and her sister attempted to work 
out for themselves. Undue dependence on the sister was the result, 
and the death of this same sister caused a severe attack of depression, 
with, it was stated, an attempt at suicide. The girl partially recovered 
from this by repressing the whole circumstances. The recent break¬ 
down was brought about by a severe shock to her love affairs through 


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anonymous letters from a rival. She had been loving her fianci as her 
father on account of her sexual repression due to a forgotten episode, 
which occurred at a very early age when she had heard a woman 
shrieking in childbirth. The analysis was prolonged, but I may here 
state that the girl resumed her teaching, and has lately called expressly 
to tell me that she has lost all fear of insanity and that she feels she is 
now well. 

Suicide of a patient has its horrors for the physician, but perhaps the 
risk is much greater in our imagination than in actual fact. I feel sure 
that had in-patient treatment been adopted in the case above mentioned, 
recovery would have been jeopardised. 

I think I may say that out of the 149 civilian patients whom I have 
personally treated at the clinic during the last three and a half years, 
excluding organic cases, I have only been really anxious to find accom¬ 
modation as in-patients for three children, who would probably have- 
been cured quicker and with more ease had it been possible to remove 
them from parents or relations, who tended rather to aggravate than ta 
cure their disorder. 

Of the adults two cases have required certification, one of senile 
melancholia and the other an old-standing case of dementia prsecox. 
Both these were of long duration, and were only fit for treatment 
in a mental hospital. One case of senile melancholia with marked 
hypochondria, who was an in-patient for bronchitis under one of the- 
physicians, apparently improved under treatment and was discharged, 
but later committed suicide at his own home. 

No acute toxic mental cases (and amongst these I include puerperal 
and confusional cases) have up to the present applied for treatment. 
Such cases would, of course, require in-patient treatment, and I am of 
the opinion that a special ward in a general hospital is the best place 
for them in the earlier stages until one is convinced that recovery is 
unlikely. It appears to me that the sooner the general hospital is 
linked with the mental hospital, by having on the staff a psychiatrist 
with beds at his disposal, so much the sooner shall we be able to 
remove from the mind of the public the obstructing idea that mental 
disorder is a disgrace carrying with it an everlasting stigma. Except 
where there is a definite organic disease associated with the mental 
disorder, as in general paralysis, alcoholic, traumatic, and toxic psy¬ 
choses, as far as my personal experience goes the clinic would tend to 
prove that manic-depressive, obsessional, impulsive and non-systematised 
delusional mental disorders are mainly environmental in their origin. 

Not only are civilians treated at the Oxford clinic, but discharged 
soldiers suffering from nervous disorders have from the beginning been 
sent there by the Pensions Committees of Oxfordshire and the sur¬ 
rounding districts. 


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In fact in the earlier months the pensioner patients were far in 
excess of the civilians. As I stated at the commencement, we gave 
one afternoon a week for treatment, but as civilians increased and 
pensioners continued to come in great numbers, we found it necessary 
to give two afternoons, and that still continues. The waiting list of 
pensioners is not so large, but the number of civilians applying for 
treatment is greatly increasing. When Dr. McDougall went to America 
his place at the clinic was taken by Dr. A. T. Waterhouse. 

Speaking as the Medical Superintendent of a Ministry of Pensions 
Neurasthenic Hospital, namely Ashhurst Hospital, Littlemore, the fact 
that I have only taken in three pensioners to Ashhurst from Oxfordshire 
and district during the last two years is, I think, a very strong proof 
that in most cases out-patient treatment for a pensioner is far the best. 
I have treated 344 pensioners at the clinic and I would like to 
•emphasise this point: I consider that to the neurotic pensioner in¬ 
patient treatment, except in a very small percentage of cases, is even 
more harmful than to, the civilian. I am, of course, excluding organic 
and such other toxic cases as I mentioned before would necessarily 
need in-patient treatment. 

With pensioner and civilian the illness is the same though the cause 
may be different, and yet a greater difference lies in the condition 
under which each comes for treatment. The civilian comes of his 
own accord and with everything to gain by recovery: the pensioner 
■comes often only because he is forced, and if he recovers he will lose 
his pension. The civilian probably has work which he can carry on 
during treatment: the pensioner has often been in hospital, thereby 
losing his job or possibly a business of his own, and enfeebling his 
body, therefore he comes for treatment with the added anxiety of 
unemployment. 

During the last year a large percentage of pensioners presenting 
themselves for treatment have shown toxic and organic troubles of 
some kind, such as rheumatism, malaria, V.D.H., neuritis, old head 
■and spine injuries which unfit them to compete with sound men in 
their work. In these cases the anxiety caused by this incapacity to 
support themselves often masks the real organic mischief. These men 
have been discharged from the Army labelled “neurasthenia,” and 
sent to one hospital after another, an unconscious suggestion having 
accompanied them that all their complaints are but figments of their 
imagination, and consequently these complaints have been treated 
with suspicion. Such cases are often confused with the malingerer. 
Time and patience alone may enable us to find the cause of the illness 
and they may improve with treatment. Both for their own sakes and 
al$o from an economic point of view these cases have a better chance 
of improvement under treatment at an out-patient clinic, where they 


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can live at home and do some work, than they will ever have in a 
hospital. Thus it will be clearly seen that the treatment of the 
pensioner is far more difficult than that of the civilian, as the physician 
has to cope with the pension and unemployment complexes in addition 
to the ordinary difficulties in dealing with the neurotic. 

I will now briefly mention the methods of treatment used at the 
Oxford Clinic. 

To a certain extent drugs and physical methods are employed, 
especially with the semi-organic cases, massage being included. This, 
however, is only used in the cases in which there has been loss of 
mobility of a limb and as an aid to psycho-therapy. In other words 
massage is employed to help the nutrition and also to assist relaxation 
of the opposing muscles, but it is only used with careful explanation 
of the reason of its employment, and the patient is instructed as to 
how to co-operate and re-associate the lost movements. 

Psycho-therapy: (i) Persuasion, in which the cause of the neurosis 
is explained to the patient, combined with a stimulation of his interest 
and determination to recover, and a re-education of his mental and 
physical processes. (2) Suggestion, which includes (a) waking suggestion, 
(1 b) suggestion under hypnosis. (3) Hypnosis. (4) Analysis. I mention 
analysis last as being the hardest, the most scientific and thorough 
of all methods of psycho-therapy, though I think in order of merit it 
should come first. 

There are many reasons why analysis cannot always be employed— 
time, the number of patients to be dealt with, and last but not least, 
the fact that only a certain percentage of cases can be treated by 
this method. 

Personally I use any of these methods according as to which I feel 
may be suitable to the case. Time prevents me from illustrating the 
results of these different methods of treatment. I should like, however, 
to state that I have mainly used hypnosis for recovering war-amnesias 
and for inducing sleep; and as far as possible never do I use hypnosis 
with deliberate suggestion as a method of cure except as a last resource, 
as I never feel sure how long the good results obtained by suggestion 
alone are likely to continue. 

In order to endorse any statement I have made as to the result of 
treatment of pensioners at the clinic, I would like to quote some 
remarks and read some figures as given to me by the D.G.M.S. of the 
Oxford Area. 

He states as follows: In my opinion, in a large proportion of the cases 
treated at the clinic there is definite and distinct improvement. Of 
those patients who have been discharged from the clinic as requiring no 
further treatment, very few have relapsed. Most of the men are at 
work, and but for the fact that there is a slight residual trace or undue 


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PSYCHOLOGY AND PSYCHO-THERAPY. 


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tendency to neurosis to be detected they appear well, and in 40 or 50 
per cent, their pension is only 20 per cent, or less. The number of high 
assessments is extremely small. 

The following figures give the number boarded and the pensions 
assessed in the last four months, and in the opinion of the D.G.M.S. the 
number of high percentage pensions is unduly high in this period as 
compared with the average for the whole year. 

Of total number (65) boarded: 2, or 3 percent ., were assessed at 80 ; 
3, or 4 per cent., at 70 ; 3, or 4 per cent., at 60; 4, or 6 per cent., at 50; 
9, or 14 per cent., at 40 ; 14, or 21 per cent., at 30 ; 24, or 38 per cent., 
at 20; 6, or 9 per cent., at less than 20 per cent. 

The average percentage of assessment for the whole number during 
that four months is 30 percent, pension. These figures include patients 
still waiting for treatment and also some organic cases. During the 
whole period less than five cases have had to be certified in this area. 
In the last two years only three cases have been admitted to a neuras¬ 
thenic hospital: 

(1) A case of alcoholic and syphilitic dementia. (2) A case who 
was waiting for training had depression and a hostile environment. 
(3) A case from the permanent staff of the Ashhurst Hospital— 
the only survivor of H.M.S. “Vanguard,” who had never mentioned 
that he had been subject to fugues about the date of the catastrophe. 

These figures I submit support the contention that out-patient treat¬ 
ment for pensioners is probably better in most cases than keeping them 
in expensive hospitals, both from the point of view of the health of the 
patient and the expense to the State. 

As regards civilians, the increasing numbers presenting themselves 
for treatment is perhaps the best evidence I can produce, that an 
out-patient clinic for nervous disorders will well repay every member of 
our branch of the medical profession who gives his time to trying to 
treat and understand every form of nervous and mental disorder. 

(For the discussion which followed see pp. 525-534, vol. lxvii, 
October, 1921.) 


Psychology and Psycho-therapy.i 1 ) By William Brown, M.A., 
M.D.Oxon., D.Sc., M.R.C.P.Lond., Wilde Reader in Mental 
Philosophy in the University of Oxford. 

When your President did me the honour of asking me to read a 
paper before this Association, it occurred to me that a subject not 
lacking in topical interest at the present day might be such an one as 
the relation between suggestion and psycho-analysis. But, on second 
thoughts, I felt that this would be giving undue emphasis to a tendency 
(') A paper read at the Annual Meeting held in London, July 15th, 1921. 


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24 PSYCHOLOGY AND PSYCHO-THERAPY, [Jan., 

at the present day that does not need encouragement, and perhaps one 
may say should not be encouraged. There is just now a strong 
tendency towards a turning away from earlier modes of thought with 
regard to the science of psychology, almost a looking down upon its 
past history and attempting to form a new science ready-made upon the 
basis of certain modern theories and observations. And you have a 
group of people who talk proudly of “ the new psychology,” although, 
when you go into their antecedents, you find that the majority are 
themselves new to psychology. And you find that, in their intellectual 
ambition, although they may start out from facts of pathological 
psychology, they are ever more anxious to extend their generalisations, 
mainly based upon those facts, to wider and wider problems of human 
nature, of sociology, and of civilisation. So that at the present day 
there is a danger of a new philosophy,—I might call it following the 
William James nomenclature a chromo-philosophy—being built up on 
the basis of certain observations, and worked out in undue dissociation 
from earlier modes of thought. As to many others, it seems to me that 
at the present day we need to recognise that we must work according to 
certain criteria that we can trust, according to certain methods that we 
can verify. Verification has always been the rule in scientific work. 
From the time of Plato onwards it has been realised that all science 
proceeds by the method of generalisation, by the method of producing 
hypotheses; but these do not become scientific theories until they have 
been verified and confirmed in various directions and according to 
various criteria. In the physical sciences this verification is not only 
allowed for, but it is ensured by the nature of the work that is done. 
In physics, for example, you have measurement there, at your elbow, to 
keep you straight. Although the principles of measurement themselves 
involve certain assumptions, certain postulates, still, having accepted 
those, you have a very sure instrument of testing. Your general theories 
in physics are tested and fixed by the measurements made. And so 
also with other physical sciences which are based upon physics; in 
chemistry, even up to biology and physiology, you have similar safe¬ 
guards. In psychology the attempt has for some years—ever since 
Wundt founded his first laboratory for physiological psychology—been 
made to bring in a similar controlling factor on the quantitive side. 
But the attempt has perhaps rather disappointed us in its outcome at 
the present time, though, no doubt, it has great victories in store for it in 
the future, when a full realisation has been reached as to the difficulty 
of measurement in psychology. Still, apart from this, psychology is in 
the difficult position of being descriptive, of being impressionist, lacking 
that hard exacting previous training which you get in the other sciences. 
But I say this with certain reservations which I hope will remove its 
sting. It is peculiar in being supported, mainly, on two great piers or 


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pillars. On the one side you have mind as embodied mind and its 
relation to the physical organism : and so you find growing up a psycho¬ 
biology which is thoroughly scientific, and which is linked up with the 
general body of physical and physiological knowledge, which has been 
pushed forward, in our country particularly, by such men of brilliant 
ability as Lloyd Morgan, McDougall, C. S. Myers and Rivers. And in 
studying a science like that of psycho-biology you have every security 
for gaining strict modes of thought and carefulness in investigation, and 
also of gaining a scientific conscience in the matter. The other pier is 
that of philosophical psychology, which, it seems to me, is of extra¬ 
ordinary importance, absolutely essential to the science. Psychology 
is different from every other science we know, in that it is the 
science of the mind, i.e., of something which itself is the instrument 
of all knowledge. In the mind we have problems of knowledge 
arising; how the individual mind can know the external world, not 
only adapt itself in a rough-and-ready way, but get deeper knowledge, 
theoretical as well as quasi-practical knowledge of the world. Besides, 
it is through the mind that we can appreciate the beautiful, as distinct 
from the ugly, and the concept of duty and good, as distinct from evil. 
And, whatever may be our distinctions, however our systems may vary 
from one nation to another, or from one generation to another, yet all 
through, in the science of ethics or moral philosophy, from the time of 
Aristotle onwards, it has become more and more apparent that there must 
be assumed an insight into moral values which gradually grows in the 
course of life. So you have a problem which is essential to psychology 
which cannot be ignored by any psychologist, and which certainly 
cannot be ignored in pathological psychology. And that is why I would, 
in passing, put forward a plea for the continued study of philosophy in 
relation to psychology. I may be considered to be reactionary in this 
but I do not think so. It seems to me that it is essential, that it is 
called for by the nature of the science; and also that it is justified by 
results. On this side we have a very solid system of knowledge which 
is much more consistent and much more universally accepted than 
some people who are not particularly interested in philosophy may 
believe. Works like those of James Ward, Stout, and William James 
are in harmony with one another. The differences are very slight as 
compared with the resemblances, and it seems to me that this part of 
psychology, too, is essential for psychopathology : I hope to show you 
why presently. The difficulty in medical psychology is to build a 
bridge between the two piers, or to complete the arch linking up these 
two solid, well-established and difficult modes of thought. And here a 
number of people rush in with facile generalisations, with a ready use of 
metaphor, with a tendency to lack of criticism which is astounding, and 
■a general theory that is unsupported by any single psychologist you can 


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PSYCHOLOGY AND PSYCHO-THERAPY, 


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name in any country. This general theory or mixture of theories is. 
popularly known as “ psycho-analysis.” The name is an unfortunate 
one, since it is used interchangeably for a particular psychological 
method and for the theory or theories based upon the results obtained 
by this method. It were better restricted to the former of these two 
things—the method of “ free ” association invented by Freud. Psycho¬ 
analysts deal with psychological concepts, but if one analyses their con¬ 
cepts one finds there is a tremendous degree of metaphor which is most 
misleading. I have no time now to illustrate that in any detail, though 
it can be illustrated, and I am sure it will be illustrated in the next few 
years. We shall have a united attack upon the general system of psycho¬ 
analysis from the point of view of psychology, because we shall have 
gained enough knowledge of the subject and practice in carrying out 
the method to be fully justified in giving our views. But there are 
problems here which are better attacked by a similar method than by 
any other. These are especially the problems of psycho-pathology. 
You have all no doubt felt a certain degree of disappointment after 
studying experimental psychology, and found how little, apparently,, 
as yet it admits of application to your science. It does admit of 
application. The Binet tests, e.g., and the various forms of the 
three psycho-physical methods which have been applied in numerous 
forms of mental testing are due to experimental psychology and to the 
efforts of earlier experimental psychologists. Methods of measurement 
are all based upon one or other of these three great psycho-physical 
methods of Fechner, and in the future, no doubt, more will be done * r 
at the present time much is being done. Still, up to the present no 
very great increase in our knowledge of psycho-pathology has resulted 
from this mode of approach. Methods have been devised, mainly 
towards the measuring of symptoms and classifying them, and stating 
them as accurately as possible, and only now is an attempt being madfr 
to go deeper and measure the causes of symptoms and get a deeper 
view of them. In the meantime we have this temporary structure of 
psycho-analysis, a term invented by Freud to correspond to a definite- 
method, one method among others, of free association, which had as 
its presupposition a belief in subconscious tendencies of the mind 
which were held down by certain repressive forces; and that if the 
critical faculty were kept in abeyance, these subconscious tendencies 
would move gradually up to the surface of the mind and appear in 
consciousness again. It is merely a method of evading resistance, and 
keeping the critical faculty out of action. Besides connoting the- 
method of free association, psycho-analysis also connotes a theory, and 
the term is used interchangeably by psycho-analysts in these two senses. 
Psycho-analysis is a theory of Freud and of his disciples, and his 
disciples have added little to what he has said, and have made- 


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practically no alteration in his views. It is a theory which regards all 
psycho-neuroses, all forms of psychical disturbance in nervous disease 
where there is no obvious or demonstrable organic injury as expres¬ 
sible in terms of repressed sexuality, although that word is used in a 
wider sense than usual and to cover many forms and modes of mental 
activity in childhood, which no one who was not a Freudian would 
dream of bringing under that heading. It is a theory which assumes 
many mechanisms, though mechanism is a bad term to use in 
psychology. There is a general mechanism of repression; there are the 
factors of displacement, transference, distortion, sublimation, etc. Words 
like these correspond to forms of mental process, which are all called in 
as supports of the theory. The method is that of free association ; and 
in attacking the findings of the method we must consider the implica¬ 
tions of the method itself. But, besides that, we should ourselves use 
the method. Jung was right when, before the war, he taunted his 
opponents with the criticism which Galileo brought against his 
opponents, that they would not use his telescope. But many people 
have now used this telescope and have shown a clear understanding of 
its nature, using it in a thoroughly unexceptionable way, but have yet 
failed to obtain results in entire harmony with Freud’s theories, or with 
Jung’s theories. Great as is the value of these theories for psycho¬ 
pathology, blindly uncritical adherence to them on the part of 
inexperienced disciples is wholly detrimental to the science. 

At the beginning of my address I mentioned the problem of the 
relation of suggestion to psycho-analysis, and, if I may, I should like to 
make a few remarks upon this, because it should go to the heart of the 
difficulty of psycho-analysis, and the difference in views between extreme 
psycho-analysts and others. According to the theories of psycho¬ 
analysis, the symptoms of psycho-neuroses are due quite generally to 
mental conflict and repression, the symptoms being “compromise- 
formations,” satisfying, as well as may be, both the repressed tendencies 
and also the main personality which has endeavoured to disown them. 
And a cure, in general terms, is by the method of free association and 
by other methods devised to evade the resistance between the repressing 
and the repressed material, between the ordinary conscious mind and 
the repressed mind, to allow the repressed material to come up again, 
and then to encourage the process of “sublimation,” whereby these 
tendencies are diverted along other paths and towards other objects. 
That is one line of thought at the present day. It is complicated in 
extraordinarily intricate ways in the specifically Freudian form of theory- 
and is further modified in others, but that is the general line of move¬ 
ment. And there is another line of thought which has been in existence- 
for many years, a line which is summed up in the ideas of auto¬ 
suggestion and hetero-suggestion. According to this—to go back as. 


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far as F. W. H. Myers—there is the conception of the sub-conscious 
mind as that part of the mind below the threshold, which possesses 
faculties or powers in an intimacy of relation to the physical organism 
which is denied to the conscious mind. So you have F. W. H. Myers 
giving as his definition of suggestion “a successful appeal to the 
subliminal.” If you turn to that excellent modern book of Baudouin’s, 
Suggestion and Auto-suggestion t you find suggestion defined as “the 
subconscious realisation of an idea.” This definition contains two 
parts. There is, firstly, the aspect of acceptation—an idea which is 
brought from the outside is accepted by the subconscious. (Not by 
the conscious mind, because if it is accepted and acted upon by the 
conscious mind you have another kind of mental process which is not 
suggestion in the narrower technical sense.) But, secondly, the idea 
which is accepted by the subconscious or unconscious mind is realised 
by it, often in secret, often with a latent period between the moment 
at which it is accepted and the moment at which it makes itself 
apparent in clear consciousness. You have here a technical definition of 
suggestion which can be employed to explain the causation of mental 
illness, or at least certain aspects of illness in psycho-neurosis, and 
also to explain their cure. You might say that illness sets in as a result 
of bad auto-suggestion, coming from the conscious mind acting on the 
subconscious mind, and producing, after a period of incubation, a result 
in clear consciousness. And in treating these patients you would 
endeavour, by good hetero-suggestions, to neutralise previous bad auto¬ 
suggestions and rectify mistakes. 

How can these two lines of thought be harmonised with one 
another? The former, viz., analysis, is obviously a correct line of 
thought, however anxious we may be to avoid the extravagances of its 
development in certain minds. It corresponds with real factors at 
work, as we see when we begin to analyse. Must we say, with the 
psycho-analyst, that it is a complete explanation of cause and cure? 
I think the evidence is against this. But let me consider it in an 
a priori way. We might, cl priori , say that as a result of mental 
conflict in early years one might expect to get a weakening of the mind, 
a weakening of mental synthesis, with the resultant tendency to be more 
readily overwhelmed by emotion, more readily carried away by certain 
ideas, especially if they are supported by certain feelings; and that in 
this way our subconscious is more ready to accept fortuitous, bad auto¬ 
suggestions coming down from consciousness. So you can have both 
general factors at work in {etiology—mental conflict and repression, and 
also bad auto-suggestion. And so, as regards cure, you can by analysis 
resolve these mental conflicts; you can, at any rate, help the patient to 
see the relationship between the systems or streams of ideas which have 
been in conflict, and help him to make up his mind as to what line he 


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should take to overcome the physiological and psycho-physiological 
effects of repression, and so improve his condition. But, also, there is 
an habitual mode of response which you have to destroy and which is 
resistant to analytic treatment and needs suggestion. That suggestion 
may come in two ways ; it may come in an informal way in the course 
of the psycho-analysis itself. This is the unconscious suggestion which 
springs from the emotional relation of patient to physician which Freud 
calls transference. But suggestion treatment may then be given in a 
more formal way. This is most conveniently done by asking the 
patient to lie on a couch with the muscles relaxed, in the posture in 
which he usually sleeps, either on the back or on the side, and to think 
of sleep in a passive way, not in an active way—to avoid voluntary 
attention and yet to get concentration. The mental state must be one 
of attention, but it must be attention minus effort, because voluntary- 
attention means the mind moving from one thing to another on the 
conscious plane. If you encourage the patient to relax all his muscles 
he cannot attend voluntarily, yet he can get conscious concentration or 
“collection ” in which his conscious mind is in a state of minimal 
activity, where there is an outcrop of the subconscious, and he can 
accept suggestion. It is not necessary for him to sleep; there is no 
question of hypnosis; you are not producing an artificial dissociation,, 
you are merely producing artificially a normal form of dissociation,, 
such as occurs every night when we go to sleep: it is a half-waking 
state. It is because these suggestions do take effect that one theorises, 
about the matter; it is not that the theory came first. The results came 
first, and in looking for a theory we have to assume the subconscious 
and the way in which this subconscious reacts to appeal. And we find by 
experience that it is essential that the will, at least in its less developed 
spasmodic and impulsive form, should be in abeyance. The patient 
must not have in mind the idea, “ I have a certain time, which I am 
paying for, I must go to sleep.” If he feels that, he will not go to 
sleep. And if he is too determined and spasmodic you will get no 
results, or there will be an opposite result; he will get worse, not 
better. M. Coue, of the new Nancy School, has been the first to 
enunciate this in the form of a law, the Law of Reversed Effort, and it 
had been insisted by British investigators that you must avoid voluntary 
activity, that suggestion is something which is passively accepted. It is 
that attitude of acceptance and feeling of belief, free from effort and 
from over-anxiety, which is essential. Any element of fear neutralises 
the result. Coue sums up this law of reversed effort in the words: 
“When will and imagination are in conflict, imagination always Vins.” 
By imagination he means what is ordinarily known as suggestion. 
Cou£ says that in this conflict between will and imagination the 
imagination varies roughly as the square of the will; so that if you. 


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PSYCHOLOGY AND PSYCHO-THERAPY, 


[Jan., 

increase the effort of the will two-fold, you have increased the opposing 
power of imagination four-fold. If you suggest, in the hypnotic state, 
that a man cannot open his eyes, he may not try. If you say, “Try as 
hard as you like, you will be unable to open your eyes,” the more he 
tries the more tightly closed the eyelids become. That is a process 
which well illustrates this law of reversed effort. Another illustration is 
the effort to remember a name. If you are over-anxious to remember 
it, you find the name has disappeared. But if you say, “ It will come in 
a moment,” and you relax the intensity with which you try to remember 
it, it does come to you. Another is when you carry out a skilled 
action, such as swimming, or riding a bicycle. When you can just ride a 
bicycle you say, “ I will not go over that stone,” and the more determined 
you are to avoid the stone, the more surely will you steer your bicycle 
-towards it. That point needs emphasis, because ignorance of it, or at 
all events the ignoring of it, accounts for much failure in suggestion treat¬ 
ment. Those of us who have spent much time on suggestion treatment 
and look back on our partial failures can see that much of our failure 
was due to our not being on the look-out for this law of reversed effort. 
How is it explained psychologically ? In this way. When you will to 
do a thing in an over-anxious, spasmodic way, your mind becomes 
• acutely conscious of what you are aiming at, with the result that the 
idea of possible failure is aroused, and that brings with it the emotion 
of fear. The emotion of fear may be subconscious, or it may be 
■ clearly conscious. So that there is a suggestion-effect in an opposite 
direction; this is reinforced by the emotion of fear, and there is an 
unsatisfactory result. As long as one takes into account the law of 
reversed effort and does not do violence to it, one gets extraordinary 
results by suggestion treatment following upon psychological analysis, if 
-one uses the cumulative method. I take a patient an hour at a time, 
and I give suggestions every five or ten minutes during that hour. 
They are general suggestions as well as particular ones; I do not make 
him over-suggestible in the ordinary sense, I simply make use of the 
ordinary suggestibility which becomes prominent as he falls to 
sleep, owing to the greater accessibility of his subconscious. After the 
first five or ten minutes I leave him to himself, with the instruction that 
he should go on thinking of sleep, though whether he actually sleeps or 
not does not matter. At intervals of five to ten minutes throughout the 
hour I return and give the requisite suggestions as to the disappearance 
of his symptoms, and of their underlying causes, where known or sus¬ 
pected. I also suggest general improvement in health, and state that he 
will be able to use auto-suggestion, and so complete the cureby himself. 

This is one way of applying suggestion, and I think it is psycho¬ 
logically sound, and involves no drawbacks. As long as you avoid 
^hypnosis, and as long as you explain to the patient how it differs from 


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31 


hypnosis, it is successful; though the Nancy school talk about hypnosis and 
suggestibility being interchangeable, they differ from one another. Shell¬ 
shock patients seen immediately after the shock were easily hypnotised> 
but were not always very suggestible in the hypnotic state; hypnotis- 
ability was, however, found to be completely correlated with dissociated- 
ness; the .more dissociated a person was, the more hypnotisable he was. 

And now with regard to the other way of applying suggestion to 
analysis. This is partly unconscious, where the patient is analysed 
hour after hour, and is given to understand that the analysis will be a 
protracted one, and will involve re-arousal of early memories and 
fantasies of childhood, after which recovery will occur. The result 
may be that the patient is resistant until deeper and deeper analysis 
occurs, when the symptoms may clear up. But when they do clear up 
you cannot say suggestion has been absent. Although in test cases you 
can prove that the overcoming of repression, the liberating of “ bottled- 
up” emotion, etc., do get rid of the symptoms, apart from suggestion, 
yet in psycho-analysis there must be much suggestion all the time. 
There is suggestion in the form of what Freud calls “transference,” or 
41 emotional rapport ” between the patient and the doctor. According 
to French the patient feels towards the doctor a second edition of 
the feelings which he felt towards his father, mother, or other near 
relative in earlier life. Freud admits that this emotional rapport is 
essential in cure; because without it, after the temporary readjust¬ 
ment and overcoming of the mental conflicts, the repressed material 
would fall back into the unconscious once more, and the patient would 
be where he was before. But, according to Freud, this transference 
may be, and should be, resolved by being traced back to the cedipus 
complex. It is, however, doubtful whether this theory of transference 
applies at all. In different analyses there are all degrees of emotional 
rapport , every degree of emotional attachment. Certain emotions are 
excited more and more, and, sooner or later, you are bound to get one 
thing or another occurring : either the patient likes you more and more, 
or he dislikes you. And, as far as one goes, it seems that is sufficient 
to help us. But this emotional rapport , which has always been 
recognised, is of great suggestive power, because it provides the 
emotion which is the great auxiliary in the actualising of suggestion, 
and even if the doctor is preserving silence as much as possible in his 
consulting room, just letting the patient talk, unconscious suggestion is 
going on, and it is the more potent the more unconscious it is. And 
patients who have been analysed by others have said how they felt more 
and more influenced by the course the analysis was taking. Patients 
have said afterwards, “ Although you say nothing, I am always guessing 
what you are thinking, and if you say a word I dwell upon it until the 
next hour arrives, and generally I take a particular word in a particular 


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32 


PSYCHOLOGY AND PSYCHO-THERAPY. 


[Jan., 

sense.” That is suggestion in the course of treating by psycho-analysis. 
You can, without formal suggestion, produce much effect on the sub¬ 
conscious mind, and alter the patient’s general outlook. 

That brings me to speak of another factor, which I have called 
autognosis. It is not simply a new word to express an older theory of 
psycho-analysis; I suggest it simply because I have found it impossible 
to use the word “ psycho-analysis ” in my own sense, because psycho¬ 
analysis means a certain method and a theory also. Autognosis means 
neither of them, although it makes use of both where circumstances 
indicate their appropriateness. It involves analysis, and analytic work 
makes clearer its value and importance as a psycho-therapeutic factor, 
because you find that it is an analysis directed to the patient’s past life, 
which enables him to get an insight into his present condition. On the 
other hand, if you say, “ The past is done with ; it is the present we have 
to consider, your aims and your ambitions for the future,” he does not 
get a thorough understanding of his mind, and it is only as you show 
him what has been that you can get him to understand. If he can see his 
past and his present in relation to the possibilities for the future, in 
relation to his hopes and his fears, he acquires more control of his 
mind and of his intellectual nature, and that is a definite fact in 
therapy, and worthy of having a definite name. That reminds me of 
what I said earlier as to the importance of philosophy in psychology. 
You must have a philosophic outlook if you are going to deal with the 
minds of men. You must have formed a certain system: you need not be a 
professed philosopher, but you must have tried to see life steadily and see 
it whole ; you must realise that any extreme philosophy is bad, and that 
your system of bad philosophy is bound to react upon the patient. 
The patient’s need when he comes to you is the need of a general 
outlook on life; it is what he comes to you for. He tries to guess what 
is your own outlook, and it seems to me you should be ready to meet 
his difficulties as they arise, to discuss things with him. You need not 
try to oonvert him to your belief—indeed, you should not do so; but 
you cannot ignore his religious and philosophic needs; the meta¬ 
physical need is there. It is always there, and even in the most 
extreme materialist amongst us it is present. If there is a creed more 
general than any other, it is—“ I believe in a metaphysic.” That was 
Schopenhauer’s creed. We must have a general philosophy, and we 
shall find we can help our patients philosophically without giving 
philosophic disquisitions. If we can help a patient to see how certain 
steps are best solved, by enabling him to take the widest possible 
outlook on life, and the widest conception of his duties, we shall help 
him immensely. 

(The discussion which followed will be found on pp. 553-6, vol. lxvii, 
October, 1921.) 


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192 2.] FANTASIES OF CHILDHOOD AND ADOLESCENCE, 33 


Fantasies of Childhood and Adolescence as a Source of Delusions .( 1 ) 
By E. Mapother, M.D.Lond., F.R.C.S., M.R.C.P., Deputy 
Medical Superintendent, Long-Grove Mental Hospital, Epsom; 
and J. E. Martin, M.B.Lond., B.S., Assistant Medical Officer, 
Hanwell Mental Hospital. 

The subject of the relation of recurring dreams of adult life to that 
almost inseparable mixture of real experience and fantasy which forms 
the mental life of the child was dealt with by Rudyard Kipling in The 
Brushwood Boy , and by George du Maurier in Peter Ibbetson , after a 
fashion not given to psycho-pathologists. The psycho-analytic school 
has of late years endeavoured to trace the genesis of the psycho- 
neuroses to aspects of the same period generally considered less 
attractive. There has, I think, been less effort to establish such a 
connection in the major psychoses. 

We wish to-day to bring to your notice a case of some interest,in 
which the content of a psychosis was pretty obviously in the main a 
morbid reaction to an earlier fantasy, and the mechanism was unusually 
clear. 

We should like also to describe more briefly a few other cases seen 
recently, illustrating analogous or different relations of the symptoms to 
a fantasy dating from, or anyhow concerned with, events of childhood. 
If time permits we should like to make a few general remarks on the 
question of whether there is any causal relation between fantasy and 
psychosis, and, if so, what it is ; secondly, on the question of whether 
there is need for any special technique in eliciting such memories of 
either real events or fantasies as are truly relevant to the psychoses; 
and lastly, whether there is any evidence that such elucidation is bene¬ 
ficial to the patient as well as profitable to the investigator. 

The first case which we wish to record was admitted to Long-Grove 
Mental Hospital on July iotb, 1920, and until the following November 
was under the care of Dr. J. E. Martin. From November until the 
date of her death, January 23rd, 1921, she was under Dr. Mapother’s 
observation. 

The patient, who will be referred to, when necessity arises later, as 
Mary, was a domestic servant, set. 21. The history was that until 
May 27 th she had been perfectly well, both physically and mentally, 
had then been taken suddenly ill with acute abdominal pain, and two 
days later admitted to the Middlesex Hospital as a case of possible 
appendicitis, but not operated on. 

On admission blood and casts were found in the urine, and she was 
transferred to the medical wards as a case of acute nephritis. The 

(*) A paper read by Dr. Mapother at the Annual Meeting, July 13th, 1921. 

LXVIII. 3 


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34 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 

condition of the urine cleared up in a couple.of days, but the abdomen 
remained much distended. The Widal reaction was negative; no 
definite localised pain or swelling was present, but fever, occasional 
vomiting and persistent general distension continued for four weeks. 
The diagnosis finally reached seems to have been diffuse plastic 
peritonitis, probably due to leaking gastric ulcer or to disease of the 
appendix or Fallopian tubes. 

About a fortnight after she was admitted to the Middlesex Hospital 
mental symptoms began to develop, for which she was seen by our 
President, Dr. C. Hubert Bond, and eventually, on his advice trans¬ 
ferred to Marylebone Infirmary and thence to Long-Grove. 

Our only information as to the form of the initial mental symptoms 
was that provided later by her elder sister, to whom we shall refer here¬ 
after as Jane. These symptoms were interesting and significant, but we 
shall hope for some amplification of her account from Dr. Bond. 

She was a woman, set. 21, rather pretty, but childish in respect of 
appearance, manner, speech, and development of secondary sexual 
characteristics. 

On admission she was in fair general health, and no definite physical 
abnormalities were present apart from the abdominal condition. As to 
this acute symptoms had passed off, but there was a fairly well-defined, 
painless, rounded mass filling the central two-thirds of the abdomen 
and not moving with respiration. It was smooth, firm, but elastic, and 
rather suggested a collection of fluid or a cyst fixed to the posterior 
abdominal wall, but it was resonant all over. 

Bimanual examination under an anaesthetic by Dr. Martin revealed 
firstly that the patient was not a virgin ; secondly, that the mass had no 
extension to or connection with the pelvis; thirdly, that the uterus 
could be felt separately, a little enlarged and regular, and that the 
uterine appendages seemed normal. 

Three diagnoses were mainly considered by those who saw her: 
(1) Tuberculous peritonitis; (2) some form of subacute septic peri¬ 
tonitis, as suggested at the Middlesex Hospital, secondary to leaking 
gastric ulcer, or less probably to disease of the appendix or tubes; 
(3) pancreatic cyst. The balance of evidence seemed in favour of 
tuberculous peritonitis, and the post-mortem proved this to be the 
correct diagnosis. 

In the course of the case the progress of the mental and bodily 
symptoms was closely parallel. In respect of both the first phase at 
Long-Grove lasted until about the beginning of November, 1921. 
Before passing to the mental symptoms we may state briefly that 
during this period she appeared to be going steadily downhill physi¬ 
cally. Though the abdominal tumour remained practically unchanged, 
and though there was no fever and no signs of disease could be detected 


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1922.] BY E. MAPOTHER, M.D., AND J. E. MARTIN, M.B. 35 


-elsewhere, she steadily lost weight, largely, as it seemed, on account of 
persistent vomiting. The vomit was coloured brilliant green with bile. 

Turning now to the mental symptoms, the striking features during 
this first phase were the patient's loss of contact with reality, and the 
apparent lack of meaning and connection in such signs of mental activity 
as she showed. An early note puts the matter concisely by saying that her 
condition daily becomes more suggestive of dementia praecox. In her 
customary state she was mute and inert, gazing vacantly into space and 
dribbling saliva. Her attention could only momentarily be attracted to 
cither a question or an order. She admitted hearing voices and seeing 
a face which stared at her and vanished. She displayed no interest in 
her surroundings beyond occasionally looking round in a perplexed 
fashion. She was wet and dirty, micturated during examination, and 
when this was pointed out merely remarked “ Elephants.” 

This prevailing state of stupor was interrupted at short intervals by 
manifestations of three other kinds. Firstly, the performance of 
isolated impulsive acts and the making of disjointed remarks. She is 
described as adopting fixed attitudes and making studied movements 
and gestures. Her few spontaneous questions were apparently 
meaningless. She asked : “ Is my head full of shells ? ” and again, 
41 Why wasn't I spanked at school ? ” Secondly, there were outbursts of 
weeping, for which the reason could not be elicited, coupled at times 
with evident apprehension. Thirdly, there were phases of joyous and 
defiant excitement, in which she snatched crockery from the nurses 
and hurled it at them, poured forth a stream of obscene chatter or sang 
smutty limericks at the top of her voice. 

This mental state—presenting as a whole an unmistakable resem¬ 
blance to dementia praecox—persisted with little change until the 
beginning of November, 1920, when she began to improve, both 
mentally and physically. 

Before going further, however, it will be well to state the facts that 
had so far been elicited in regard to history from the patient's elder 
lister, Jane. 

Jane stated that her sister Mary had been in perfect bodily health 
within a few days of admission to the Middlesex Hospital and normal 
mentally for a fortnight after that. She had for about two years been 
4 ‘ keeping company ” with a certain young man, A. D—, and from 
certain remarks Jane had adduced, rightly or wrongly, that intt rcourse 
was occurring. About a week before the onset of the illness Mary had 
appeared depressed, and on questioning had replied that she supposed 
that now she would never get married. At the time Jane had supposed 
she was referring to the fact that the young man had recently fallen 
out of work, and had thought there was some question of breaking it off 
on this account. The sudden onset of abdominal symptoms made the 


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36 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 

sister suspect that Mary had found herself pregnant and had taken 
something to terminate it. She taxed the young man, but he absolutely 
denied intercourse to her, as he did later to Dr. Martin. 

The early mental symptoms, as reported by Jane, were very highly 
suggestive of symbolically disguised self-reproach. Mary talked of the 
awful smell emanating from her body, warned her sister against 
allowing Jane’s baby to sit on the patient’s bed, as she would taint or 
infect it; and on seeing two policemen bring an accident case into the 
ward screamed out not to let them take her away as she had done 
nothing wrong. 


By Dr. Mapother. 

Now returning to the facts as observed at Long-Grove, about the 
beginning of November, 1920, the patient began to take a definite turn 
for the better. Though the abdominal mass remained unchanged till 
her death, vomiting ceased and she began to steadily put on weight. 
By the beginning of January she was sitting up in the open air all day. 
Simultaneously a gradual mental improvement was occurring. The 
earlier condition of detachment from reality vanished. She became 
alert and cheerful, tractable and grateful for any little attention, 
interested in her personal appearance, and quite accessible to questions 
about passing events and communicative in reply. She ceased making 
disjointed remarks and performing unintelligible actions, but still 
occasionally milder examples of the other three-fold abnormality of 
reaction would occur spontaneously. She would have a little outburst 
of crying for no apparent reason, which could be stopped by distracting 
her like a child, or she would sing comic songs rather boisterously for an 
hour or more. Rarely she would pass into a dream state. 

But the noteworthy fact was that with unfailing certainty one of the 
three same modes of reaction could be evolved by any question as to 
events leading up to her admission to the Middlesex Hospital. To 
avoid suggestion no leading questions were ever asked, but any refer¬ 
ence to that period promptly provoked one of three phases analogous 
to those occurring spontaneously—either a flood of silent tears, or a 
state in which she became entirely abstracted, glassy-eyed, and 
temporarily like a case of katatonic stupor, or an outburst of incoherent 
disjointed babble mainly about her days as a munition girl and full of 
references to a girl-friend of the period. This babble was delivered in a 
curious unmodulated monotone with a sort of syllabic utterance and 
total absence of expression. It was obviously what is called “Vorbei- 
reden.” It could not be stemmed, and would go on as long as any 
attempt was made to investigate the past. 

It required, therefore, no flight of fancy or gift of prophecy to guess 


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that underlying these manifestations, making as a whole a picture so 
typical of dementia prsecox, was some cause of remorse, and that the 
phases represented respectively the direct reaction by grief, the attempt 
to forget by withdrawal from reality, i.e., morbid introversion, the 
attempt to forget by hyperactivity, coupled with obscenity and defiance 
as the converse of the real shame present, and lastly, that of the earlier 
disjointed actions and remarks, some at least would prove to be 
symbolic expressions of the same feelings coupled to associated ideas— 
in fact, thinking in metaphor without recognising it as such. 

This proved to be the case. She was immensely pleased with herself 
and with me because I gave her permission to go and look on at the 
Fancy Dress Ball on January 14th, 1921. 

On the following morning I was examining her abdomen, and I said, 
“ Now I want you to tell me about the time you went to the Middlesex 
Hospital.” Instead of one of the usual reactions she said suddenly, 
“ I want to confide in you.” She then went on to make a lengthy 
statement. It was couched in a vernacular so unrefined as to be quite 
unsuitable for reproduction to this audience, and interrupted by out¬ 
bursts of weeping and exclamations that she was bitterly ashamed of 
herself and wished she were dead. But it was otherwise continued, 
spontaneous and unprompted by questions. She stated that between 
the ages of n and 14 she had had habitual sexual intercourse with one 
of her own brothers; that she was then discovered in the act by her 
mother, who beat her, and afterwards sent her to an industrial home. 
She declared that there she found, as she put it, “ that she could not 
do without it,” and masturbated regularly, taught to do so by the 
“ bad girls ” there. She said that during the period of incest she had 
been terrified of pregnancy. 

She stated that she had never menstruated. This apparently did not 
worry her at all until 1916 her brother was killed. She was then just 
eighteen, and in domestic service. She had remained greatly attached 
to him. Her grief was intense, and memories of her former relations 
with him revived. She had a period in which she felt muddled, began 
again to fear she might be pregnant, got very worried about her 
amenorrhcea, and went to her mistress. Her mistress gave her gin, 
which is, of course, a popular panacea for all disorders of menstruation. 
I could not ascertain what effect it had, but apparently she ceased to 
worry. She told me that soon after she left this situation, and a little 
later became a munition worker, and fell in with more “ bad girls.” 
She would not particularise about this period, but from it dated her 
knowledge of the pornography she used to sing. 

After the war she returned to domestic service. She denied with 
fervour sexual connection later than the period of incest. For the past 
two years she had been “ keeping company ” with A. D—. Questioned 


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38 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 

about relations with him, she murmured about an incident in the park, 
but absolutely denied intercourse. 

Lately she said she had fallen in love with A. D—’s brother. He, 
however, seems to have had higher social aspirations and rebuffed her. 
She said it was on the grounds that she was a mere domestic servant, 
but she felt herself that she was disqualified for marriage with anyone, 
and especially with him. The shame and grief of this period had 
again rendered very prominent memories of former incest. At this 
time she noted that her abdomen was beginning to swell. Ideas of 
pregnancy recurred, and she started to worry about her amenorrhcea. 
Prompted by memories of the gin given her on a former occasion, she 
took large quantities of methylated spirits and also of some other 
medicine in the hope of ending either the imaginary pregnancy or her 
life, not much caring which. This accounted for the sudden onset of 
the abdominal pain, and probably for the transitory haematuria present 
on admission to the Middlesex Hospital. 

Four days later I had a second long interview with her. At this she 
fully confirmed the story noted above. Suddenly she branched off in 
the monotone described before into what was an obvious fantasy. She 
said that her supposed mother was not so at all, that she did not know 
who her real parent was, that she was a foundling, and that her supposed 
mother—a cruel foster-parent—hated her, and had sent her when a 
baby to a brothel. It was there she said that she acquired that 
knowledge of wickedness that had ruined her life. At the end of this 
statement she said in the same tone, “ I think that is all for to-day,” and 
could not be induced to say another word. 

During the interval between these two interviews and after the second 
the patient seemed much as before—cheerful, alert and interested in 
the occupations and amusements of the ward. 

Suddenly on the evening of January 22nd she had the wildest 
outburst of excitement that had ever occurred, shouting loudly, and 
singing her obscene limericks, defying and threatening the staff. She 
had to be moved to a single room, and there became quiet, but when 
roused next morning appeared ill. A little later she became collapsed, 
and she died in half an hour. 

The post-mortem examination showed all the intestines were densely 
matted together, and that the parietal peritoneum of the anterior 
abdominal wall was so closely adherent to them that it was very difficult 
to dissect off. Scattered over both parietal and visceral peritoneum 
were innumerable grey tubercles, but no caseous masses were present. 
The substance of both ovaries, however, was largely replaced by caseous 
material, the replacement being almost complete in the case of the left. 

The rest of the organs were healthy with the exception of the lungs, 
which showed a few scattered grey tubercles throughout and a little 


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disease of older standing at each apex. It was insufficient to have 
produced any obvious physical signs. There was no adequate explana¬ 
tion of the suddenness of death after improvement, which could only 
be ascribed to exhaustion from the attack of excitement. 

So far the case had appeared to me one of a typical Freudian type, 
and I had accepted the central factor of incest as a real happening, in 
spite of the warning conveyed in the obviously fantastic nature of the 
story regarding the brothel and the foster-parent. 

The supplementary history from the elder sister Jane, however, 
placed the matter in a fresh light, and enforced the moral of the need 
for that corroboration of the neurotic’s statements from outside sources 
which is so conspicuously absent in many accounts of cases. This 
history, though leaving the psychosis as a reaction to the idea of incest, 
reduced that idea to an ordinary fantasy of adolescence of the kind 
commonly associated with masturbation. The brother was probably 
selected as partner therein for the simple but sufficient reason that he 
was about the only man with whom the child was familiar when the 
sexual craving underwent its usual increase at puberty. 

For the proof of this view and for the understanding of the case 
from other aspects, it is necessary to recount the family history at some 
little length. The parents were married in 1888, the mother being 
then 17. There were altogether thirteen children, Jane, the eldest, 
being ten years older than the patient, while the brother Alfred, who 
figures in the story, was nearly eight years older. 

The mother for a short time after marriage was a decent hard-working 
woman, but she became negligent, slovenly, and a chronic drinker; in 
consequence, all the younger children were practically brought up by 
Jane. The mother had her first definite mental breakdown when Mary 
was born. This and another were treated in the infirmary, but in 
September, 1902, when Mary was set. 4, the mother was sent to Horton 
Mental Hospital. She was discharged in June, 1902. Ten months 
later the last child now living was born, and during the following years 
a series of others, which died as infants. After leaving Horton the 
mother was better for a time, then became again neglectful and drunken. 

Jane, who had brought up and protected the younger children, had 
married in 1908, and had her first child just at the same time as the 
mother had her last. With Jane gone, the treatment of the younger 
children became so scandalous. that the mother was prosecuted at the 
instance of the National Society for the Prevention of Cruelty to 
Children, and got six months in Holloway. 

This imprisonment of the mother led to the break-up of the family 
home, and it was this that caused the admission of Mary and her little 
sister to the Industrial Home. Obviously discovery of incest had 
nothing to do with it. Mary was only set. 12, not set. 14 as she stated; 


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40 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 

the brother was devoted to Mary and she to him, but he was nearly 20 
at the time and engaged to be married. He joined the Army, and 
hardly saw Mary afterwards, thereby no doubt consolidating his 
position as her ideal. Jane, who practically mothered the younger 
children, and who discussed the whole matter calmly and sensibly with 
me, had never heard a word of the incest story before, and was certain 
she would have known if there had been any truth in it. 

Returning from Holloway the mother lived apart from her husband, 
until in July, 1913, she was admitted to Colney Hatch, and there she 
remained five years. Her condition on admission was a superimposed 
alcoholic, delusional and hallucinatory one. With the passing off of 
this there was revealed a more permanent state of chronic melancholia. 
She is described as depressed and sullen, irritable, quarrelsome, and 
obscene. This was essentially the state also noted at Horton, and was 
that which in the years between had made their home a hell to the 
younger children, and which adequately accounted for the fantasy of the 
cruel foster-mother. It is an interesting coincidence that an early note 
at Colney Hatch on the mother’s case says, “She states that she has 
seen nothing for four months, and is evasive, and becomes confused 
when questioned about her chance of pregnancy.” I may say that 
after five years the mother appears to have made rapid improvement, 
and was discharged recovered in May, 1918. She has since kept very 
well, and is now employed as a housekeeper.( 2 ) 

The only other point about the case that needs recording is that the 
sister confirmed, as far as could be expected, the fact of Mary’s first 
breakdown on receipt of the news of her brother’s death. This death 
occurred in February, 1916. Mary suspected it from the fact that her 
letters to him were unanswered, but the confirmation of her suspicions 
came quite suddenly. She was prostrated for a time, and then confused 
and depressed. 

The case illustrates a number of points of considerable interest. The 
first of these is the wealth of meaning which, without any far-fetched 
interpretations or assumptions, lay behind the apparently disconnected 
symptoms of a case of early dementia prcecox. It is the rule, not the 
exception, that the meaning of such behaviour can be elicited during 
the lucid intervals which are customary in early dementia prsecox. It 
is certain that such behaviour, though unrelated to the environment, is 
neither meaningless, nor the reproduction of disjointed fragments of 
past experience, but closely related to a highly-organised system of 
ideas which the patient can be got to expound when accessible. The 
actions and words may appear as disconnected as those of a somnam¬ 
bulist, but behind them lies something much more coherent and closely 
woven than a dream. It is only later that these actions and words 


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become habitual and meaningless, even to the patient. To employ a 
much-abused word there is a “complex,” but not an unconscious one. 

Another point of interest is the co-operation of numerous factors, 
both physical and mental, in the production of the psychosis. It is, of 
course, the rule in practically all properly investigated cases of insanity 
to find that it is the result of the summation of multiple causes, 
effective in combination, though inadequate singly. It is this that 
renders all controversy between extremists of the physiogenic and 
psychogenic schools so futile. Our standpoint is, that one must dis¬ 
tinguish between the form or content of the psychosis and its occurrence. 
The mode of thought constituting a psychosis is a parody of the 
normal. The occurrence of the psychosis, the fact of more or less 
sudden adoption of distorted modes of representation, is not in the least 
explained by the demonstration of what is being caricatured or what 
methods of distortion are adopted. This is so obviously a truism that 
it would be necessary to apologise for it if it were not habitually ignored. 
The material which is elaborated in the psychosis is necessarily previous 
mental experiences, but we think the occurrence of a psychosis is in the 
great majority of cases due to intervention of something quite other than 
a mental experience. In fact, even in so-called functional psychoses, 
the relation of mental symptoms and physical basis is probably as a 
rule that seen in febrile delirium or general paralysis. 

Occasionally the physiological apparatus of emotion may, by recent 
mental impressions of excessive intensity or duration, be given a set or 
direction which amounts to the occurrence of a psychosis. 

But remote events cannot be regarded as specific causes, or as con¬ 
tributing more to the occurrence of a psychosis than a general modifica¬ 
tion of the emotional apparatus. 

In practice it is extremely difficult to distinguish the mode of action 
of a single factor, whether it acts physically or mentally, and probably 
the truth is generally both, e.g., in the case in question the insane 
mother may have contributed to the instability of the daughter by 
endowing her with an unstable nervous system, or by determining for 
the child’s emotional apparatus a certain development, due to misery. 

The disease of the ovaries probably determined that amenorrhoea 
which twice was one of the main factors suggesting pregnancy. It very 
probably also contributed by retarding full sexual development and the 
mental evolution which normally accompanies it. It may thus have 
protracted that tendency to fantasy and that difficulty in the distinction 
of it from reality which is equally characteristic of the child and the 
neurotic—which, in fact, constitutes the lasting disposition of the 
neurotic to fixation and regression. 

The tubercular peritonitis, in view of the parallelism between its 
progress and the mental state, probably contributed in a purely physical 


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42 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 


way to the onset of the disease, as well as by suggesting pregnancy 
through causing abdominal swelling and discomfort. 

Some recent mental impressions certainly played a part in the 
precipitation of the psychosis as well as the determination of its form, 
notably the revival of her feeling for A. D—’s brother, and possibly 
recent incompatible relations with A. D— himself. 

But whatever the influence of these recent mental events, we decline 
to ascribe any serious causal importance to the incestuous fantasies of 
years before. Though they were the central point of the content, their 
significance was in our view entirely a consequence, not a cause of the 
psychosis. In fact if the title of this paper draws attention to the 
occasional prominence of such fantasies, it is in order to emphasise that 
the significance of these and equally of remote real events in the 
psychoses is as a rule entirely secondary. 

Confining one’s attention to the special group of the sexual activities 
and fantasies of adolescence one may, we think, say that masturbation 
at puberty is absolutely natural and instinctive. One must then forestall 
criticism at once by saying that this remark implies no approval. Every 
moral code, right or wrong, consists in the prohibition of natural 
instinctive acts. What is meant is that the tendency thereto is simply 
analogous to the play of a kitten chasing moving objects as a pre¬ 
liminary to hunting for a living. 

Fantasy is a mental substitute for such preparatory activities. The 
vividness of the sexual fantasies of this period is a fact well known to 
criminal lawyers, and of great practical importance in connection with 
charges of intercourse under the age of consent. 

The sexual fantasies of adolescence are as natural as the ambitious 
ones generally coupled with them, for the reason that puberty is the 
natural time for breaking the family tie and commencing independent 
self-support. Civilised man is not yet adapted to the post dating of both 
sexuality and independence. 

The ban on masturbation enforced by the herd instinct is probably a 
few hundred generations old, and man had probably been developing 
the typically human instincts for some thousands of generations before 
this ban was introduced. 

It is not surprising therefore if in most individuals at puberty the 
herd instinct fails of complete dominance at times. If occasional actual 
masturbation is not universal at puberty it is I think pretty certain that 
sexual fantasies are universal. 

Now with the same protest that we are not expressing approval, it 
seems very natural that the sexual tendencies of puberty should often 
be incestuous. There seems little need to regard this tendency as 
specific, or to dignify it with special names. The adolescent takes as 
the material for fantasy production that which is available ; frequently, 


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as in this case, the only familiar figures of the opposite sex are members 
of the family. 

The taboo on incest also is probably a novelty in the race, having no 
obvious survival value and needing reimposition in each generation, so 
that the dictate of the herd in this matter needs careful reinforcement 
to be effective. I remember listening to Mr. Trotter some years before 
the publication of the first papers which were afterwards embodied in 
his book on the herd instinct, and that when questioned as to the 
efficacy of the herd instinct against natural impulses, he pointed to the 
abolition of incest as the greatest example of what it could achieve. 

I agree with the reservation that the triumph of the herd instinct is 
not seldom incomplete in fact. In fancy this triumph is so often incom¬ 
plete that it is absurd to call incestuous fancies a cause of psychoses. 
Many histories of such facts and fancies can be obtained from neurotics 
and from the insane without special methods or difficulty. I have seen 
several during the past year who poured out such stories spontaneously, 
but I know of no proof that the history would be more common in the 
insane than in the sane. Housed as they are, you cannot expect all 
the children of the poor to have the minds and manners of young ladies 
and gentlemen. We venture to think that if juvenile incest were a 
common cause of psychosis, the mental hospitals would require con¬ 
siderable enlargement, and that if incestuous fancies were effective there 
might be some difficulty in finding the necessary staff. 

Our own feeling about the relationship of remote real events and 
fantasies to the psychoses is therefore this : That to say the fantasy is 
causal is to put the cart before the horse ; that the psychosis consists 
in the establishment of a certain set of the emotional mechanism by 
physical or by recent mental events; that the significance to fantasy is 
secondary and due to harmony with that morbid mood, and that various 
other symptoms are tertiary reactions to the prominence of the fantasy. 

It is of importance, as seen in this case, that fantasy is as effective 
as remote real experience—either active or passive—in provoking the 
reactions constituting the psychosis because this reduces such real but 
remote experience to its proper place. The prototype of this sort of 
thing is the dementia praecox making eternal hand-washing movements 
on account of the practically normal act of youthful masturbation. The 
abnormality lies not in the action but in the reaction. 

Rather less commonly, the earlier actions of the patient are expressions 
of the same tendency that, exaggerated later, constitute the psychosis. 
It may well be that the special vividness of the neurotic’s fantasies is 
an earlier expression of his capacity for hallucinations. 

This question of the primacy of the psychosis or of remote events 
and fantasies is the central problem of the treatment of insanity to-day. 
The time is past for crying that Freud’s findings as to the contents of 


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44 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 


the neuroses and psychoses are horrid or “ made in Germany,” and for 
substituting witticism for criticism. [For my own part, without claiming 
the title of psycho-analyst or using any special methods and avoiding 
suggestion to the best of my ability, I find that in 90 per cent, of cases 
where the patient is accessible the content of the psychosis is a reaction 
to events of sexual life in the narrowest sense of the words, and generally 
to the memory of offences against the code. I only put this forward as 
representing my recent experience, limited mostly to women of the lower 
classes.—E.M.] But even some of us who are not afflicted with excessive 
prudery or patriotism are disposed to dispute the causal importance 
of remote mental events and the necessity and efficacy of eliciting them. 
The whole question of treatment turns thereon. If the relation be such 
as we have suggested, it undoubtedly is still of immense interest to trace 
the connection of every feature of a psychosis with the previous life, 
but that interest is academic. 

The hope of practical benefit depends on attention to the bodily 
state and to the difficulties of the present, and is limited by the extent 
to which these can be adjusted. This is, of course, the view on which 
is based the practice of the majority of psychiatrists. If the views of 
the psycho-analytic school are accepted this is obviously for ever futile 
in the majority of cases. Jung, at any rate in his middle period, would 
seem to have definitely adopted the all-importance of the present, but 
he coupled this with a treatment by revival of remote memories and 
fantasies. This is alleged to be necessary for the purpose of detaching 
libido from fantasy and liberating it for use in external activity. This 
appears to be an elaborate form of begging the question whether that 
which is the essence of dementia praecox can be cured in such fashion. 

The events of the distant past, more or less distorted, often constitute 
the content of that peculiar form of thought we call a dream. They 
did not cause the sleep on that night when the dream occurs, nor will 
the establishment of connection between the content of the dream and 
the past cure the tendency to sleep in the future and to think in the 
fashion called dreaming. Similarly, we think the events recurring in 
dementia praecox do not cause it, and their elucidation will not cure 
the standing loss of touch with reality which is the essence of the 
disease. 

Lastly, we remain unconvinced as to the necessity, anyhow in the 
psychoses of the special technique, which really constitutes psycho¬ 
analysis, viz ., free association and analysis of dreams. It is an important 
point, as psycho-analysis in orthodox form is permanently impracticable 
in institutions. 

Personally we find it quite easy to elicit in cases of psychosis by 
ordinary conversation with occasional questions the sort of story which 
the psycho-analysts have led us to expect. A little intelligence and 


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imagination as to the probable meaning of symbolic symptoms is 
required, and of course we owe to Freud almost the conception that 
symptoms commonly are symbolic. 

But the real point is that cases where the main symptoms are 
symbolic of remote mental states which genuinely cannot be recalled 
are pathological curiosities. 

In many cases the connection between the symbolic reactions and 
the complex is not obvious to the patient, but the complex itself is 
practically always in the foreconscious, as Freud would say. The 
formidable structure of the psycho-analytic theory is based historically 
on the opposite view as to this point. There are other arguments for 
and against the existence of the unconscious, but this one seems to us 
to be in conflict with clinical experience of the psychoses. 

Granted that a patient is accessible at all, our experience is that 
extraction of what is relevant is not limited by amnesia but by reluctance. 
Many are bursting with anxiety for confession, but others are inhibited 
by shame and doubt as to the reception of their confidence. If this 
can be allayed no special technique is required. Our feeling is that the 
main value of psycho-analytic technique consists in this : that it enables 
the neurotic instructed in regard to “ the unconscious ” to save his face 
by deceiving himself that what is thus elicited is something foreign to 
his true self. 

By Dr. Mapother. 

Referring to our special topic of fantasies of youth as the source of 
delusions, cases are common where a mere detail of the clinical picture 
is a derivative of childhood, e.g., the identification of the self or others 
with figures out of remembered fairy stories. Omitting consideration of 
these, the case described above combines the two types of fantasy which 
have seemed to us to reappear most commonly in subsequent delusions, 
viz., those of early childhood about the parents and those of adolescence 
in regard to sexuality. 

Some at least of the delusions of royal birth seem to be revivals of 
ideal parents created for themselves by those whose childhood is 
unhappy. 

Of this type is the case of a patient, E. H—, an intelligent and well- 
educated woman, set. 55. About three years ago it became clear to 
her that she was a personage of great importance, and gradually it has 
been revealed that she is the Princess Victoria, and that she and the 
Duke of Clarence were the children of Edward VII by his legal 
marriage with an elder sister of Queen Alexandra. She says that 
Edward VII then put aside this queen and replaced her by Queen 
Alexandra, who was her indistinguishable younger sister. 


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46 FANTASIES OF CHILDHOOD AND ADOLESCENCE, [Jan., 

The patient declares that as the legitimate queen she is persecuted 
by the rest of the Royal Family. 

The real facts have been ascertained from a friend who knew the 
family by whom the patient was brought up. These facts are that she 
was taken from an orphanage when a child of about five to be a 
companion to another little girl of the same age. The latter was the 
only child of well-off parents, but probably defective, and later became 
definitely insane. The father was kind to the patient during his life, 
but the mother treated her with the greatest harshness, discriminating 
always in favour of her own child and rubbing in how dependent she 
was on their charity for the food she ate. Eventually she was given a 
training as a Norland nurse and with this turned out to make her living, 
which by a hard struggle she has done until she broke down recently. 

The patient claims to be able to remember her splendid real mother 
before adoption, and even the visits of Edward VII coming to see her 
mother just after the parting. 

But she also says that she was warned never to go near a public- 
house for fear of meeting her dissolute father. She says triumphantly, 
“ You know what a bad man Edward VII was,” and regards this as a 
fairly conclusive piece of evidence of her parentage. 

I think this identification of “ bad men ” with the sort who frequent 
public-houses stamps the fantasy as probably really originating in 
childhood. It will remind those who know Kipling’s story of the 
sinister figure of Policeman Day, the principal enemy of the Brushwood 
Boy and descended from the policeman, to whom the nursemaid had 
threatened to deliver the hero at the age of three. 

A case illustrating the sexual fantasies of adolescence is that of a 
typical dementia praecox, set. 20 on admission. She was then intensely 
agitated and full of self-reproaches. Her principal remorse was in 
regard to having, at the age of 13, entertained a fantasy of intercourse 
with God, associated with masturbation. There is some reason to 
suspect a tendency to identify God and her father. She accused herself 
also of having killed God and her father, and described the battle of 
Armageddon, in which she commanded the forces of Evil. 

This case differs from the first in that the remorse on admission was 
in respect of what was recognised as a fantasy. But already since 
admission a growing tendency can be observed to give to this incident 
the quality of reality. 

I may say that the same patient gives a history of intercourse at the 
age of 9 with her own brother and other small boys with a wealth of 
detail which makes it very strongly suggestive of reality. 

Two further cases I would mention, rather by way of contrast. 

In the first it is current , not re-current, fantasies which provide the 
material for the delusions of a psychosis originating about puberty. 


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192 2.] BY E. MAPOTHER, M.D., AND J. E. MARTIN, M.B. 47 

The patient is a dull, dreamy girl, set. 16, but seeming younger in all 
ways. She is obviously in the early stages of dementia prsecox, and her 
parents are typical degenerates. She was employed as a housemaid at 
the college attached to one of the London hospitals, working in the 
students’ quarters. 

She fixed her affection on one of the students, and in her enthusiasm 
used to call him hours before it was time for him to get up. She 
declared the matron had said she was to be married to him, and since 
the day after her transfer to the infirmary has believed she had a baby 
on the night of admission, because “ she heard the other patients say so.” 

This is, of course, only a simple example of the wish fantasies of 
adolescence being accepted as fulfilled in reality owing to impairment 
of the capacity for discrimination by dementia prsecox. Perhaps the 
most interesting fact about the case is that the girl is absolutely and 
entirely ignorant of the nature of sexual relations, gestation and 
parturition. 

The last case is given as a type contrasting with the earlier ones, in 
that the fantasy, though concerning the events of childhood, is created 
in the present and referred back to the past—in fact it is merely pseudo- 
Teminiscence. 

The patient is a constitutional neurotic now set. 39. She left home 
about the age of 18 and has tried to earn her living since as a nurse, 
but has always been inefficient, unduly dependent, and incapable of life 
apart from her family. She has had one previous definite mental break- 
•down. The content of her last psychosis seems, however, to have been 
pretty clearly determined in large part by a story read to her when in a 
condition of confusion and depression at the onset of the attack. The 
•central figure of the story was, like herself, the daughter of a clergyman 
brought up in a country rectory. In the story the clergyman was unable 
<0 do anything with the child or to win its affection. 

It is impossible to go into adequate detail. It can merely be said 
that she identified herself with the child in the story, introjected various 
incidents of it into her own past, and gave to various incidents—possibly 
truly recalled—an absurd significance in keeping with two central ideas. 
The first was that her father had warned her that she was inevitably 
•damned on account of caring insufficiently for her parents. The second 
that her father had advised suicide. The evidence of the second belief 
which she adduced was a recollection of his saying to her, at the age of 
four, “ Go home, baby.” 

A persistent suicidal tendency which she displayed during the early 
part of her psychosis she herself refers to this imaginary injunction. 

She has recently greatly improved and become aware of the origin of 
these ideas. 


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CHANGE OF PHASE IN THE PSYCHOSES, [Jan., 


We are fully conscious of the imperfections of this paper, which is 
designed chiefly to elicit the experience and the views of others. The 
description of cases has necessarily been somewhat summary and the 
statement of theoretical views rather dogmatic in form. As to the 
latter, we put them forward tentatively as impressions which we hope 
we are ready to modify in the light of further experience. 

(The discussion which followed will be found on p. 534, vol. lxvii, 
1921.) 

(*) We have to acknowledge the kindness of Dr. GilfiUan, Medical Superinten¬ 
dent of Colney Hatch, and Dr. Lord, Medical Superintendent of Horton, in 
providing us with information as to the condition of our patient's mother during 
the periods she spent at their respective hospitals. 


Change of Phase in the Psychoses. ( J ) By Thomas Beaton, O.B.E. y 
M.D., M.R.C.P.Lond., Senior Assistant Physician, Bethlem Royal 
Hospital. 

Change of phase is a well-recognised feature in the course of certain 
of the psychoses. In manic-depressive insanity it is on the phasic 
variation of the affective state that the separation of that type of mental 
disorder is based. So, also, in many cases of the chronic psychoses 
phase changes occur as the disorder progresses, and as the patient fits 
in new experience and builds up fresh mental content on the basis of 
the already existing delusional state. 

Such changes, however, are to be regarded as part and parcel of the 
particular psychosis concerned. Apart from the interest of watching 
the gradually expanding self-regard of the paranoiac, or the gradually 
increasing inhibitory control of the maniac who is becoming quiescent, 
such changes have no value, and they bear no practical significance as 
regards the future of the case. The patient is still the subject of 
manic-depressive insanity whether he be exalted or depressed, and the 
paraphrenic battling with his difficulties as plain Mr. Smith, or reacting 
dominantly, as his condition advances, as Lord Smith of Smithshire, 
remains fundamentally a paraphrenic of whose mental future there is. 
little doubt. 

In this paper it is not proposed to consider such changes as those 
indicated above, but it is desired to draw attention to the occurrence of 
certain variations of phase which frequently may be observed in early 
psychotic derangements. These changes are fraught with the highest 
import to the subject, for not only do they often result in a totally 
changed attitude to the hospital environment, but not uncommonly 
they lead to a re-adjustment to social life. 

The text-books on mental disorder, as is indeed necessary, are 

(') A paper read at the Annual Meeting held in London, July 14th, 1921. 


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49 


concerned with the exposition of more or less definite and distinct 
disease types, the underlying psycho-pathology of defined disorders 
being explained, and the evolution of the finished specimen followed 
step by step, from the initial departure from sanity up to the onset of 
the secondary dementia. On this basis, therefore, it should be possible 
in observing the early case to place the type of disorder with a fair 
degree of accuracy, and so to establish a fairly certain prognosis, but 
experience of the early case in clinical practice goes to show that this 
highly desirable state of affairs is far from attainable as yet. Personally, 
I have found that those physicians with the widest experience are those 
who are the most reluctant in coming to a diagnosis in any particular 
case. I consider that it is a striking testimony to the frequency of 
occurrence of these little-considered early-phase variations, as well as a 
distinct reflection on the position of clinical psychiatry as a branch of 
scientific medicine, that it is usually necessary to keep a case under 
observation for a period in many cases of from at least six to more 
than twelve months, before the conformation to type becomes sufficiently 
close to permit of a reasonable possibility of prognosis. 

Bearing in mind this general experience, one is forced to the con¬ 
clusion that the general types of chronic insanity which have been 
separated out are really to be regarded purely as secondary manifesta¬ 
tions, and that whether the origins of the psychoses are to be found in 
individual incidents of psychic life, as is the teaching of the analytic 
school, or whether they rest in the more fundamental processes under¬ 
lying the absorption of experience and the building up of the personality ; 
such is the homogeneity of the human species that, in spite of the 
diversities of experience and of individual make-up, ultimately the final 
settled adjustments may be counted up on the fingers of one hand. 

However, to return to the actual subject-matter of this paper: it 
would be impossible to deal adequately with the full range of the early 
phase changes within the limits of the time permitted, therefore I 
propose considering only that phase which is productive of the most 
marked effects on the mental condition of the patient, and, in my 
experience, the most striking changes are to be anticipated following 
the exhibition of a confusional phase. 

It may be objected that in considering confusion one passes from the 
psychoses proper to quite another group of disorders, and that the fact 
of recovery following confusion is only in accord with the recognised 
course of events, in that confusional states of mind do tend to recovery. 
With this objection it is quite possible to agree, and, indeed, I wish 
to emphasise the fact that recovery is common in these states, as I feel 
that the significance of this has been largely overlooked in the general 
distraction of attention by the modern trend of psychological thought. 
In support, however, of the inclusion of a confusional phase in the 

LXVIII. 


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50 


CHANGE OF PHASE IN THE PSYCHOSES, 


[Jan., 


course of a true psychosis, it is contended that it is at least as possible 
for a psychotic as for a rational individual to develop an exhaustion 
state, or, in view of the self-neglect so common in the psychotic 
patient, a toxic confusional state. 

Now, in considering a case of early psychotic derangement, it is clear 
that, whatever be the cause, the subject is being confronted with a set 
of novel experiences which are very different from, and may be directly 
opposed to, any experience which had been undergone previously in the 
individual life. To the patient these experiences are, of course, 
perfectly real, and, from their very novelty and their personal applica¬ 
tion, they become the dominant factor in determining the direction of 
flow of the interest or attention. To them the patient attends, “willy 
nilly ” he must think about them, he must reason them out. By the 
rationalisation which occurs the new experiences are built up into an 
organisation of new sentiments, and, owing to the strength of the affect 
all that conflicts with them must go by the board. So retrospection 
undermines what is left of the previous experience, and new perceptual 
experience is accumulated as the days go by under the influence of the 
prevailing affect, all to the effect of strengthening the delusional state 
and of removing the patient still further from the possibility of proper 
social adjustment. 

The greater the intellectual capacity, the wider the sphere of know¬ 
ledge ; the longer the new organisation is in existence, the more extensive 
will be the systematisation. For instance, the paraphrenic differs from 
the paranoiac in other ways than in mere mental content, the latter 
individual being invariably of a much higher intellectual capacity; also 
the chronically insane subject gradually changes his sentiments towards 
objects which previously had a high interest value, visits from relatives 
being received apathetically even if the patient has not earlier rationalised 
a hostility to all his friends, on the grounds that they do not come 
forward to help him substantiate his delusional ideas. 

Meanwhile the patient is quite unamenable to any influence save 
that of force, he can be cajoled into behaving properly, and he can be 
persuaded into conforming to the rules of the hospital up to a point, 
but his new outlook on life, his new sentiments cannot be altered by 
the slightest fraction; such intellectual ability as he has is used to 
counter any attempt to argue him out of his beliefs, and the only effect 
of such an attempt is that the patient is stimulated to forge still more 
firmly those intellectual bonds which hold his delusional state together. 
It is highly probable in many cases, also, that the original cause which 
set off the whole affair subsides and is no longer operative, but the 
organisation of delusional experience has by this time become so firmly 
fixed into the personality that the condition is self-perpetuating, and 
consequently unalterable. 


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51 


1922 .] 

So long, therefore, as the capacity for intelligent thought remains active, 
so long must the compound of delusional sentiments grow and cohere, 
until finally the element of novelty wears off, the patient ceases to 
think about his experiences, he takes them for granted and settles down 
to his new adjustment, which takes the form of one of the recognised 
types of the psychoses. This is the reason why it is found that many 
of the chronic patients in our county hospitals are quite capable of 
useful work under the hospital environment. 

If, however, the patient develops a confusion for any reason, a very 
different course of events must follow. In the first place the continued 
addition of strengthening perceptory experience must cease because the 
processes underlying intelligent association are no longer operative. 
Secondly, the organisation of the new experience is badly strained, its 
intensity and clarity are markedly reduced in proportion to that of 
previous experience, according to the rule that the latest acquirement 
is the first to be lost. Finally, influence can now be brought to bear on 
the patient, who, owing to his difficulty of intelligent thought, cannot 
meet argument with argument and is therefore more capable of taking 
a suggestion. His perceptual experience is more likely to be dominated 
by the original compound of sentiments developed prior to his 
psychosis, and in consequence he is more amenable and easier to 
handle. 

Compare, for example, two cases of what may be termed melancholia 
of the involutional period. The first was admitted to hospital with the 
usual ideas of depression, of financial difficulties (which were real 
enough), and with the conviction that he could no longer keep up the 
struggle of making ends meet. His delusional state developed, he was 
hopelessly lost, he was to be killed, his wife and family were to be 
murdered, etc. He was passively resistive to treatment but never 
developed any signs of extreme anxiety, and he has settled down to his 
position in hospital, smokes his pipe, reads the paper, but turns a deaf 
ear to any talk directed to showing the falsity of his beliefs. The second 
was admitted in a very similar mental state, with ideas of financial ruin 
and that he also was hopelessly lost. He, however, showed a more 
active resistance, it was difficult to ensure his proper nourishment, his 
expenditure of energy was much higher, and, within three months of 
admission he developed a confusional state which I regarded as an 
exhaustion. With careful attention it was possible to restore his 
physical strength, the confusion gradually cleared and he began to 
rationalise again. This time, however, he no longer built up on the 
basis of the former delusional ideas, he adopted the attitude that he 
was being kept, that he would never be allowed to go out again, that, 
far from being lost by virtue of his own condition, he was only being 
held back by the authorities of the institution. This attitude, though 


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52 CHANGE OF PHASE IN THE PSYCHOSES, [Jan., 

appearing to be delusional, was not an unreasonable one under the 
circumstances. Later on, when he was well enough, he was sent out to 
show him that it was not intended to keep him indefinitely, and with 
the removal of his doubts on that point he quickly reached a truly 
rational view of the whole question of his illness. 

It is not always that the interception of a confusional phase results 
in readjustment to social life, as the following case shows: A very 
intelligent and well-educated woman, aet. 37, by profession a nurse, was 
admitted in a highly emotional depressed condition, the prominent 
affect being that of remorse. She had neglected her patients, she had 
fallen short of her religious ideals. She was quite inaccessible to 
argument, and she rapidly developed her delusional state. Finally she 
became convinced that she was to die, and she would fix the time at 
which “God would take her.” This having arrived, she would go 
through the semblance of a death scene. As was to be expected she 
exhausted herself with the tremendous amount of emotional agitation 
she experienced, and in addition she contracted a rather acute colitis, 
the combination of circumstances resulting in an acute confusional 
breakdown. For a time her life was despaired of, but eventually the 
colitis was got under control and her strength began to return. Her 
attitude had changed completely when she again commenced to 
rationalise her position ; instead of upbraiding herself she turned on her 
doctor and demanded to know what had been done to her, why she was 
made ill, why did she not receive any treatment, etc. Unfortunately it 
has not been possible to break through her hostility, but evidently her 
perceptive experience derived during the first phase of her malady has 
been quite obliterated. 

A case which is of interest as showing the attempt at readjustment 
following a confusioual state is that of a woman, set. 34, who was 
admitted to hospital in a state of confusion with excitement. She had 
vivid hallucinations of a terrifying nature, and her general effect was that 
of intense apprehension and fear. She became thoroughly exhausted 
and stuporose, but more amenable to treatment, until after about three 
weeks she began to take some notice of her surroundings. Attempts 
were made to explain her situation to her, for of course she had no 
idea of where she was or of how she came to be there. Her first 
endeavour at putting things together resulted in the idea that she had 
committed some crime, that she had disgraced herself, that her people 
would not have her at home, and she begged to be killed to put a stop 
to her disgraceful life. This state of mind was naturally accompanied 
by much agitation, and after a few days of incessant mental activity 
she became exhausted and again confused. In a week she was re¬ 
covering again; this time her attitude was that she was being kept in 
prison, that her relatives were all being tortured, that she was to be 


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1922.] 

tortured also, and finally killed. She no longer held her ideas of 
unworthiness, but put down the whole trouble to the authority detaining 
her and keeping her from her home. Her affective state now was that 
of acute fear, and this again was too much for her low stability, and 
again confusion recurred. With another interval of about a week she 
once more commenced to rationalise, she was still very apprehensive, 
but she was more suggestible ; and, finally, her confidence was obtained, 
and she began building up experience on the true basis. 

It is very difficult, of course, to say whether a confusional phase is 
likely to occur in the course of any particular early psychosis; in many 
cases it arises accidentally as the result of some toxic infection, but 
there are certain developments which are liable to lead to exhaustion. 
Such conditions as a rapidly developing paranoid state, an acute anxiety 
state or a remorse or self-reproach psychosis involve a great expenditure 
of mental activity by the patient, and are therefore liable to lead to 
exhaustion, while, on the other hand, phantasy developments are not 
associated with much emotional activity or intense intellectual effort, 
and therefore do not commonly exhibit a confusional phase. 

The practical question presents itself as to whether it is advisable to 
encourage confusion in a case which is showing every evidence of 
building up an organised scheme of false ideas, and I feel that if a 
confusion can be induced early enough, the chance of obtaining access to 
a patient during the recovering period would justify whatever measures 
were taken. I was much impressed with the early recovery of many of 
the psychoses met with in service patients during the war, and I think 
that in most of them the explanation was to be found in the element of 
exhaustion with mild confusion which was almost invariably present. 
I will mention one case which came under my care. An officer of 
excellent past record and good physical health was sent to me with what 
appeared to be a well-established paraphrenic condition. He had the 
delusions that he was thought to be a spy, that he had given important 
plans away to the Germans ; he heard voices accusing him of various 
misdeeds, and he saw Germans wherever he went. There was no 
confusion, but he was intensely suspicious and hostile, and the circum¬ 
stances of the hospital were such that he could not be placed under the 
requisite care and control necessary in his state. Eventually he was 
persuaded to submit to a hypodermic injection of morphine and 
hyoscine. Under the influence of the drug he was got to bed and 
kept there with an injection twice daily. This was continued for four 
or five days, during which he remained in a semi-stuporose confused 
state, then, arrangements having been made for his removal elsewhere, 
the injections were stopped and the patient allowed to adjust himself 
to his environment. It was then found that his suspicions had quite 
disappeared, his former delusions and hallucinations had faded to that 


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dream-like intensity so characteristic of the recent memories of the 
confusional case, and within a few days’ time the patient was perfectly 
readjusted with a good insight into his previous psychotic condition. 
In this case the derangement was caught at a very early stage, it could 
not have been in existence at the outside for more than two months, 
therefore the delusional compound was poorly organised and easily 
broken up to leave the field clear for a proper readjustment. One 
cannot assume, of course, that the case would not have terminated 
favourably under more usual methods of treatment, but certainly I have 
never observed such a remarkably complete recovery of sanity in so 
well developed a delusional state in the very brief period of time, and 
I feel that the case is exceptionally interesting from this point of view. 

In conclusion, I would again emphasise the necessity of not allowing 
the systematic classification, which is applicable to long-standing cases, 
to obscure the fact that the early case almost invariably shows change 
of phase before the secondary final adjustment is reached ; and I would 
draw attention in regard to the particular phase of confusion to that 
very old tradition that an acute infectious disease, probably accom¬ 
panied by delirium, is often beneficial to a mental patient so far as his 
future mental state is concerned. 

(The discussion which followed will be found on p. 546, vol. lxvii, 
1921.) 


The Goldsol Test in Mental Disease .0 By P. W. Bedford, M.D., 
D.P.M., Assistant Medical Officer, West Riding Asylum, Wakefield. 

General paralysis is often very difficult to diagnose, and the responsi¬ 
bility of coming to a decision is not lessened by the fatal character of 
the disease. Amongst the protean manifestations of neuro-syphilis, the 
early and definite recognition of this, its most deadly and intractable 
form, offers a problem in nice discrimination—a problem which is in 
the present tense and imperative mood. According to Southard, of 
119 cases diagnosed as general paralysis, post-mortem examination 
revealed a diagnostic error of 26 per cent. If anyone had been able to 
devise a less intricate test for syphilis, the Wassermann reaction would 
never have survived to the present day. It is one of the most com¬ 
plicated methods that have been applied to diagnosis in medicine. Any 
simple test, therefore, which promises increased precision in diagnosis, 
is worthy of that careful investigation which is the half-way house to 
knowledge. 

The general utility of any diagnostic method, and in a measure its 
reliability, is determined chiefly by the simplicity of its unspecialised 

(') A paper read at the Annual Meeting held in London, July 12th, 1921. 


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technique and its consequent ease of application. This requirement is 
fulfilled by the goldsol test, for it consists merely in making a series of 
ten saline dilutions of the spinal fluid to be examined, and adding 
thereto a small quantity of the goldsol reagent. Its technique is so 
simple that the performer cannot make a mistake without bringing the 
most ingenious carelessness to his aid. 

The performance of the test itself occupies but fifteen minutes, and 
is within the reach of every clinician and medical officer. The result 
may be read a few hours later, and is interpreted according to the 
degree of precipitation of gold that has occurred—as evidenced by 
various colour-changes in the goldsol—and according to the particular 
dilutions of spinal fluid most affected by these changes. 

The typical reaction obtained with the fluid of a case of general 
paralysis consists in a complete precipitation of the first four or five 
dilutions, so that their ruby colour is entirely discharged, with partial 
precipitation of the next two or three, and no change in the remainder. 
This complete decolorisation of the first four, five or six dilutions is 
clear-cut and unmistakable, and does not occur in any other disease 
than general paralysis. It is claimed that in cerobro-spinal syphilis and 
tabes dorsalis the maximum colour-change occurs in the third, fourth 
and fifth dilutions, but that precipitation is never complete. In 
epidemic meningitis the chief reaction is said to occur in the sixth 
to the ninth dilutions, and should be of still less degree. If these 
results are shown graphically by assigning figures to the five different 
degrees of precipitation, certain “ curves ” become apparent, of which 
the “paretic” curve is the most characteristic. The so-called “luetic” 
curve of cerebro-spinal syphilis I believe to be of doubtful value. Of 
the “ meningitic ” curve I have had no experience. 

A completely negative reaction would show no colour-change at all, 
and would be indicated by a straight line. In reading the result, it 
is the degree of decolorisation and not the number of dilutions affected 
which has the diagnostic value. But an absolutely negative reaction in 
which there is no colour-change whatever is, in my experience, rare. 
Out of my series of 250 examinations only two fluids gave this result. 
The great majority of fluids from the insane react to the extent of the 
first or second degree of colour-change, and these should be considered 
negative. A third-degree reaction is doubtful, a fourth-degree highly 
suspicious, and a fifth-degree reaction is definitely positive. The whole 
value and success of the test depends upon the use of a good goldsol, 
and its preparation is the only uncertain part of the procedure. 

The method I have found most reliable is that described by Weston, 
Darling and Newcombe, and modified by Lowrey. The process is 
simple enough, but care and attention to detail is essential, for all 
possible sources of error are not yet known. Failures are usually trace- 


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able to impurity of the water used. Before the goldsol can be used 
with confidence for diagnostic purposes it must fulfil certain require¬ 
ments. The chief test should be, that it must give a typical reaction 
with a known paretic fluid, and that it must produce no reaction greater 
than a No. i or 2 change with a known normal fluid. Further, on 
the day on which it is used the sol must be neutral to the alizarin 
test, for alkaline sols are almost inert, and acid sols give atypical 
reactions. Another suggested criterion of suitability is the saline test, 
to discover whether the sol is “ protected ” or not. A non-protected 
sol—which is the type required for the goldsol test—is one that is 
completely precipitated in one hour, when 5 c.c. of it is mixed with 
i '7 c c - of a 1 per cent, solution of sodium chloride. In appearance the 
sol should be clear by transmitted light, and by reflected light a very 
slight turbidity, not amounting to more than a golden shimmer, is 
permissible. 

In my experience good goldsols have a beautiful ruby-red colour, but 
the orange-red sols give the most clean-cut reactions. If kept well 
stoppered in a dark place, the sol retains its properties for a considerable 
period, but tends to become slightly alkaline, and therefore less sen¬ 
sitive. In bright light it becomes darker, and may lose its reliability. 

In order to test the value of the reaction I examined the spinal fluids 
from 250 selected cases. These were arranged in twelve groups, as 
follow: Nine groups of non-syphilitic psychoses, each group containing 
15 cases and totalling 135 fluids; one group, comprising 84 general 
paralytics; one group, containing 19 fluids from miscellaneous diseases; 
and one group of 12 fluids, obtained post-mortem. 

For control and comparison, the Ross-Jones and the Wassermann 
reactions were used as representing reliable tests. The non-luetic 
psychoses chosen were: Mania, melancholia, epileptic insanity, amentia, 
dementia praecox, adult dementia, senile dementia, confusional insanity, 
and delusional insanity; 15 examples of each type. Of these 135 non¬ 
syphilitic fluids, not one gave a “ positive ” goldsol reaction, and only 
two were “doubtful,” both these fluids being from cases of severe 
epilepsy that had the facial appearance of congenital syphilis. 

Whereas the Wassermann test gave two positive reactions, one of 
them being in an epileptic imbecile and the other in an epileptic dement 
with an old-standing hemiplegia, the Ross-Jones test gave two positive 
reactions and thirteen doubtful ones in these non-luetic psychoses. 
The “miscellaneous” group does not contain a sufficient number of 
examples of any one disease to justify generalisations, but it displays 
some points of interest. Thus, the five instances of cerebro-spinal 
syphilis all gave a goldsol reading that reached the third degree of 
colour-change—that is, a suspicious or doubtful reaction. Similar 
results were obtained from two cases of old-standing hemiplegia, possibly 


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57 


due to syphilitic arteritis. Two cases of tabes dorsalis and two of 
disseminated sclerosis gave negative tests, as did also three cases of 
alcoholic psychosis, selected because they were suggestive of general 
paralysis; the laboratory findings disproved the suggestion. Negative 
results were obtained in motor aphasia, Huntington’s chorea and 
glioma of the cerebrum. 

The examination of the twelve fluids obtained post-mortem by 
puncture of the cisterna cerebro-medullaris showed that the goldsol test 
and the Wassermann reaction are equally reliable when applied to 
specimens taken after death. 

Regarding general paralysis, the 84 cases in this group comprise 
79 ordinary examples of this disease, 2 juvenile cases, 2 chronic cases 
and 1 senile case. Out of the total of 84 fluids, 80 fluids gave a 
positive goldsol test, 76 gave a positive Wassermann reaction, 67 gave 
a positive Ross-Jones test, and 75 showed agreement in reacting 
positively to both goldsol and Wassermann tests. A few examples may 
be singled out for special comment. Thus, one fluid was from a 
patient with grossly obvious physical signs, yet both Ross-Jones and 
Wassermann reactions were negative; not so the gold test. Another 
noteworthy instance is that of a woman who was diagnosed a paretic 
three years ago and reached the helpless and bedridden stage. Within 
the last year, however, she passed into a phase of such marked remission 
that she has since been discharged to the care of her friends. Her 
spinal fluid gave a negative Wassermann reaction during the period of 
remission, whereas the goldsol test was positive. Puncture of the two 
congenital cases produced fluids which reacted positively to all three 
tests, whereas the fluids from the two chronic cases were both negative. 
Of these latter, in one the clinical diagnosis is open to doubt. The other 
is interesting. The patient was admitted twelve years ago at the age of 
forty-nine. In 1911 his spinal fluid gave a positive Wassermann reaction ; 
in 1912 the reaction was weak, now it is negative. Speech defect, pupil¬ 
lary reactions and absurdly grandiose delusions leave little doubt of the 
diagnosis. The senile case refers to a man who was admitted six years 
ago at the age of sixty-nine. His spinal fluid is negative to all tests. 
He is still alive and shows some of the signs of general paralysis. It is 
claimed that the goldsol test is more sensitive than the Wassermann 
reaction, without being any less reliable. 

Thus an analysis of eleven separate series of investigations, carried 
out by different observers and comprising 523 cases of clinically obvious 
general paralysis, shows that the goldsol test was positive in 485, the 
Ross-Jones in 470 and the Wassermann in 465—a difference of 4 per 
cent, in favour of the gold test. 

Again, in tabes dorsalis, Lee and Hinton obtained positive gold 
reactions in 24 cases, of which 9 gave negative Wassermann reactions 


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58 THE GOLDSOL TEST IN MENTAL DISEASE, [Jan., 

in both blood and spinal fluid; of these 9, 2 gave no other spinal test 
positive. These 24 patients all had a definite syphilitic history. 

Further, in 8 cases of syphilis without clinical evidence of involve¬ 
ment of the nervous system and with negative Wassermann reactions in 
the spinal fluid, 4 positive goldsol reactions were obtained. The 
blood Wassermann was positive in these 4 cases. 

Weston, in an article questioning the relationship of the gold test 
to syphilis, gives in support of his argument details of three mental 
cases, who during a period of two years under repeated examinations 
always gave “ paretic ” curves with the gold test and negative Wasser¬ 
mann reactions. But in a footnote to his paper he records that one of 
these patients, tested once more while the article was in the press, 
had developed a positive Wassermann reaction. 

Surely all this indicates that the gold test is of value in the early 
diagnosis of neuro-syphilis, which is the view put forward by Lange 
originally, and since endorsed by Kaplan and by Black and his co¬ 
workers. If this claim can be definitely established, the possibility of 
preventing or of modifying severe neuro-syphilis by timely treatment will 
be greatly increased. The early involvement of the nervous system by 
syphilis is well known. By the time neurological signs and symptoms 
have appeared, too often irreparable mischief has been done. As yet 
there is no evidence that the goldsol test is specific for syphilis in the 
sense of an immunity reaction. But it is specific for general paralysis 
in so far as it is so strikingly constant and more frequent in this disease 
than in any other. 

Another great merit of this test is, that it is as equally well applicable 
to old as to fresh spinal fluids. In my experience, specimens kept eight or 
ten days in the ice-chest do not materially alter in their reaction. One 
author found that a spinal fluid was as active after a year as in the 
beginning. Of course, if the fluid is contaminated so that it becomes 
turbid through bacterial multiplication, it is untrustworthy. The value 
of this is, that a sample of paretic fluid can always be kept at hand in 
order to test new goldsols as they are made. The permanence of the 
reaction is another outstanding feature. After the first twelve or fifteen 
hours the tubes show little change for several days, except perhaps to 
become rather paler in tint. If the tubes are stoppered and kept in the 
ice-chest the reaction may be preserved for weeks. 

The test has other interesting charactersitics. The presence of a small 
amount of blood in the spinal fluid does not render it unfit for testing. 
Fluids with a faint pink tinge, or which deposit on standing a clot the 
size of a large pin’s head, are admissible. Such specimens should be 
allowed to sediment overnight and the clear, supernatant fluid used. I 
have found this preferable to separation by centrifuge. This amount 
of blood may cause slight changes in colour in the higher dilutions, but 


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59 


will not convert a negative into a positive reaction. Of course, gross 
contamination by blood is inadmissible. 

The gold test has been applied to blood-serum. It was found that a 
dilution of fresh human serum corresponding to o - o8 per cent . in 
ordinary salt solution, when used in place of spinal fluid, causes pre¬ 
cipitation of gold in the same way as a strongly positive paretic fluid. 
The lest is therefore not applicable to blood as a means of diagnosing 
general paralysis. 

Warwick and Nixon examined the fluids of 240 miscellaneous cases, 
comprising a great diversity of medical and surgical patients. They 
found that a reaction of a third or greater degree occurred in only nine 
instances. Of these, four were syphilitic conditions and the remaining 
five were affections of the nervous system, such as sciatica, myelitis, 
etc., which were possibly associated with syphilis. On the other hand, 
Moore writes that a “ paretic gold curve ” has been obtained in such 
diseases as lead poisoning, tuberculous meningitis and multiple sclerosis. 
Further investigation along these lines is obviously indicated, especially 
in incipient nervous and mental disease. 

As a means of measuring the efficacy of treatment the goldsol test 
would appear to be of little or no value. Under treatment some paretic 
fluids lose their positive reaction, others remain unchanged, whilst yet 
others give a more intense response of the nature of a “ provocative 
reaction.” 

The goldsol test has its origin in certain unexpected results that were 
obtained in experiments on the differentiation of proteins by colloidal 
gold. It was known that goldsol was electrically charged and could be 
precipitated by a suitable electrolyte. Zigismondy then discovered that 
the addition of a very small quantity of protein to the goldsol conferred 
“ protection ” on it and prevented the gold from being precipitated. 
He found, further, that different proteins differ in this protective 
action, and he was able to determine their relative protecting power or 
“gold number.” Lange then attempted to apply this method in 
investigating the nature of the proteins precipitated from spinal fluid 
by ammonium sulphate solution. Contrary to his expectation he found 
that spinal fluid containing an excess of protein precipitated the goldsol 
instead of protecting it. He was unable to explain this occurrence, but 
the reaction suggested the possibility of using goldsol as a test for 
neuro-syphilis. The practical application of this idea resulted in the 
goldsol test, and his discovery that general paralysis gives an absolutely 
typical reaction. Since that time the reaction has been tested by many 
observers and has yielded consistent results. It is now generally agreed 
that in the goldsol test we have a diagnostic method of greater precision 
and discriminative value than any other hitherto in use, and that it is 
the most valuable of all confirmatory evidence. 


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Before discussing the various hypotheses that have been put forward 
to explain the mechanism of the goldsol reaction, it becomes necessary 
to consider briefly the composition of its three ingredients, namely, the 
spinal fluid, the saline diluent, and the goldsol itself. I shall refer to 
those properties only which appear to have some bearing on the test. 

The identity of the protein or proteins present in spinal fluid is in 
doubt. For practical purposes it would seem advisable to regard the 
protein of normal spinal fluid as a mixture of albumen and globulin, 
the latter preponderating in the proportion of about 3 to 1. A well- 
marked protein increase is always pathological. Taking o’2S grm. of 
protein per litre of fluid as the normal, cerebro-spinal syphilis may show 
1 ’2 grm., tabes dorsalis 1*5 grm., and general paralysis 22 grm—that 
is, there may be eight times as much protein in the spinal fluid of 
paralysis as in the normal: a fourfold increase is common. On the 
other hand, a normal protein content does not exclude organic changes 
in the central nervous system. 

The saline solution which is used in diluting the spinal fluid contains 
o‘4 per cent, of chemically pure sodium chloride. This particular 
strength is used because it has been found experimentally that by itself 
it causes no precipitation of the colloidal gold as a stronger solution 
would do, yet is of sufficient concentration to hold the globulins and 
nucleoproteins of the spinal fluid in solution. Its presence is essential 
to the test, for pathological fluids used by themselves or diluted with 
distilled water produce no effect upon the goldsol. Its virtue is 
dependent upon its electrolytic activity. When the salt is dissolved 
the salt molecule itself is broken, so that ions of sodium and of chlorine 
move about in the water. Moreover, the sodium ion is associated with 
a relatively enormous electro-positive charge, and the chlorine ion with 
an equal and opposite electro-negative charge. Now the saline solution 
has become a good conductor of electricity. When it is remembered 
that the particles in a goldsol are known to be electro-negatively charged, 
the significance of the electro-positive sodium ion in the mixture 
becomes obvious. If there were no electrolytes, such as salt, electric 
charges could not be carried about and chemical reactions could not 
occur. 

Biological phenomena are conditioned in the same way—for the 
living body may be regarded as a framework of non-conducting material 
immersed in and soaked by solutions of electrolytes. It is the electro¬ 
lytes that put life into the proteins and control metabolism, just as the 
figure placed in front determines the value of an otherwise meaningless 
row of cyphers. 

Colloidal solutions of metallic gold have been known for over 200 
years. The “ potable gold ” of the alchemist in search of the elixir of 
life was probably a goldsol; it was a solution of gold salts in ethereal 


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oils. With a better understanding of chemistry, the distinction between 
colloids and crystalloids, at one time thought to be fundamental, is now 
known to be a difference in degree only. They are not different kinds 
of matter, but rather are different states of matter. The colloid is the 
dynamical state, the crystalloid the statical condition. “ Colloid,” then, 
is not a chemical entity like “ acid ” or “ base,” but is expressive of 
certain physical elements like mechanical heterogeneity. The word 
“ colloid ” has thus lost some of its original significance; for the 
colloidal metals have the chief properties of colloids but never are 
“ glue-like.” In a colloidal solution of any substance the particles are 
composed of variable and rather large numbers of molecules of that 
substance. It presents an instance of very fine, but not molecular 
subdivision. Colloidal solutions or “sols ” thus occupy an intermediate 
position between true solutions on the one hand and suspensions on 
the other. There is thus an unbroken continuity from the coarsest 
grained heterogeneity of suspensions, through the highly dispersed 
state of colloidal solutions, to the apparent homogeneity of the true 
solutions and the molecular state in gases. Now the goldsol used in 
this test is composed of fine particles of metallic gold suspended in 
water. Having regard to the density of gold, it is a little surprising 
that the particles do not sediment. But as a matter of fact goldsols 
do not precipitate at all so long as the subdivision of the gold is 
maintained. One of Faraday’s goldsols made in 1858 is still preserved 
in the Royal Institute. 

The explanation is molecular motion. It has recently been shown 
by Perrin that this movement of particles is identical with that of the 
molecules of the containing liquid as postulated by the kinetic theory. 
If it be assumed that the kinetic theory of gases is applicable to 
colloidal solutions, it follows that the gold particles in a sol are battered 
on all sides by a hailstorm of molecular impacts from the surrounding 
water. If the gold particle is very large in comparison with the mole¬ 
cules of water by which it is surrounded, it will be bombarded from 
every direction by a large number of water molecules moving in all 
possible directions, so that the blows will neutralise one another and no 
movement will occur. But as the gold particle becomes smaller and 
smaller until it is not so very much larger than the water molecules 
themselves, it will be hit by fewer and fewer molecules simultaneously, so 
that the forces acting on it will cease to be balanced, the unidirectional 
impacts will rapidly increase, and the particle will be driven hither and 
thither in a rapid sequence of zig-zag straight lines till it begins to 
behave like a molecule itself, and is swept along in the endless mole¬ 
cular movement. 

Thus the cause which prevents the particles in a goldsol from settling 
is in no way different from the cause which prevents the earth’s atmo- 


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sphere from subsiding to a snowy level a few feet deep on the surface of 
the planet. Moreover, each gold particle in a sol ordinarily possesses an 
electric charge, which is usually negative in sign because the dispersion 
medium—that is, the water—has such a high dielectric constant. This 
charge can be varied and even reversed by the addition of an electrolyte 
like sodium chloride, and may become zero at suitable concentrations. 
In this condition the sol becomes very unstable, and subsidence 
preceded by coalescence of the small particles which have thus been 
deprived of their charge, readily but not necessarily occurs, for the 
molecular movement may be sufficient to keep the particles in sus¬ 
pension. Whenever sedimentation does occur it is preceded by the 
aggregation of the particles into larger particles, which finally attain a 
diameter of one thousandth of a millimetre or over, and slowly subside. 

Hence it may be inferred that the first step in the precipitation of 
the goldsol by the spinal fluid of a general paralytic is the neutralisation 
of the negative electric charge on the gold particles by that of an 
oppositely charged electrolyte. In the case of common salt this would 
be the sodium ion. It follows that a possible explanation of a positive 
goldsol reaction may be that the spinal fluid of a general paralytic 
contains an excess of sodium chloride or other electrolyte. Now, if the 
goldsol be examined with the ultra-microscope, the gold particles 
become visible as brilliant dancing points on a black background. The 
tiny particles do not float; they move, and with astonishing rapidity. 
The activity of a swarm of gnats dancing in a sunbeam conveys some 
idea of the restlessness of these lively and electrically-alert particles. 

This movement is able to overcome the influence of gravity, and 
gives an indication of the continuous mixing up of the sol, which goes 
on for weeks, months, and even years if the sol is sufficiently stable. 
So that Graham’s statement, made in 1849 with the unconsciousness of 
the predestined, that the colloidal is in fact a dynamical state of matter, 
is now shown to be well founded. Yet a few drops of paretic spinal 
fluid, diluted to the extent of 1 in 320, strikes down these lively 
particles from their unremitting activity into an inert mass of sediment. 
This constitutes a *' positive goldsol reaction.” 

But this precipitating effect of an electrolyte upon the goldsol may be 
delayed or even prevented by the protective effect of mixing the sol 
with one or more stable colloids, such as albumen. Instances of this 
curious “ protection ” are common; for example, ink often contains a 
colloid, which protects the pigment and prevents it from settling. The 
question here arises whether the normal spinal fluid contains some 
protective colloid which is absent from the fluid of a general paralytic. 
This inhibition of precipitation closely resembles the phenomenon 
observed in the “ precipitin reaction,” where an excess of the antigenic 
protein will prevent precipitation. “ Agglutination ” is a similar process, 


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for agglutinins carry positive electric charges whilst bacteria are nega¬ 
tive. Other instances of such complex mixtures of interacting colloids 
occur in the varied phenomena of haemolysis, immunity, and anaphylaxis. 

The complexity of the problem now becomes manifest. In delving 
into it one finds that the deeper one excavates, the greater is the 
surface to work at and the larger the hole one is in. It may be stated 
at once that the mechanism of the goldsol test is not yet fully under¬ 
stood. Some of the factors influencing precipitation are known, and 
have already been described. But the real nature of the substance 
which initiates the sequence of changes in the goldsol, resulting in its 
complete sedimentation, is unknown. 

Lange suggested that the reaction might be due to certain quali¬ 
tative changes in the fluid’s proteins rather than to their quantitative 
increase. This is supported by the fact that some fluids which give a 
typical paretic gold curve show no excess of globulin by the Ross-Jones 
test. Conversely, a fluid giving a positive Ross-Jones reaction, may be 
negative with the gold test. Further, globulin collected from large 
amounts of negative fluids and concentrated in saline solution causes 
little or no precipitation of gold. 

This disposes of Felton’s plausible suggestion that the reaction is 
caused by a change in the relative proportions of the albumen and 
globulin fraction of the fluid’s proteins—that is, a change of ratio 
implying a quantitative increase of globulin without any qualitative 
change in its nature. Yet the various types of goldsol reaction can be 
reproduced artificially by using suitable mixtures of globulin and 
albumen, the former causing precipitation and the latter conferring 
protection. 

Zaloziecki regards the test as a form of immunity reaction; this is 
true enough in the sense that probably all the serum reactions are 
colloidal phenomena. Jager and Goldstein think it may be a physical 
effect of an electric nature. Eskuchen holds that a pathological 
increase of albumen is the cause. This is difficult to accept in view 
of its known protective power against precipitation. McDonagh’s 
hypothesis is, that there is an increase of electrolytes in luetic spinal 
fluid, and that these are absorbed by the lipoid protein particles, these 
combined electrolytes being the active bodies. The chief electrolyte in 
the spinal fluid is sodium chloride ; I have not been able to find any 
record that its percentage is increased in paretic fluids. 

Weston’s experiments established that the gold-precipitating sub¬ 
stance is not present in normal fluids, that it is destroyed by heat, and 
therefore is not peptone, and that the salts and the copper-reducing 
substance of the spinal fluid are not responsible. 

Cruickshank dialysed paretic fluids for seventy-two hours in a 
celloidin capsule without finding any trace of gold-precipitating sub- 


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64 THE GOLDSOL TEST IN MENTAL DISEASE, [Jan., 

stance in the dialysate, whereas the fluid within the thimble retained its 
activity almost unimpaired. This shows that the gold-precipitating 
substance is present in colloidal form. Now it is known that the 
Wassermann reacting substance resides in the globulin fraction of the 
protein of the paretic spinal fluid—that is, in colloidal form. To investi¬ 
gate this similarity Cruickshank precipitated the globulin from paretic 
fluids, washed it free from albumen, and found that it was very active in 
precipitating gold and in giving a positive Wassermann reaction. The 
same experiment performed with the globulin from negative spinal fluids 
caused no gold precipitation and no Wassermann reaction. Further, 
when paretic spinal fluids which gave anomalous reactions with the gold 
test were examined in the same way, the globulin, when isolated, gave 
paretic reactions; and it became evident that it was the presence of the 
albumen that was interfering with the precipitation—acting, in fact, as a 
protective colloid. For Cruickshank was not only able to convert a 
positive reaction given by a paretic fluid into a negative one, but could 
make the fluid react in any zone at will by the previous addition of 
suitable proportions of human serum albumen to it. 

It seems hardly possible that the factors so far discussed do not exert 
a considerable influence on the reaction. But there are other features 
that require explanation. For example, if albumen is the protecting 
agent, how is it that when a spinal fluid is deprived of its albumen by 
boiling and subsequent filtration, the protective effect of the fluid is 
not lessened, and may even be increased ? The explanation I offer is 
purely hypothetical, but right or wrong it is of value so long as it tends 
to further investigation. It seems to me that there must be some 
change in the electrolytic constitution of a paretic fluid. On this 
assumption, the problem just stated can be explained by saying that the 
fluid after removal of its albumen gains in protecting power, because the 
precipitating electrolytes have been removed along with the albumen, to 
which they were absorbed in a colloidal union. 

Cruickshank seeks to exclude electrolytes as the precipitating cause 
on the grounds that they are present in such small amounts, and that 
they would need to be attached to the globulin fraction in such a way 
as not to be freed by dialysis. But it is an established fact that only 
minute traces of electrolytes are sufficient to bring about colloidal 
phenomena, and surely it is no more unreasonable to assume that the 
electrolytes are absorbed by the proteins in an unaialysable combi¬ 
nation, than it is to assume that the gold-precipitating substance resides 
in the globulin fraction because it does not dialyse out. Now it has 
been shown by Bayliss that if the suspensoid particles of a colloidal 
protein are given a positive or a negative charge by traces of acid or 
alkali respectively, the precipitating effect of electrolytes comes into 
play, and the anion or cation respectively becomes prepotent according 


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BY P. W. BEDFORD, M.D. 


65 


to Hardy’s rule. Further, the salts of proteins are electrolytically 
dissociated in solution. The sodium salt of globulin, for example, 
partially dissolves into sodium, and a large organic ion which has the 
properties of the colloidal state, the hydrochloride, dissociates into 
chlorine and a large, colloidal, organic cation. 

Thus by direct chemical means we can obtain the same protein with 
a negative or a positive charge, and these colloidal ions are very ready 
to form aggregates. It follows that in an acid spinal fluid the particles 
forming the internal phase—that is, the protein particles—will have a 
positive charge, and the converse holds true for an alkaline fluid. This 
can be demonstrated experimentally, for the addition of small amounts 
of acid to paretic fluids increases the zone of precipitation, while the 
addition of alkali diminishes it. 

It has already been noted that acid goldsols precipitate with negative 
fluids and that alkaline sols are inert with positive fluids. This is 
simply another aspect of the same phenomenon. At this point it 
becomes obvious why it is necessary that for diagnostic purposes a 
goldsol should be neutral. In preparing the sol, the reduction of the 
gold chloride by the formaldehyde is accompanied by the liberation of 
free acid. If this is insufficiently neutralised by shortage of potassium 
carbonate in the alkaline solution, or rendered too alkaline by excess of 
carbonate, the corresponding type of sol will result in each case. 

From all this there emerges the important conclusion that in 
performing the goldsol test we are mixing a negatively-charged colloidal 
solution (the goldsol) with a positively-charged colloidal solution (the 
paretic spinal fluid), in the presence of an electrolyte (the saline diluent), 
and obtaining a precipitate. Further, that the result can be reversed by 
previously altering the chemical reaction of either colloidal solution. 

It seems to me, therefore, that the change which has occurred in the 
paretic fluid is that it has acquired an acid reaction and thereby 
developed a positive electric charge on its globulin particles. In other 
words I venture the opinion that the goldsol test is nothing more or 
less than a rough but easy method of demonstrating changes in the 
hydrogen-ion concentration of the spinal fluid, or alternatively, that it 
is an index of the static equilibrium of the fluid’s colloidal content. 
Levinson has shown that such changes in concentration do occur in the 
meningitides, but the biological phenomena initiating them are yet to seek. 

In reviewing the work that has been done on this test, it would 
appear to be established— 

(1) That typical, well-marked reactions are obtained only in general 
paralysis, tabo-paresis and juvenile paresis ; and that the percentage of 
positive reactions is 95 in these diseases. 

(2) That normal fluids give negative reactions. 

(3) That the goldsol reaction is more sensitive than the YVassermann 

LXVIII. 5 


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66 THE COLLOIDAL GOLD REACTION, [Jan., 

reaction, quite as reliable, and probably of more value in the early 
diagnosis of neuro-syphilis. 

(4) That the test is helpful in the recognition of acute poliomyelitis. 

(5) That it may prove to be of much more value in the diagnosis of 
congenital syphilis than any other tests hitherto employed. 

(6) That important points in its favour are : its simplicity minimising 
chances of error, its performance occupying only a few minutes, and its 
need of but two or three drops of spinal fluid. 

(7) That its chief drawback is the uncertainty of being able to prepare 
A good goldsol at every attempt. 

The present-day tendency to exalt laboratory diagnosis at the expense 
of.clinical experience is liable to cause extravagant claims to be made 
for such a test as this. But it must be borne in mind that a diagnosis 
cannot be centrifuged nor extracted, nor even precipitated from a spinal 
fluid, and that any expectation of obtaining an infallible and character¬ 
istic laboratory test is unreasonable. 

(The discussion which followed will be found on page 519, vol. lxvii, 

1 9 ai 0 


The Colloidal Gold Reaction in the Cerebrospinal Fluid.( l ) By 
W. Whitelaw, M.B., Ch.B.Glasg., Director of the Western 
Asylums Research Institute, Glasgow. 

In this paper I should like to emphasise the technique of the 
colloidal gold reaction rather than the results I have obtained, for the 
cerebro-spinal fluids I have been so far able to examine have been 
mostly from cases of dementia paralytica, and, though the results are 
interesting and suggestive, the number of cases is too limited to allow 
one to dogmatise on the findings. 

The examination of the cerebro-spinal fluid is essential in the study 
of neurological conditions. From it we obtain information which is of 
diagnostic and prognostic value, and, also as shown in the work of 
Swift and Ellis (1), it is a valuable index of the efficacy of treatment. 
The three reactions in use at the present day, the Wassermann reaction, 
the cell count and the globulin estimation, suffice for most of the 
requirements of clinical diagnosis, but, in the syphilitic infections 
especially, they have their limitations. From such an examination we 
can say that a certain case is suffering from a syphilitic infectioh of the 
cerebro-spinal axis. We cannot go further. Any reaction that offers 
to yield fuller information has to be tested. This can only be done by 
the examination of a large number of cases of different conditions, so 
that one may establish a foundation from which to build. 

An enormous amount of work has been done during the recent 
development of colloid chemistry towards the elucidation of some of 

(*) A paper read at a meeting of the Scottish Division, March 18th, 1921. 


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BY W. WHITELAW, M.B. 


67 


the perplexing and complicated reactions of biology. This has been 
done, to mention a few of these problems, in the blood oxygen content, 
enzyme reactions, Wassermann reaction, immunity, and the estimation 
and differentiation of protein substances. 

Faraday in 1857 (2) found that goldsols (a sol is a liquid colloid 
•system) were more stable when “jelly” (probably gelatine) was added 
to them—that is to say the goldsols were protected by adding another 
more stable colloid to them. Zsigmondy in 1901 (3) investigated this 
action quantitatively by means of his goldsol, which is itself very stable 
and is also very sensitive to the action of salts. He determined 
the protecting power of various proteins and other colloid substances to 
the goldsol. The degree of protection he expressed as the “gold 
number” of the particular substance under review. This reaction is 
used in the identification of proteins. 

Lange (4) in 1912 applied the gold protection method of Zsigmondy 
to the cerebro-spinal fluid, and found that in certain fluids, instead of 
getting protection to the goldsol, quite the reverse occurred. This was 
noted in fluids that had an abnormal protein content and especially in 
cases of syphilitic disease of the central nervous system. There was an 
optimum dilution for this reaction and this was evidently specific, so 
rendering possible the differentiation between syphilitic and non-syphilitic 
conditions by the colloidal gold. There were two types of reaction 
recognised by Lange, the reaction in the “ luetic zone ” and the reaction 
in the “meningitic zone.” The term “paretic zone reaction” was used 
by Miller and Levy in 1914 (5). 

Technique of the Test. 

All glassware used in the test requires to be chemically clean. The 
water used in the preparation of the goldsol and in the diluting fluid is 
-double distilled through an all-glass still, using potassium permanganate. 
The preparation of the goldsol is as follows: roo c.c. of the double 
distilled water are heated in a 500 c.c. Florence flask. During the 
heating process 1 c.c. of a 1 fer cent, gold chloride and 1 c.c. of 2 per 
cent, potassium carbonate are simultaneously added and the flask well 
shaken. At the boiling-point the gas is removed, and 1 c.c. of a 1 fer 
cent, solution of 40 per cent, formaldehyde is added rather slowly, the 
flask being vigorously shaken during this addition. The reaction com¬ 
mences in a few seconds, or at most a minute, when an intrinsic clear 
bright red colour is gradually developed. A good sol should be pure 
red in colour, with no suggestion of any blue by any light. It should 
be clear and transparent in both transmitted and reflected light. It 
should not dialyse or diffuse. Five c.c. of the sol should be completely 
precipitated by 17 c.c. of a 1 per cent, solution of sodium chloride in 
one hour. The solution should be neutral in reaction using alizarin 
red as indicator. 


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68 


THE COLLOIDAL GOLD REACTION, 


[Jan., 

The cerebro spinal fluid is collected in two chemically clean tubes. 
The colloidal gold reaction is done with the fluid in the second tube, as 
a trace of blood interferes with the reading. Fluids can be kept several 
days provided they are uncontaminated, though I have examined all 
specimens as soon as possible. 

The test is performed as follows: 11 chemically clean tubes are 
placed in a rack. Pipette into tube i, i*8 c.c. o'4 per cent, saline, and 
into the other tubes ro c.c. saline. Into tube 1 deliver o'2 c.c. 
cerebro-spinal fluid, mix, withdraw 1 c.c. and place in tube 2, mix, and 
place 1 c.c. in tube 3, etc., to tube 10. Each tube will contain 1 c.c. of 
fluid in dilutions from 1-10 to 1-5120. Tube n contains 1 c.c. of 
saline only and serves as a control. To each tube add 5 c.c. of the 
colloidal gold reagent. This can be added with a burette. The reagent 
should be added and mixed as rapidly as possible. The reading is 
made after standing at room temperature for 12 hours. Half the above 
quantities may be used with no effect on the results. 

The Reaction Observed. 

The reaction observed in the tubes is a colour change due to an 
alteration in the dispersity of the gold colloid. A normal fluid at the 
end of 12 hours shows no change in any of the tubes. Such a tube 
may be represented by the figure o. The colour changes consist of a 
series of shades passing from red through blue to a clear fluid with a 
deposit of blue granules. The shades usually selected to give a standard 
are red, reddish blue, lilac or purple, blue, grey-blue, and colourless. 
These shades are given the numbers from o to 5 respectively, and from 
the results one can plot a curve for each fluid examined. 

Three types of curves are at present recognised: (1) The paretic 
curve. This zone comprises the first 3 to 6 tubes in which the 
reaction is characteristically of the 5 type. (2) The luetic curve. 
This zone also comprises the first 6 tubes, but the reaction is not 
nearly so complete. The maximum point occurs in the dilutions of 1 
in 40, 1 in 80, or 1 in 160, and the reduction never exceeds a 4. (3) 

The meningitic curve. Here the reacting zone is in the higher dilutions, 
with no reduction in any of the tubes up to the dilutions of 1 in 40 or 
1 in 80. 

Results Observed with the Reaction. 

The present results are based on the findings in 63 fluids from 62 
patients. The following routine has been employed in the examination 
of the fluids : (1) A cell-count has been done with the Fuchs-Rosenthal 
counting chamber as soon as possible after obtaining the fluid. In the 
few cases in which the cell-count has not been recorded this was due to 
there being too little fluid, blood being present for too long after with¬ 
drawal. No attempt has been made at a differential count. (2) The 
increase in the protein content has been tested for by the Ross-Jones 


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BY W. WIIITELAW, M.B. 


69 


method. In a good number of cases this reaction has been confirmed 
by the butyric acid reaction of Noguchi. The results have been 
parallel in every case so tested. (3) The Wassermann reaction has 
been done by the Harrison method, and in the case of the blood, 
where that has been available, the Harrison method has also been 
employed. (4) The colloidal gold reaction has been performed as above. 

The details of the results are presented in the four tables. 


Table I .—Dementia Paralytica . 



i 


Cerebro-spinal fluid. 



Ca*e 

W.R. 1 





Remarks. 





No. 

blood. ! 







i 

C ell count. 

Globulin. 

! 

W.R. 

Gold reaction. 


1 

i 

15 per c.mm. 

1 

* i 

4 - 4 - 4 - 4 - 

5555542 ioo 


3 


i '5 

+ 4* 

4 - 4 - 4 - 4 - 

5555553 ioo 


4 


40 

4- 4- 

4 - 4 - 4 - + 

4555553200 


5 


S 4'6 

4- 4- 1 

+ 4 - 4 - 4 - 

555555 iooo 


6 


I 9' 1 

4- 

anti-corn- 

5555552000 






plementary 



7 

1 

Not counted 

± trace 

+ + + + 

5555530000 


12 

+ + 

1 53*8 per c.mm. 

4 - + 

+ + + + 

55553 ioo oo 


13 

+ + 

104 

+ 4 - 

[ + + + + 

5555530000 


15 

+ + 

I 2‘5 

4 - 4 - 

+ + + + 

5542210000 


17 


54*17 n 

4 - 4 - 

+ + + + 

5554432000 


18 

+ + 

1527 

4 - 4 - 

+ + + + 

5555432000 j 


20 

+ + 

15*9 

4 - 4 - 

+ + + + 

5555442000 j 


22 


Not counted 

4 - 4 - 

I + + + + 

5554422000 


23 

i 

| 7*6 per c.mm. 

Negative 

+ 

1111100000 

Intra-spinous 


: 





treatment one 







year ago, now 







stationary. 

24 

+ + 

25*7 

4 - 4 - 

+ + + + 

5555443210 


25 


825 

4 - + 

+ + + + 

5555543000 


26 


12-2 „ 

+ 4- 

+ + ± 

5554321000 


27 


993 

4 - 

+ + + + 

5554422100 


29 

+ + 

68 

4 - + 

4 + + + 

5555552100 


30 

+ + 

22-2 

I 4- + 

+ + + + 

5555553100 


3 1 

+ + 

Not counted 

1 + + 

+ + + + 

5555544210 


32 


a >t 

1 No test 

+ + + 4 - 

1243344420 

Quantity of 




1 



blood present 







in fluid. 

33 


M >> 

)* 

+ + + + 

1234443422 

Ditto. 

34 

+ + 

116 6 per c.mm. 

4 - + 

+ + + + 

5555543200 


35 

+ + 

503 n 

4 - + 

+ + + + 

5555443200 


3 6 


j *63*8 „ 

4- + 

+ + + + 

5554432000 


38 


I 45 

+ 

+ + + + 

5555552200 


39 


25 7 ». 

4 - 

+ + + + 

5555553200 


41 


45*2 tt 

-+■ 

+ + + 

4445321000 


42 


4i 

+ + 

+ + + + 

5555553310 


43 


617 »> 

4* .+ 

+ + + + 

55555543 10 


44 


Not counted 

+ + 

+ + + + 

5555431100 


49 


17*6 per c.mm. 

+ 

+ + + + 

5555543100 



+ + 

37 *i 

4 - + 

+ + + + 

5555542100 


52 


98*6 „ 

4 - + 

+ + + + 

5555543200 


53 

± 

406 „ 

4 - 

+ + + 

5555543300 


59 


321*9 >, 

4 - + 

+ + + + 

5555555210 


61 

+ + 

45 

+ + 

+ + 

5555553210 


37 


9*7 „ 

± 

+ + ± 

4433221000 



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70 THE COLLOIDAL GOLD REACTION, [Jan., 

The first table contains 39 fluids from 39 cases of dementia para¬ 
lytica; of these 35 gave a typical reaction in the paretic zone. Two of 
the four fluids that did not give this curve contained a considerable 
quantity of blood. For the present these may be neglected, and I shall 
refer to them later. Another of these cases, No. 23, had a course of 
intra-spinous treatment over a year ago, and clinically he has remained 
stationary since that time. His cell-count was within normal limits 
(9 per c.c.), there was no reaction to the globulin test, the Wassermann 
reaction was slightly positive, giving a reaction only in the highest 
concentration of fluid, and the colloidal gold showed a slight reduction 
in the first 5 tubes, the reading being 1, 1, 1, 1, 1, o, o, o, o, o. In 
one of Miller’s and Levy’s cases there was a marked diminution in the 
intensity of the gold reaction after intra-spinous treatment, though the 
usual result they obtained was to remain “gold fast” as well as “ Wasser¬ 
mann fast” (5). The last case in Table I, No. 37, tended to the paretic 
curve. It read 4, 4, 3, 3, 2, 1, 1, o, o, o. The percentage of positive 
cases so reads at 97 per cent. This is in general agreement with the 
findings of other writers. For instance, Miller and Levy (5) obtained 
49 paretic curves from 49 cases of dementia paralytica; Miller, Brush* 
Hammes and Felton (7), 126 paretic curves from 130 cases of dementia 
paralytica; and Hammes, as quoted by Thompson (8), 42 paretic curves 
from 43 cases. 


Table II .—Dementia Paralytica which are Atypical Clinically. 





Cerebro-spinal 

fluid. 

! 


W R 






No. 

blood. 





Remarks. 



Cells. 

Globulin. 

W.R. 

Gold reaction. 


2 


3 

+ 

+ + 

1233221000 

14/7/20. 

2 


20*4 

+ 

+ + 

I 22322 IOOO 

15/12/20. 

II 

+ + 

30 

+ 

+ + 

I2233IOOOO 


l6 

+ + 

937 

+ + 

+ + + 

44422IOOOO 


28 


7 i *5 

+ 

+ + + 

1233321000 



The next group, as shown in Table II, includes 5 fluids from 4 patients 
who were atypical cases of dementia paralytica from the clinical point 
of view. The curves they gave were of the luetic type except in case 
No. 16, which was of the paretic type, and read 4, 4, 4, 2, 2, 1, o, o, o, o. 
Case No. 2, beyond the increase in the cell count, showed very little 
difference in the two examinations at an interval of 5 months. 


Table III .—Other Syphilitic Conditions. 


Case 

No. 

W.R. 
blood, j 

Cerebro spinal fluid. 

Remarks. 

Cells. 1 Globulin. [ W.R. 

| Gold reaction. 

H 

57 

62 

+ 1 
+ + 

+ + 

55 ! ± ! + + 

7*6 | — j — | 

15*6 j + + | + + + 

3II22IOOOO 

III2IOOOOO 
2223422000 

Syphilitic dementia. 
Syphilitic history. 
Meningeal syphilis. 


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1922 .] 


BY W. WHITELAW, M.B. 


7 * 


Table III contains three fluids from syphilitic conditions. These all 
gave the reaction in the luetic zone. Case No. 62, a case of meningeal 
syphilis, is in agreement with those of Miller and Levy (5), who found 
that 13 out of 15 cases of cerebro spinal syphilis gave a luetic curve; the 
other two cases gave no reaction. Thompson (8), on the other hand, 
out of 31 cases of this kind obtained 15 paretic curves, 6 of the luetic 
type, 6 atypical and 4 negative. 


Table IV .—Miscellaneous Group. 




Cerebro-spinal 

luid. 


Case 

VV.R. 


____ 


No. 

blood. 

! 


Remarks. 



Cells. Globulin. W.R. 

Gold reaction. 


8 

— 

2-8 ! - i - 

OOOOOOOOOO 

Mania, simple. 

9 


2-2 i ; - 

OOOOOOOOOO 

Dementia praicox. 

10 



OOOOOOOCX)0 

•> 

48 


86 - j - 

OOOOOOOOOO 

ri 

55 


2' I ! — j — 

OOOOOOOOOO 

. 

19 

— 

i*3 j - : ~ 

OOOOOOOOOO 

Dementia, alcoholic ? 

21 


J ’4 - ! - 

OOOOOOOOOO 


54 

— j 

07 — — ! 

OOOOOOOOOO 

Dementia, simple. 

45 


6 ■ - - I 

OOOOOOOOOO ! 

Post-operative dementia; 




1 

1 

cerebral tumour. 

63 

— 

Clot + + — 1 


Cerebral tumour,glioma. 



present ! 1 ; 

OOOOOI 2210 j 


60 1 


4*5 ; ± — i 

1111122210 | 

Traumatic dementia. 

40 

— 

1*4 

OOOOOOOOOO j 

Manic-depressive. 

56 


5 *5 — j 

II 1 lOOOOOO ; 

»» 

5S 

I 

9*3 - . - ; 

011 2100000 ! 

Delusional insanity. 

50 

I 

66 - - j 

OOOOOOOOOO | 

Epilepsy. 

47 

_j 

4*5 , - ~ | 

OOOOOOOOOO j 

Melancholia. 


Under W.K. blood: — a negative, i = trace positive, + * positive, 
+ + = strong positive. 

Under cells : Number given per e.mm. 

Under globulin : — = none present, ± = trace, + distinct, + + = marked 
ring. 

Table IV shows the findings in 16 cases of various other conditions, 
such as dementia prsecox, manic-depressive insanity, cerebral tumour,, 
epilepsy, etc. Twelve of these were negative. Two cases, Nos. 63 and 
60, one a case of cerebral tumour, the other a case of traumatic 
insanity, showed the reduction of the colloid in the higher dilutions— 
the meningeal or chronic curve. This change is obtained in acute 
meningeal infections and in the late stages of tuberculous meningitis 
(Miller and Levy). One also obtains such a reaction in fluids which 
contain a mixture of blood ; Harrison (9), among others, mentions this. 
It is of interest in this connection to refer again to Cases 32 and 33— 
the two cases in the first table that had blood present. They showed 
as if they had two curves—a luetic curve and then a curve in the higher 


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72 


THE COLLOIDAL GOLD REACTION, 


[Jan., 

dilutions superimposed. One read i, 2, 4, 3, 3, 4, 4, 4, 2, o. One 
case of manic-depressive and one case of chronic delusional insanity 
showed a slight reduction in the luetic zone. Unfortunately the blood 
for the Wassermann test was not obtained from either case. 

Nature of the Reaction. 

The exact nature of the reaction is at present not known. This is 
natural when we consider that our knowledge of the chemistry of the 
proteins does not extend very far, and that the electrolytic changes 
which take place in the colloids are not fully understood. The generally 
accepted view regarding the reduction of the colloidal gold which takes 
place on the addition of a pathological spinal fluid is that it is due to 
the action of positively charged ions present in the fluid. Lange (4) 
was inclined to the opinion that the reduction was an indication of 
different qualitative mixtures of the protein substances rather than a 
quantitative change. This is supported by the fact that the reactions 
bear no relation to the amount of protein present as revealed by the 
ordinary tests. 

Most colloid sols in water—hydrosols as they are termed—have a 
negative electric charge ; a few are positive, as the oxides of the metals, 
etc. Colloids are reduced or precipitated out by salts, and it has been 
shown that it is the ion of the opposite charge that is responsible for this, 
and the power of reduction is proportional to the valency of the ion 
(see Taylor, 6). Also it has been shown that, as well as one colloid 
protecting another, as I mentioned at the beginning of this paper, 
some colloids precipitate others. This also depends on the electric 
charge. Colloids with different electric charges precipitate each other 
(Lottermoser, 11, and Linder and Picton, 12). Colloids with the same 
electric charge do not precipitate out, but the mixed sol acquires the 
stability of the more stable component (Henri, 13). The precipitation 
of colloids with different electric charges takes place only at optimum 
dilutions, no reaction taking place at either side'of this optimum. 

McDonagh (10) has brought evidence suggestive of the fact that the 
reaction depends on the hydrogen ion concentration of the fluid. He 
added acetic acid or ammonia to normal and paretic fluids. No 
reaction took place on the addition of ammonia to a paretic fluid, but 
acetic acid with a normal fluid might give a paretic curve. Acetic acid 
is positive on account of its hydrogen group, while ammonia is negative 
from its OH group. Acetic acid should then precipitate colloidal 
gold, and also cause a precipitation when added to a normal fluid, since 
the colloidal gold is negative. On addition of ammonia to a paretic 
fluid the electric charge will be reversed and no precipitation will take 
x place in the goldsol. This is what takes place according to McDonagh’s 
facts. 


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The nature of the particles in the cerebrospinal fluid which bear the 
positive charge is still not quite clear. Cruickshank (14) locates the 
substance giving this reaction in the globulin fraction. 

A paretic curve has been obtained in conditions other than dementia 
paralytica. As noted above, out of 31 cases of cerebro spinal syphilis, 
Thompson had 15 cases which gave a paretic curve. He states that 
of these 15, all but 3 showed marked mental symptoms; while in the 
16 with the milder gold reaction the mental symptoms were in the 
background. In disseminated sclerosis Moore (15) showed that a 
paretic curve was the usual reaction, and in 20 cases obtained such 
a reaction in 18. Thompson had 5 cases of disseminated sclerosis 
which gave a paretic curve, and Adams (16), out of 41 cases of this 
condition, obtained a paretic curve in 5 and a luetic curve in 34. In 
addition to these a paretic curve has been occasionally found in a few 
-other conditions, such as brain abscess, Warwick and Nixon (17), 1 
case; cerebellar tumour, Thompson, 1 case; epilepsy, Larkin and 
Cornwall (18), 1 case; etc. These conditions would indicate a 
more or less destruction of nerve-cells, and, as Thompson suggests, 
a paretic curve points towards a parenchymatous involvement of the 
brain. 

Conclusions. 

(1) The colloidal gold reaction is a laboratory test, and can be 
performed rapidly with a minimal amount of cerebro-spinal fluid. 

(2) Extreme care is necessary in the cleaning of glassware and the 
preparation of the reagents. 

(3) The paretic reaction occurs in dementia paralytica with great 
constancy but is obtained in some other conditions, and so the results 
from a laboratory test such as this should only be considered in relation 
to the other evidence in the case, both clinical and pathological, as the 
tendency might be to depend too much on an unknown test of this 
kind at the expense of the other facts. 

(4) Wider use should be made use of the test in order that numbers 
will eliminate discrepancies. 

In conclusion I would like to thank the medical superintendents and 
medical officers of the various asylums for the facilities they granted me 
to obtain the material for this paper. 

References. 

(1) Swift and Ellis.— -Journ. Exper. Med., 1913, xii, p. 331. 

(2) Faraday.— Phil . Trans., 1857, p. 154. 

(3) Zsigmondy.— Zeit . Anal. Chern ., 1901, xl, p. 697. 

(4) Lange.— Berlin, kliti. IVoch ., 1912, xlix, p. 897 Zeit. f. Chemo- 
Jherap ., 1913, 1 , p. 44 - 

(5) Miller and Levy.— Bull. J. Hopkins Hasp., 1914, xxv, p. 133. 


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(6) Taylor.— The Chemistry of Colloids. (Arnold, 1916.) 

(7) Miller, Brush, Hammes and Felton.— Bull. J. Hopkins Hosp., 
1915, xxvi, p. 391. 

(8) Thompson.— Amer. Arch. Neurol, and Psychiat., 1921, v, p. 135 
(February). 

(9) Harrison .—A Manual of Venereal Diseases. (Oxford Medical 
Publications, 1916.) 

(10) McDonagh.— Lancet , 1920, ii, p. 991 (November 13th). 

(11) Lottermoser.— Anorg. Kolloide, 1901, p. 77. 

(12) Linder and Picton.— Chem. Soc.Journ., 1897, lxxi, p. 568. 

(13) Henri.— Compt. Rend. Biol., 1904, lv, p 1666. 

(14) Cruickshank.— Brit. Journ. Exper. Pathol., 1920, i, p. 71. 

(15) Moore.— Arch. Internal Med., 1920, xxv, p. 58 (January). 

(16) Adams.— Lancet, 1921, i, p.420. 

(17) Warwick and Nixon.— Arch Internal Med., 1920, xxv, p. 119 
(February). 

(18) Larkin and Cornwall.— fount. Lab. and Clin. Med., 1919, iv, 
P- 352 - 


Part II.—Reviews. 


Sexua/pathologie. Dritter Teil. Von Dr. Magnus Hirschfeld. 

Bonn : Marcus und Weber’s Verlag. Pp. xi 4- 340, Svo. 

This is the third and last volume of Dr. Hirschfeld’s handbook of 
Sexual Pathology. The earlier volumes have previously been noticed 
in the Journal, and this final volume confirms the impression that we 
here have a work of the first practical importance in this special field, 
and completely superseding Kraflt-Ebing’s Psychopathia Sexualis, once 
so well known but long since out of date, great as was its pioneering 
significance half a century ago. Dr. Hirschfeld is not concerned to- 
discuss the literature of his subject, and seldom either criticises or 
approves the investigations of others. He relies on his own experience 
and the conclusions to which that experience has led him; frequently 
he devises his own technical terms (which are sometimes open to 
criticism). But his practice has been so extensive during the past 
twenty-five years, both privately and medico-legally, and his judgment 
is usually so sound, that no living expert could hope to put forth a 
treatise likely to rival this work in practical value. It is much to be 
hoped that it will soon be translated into English. 

It is impossible here to deal in detail with the numerous subjects 
included in the present volume. It must suffice to mention a few 
of them. The author describes the general subject of this volume 


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as “ disturbances of sexual metabolism with special reference to* 
impotence,” but, as here understood, this subject covers a vast number 
of topics, though they may be said to be bound together by the fact 
that variations in hormonic processes—and such variations may be very 
numerous—all tend to induce deviations of the sexual impulse which 
diminish or altogether abolish the strength of the normal impulse. 

The first chapter covers concisely but comprehensively in eighty 
pages the whole vast field of sexual symbolism, that is to say, the erotic 
fetichisms, of which, it is probable, more are here recorded than have 
ever been noted before. We then pass on to hyper-eroticism, which, 
as here understood, overlaps sexual symbolism, and is made to include, 
not only the unquestionable anomalies of excess, but sadism, which 
is very dubiously an anomaly of excess, and other deviations bordering 
on fetichism. The third chapter deals directly with impotence, 
beginning with an exposition (with diagram) of the complicated 
subject of genital innervation, and proceeding to separate methodically 
the various forms of impotence in both men and women. In the 
succeeding chapter, on the sexual neuroses, the author comes most 
closely in touch with psychiatry, for he is here occupied with, among 
many other allied subjects, hysteria, anxiety-neurosis, sexual hypo¬ 
chondriasis, delusions of jealousy, masturbational neurosis, etc., and 
sets forth his cautious relationship to psycho-analysis. Finally, the 
concluding chapter presents the psychologically interesting and medico- 
legally important subject of exhibitionism. 

Throughout, Dr. Hirschfeld maintains the strictly practical character 
of his work, and throughout, also, he bears in mind that hormonic 
basis of the sexual life to which he was already attracted before it 
gained its present prominence in medicine. Havelock Ellis. 


Symptomatology, Psychognosis and Diagnosis of Psychopathic Diseases. 
By Boris Sidis, A.M., Ph.D., M.D. Edinburgh: E. & S. 
Livingstone, 1921. Pp. xix + 448. Large crown 8vo. Price 
21s. net. 

The student of morbid psychology and psychotherapy is living in a 
difficult age. He is bombarded on all sides by books dealing with 
these subjects, and the ammunition seems to be unending. Moreover, 
there are many different schools of thought, and each one claims that 
its teaching is the only one to be relied upon. The arguments used in 
sustaining the rival claims are not always advanced with the sobriety 
one expects from a scientific discussion, and in many cases a certain 
amount of heat is engendered in the combatants. This we have grown 
accustomed to, but in the introduction to the volume under review we 
meet with language which is out of place in a scientific work, and the 
only parallel which suggests itself is the odium theologicum. The author 
in writing of Freud says that psycho-analysis is “ sheer humbug,” 
“Talmudic hair-splitting sophistry,” “a mental debauch,” “a form 
of medical bacchanalia,” “ better Christian Science than psycho-analysis.” 
These statements often appear in italics—a form of letter-press which 
the author is very fond of—and are only a sample of many others. 
Through the greater part of nineteen pages of introduction, and occa- 


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sionally in the remainder of the book, psycho-analysis, like King Charles’ 
head in the case of Mr. Dick, will obtrude itself, and when it conies it 
is execrated. It is a strange phenomenon, for, to an ordinary observer 
Dr. Sidis would seem to follow in paths similar to those trodden by 
his adversary. For example, the book is written to indicate the 
powerful influence of the subconscious on psychopathic states. The 
author believes that no diagnosis and treatment is possible without a 
complete history of the life of the patient, and especially of his earliest 
years. He also attaches a considerable value to the study of dreams, 
and though he declaims against Freud’s work in the sexual sphere he 
discusses a case at considerable length, recounting unsavoury details of 
-a sexual nature. 

It is a pity that Sidis has allowed his zeal to outrun his discretion, as 
it causes the reader to feel that one who is so intemperate in his 
language may not be a safe guide to knowledge, with the result that the 
remainder of his book is unread. This would be a matter for regret, 
for there is much therein to interest and to instruct. 

Psychognosis means “a working knowledge of the patient’s soul,” 
and this is to be attained “ by all kinds of methods—hypnoidal, hypnotic, 
and especially by a close observation of the waking states.” Most 
readers will find the chief interest of the book in the account of the 
hypnoidal state, as this is a subject which the author has made particu¬ 
larly his own. It is a sub-waking state, in which the patient, though not 
asleep, is yet not fully awake, and is in that half-drowsy condition in 
which we hover between wakefulness and sleep. The hypnoidal state 
may lead to sleep or hypnosis. Details are given as to how the state 
may be induced, and these consist chiefly of quietness, darkness, the 
closure of the eyes, and some monotonous stimulus. When he is in 
this state it is more easy to tap the subconscious than in the ordinary 
waking state. An interesting account of hypnotic states and hypnoid 
states is given. The latter signifies the condition which exists in 
phenomena such as automatic writing, crystal-gazing, and double or 
multiple personality. 

It is impossible in a short review to give an account of the author’s 
views on hallucinations, aphasias, amnesias, etc., but it may be remarked 
that there is plenty of food for discussion under these headings. His 
classification of mental diseases is simplicity itself, and if it could be 
accepted, would save much time and trouble, but one wants further 
proof than the ipse dixit of the author. For example, general paralysis 
and dementia prcecox are “ organopathies ” in which there is death of 
the neuron. “ Neuropathies ” are diseases in which the neuron is 
affected by toxic products, and include manic-depressive insanity and 
all the mental affections caused by poisons, such as chloral, etc. 

Two of the most interesting chapters are those in which actual cases 
are recorded, and in whom the “ psychognosis ” has been worked out 
by hypnosis or by hypnoidal states. One longs to know the method of 
treatment adopted by Dr. Sidis, but he is stern with us, and keeps 
strictly to the text of his title, namely “ symptomatology, psychognosis 
and diagnosis.” R. H. Steen. 


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JSinfiihrung in die psychiatrische Klinik. By Prof. Emil Kraepelin. 
Leipzig: Johann Ambrosius Barth, 1921. Fourth, fully revised 
edition. In three volumes, 8vo, paper boards. Vol. I, pp. 263, 
price 38 marks. Vol. II, pp. 314, price 44 marks. Vol. Ill, 
pp. 407, price 52 marks. 

The second edition of Kraepelin’s lectures on clinical psychiatry r 
published in 1905, is very familiar to our readers, in translation if not 
in the original. A third German edition appeared in 1916, and now 
we have another in the volumes before us. In these, however, we have 
very much more than a revision of those lectures. What here remains 
of the famous lectures is confined to the second volume ; the first and 
third volumes are new. Each of the three—which are sold separately— 
is independent of the others, differing from them in its scope, and to 
some extent also in the class of readers to whom it will chiefly appeal. 

Considering first the second volume, we observe that the number of 
the lectures is reduced from thirty-two to twenty-five, and by a process 
of checking we find that, of the ninety-three clinical cases described in 
the second edition, only forty-seven remain, to which twenty-eight new 
ones have been added. The order in which the cases are presented 
has been radically altered. Whereas formerly, for purposes of com¬ 
parison and finer contrast, examples of clinical states having more or 
less outward resemblance to one another were grouped together (for 
example, various conditions in which delusions are prominent), the 
cases are grouped now, not according to present state, but according to 
the disease forms to which they belong. Thus, all the cases assignable to 
manic-depressive insanity are kept together, however outwardly diverse, 
and similarly all those assignable to dementia prcecox, and all those to 
general paralysis. The change is a great improvement. At the same 
time there has been no widening or narrowing of the scope and purpose 
of the lectures as a whole, which are intended to present to the student 
as vivid a picture as the written word can give of cases of mental 
disorder as they are most commonly met with. 

The first volume is a text-book. After fifteen pages of psychological 
prolegomena, there are 108 pages on the clinical forms of insanity, 
arranged under the heads of psychoses produced by bodily injury from 
without, psychoses following internal bodily disease, psychogenous 
affections, constitutional mental disorders, and congenital states. Then 
come forty-one pages on clinical pictures considered in relation to 
disease forms, and thirty-two pages on clinical signs and examination of 
patients; these two chapters together provide a magnificent and 
altogether unique apparatus of differential diagnosis. Tables of weights 
and measures follow, and then a list of 170 questions useful for testing 
a patient’s mental state (with three sets of specimen answers to these), 
a chapter on the word-association test (with four full examples), a chapter 
on Binet-Simon tests, and a chapter on drugs and other means of 
treatment. We should hardly have believed it possible to compress so 
much practical information into so small a volume of decent print. 
This book is a very striking example of what can be achieved in the 
way of sound brevity by one who is a master, not only of psychiatry, 
but of authorship. It puts all other small and medium-sized text-books 
of our subject deep in the shade; and besides being much better 


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adapted to the requirements of students preparing for examinations 
•(such as for diplomas in psychological medicine) than any other psychi¬ 
atric text-book that there is, it will be of great interest and convenience 
to experienced psychiatrists, however familiar they may be with its 
author’s other and more voluminous writings. 

The third volume consists of a new set of clinical lectures, quite in 
the style of those we know so well, and infused with all their charm, 
but dealing with a different class of material. The ninety cases here 
described are examples of rare conditions, or are cases presenting 
special difficulties. It is obvious that such a series could not nearly 
exhaust the multitude of rare conditions met with, but the cases have 
been selected to afford as great a variety as their number admits, and 
are gathered from every corner of the field of clinical psychiatry. The 
volume is intended, not at all for examination purposes, but to stimulate 
scientific study. Kraepelin would dedicate these lectures to his younger 
colleagues in asylum practice : “To counteract the paralysing influence 
of the monotonous care of the frightful mass of patients who are mentally 
•defunct, the attainment of a higher point of view is necessary. May 
these lectures help to bring again and again before the young physician’s 
eyes the infinite wealth of our science, in phenomena, in problems, and 
in prospects.” 

This remarkable book, or trinity of books, is one that every psychia¬ 
trist will wish to add to his library, however modest, however large. 

Sydney J. Cole. 


Psychopathology. By Edward J. Kempf, M.D. London: H. Kimpton, 
1921. Royal 8vo. Pp. xxii + 762. 87 illustrations. Price 

three guineas. 

In this imposing and almost sensational volume a systematic attempt 
is made to interpret the psychoses as the outcome of uncontrollable, 
asocial, sexual cravings. The author states his case bluntly and without 
reserve, and he has brought together an astonishing amount of material 
in support of his views. Unfortunately the sentences are so awkwardly 
put together that it is difficult for the reader to assimilate easily and with 
comfort the facts and.theories which Dr. Kempf, with obvious sincerity 
and extreme enthusiasm, regards as essential for a proper understanding 
of the insane. In spite of this, and the fact that there is scarcely any 
view expressed in this book to which unqualified adherence could be 
given, the volume deserves, and well repays, careful consideration, and 
it may be regarded as a definite addition to our knowledge of the 
insane. 

The first chapter is devoted to a summary of the views previously 
expressed by the author in his monograph, The Autonomic Functions of 
the Personality. His aim is to formulate a physiological theory of the 
•doctrine of the Freudian wish, and he feels that the researches of 
Sherrington, Cannon, Pawlow, von Bechterew and Watson have placed 
the psychologist in a position to make such an attempt. The attempt 
is a most amuitious one, and there is but little doubt that a large number 
of neurologists and psychologists will regard it as altogether premature 
in the present state of our knowledge of the physiological basis of 


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thought. On the whole, however, the theory which Kempf erects may 
be regarded as a commendable effort to explain human reactions in terms 
of the whole organism, though his persistence in endeavouring to localise 
instinctive cravings in physiological segments is going much further than 
the facts would seem to warrant. KempPs views of insanity are not, 
however, strictly dependent upon his physiological theory of personality 
—indeed, in a measure he would seem to have invented a physiological 
scheme to fit his psychology—and they could have been expressed 
equally well in ordinary psycho-biologic terms. 

For the purpose of this review, therefore, and without in any way 
minimising the author’s zealous attempt to conceive behaviour physio¬ 
logically, his general psychiatric outlook may be more particularly 
referred to. 

At the outset Kempf discusses the “family romance” of the psycho¬ 
analysts. On the early environmental influences in childhood he places 
the greatest stress. ‘‘Because,” he writes, “the autonomic affective 
cravings, in the child, always become conditioned through influence of 
associates, particularly the adults of the family, and each experience 
conditions the affections so that they determine the adjustment to the 
next experience, it becomes necessary to study the family wherever a 
psycho-pathological disposition is met with in an individual.” The study 
of the affective reactions in a number of psychopathic families has 
convinced Kempf that the assumptions of “ defective heredity ” or 
“ constitutional inferiority ” in such cases reacts on extremely flimsy 
grounds. He seems, indeed, to almost reject the notion of heredity as 
a causal factor in the production of the psychoses; he finds, rather, 
that successive generations of children in certain families have been 
submitted to parental influences of such a kind as to produce morbid 
repressions of the affective functions, and a succession of neuropaths has 
thereby been created. He has observed children with “ excellent 
functional capacities, but the personal influence of the affectively 
distorted parents distorts the affective requirements of the child, and 
this mechanism, plus the insidious censorship of society imposed upon 
those who have insane relatives, may cause miserable maladjustments 
in post-adolescence and maturity, particularly if other personal inferior¬ 
ities exist, such as auto-eroticism.” It is thus suggested that many 
psychopathic conditions are created by environment, and though this 
view is here supported by a number of case-histories, there are, 
unfortunately, too many facts leading to a contrary view for such an 
opinion to be readily accepted. If it were true, many forms of insanity 
would theoretically be preventable, and it is of course possible that the 
factors to which Kempf draws attention play a larger part in the 
production of the psychoses than is generally recognised. 

The question of environment is essential to Kempfs psychology; he 
urges the point almost passionately, and summarily dismisses the 
hereditary factor as academic. He is too alive and eager to concern 
himself with influences which cannot be controlled; he is a social 
reformer on particularly broad lines, and almost obsessed by the 
problem of sex in relation to modern civilisation. He sees humanity 
engaged in the universal struggle for virility, goodness and happiness— 
all defined in his own fashion—and in so far as these aims are not 


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attained the neuro- or psychopath results. “Only those individuals 
biologically adjusted,” he writes, “whose sexual affections are so 
conditioned that, in their striving for gratification, they reinforce the 
ego’s struggle for social esteem.” And modern civilisation he finds 
opposed to the attainment of this desirable biological adjustment; 
American educational and social tendencies have a castrating influence, 
and “ out of the biological chaos of commercialised, loveless marriages 
and sterilised ideals are produced the insane and the criminal.” Briefly, 
then, Kempf regards insanity as the reaction to persistent and uncon¬ 
trollable autonomic cravings—oral, anal, incestuous, homosexual or 
auto-erotic—which conflict with the cravings of the ego for social 
esteem. Either because of the vigour of these perverse cravings, or the 
weakness of the opposing forces of the ego, or fatigue, disappointment, 
toxins, etc., the individual gives up the struggle, and the sexual craving 
dominates the personality. From this biological standpoint Kempf 
erects a dynamic-interpretative conception of the psychoses, and the 
book is largely concerned with full and elaborately worked-out cases 
exhibiting the various mechanisms which occur, and which give the 
psychoses their various clinical forms. The attitude here taken enables 
the author to suggest a new basis of classification. He rejects the 
usual grouping, emphasising symptoms and prognosis, and considers it 
much more practical to use a system of classifying psychopaths 
according to the nature of their autonomic-affective difficulties and 
their attitudes towards them, because this keeps the dynamic factors 
directly in psychiatric attention and permits of revision as the cases 
change.” 

The book as a whole is extremely revolutionary, and it will inevitably 
provoke a good deal of criticism. Some psychiatrists will no doubt 
reject the views of the author in toto. Insanity is much too complex a 
condition to be explained with assurance from one point of view, and 
the book would have been all the more convincing if the author had 
been content to suggest possibilities rather than to formulate sweeping 
generalisations. Though, however, an attitude of reserve may be taken 
towards his theories, it is certain that he has made contributions of 
practical value to the psychology of insanity. In one place Kempf 
observes with truth that “ the controversial method never does sufficient 
justice to the other student of human behaviour,” and if the book is 
approached in this spirit it will be found most stimulating and helpful. 
Kempf has described with considerable skill what is undoubtedly the 
psychological situation in many cases of insanity. An asylum physician 
who fails to observe the influence of sexual cravings in the determina¬ 
tion of many psychoses must be shutting his eyes to the obvious. Our 
asylums, for instance, are full of cases whose symptoms are perfectly 
explicable as reactions to homosexual impulses, and it is possible that if 
biological deviations are recognised sufficiently early, much may be 
done to promote a beneficial adjustment to such inferiorities as may 
exist. Forsyth has published a case which lends colour to such a 
view (i). There is much, then, in KempPs explanations of insanity, 
though he neglects factors which cannot be lightly or profitably ignored. 
He has emphasised, furthermore, that much may be done for asylum 
patients by an increased endeavour to understand them psychologically. 


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As Bleuler and Jung have shown, the insane are very sensitive to 
atmosphere, and we believe, from personal observation, that some cases 
regress into permanent turbulence because their emotional attitude is 
insufficiently understood. Why do some nurses appear to have a 
definite vocation for dealing with the insane, while others, though 
anxious to help, are more or less unsuccessful? Why does a patient 
dislike one doctor and confide in another? Why do visits produce 
relapses in some cases and promote recovery in others? Kempf 
endeavours to answer questions such as these; and in so doing he 
renders a service to psychiatry by emphasising the pragmatic value of 
approaching the insane as persons rather than as diseases. 

H. Devine. 

(i) Forsyth, David.—“Psycho-analysis of a Case of Early Paranoid 
Dementia,” Proc. Roy. Soc. Med,., Section of Psychiatry, vol. xiii, No 9. 


Therapeutic Immunisation in Asylum and General Practice. By W. 

Ford Robertson, M.D., Pathologist to the Scottish Asylums. 

Edinburgh: E. & S. Livingstone, 1921. Demy 8vo. Pp. vii + 278. 

Price 15 s. net. 

The views of Dr. Ford Robertson as to the importance of infections 
in the causation of mental disorder are well known to readers of this 
Journal. In this volume he deals with therapeutic immunisation in its 
wider aspects as applied to medicine and surgery generally, and does 
not deal very exhaustively with infections in relation to insanity. A 
great deal of the book is concerned with practical details of bacterio¬ 
logical technique and the preparation of vaccines. The author is an 
ardent advocate of the claims of bacteriology, and he feels that the 
medical profession, as a whole, has failed to utilise therapeutic immuni¬ 
sation to the extent which it deserves. He here endeavours to give a 
systematic account of all that pertains to this mode of therapy, and 
includes what he regards as most valuable in the work of others as well 
as his own personal researches. On the whole the author differs a good 
deal in his views from those generally held, and, as he himself writes, 
“many heterodox opinions are expressed that are not likely to be 
accepted without a fight.” 

Dr. Ford Robertson’s researches have led him to the view that 
bacterial infections are responsible for a greater number of diseases 
than is generally supposed. His theories of the bacterial causation of 
nervous disorders are perhaps of most interest to the psychiatrist, and 
may here be referred to more particularly. He would seem to attach 
special significance to the pathogenic influence of infection of the 
intestine or genito-urinary tract by anaerobic diphtheroid bacilli, and 
these he regards as having chiefly a neurotoxic action, which manifests 
its effects in the production of a variety of nervous disorders. Amongst 
these he includes disseminated sclerosis, exopththalmic goitre, tabes 
dorsalis, general paralysis, neurasthenia, psychasthenia, acute insanities, 
manic-depressive insanity, and dementia prsecox. He admits the almost 
constant association of syphilis and tabes and general paralysis, but 
advances the theory that in the former the cerebral vessels have been 
damaged by local infection in such a way that they have been rendered, 
LXVIII. 6 


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in places, permeable by bacteria circulating in the blood. Such views 
are not supported by therapeutic results from treatment with autogenous 
vaccines in the case of general paralysis, though the author reports 
improvement in tabes from this form of treatment. He also records 
successes in other forms of insanity and nervous disorders. 

These views will naturally be read with interest by psychiatrists; it 
would be most satisfactory to feel that the bacteriologist was in a position 
to supply curative remedies for insane cases. It must be confessed that 
the possibilities of direct therapeutic approach, based upon the patho¬ 
logical conditions, are somewhat limited in the sphere of mental disorder 
as manifested in our asylum cases. Skilled nursing, a suitable atmo¬ 
sphere, an understanding attitude and general medical treatment are 
the measures upon which reliance has to be placed in order to further a 
process of readjustment. Fortunately this often occurs, though by a 
process the exact nature of which is not thoroughly understood. It is 
probably true to say that the psychiatrist is able to do as much for his 
insane cases as the general physician is for his cases of pneumonia. 

In view of our therapeutic limitations, therefore, the discovery of a 
specific remedy for insanity would indeed be an achievement of the 
greatest magnitude, but as to whether such a remedy will be found along 
the lines in regard to which Dr. Ford Robertson writes so hopefully 
there will necessarily be a considerable divergence of opinion. It 
cannot be said that the views expressed in this book are altogether 
convincing, and they will undoubtedly meet with considerable criticism 
both from the bacteriologist and the clinician. While the author has 
rendered a service to psychiatry in stressing an aspect of mental disorder 
which cannot be neglected, his theories would seem to require a good 
deal of confirmation by other observers before they could be expected 
to gain general acceptance. The unbiassed reader may perhaps feel 
that the author tends to over-emphasise the bacterial causation of 
insanity, and to dismiss too lightly other aspects of the subject. The 
latter tendency is particularly noticeable in his rather slighting references 
to recent work on the pathology of dementia praecox. 

H. Devine. 


Examen des Aliittis , Nouvdles Methodes Biologiques et Cliniques . By 
Andr£ Barb£. Preface by J. S£glas. Paris : Masson et Cie, 
1921. Demy 8vo. Pp. xiv + 178. Price 8 frs. 

Any suggestions which might lead to the establishment of psychiatry 
on a surer basis should meet with our whole-hearted approval and 
support. Especially is this so at the present time, when public pre¬ 
judice against asylums and asylum methods is rife. There is, unfor¬ 
tunately, a tendency for each new text-book on the subject of insanity 
to be more or less a repetition of the last which found its way into 
print, though it is true that a certain amount of colour may be imparted 
by the addition of the author’s own personal views and opinions. The 
danger of this state of things lies in the fact that we may be deceived 
into imagining that psychiatry has already reached a state of perfection, 
and that in consequence nothing further remains to be done. This 
danger was apparently realised by Lugaro, who some years since wrote 


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83 

a book, 1 in which he indicated certain problems which have to be 
solved, and the lines along which future research would have to be con¬ 
ducted in order that psychiatry might be classed among the sciences 
and occupy its proper position in general medicine. 

The present volume affords an excellent opportunity of seeing how 
far the programme suggested by Lugaro has been followed. Dr. Barb6 
points out that during the last few years the progress made in labora¬ 
tory methods, and more especially in biological methods, has been 
such that it has been found possible to trace many mental troubles to 
their true origin, and to confirm the view that the intellectual functions 
are frequently dependent on or modified by other functions of the 
organism. Numerous observers have been carrying on their investiga¬ 
tions independently of one another, and the conclusions reached have 
been published from time to time in the form of articles in the scientific 
journals of different countries. 

In “ New Methods of Examination of the Insane ” the author has col¬ 
lected and summarised many of the more important of these findings, 
with the result that he has been able to produce a book which is both clear 
and practical. Successive chapters deal with the nervous system, the 
cerebro-spinal fluid, the circulation, the blood, the urinary system, the 
respiratory and the digestive systems, the skeleton, the glands of internal 
secretion, intoxications and infections. Though the greater part of the 
work is devoted to laboratory methods, yet the more recent advances 
made in clinical examination receive due attention; and it should be 
noted that the chapter on the nervous system includes a rtsumi of the 
psycho-analytic method of mental exploration. As many as fifty pages 
are devoted to the consideration of the cerebro-spinal fluid, the study 
of which, the author affirms, has become of considerable importance. 

The examination of the cerebro-spinal fluid not only gives us informa¬ 
tion as to the state of the nervous system, but it will often enable us to 
trace the relationship which exists between the nervous symptoms and 
disorders of the viscera.” 

Dr. Barb£ maintains that the clinical study of mental affections has 
remained stationary for want of definite data upon which to establish a 
classification of the psychoses; and though he readily admits that the 
new methods which he describes are far from solving many of the 
problems which have arisen, nevertheless he claims that they have 
helped to explain the role played by humoral modifications, infections, 
and intoxications in the pathogenesis of mental disorders. He suggests 
that these methods, provided they stand the test of time and of future 
researches, might form the basis of a rational classification. 

Perhaps no more opportune moment could have been chosen for the 
publication of this useful little book, of which one of the most important 
features is its excellent and exhaustive bibliography. 

Norman R. Phillpis. 

1 Modern Problems in Psychiatry. By Ernesto Lugaro. English translation, 
1909. 


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Part III.—Epitome of Current Literature. 


i. Psychology. 

The Psychological Foundations of Belief in Spirits . ( Proc . of the Society 
for Psychical Research , May, 1920.) Jung, C. G. 

Belief in invisibles, ethereal beings influencing man, was never 
entirely suppressed among the masses, and has revived recently among 
scientific investigators. Jung describes how primitive man, with his 
complete dependence on nature, was delivered from bondage to sensa¬ 
tionalism by naive belief in and awe of the spiritual. The concrete 
and spiritual worlds were equally real to him and their laws equally 
inviolable. 

He discusses, as grounds for belief in spirits, the phenomena of 
apparitions, dreams, and pathological disorders of the psyche, such as 
hysteria (in connection with which he alludes to parental influence and 
ancestor worship), and the hallucinations of dementia praecox. The 
primitive accepted these as genuine manifestations of the spirits of the 
dead, the souls of the living or elemental non-human demons. To the 
modern materialist they are either trivial or morbid. 

Psychologists of Jung’s school regard the “psyche” as divisible 
into fragments or “complexes,” of which the “ego-complex” is but one. 
Dreams, visions, hallucinations, and delusions are caused by autonomous 
complexes from the unconscious, which appear as projections from the 
exterior because they are not associated with the conscious ego and 
may be antagonistic to it. Certain experiences of St. Paul illustrate 
the mode of action of conflicting complexes which cannot occupy 
consciousness together. Hidden complexes behave like independent 
beings disturbing consciousness. The association experiment to reveal 
their existence and properties is described. 

The writer expounds his view that the unconscious is divided into 
two spheres—the personal and collective—and connects this with the 
primitive discrimination between souls and spirits. The personal uncon¬ 
scious contains psychic material forgotten, of subliminal energy, or 
that which has been repressed owing to incompatibility with the 
conscious attitude. The ego gains psychic energy when complexes 
from the personal unconscious enter consciousness, and is impoverished 
by their dissociation and repression. Similarly the primitive believed 
in a plurality of souls, of which the loss of one caused ill-health. The 
super personal ox collective unconscious contains the “congenital instincts 
and primordial forms of apprehension” which are inherited by all 
mankind or by all members of a group. It gives rise, for example, to 
mythological imagery and symbolism in dreams and in mental dis¬ 
orders. The association of complexes from this sphere with the 
conscious ego feels strange, supernatural, often dangerous, as are the 
“spirits of the dead” which “haunt” primitive man, and their removal 
from consciousness gives relief. 

Animation of the collective unconscious results either from external 
conditions or accumulation of internal energy, and may alter individuals 


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or nations, although rationalisation disguises the source of the change. 
History shows resulting national upheaval, such as the replacement of 
conscious reality by violent desires and fantasies; or resulting gradual 
development of a new, idealistic, psychological attitude. Beneficent 
or harmful, it is always somewhat disturbing and beyond man’s grasp, 
and behaves like spirits or “ghosts from the world of shadows.” The 
primitive sorcerer resembles the intuitive genius who translates the 
collective unconscious into mythology, art, language or ideas. 

“ Spirits of the dead ” may be psychologically created when attach¬ 
ment to a person is, after death, transferred to his image with associated 
psychic energy that is thus lost to the work of life. The vitalised 
image forms a harmful spirit. 

Finally, Jung explains that in treating the subject scientifically he 
leaves the question of the concrete reality of spirits open. 

Marjorie E. Franklin. 

Intelligence Tests . (The Child, June, 1921.) Watts , F 

This paper is an inquiry into the value of mental tests based on a 
historical resume : (1) The early investigators sought to devise a single 
test which would measure innate capacity apart from acquired modifica¬ 
tions. Sensory discrimination was, under the influence of Galton, first 
studied, and subsequently each of the supposed elementary mental 
functions. Apparatus was constructed and a useful technique developed. 
(2) Binet realised that no single test can adequately measure a 
personality, and that, intelligence impyling a capacity for making new 
adjustments, the subject’s stock of “common knowledge” and “every¬ 
day experience” should be investigated. His series of tests was 
standardised according to the average performance of children of 
different ages. The author discusses their merits and demerits, and 
concludes that in the main, especially in improved form, these tests 
have been justified in practice. The fractional method of scoring of 
the “point scale” systems is better, but the choice of tests inferior. 
The various “performance” tests are useful in cases where Binet’s 
more generally valuable language and ideation tests might be mis¬ 
leading. (3) As regards later tests (post-Binet period), with more or 
less agreement on principles, there is divergence in their application. 
The author examines the “alpha” tests of the U.S.A. army, which he 
considers the best attempt to measure intellectual capacity apart from 
attainment, but shows that they are more influenced by environment 
than their sponsors admit. Important points are the undue favouring 
of those accustomed to rapid arithmetical calculations and to dealing 
with words and abstract relations rather than with concrete realities. 
The results of 2,000,000 recruits tested show that such occupations as 
accountant or clerk grade higher than, e.g., sculptor, electrician or 
skilled artisan. The author raises several questions—for example, 
whether the same tests are suitable for individuals of different training; 
whether intelligence tests must be speed tests, and if so, whether 
practice should be allowed; how far to generalise from particular 
performances. He concludes that “general intelligence” in adults is, 
like “ bare native capacity,” a mythical conception. What is obtained 
by the “alpha” and the “graded reasoning” tests of Cyril Burt is a 


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useful rough estimate of intellectual ability which is but one, though an 
important, form of intelligence. An example is given of one who, 
though testing low, obtained academic honours by means of the excep¬ 
tional specialised intuition and sympathy which he possessed. A wide 
range of intellectual tests should be supplemented by tests for specific 
intelligence to demonstrate strength and weaknesses in particular 
directions. Marjorie E. Franklin. 


2. Neurology. 

Lethargic Encephalitis with Myoclonus and Bulbar Attacks [Encephalite 
Ipidemique asthlnique et myoclonique avec crises bulbaires. Evolution 
continue depuis plus <Tun a«.] (Ann. Mid.-Psychol., No. 2, 
February, 1921.) Leroy, R., et Dupouy, R. 

The authors describe the case of a man, set. 50, of great intelligence, 
who became ill in January, 1920. The illness started with insomnia for 
two nights, then symptoms suggesting influenza (which his family were 
suffering from at that time), fever, generalised stiffness in the joints, 
pulmonary congestion; he also had somnolence, it being necessary to 
shake him to wake him up; he was able with difficulty to answer 
questions and take food. The memory of the first fortnight was 
blurred. Shortly after myoclonic spasms occurred all over the body 
except the face, then diplopia (which lasted about six weeks), and ptosis 
in the left eye. About the middle of February the patient tried to take 
up his work again, hoping to rouse himself from the torpor, but he was 
unable to continue, going to sleep as he was walking and falling to the 
ground. In March he slept most of the time, had stiffness of the limbs, 
and especially dragged the left leg. In April he became better and was 
able to take short walks. At the end of April he developed a muco¬ 
purulent discharge from the nose; shortly after he had a febrile attack 
with congestion of the lungs and enteritis; this slowly improved. 
Towards the end of June he was rather better but continually fatigued ; 
he developed marked nocturnal polyuria, passing large quantities of 
almost colourless urine. This ceased later and he improved somewhat, 
but in October he relapsed, became more torpid, attacks of shivering, 
pains in the limbs, and respiratory symptoms with Cheyne-Stokes 
breathing. He was admitted into a Matson de Sante in November. 
Wassermann reaction was negative and cerebrospinal fluid contained no 
albumen and showed no lymphocytosis. The mucopurulent nasal 
discharge persisted; he still had myoclonic attacks and bulbar 
symptoms. 

The authors draw' special attention to the nasal discharge, and 
suggest that possibly the path of entry of the infection is via the nasal 
fossae, thus reaching the region of the infundibulum and the floor of the 
third ventricle, and that therapeutic measures might be directed at the 
early stages of the malady towards disinfecting these fossae. 

L. H. Wootton. 

Cerebellar Fits. (Arch, of Neur. and Pyschiat'., March, 1921.) 
MacRobert, R. G., and Feiner, L. 

The paper is based on seizures occurring in a series of forty-five cases 
of subtentorial tumour, of which twenty-three were cerebellar tumour, 


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six tumour of pons and medulla, and sixteen of the cerebello-pontine 
angle. 

It has been demonstrated experimentally that ablation of part of the 
cerebellum may be followed by peculiar forced movements of the limbs 
and body; Horsley concluded from his observations that the activity 
of nerve-centres is “ translated ” by a combination of clonus and tonus 
factors, the resultant motor manifestations differing according to the 
proportion of one or other of these factors ; clonicity is the property of 
the cerebral cortex, and tonicity of the lower centres. Hughlings Jackson, 
in agreement with this, believed that (1) cerebellar convulsions showed 
tonic spasm, cerebral convulsions principally clonic ; (2) cerebellar 
attacks affect more the bilateral muscles of leg and trunk, whereas in 
cerebral affections one side is involved more than the other, and the 
arm more than the leg; and (3) cerebellar crises resemble tetanus more 
than epilepsy. 

In the authors’ series of cases only nine showed phenomena which 
could be included under the caption of “fits.” One case presented 
attacks of major cerebellar seizures with general rigidity and 
opisthotonus, both arms being flexed and raised, lower limbs extended 
and toes pointed. Retraction of the head and rigidity of the masseters 
commonly accompany this in subtentorial inflammation, but are rare in 
cases of tumour. Four cases had attacks of tonic spasm and forced 
movement, similar in a measure to the forced movements which follow 
experimental ablation of parts of the cerebellum; these cases had 
attacks of homolateral rigidity of an extremity with irregular spasmodic 
jerking movements which were quite unlike a Jacksonian fit, being aim¬ 
less, stiff jerks with no local point of commencement, without gradual 
spread, and were not rhythmic or clonic in character. 

Four cases had cranial nerve attacks, two due to interference with 
the vagus, the others to irritation of the facial nerve. The former had 
speech and swallowing difficulties, with periodic choking sensations and 
respiratory embarrassment; these may become paroxysms of extreme 
and agonising type (cerebellar crises of Cushing). The facial attacks 
were shown by homolateral facial twitchings, not Jacksonian in type, 
and more like a convulsive tic than an epileptiform attack. None of the 
cases showed generalised or Jacksonian convulsions, though these may 
occur as a late symptom due to disturbance of other areas of the brain. 

The authors conclude that convulsive attacks are rare phenomena 
of cerebellar tumour, and that they can be differentiated from the 
cerebral attacks by their being of a tonic rather than a clonic type, and 
that Jacksonian fits can be distinguished by the deliberate, progressive, 
clonic character of the spasms. L. H. Wootton. 


3. Clinical Psychiatry. 

Reaction in Dementia Pracox to Vagotonic and Sympathicotonic Criteria. 
(Amer. Journ. Ins., April, 1921.) Raphael, T. 

The cardinal criteria selected were for vagotonia exaggerated reaction 
to pilocarpine, and positive response to the oculo-cardiac reflex ; for 
sympathicotonia, the epinephrin, eserine, and oculo-cardiac reactions. 


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Eleven cases of dementia praecox, including simple, hebephrenic and 
catatonic cases, were tested. To pilocarpine ( X V gr. hypodermically) all 
cases gave a normal reaction, viz., minimal perspiration and slight saliva¬ 
tion. Eserine (£ gr. by hypodermic) produced no cardiac slowing, and 
was therefore negative. 

The oculo-cardiac reflex was normal (retardation 4 to 12) in contrast 
to positive result (slowing over 12 for vagotonia, and retardation less 
than four for acceleration for sympathicotonia). This test gave much 
variation and necessitated repeated trials. Epinephrin (1 mgrm. sub¬ 
cutaneously) produced no glycosuria nor the necessary acceleration of 
heart rate (one-third increase). On the contrary, the blood-sugar 
content in five cases was *171 per cent., falling below the average 
normal result '198 per cent., and negativing sympathicotonia. 

There was no positive evidence of either vagotonic or sympathi¬ 
cotonic reaction. John Gifford. 

The Frequency of Albuminuria with Casts in Epileptics following Con¬ 
vulsive Seizures. (Arch, of Neur. and Psychiat., November, 1920.) 
Novick, N. 

There has been considerable variance in the findings of other 
observers. Munson found albumin and casts in 20 per cent, of cases 
following epileptic attacks. Other reports show absence or irregular 
occurrence of albumen ; the presence of semen has been suggested as 
an explanation of its presence. 

A series of sixty cases were examined. Albuminuria with granular 
casts was found in 66 per cent, after every attack, and in some cases 
persists for 24 to 48 hours. The duration of seizures has no relation to 
subsequeut albuminuria, but frequency of convulsions tends to regular 
presence of abnormalities. Seminal fluid as a contaminant occurred in 
only 22*6 per cent., and is negligible as a cause of albumen. It can be 
differentiated by the presence of casts simultaneously. Incidentally 
glycosuria did not prove demonstrable, though all specimens were not 
examined. Two cases diagnosed clinically as hysteria with epileptiform 
seizures were uniformly negative on repeated examination. The 
question arises whether this might not be a factor of some differential 
diagnostic value. John Gifford. 

The Intellectual Status of Patients with Paranoid Dementia Prcecox. 
(Arch, of Neur. and Psychiat., March, 1921.) Rawlings , E. 

This is an investigation to obtain the intellectual status of apparently 
well-preserved cases of paranoid dementia praecox. Out of fifty cases 
tested sixteen were taken, the others being rejected on acconnt of 
delusional answers, inaccessibility, or negativism. They had all received 
a good education, and showed fair or apparently normal intellectual 
preservation ; they were all men. 

Their general intelligence was investigated by the revised Yerkes- 
Bridges point scale test. They showed an average of 72 points and a 
mental age of 10 9 years compared with Yerkes’ male mill operatives, 
who averaged 88'3 points and 14 years. The praecox cases were 
particularly poor at the tests involving memory. With the Kent- 
Rosanoff test for uncontrolled association they more nearly approached 


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the norms for children under n years of age, and they had fewer 
common, more doubtful, and many more individual associations than 
normal people. Other tests were also undertaken with a view to testing 
the higher intellectual levels, e.g., controlled association tests, theme 
development, and Ebbinghaus’ test; lastly, questions were asked in 
geography, history and arithmetic. 

The author found “an impairment of the faculties of the mind, 
involving not only volition and emotion, but also the higher intellectual 
faculties of memory and the power of reasoning and the acquired 
capabilities. The disease process as a rule began insidiously with a 
progressive lowering of the intellectual levels, producing a gradual 
loosening of the train of thought with a resultant incoherence and dis¬ 
connection; a deterioration in judgment, as shown in the patient’s 
inability to order his life consistently from an environmental standpoint, 
and the presence of more or less automatic or reflex activities, which 
took the place of conscious purposeful action based on an intact 
psychic mechanism.” 

In a previous paper the author had described “singular fragmentation 
of the stellate nerve-cell stratum ” in brains of praecox cases. Arieus 
Kappers believes this to be an intra-hemispherical and short associative 
layer, and Van’t Hoog suggests that it may be a matrix cell-layer, 
capable of differentiation into cells of the more highly differentiated 
supra-granular pyramids, and the paper concludes with the suggestion 
that in the destruction or exhaustion of this cell-layer we have the 
beginning break in the connection with the lower cortico-fugal cells, 
with disturbances of the sensorimotor reflexes producing emotional and 
volitional aberrations, and the decline in psychic life is hastened by a 
continuance of disordered metabolisms, with its toxins diffusely attacking 
the nerve-cells of the upper cortical layers, rendered more liable to 
destruction by the cutting off of their reflex sensory stimulation. 

L. H. Wootton. 

Cranial Injuries and Korsakoff's Psychosis \Traumatismes eraniens et 
psychose de Korsakoff ]. {Arch. Suisses de Neur . et de Psychiat 
vol. vii, Fas. 2, 1920.) Bcnon, R., and Lehuche , R. 

The authors describe a case in a corporal, aet. 28, who had a bicycle 
accident on May 27th, 1916. From June 12th to July 14th, 1916, he 
had the following symptoms : Complete anterograde amnesia of fixation; 
very active fabulation ; false remembrances ; euphoria, intellectual excita¬ 
tion, headache ; some illusions. From July to August, 1916, there was 
rapid amelioration, and he was reported cured of the psychosis, but his 
head felt always heavy, he complained of buzzing in the ears, he could 
not resume his previous occupation ; his memory was not so good ; one 
could not contradict him. Otherwise he was well. These symptoms 
were ascribed to asthenia. 

It is important to separate the syndrome of Korsakoff from mental 
confusion proper. If one admits that Korsakoff’s psychosis is a form of 
confusion, that form merits a special description. Confusion is essentially 
characterised by profound troubles of perception, of recognition of 
places, persons and things, disorientation, aprosexia, etc. The confused 


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person is not hallucinated, nor delirious, nor asthenic ; unconscious of 
his state, he shows a very disorderly activity. The characteristic signs 
of the syndrome of Korsakoff are amnesia of fixation, confabulation, 
false recognitions, euphoria, intellectual excitement, etc. 

The syndrome of Korsakoff is different from hallucinatory delirium. 
In principle hallucinations are absent in Korsakoff psychosis ; when 
they exist they are complications. In hallucinatory delirium the patient 
is anxious, not euphoric ; he shows no amnesia of fixation, no fabulation, 
no false recognitions. 

One should hardly confound the syndrome of Korsakoff with an 
asthenic syndrome. There the fixation amnesia is less marked, confusion 
in ideas here—confusion of ideas, not confusion of perceptions—could 
give rise to troubles of recognition, but these are very slight and quite 
different from those shown in Korsakoff’s psychosis. 

What role do intoxications, specially alcohol, play ? The majority 
of cases of post-traumatic Korsakoff’s psychoses develop in alcoholic 
subjects. Is alcohol a predisposing cause, traumatism an occasional 
cause ? What is the direct determining cause ? It is also possible that 
infectious elements intervene to indicate the malady, especially if there 
is a wound of the head or body. 

The authors conclude that Korsakoff’s psychosis develops fairly 
frequently after head injuries, though this has not often been referred 
to by authors. This is explained by the fact that this psychosis is 
considered as a clinical vaiiety of mental confusion. Yet even admitting 
a common origin, it is a fact that these two syndromes differ clearly in 
their symptoms. The amnesia of fixation, the fabulation, the paragnosia, 
and the euphoria especially characterise the psychosis of Korsakoff. 
This should be distinguished from hallucinatory delirium and psychical 
asthenia. Amongst the traumatic psychoses, has that of Korsakoff an 
origin that is toxic or of an infectious nature ? What is the part played 
by the trauma ? These points are obscure. It appears to the authors 
possible to consider Korsakoff’s psychosis as a malady of memories as 
much as that confusion is derived from alterations of perceptions, of 
sensations in general. W. J. A. Erskine. 


Intellectual and Criminal Precocity in a German Child [ Precocity intel - 
lectuelle et dilinquante chez un enfant allemand\ (£’Enciphale, 
June and July, 1920.) Courbon , Paul. 

Juvenile rogues hunt mostly in gangs, and confine their depredations- 
to within sound of their own church clock. If one of them ventures on 
a long expedition, it is prompted by the reading of romantic fiction; at 
the touch of reality his dream fades, and loneliness and helplessness 
soon turn his footsteps home. Not so with this twelve-year-old, who 
wandered away alone for hundreds of miles and into an enemy country, 
on no romantic impulse, but from a reasoned judgment on international 
economics. 

His father, a miner at Konigshiitte, in Upper Silesia, had died in the 
war, and the mother, with her four small children, had since lived 
miserably by begging. Then, when the Armistice came, and people 
around him were saying that there would be no food in Germany or 


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Russia, but that the victorious allies had plenty, this boy, who had had 
no schooling since the commencement of hostilities, set out, without a 
word to anyone, for Alsace, where his German speech would not hinder 
him from profiting by the abundance of good things. Travelling some¬ 
times on foot, pilfering as he went, and sometimes by rail, having 
clambered into a carriage or truck from the off-side of the train, and 
stopping at intervals for a few days in some town, to thieve or earn a 
little money by odd jobs, he reached, after some weeks, the occupied 
territory. There he enlisted the sympathy of soldiers of the allied 
troops, who, ignorant of German, could not embarrass him with 
awkward questions, and giving them to understand that he wanted to 
go back to his mammy in Alsace, he obtained from them gifts of food 
and a lift in an army lorry. He established his headquarters at the 
railway station at Strasbourg and tried to make a living as errand-boy or 
porter. It was hard to compete with the boys of the place, who, 
observing his foreign accent, made a butt of him; and few travellers 
would entrust their baggage to a child so small. He would do better at 
home ; food might be dearer there, but with his experience no greater 
industry would be needed to obtain it. One May morning (1919) the 
police at Sarrebriick, of whom he asked the way to the Rhine, were 
curious, seeing that he had no pack, to know where he had got that 
bicycle, so much too big for him. He told them he had found it 
standing outside a house in Strasbourg a few days before, and had 
taken it in order to get back to his own country. Convicted of the 
theft, he was sent to a reformatory at Haguenau, where he behaved well, 
worked hard at his lessons, and applied himself diligently to learning 
French. After about four months he escaped and was away for twelve 
days. He had imagined that he could effect an entrance to his father- 
land most easily through Switzerland, but finding at the Swiss frontier 
that the obstacles there were insuperable he had made his way to 
Strasbourg, and here his institution dress was recognised. Two 
months later, however, he escaped again and was traced only as far as 
Speyer. 

So he disappears into his native Germany. If there is nothing better 
in store for him, at least he has all the qualities for the making of a 
captain of industry or a cosmopolitan financier. Heedless of social 
and family ties, and having no moral sense, he well knows how to 
exploit the moral sense of his fellows. Sydney J. Cole. 

A Case of Puerilism \ Un cas de pucrilisme .] {Bull, de la Soc. Clin, de 

Mid. Ment., April , 1920.) Truelle and Brousseau. 

A tailoress, set. 35, who had long appeared odd and been prone to 
suspicions, to fanciful likes and dislikes, and to sudden groundless 
changes of mind, was admitted to Ville-Evrard Asylum in June, 1917, 
in a state of acute excitement in which she expressed vague erotic and 
mystical ideas, sang hymns, would keep no clothes on, lay on the 
ground and was impulsively violent. Early in 19x8 she lapsed into 
mutism, broken only by occasional revilings of the medical officer; her 
generally hostile demeanour betokened some systematised delusion. 
In the spring of 1919 her violent propensity abated, there was a 


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marked rise in body-weight, and she began to display her present 
childishness. 

She smirks, gives little shouts of delight, claps her hands, and has 
little outbursts of temper like a spoilt child; she toddles about with 
arms outstretched, swaying as if unsure of her feet; she will sit on the 
ground for hours, arranging little pebbles about her; she seldom 
speaks, and then only in baby talk, with a lisp. But the picture of 
babyishness she presents has certain inconsistencies: if she eats 
unsuitable things, such as fallen leaves, she carefully washes them first, 
like an older child who plays housewife. In several respects her 
behaviour differs from that of any child ; she shows none of the child’s 
inventiveness in her play, none of the child’s coquetry, none of the 
child’s favouritism towards particular persons; her way of collecting 
stones and bits of wood is a dement’s way; and as regards matters 
sexual, though she exhibits an infant’s immodesty, and though she 
treats her husband with indifference, seeming to care only for the 
eatables he brings her, yet when she hears another woman propose to 
make conquest of him she objects bluntly, saying he is hers. 

Her childishness is simply a mannerism of dementia praecox, such as 
might later be exchanged for some other mannerism having no childish 
quality. Its distinction from the affected childishness of an hysteric 
may perhaps be somewhat nice, but the childishness in this woman’s 
case is evidently quite different from that of senile dementia, i n which 
the principle of regression operates, or of severe shell-shock, where an 
amnesia, stripping the civilised adult of his social acquisitions, leaves 
only infantile activities. Her childishness is not a bare state of mind, 
but an assumed garb. Sydney J. Cole. 


4. Treatment of Insanity. 

La Phinylethylmalonyluree (Cardinal, Luminal) dans le Trailement de 
PEpilepsie. Bergbs , Gaston. 

This substance, first obtained by Horlein, and best known by its 
German name “luminal,” is akin to veronal, from which it differs in 
the substitution of a phenol group for one of the two ethyl groups. It 
is a crystalline solid, melting at 172 0 C., and is almost insoluble in 
water, but soluble in alkaline solutions (forming a sodium salt, which 
can be isolated); from such solutions it is precipitated by addition of 
hydrochloric or acetic acid. It was first studied pharmacologically in 
1912 by Impens, and in the same year Kino published some remarkable 
results obtained with it in epilepsy. It soon attracted considerable 
attention in Germany, and was beginning to be noticed in other 
countries when the war put a stop to research. 

The drug is best given by the mouth, either in cachets or in the form 
of tablets, which should be crushed. It has a bitter but not disagree¬ 
able taste. It should be taken on an empty stomach or between meals, 
and accompanied by some hot beverage. The daily quantity for an 
adult is from 20 to 30 cgrm., which should be divided into two or three 
doses. Hypodermic administration is unsatisfactory and uncertain in 


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its results, for it necessitates the use of the sodium salt, which is 
exceedingly prone to decompose and become inert. 

The author of this brochure gives a glowing account of the action of 
luminal in epilepsy. At the commencement of the treatment the 
hypnotic effect of the drug is very marked, and after three or four days 
a condition of torpor may be produced, or in some cases excitement, 
whose appearance, however, if it occurs at all, may be delayed till the 
second week. After two or three weeks of the treatment the somnolence 
and other psychic disturbances disappear, while the therapeutic effect 
upon the epilepsy remains. The action of the drug in inhibiting the 
fits is very rapid; within a day from the commencement of the treat¬ 
ment the fits cease, even in inveterate cases in which they have been 
habitually frequent. If, however, they continue to occur, the daily 
quantity of the drug is increased to 30 or even 40 cgrm., but the 
increased doses are not to be continued beyond two or three days if 
there is excitement. After their initial cessation the fits recur, if at all, 
only at long intervals and in a milder form. In the first six months of 
treatment, the average number of fits per month is about one-tenth of 
what it was before. In some cases major fits are reduced to minor fits, 
or to other epileptic equivalents, such as fugues; these modifications are 
generally favourable unless, as exceptionally happens, occasional major 
fits are superseded by frequent minor fits. Attacks of petit mal are 
usually inhibited like major fits, but upon those the ^effect is less clear 
and often less rapid. In some of the cases of traumatic and Jacksonian 
epilepsies in which the drug has been tried good results have been 
obtained; but the cases in which the benefit is most striking are the 
cases of genuine epilepsy with frequent typical major fits, in which 
bromide has proved ineffective. 

Luminal is said to have a beneficial influence also on the chronic 
mental troubles of epileptics. The mental retardation is diminished, 
the patient becomes brighter and more quick-witted, and his memory 
improves. He becomes less irritable. These good effects are most 
marked in children, but are observed also, though in less degree, in 
older and more chronic cases in which mental deterioration has been 
long in progress. The improvement is not due simply to disuse of 
bromide, for it occurs also in cases in which bromide has either not 
been used at all or has been abandoned long before the administration 
of luminal was begun. There is often also a physical improvement—an 
increase in body-weight and in appetite for food. 

In the initial period of the treatment the drug sometimes provokes 
acute mental disturbances; the convulsive attacks being restrained, the 
epilepsy finds a psychic manifestation in excitement, delirium or con¬ 
fusion ; and even long after the beginning of treatment there may be 
choleric outbursts and alterations of character and mood. Though the 
drug is evidently responsible for these phenomena its action is said ‘to 
be only contributory, for they occur only in cases in which they have 
already occurred before the treatment was instituted. On the other 
hand, the drug seems often to prevent or mitigate such attacks in 
patients previously subject to them; they become slighter and less 
frequent, but are more prone to recur than convulsive fits. 

As the treatment is not curative but only symptomatic, it must be 


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continued for months or years. If for any reason it is to be dis¬ 
continued, this must be done gradually; abrupt discontinuance almost 
invariably induces a grave general disturbance, with numerous fits, and 
sometimes status epilepticus. If, however, under treatment the patient 
has for many months shown no epileptic manifestations even of the 
slightest sort, it may be possible to reduce the daily 20 cgrm. to 
10 cgrm. 

In early stages of treatment the drug often causes a skin-eruption— 
a transient erythema, never serious—and occasionally vomiting. This, 
or a dangerous fall of blood-pressure and pulse-rate, may necessitate the 
reduction or abandonment of the drug. In severe chronic cardio¬ 
vascular affections, in uncompensated heart disease, and in renal disease 
the drug is very decidedly contra-indicated. Several deaths have been 
reported which appeared to be due to it. 

The author adds notes of seventy-five cases, observed personally or 
collected, and a bibliography of fifty-six items. 

Sydney J. Cole. 

Analysts of more than 200 Cases of Epilepsy Treated with Luminal ’ 
( Amer. Journ. Ins., April\ 1921.) Kirk , C. C. 

In 1914 Dr. Richard Eager directed the attention of Dr. Dercum to 
the value of luminal in epilepsy. Luminal is pheno-barbital, and the 
addition of the phenyl group is claimed to advantageously increase the 
hypnotic power. Luminal in the cat or dog affords quiet sleep, rarely 
preceded by excitement. It lessens the frequency of breathing, but 
increases its volume. It is eliminated by the kidneys, and injury to these 
organs has not been observed. There is considerable range between 
effective and lethal doses. It kills by respiratory paralysis. The dose 
is 3 to 5 gr., if need be increased to but not exceeding a maximum of 
12 gr. Luminal-sodium has a dosage 10 per cent, greater. It may be 
used hypodermically in 20 per cent . solution in distilled water. The 
hypodermic dose may be from i£ to 5 gr. 

In 1919, after lengthy trial, Dercum reported astonishing improvement 
even in old-standing epilepsies, and stated that luminal acted as a 
specific in idiopathic epilepsy, seizures being abolished for several 
years. 

In December, 1919, Kirk adopted its use with reservation. The 
cases selected were those with frequent and profound seizures, some 
having been bed-ridden for months or years. Certain results were so 
amazing that within a month luminal was being administered to all 
cases of essential epilepsy, i£ gr. in tablet at bedtime. Luminal-sodium 
appeared equally effective. In only five cases was the treatment varied, 

1 \ gr. night and morning, and in two instances the same dose three 
times a day. In all cases on improvement the doses were reduced to 
to one at bedtime. Continuous treatment was persisted in for four to 
five months, when the stock of the preparation was exhausted ; this 
was May 1st, 1920. During the month after cessation the number and 
strength of seizures were appreciably increased; but there had been no 
retrogression to the position prior to treatment. 

All stimulants, tea, coffee, tobacco, were prohibited. The diet was 
unaltered except for closer supervision as to quantity. The secretion 


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of food by patients in their clothes proved a troublesome factor. The 
usual adjuncts, bowel elimination, occupation and fresh air were 
maintained. Serial seizures and status epilepticus were as usual 
combated by elimination and restricted diet, with luminal gr. v every 
three hours to the exclusion of the ordinary drugs. 

No deleterious effects were produced. The drug is not habit- 
producing as there is neither pleasurable nor disagreeable sensation. 
In some cases the drug is effective in 24 or 48 hours, in others only 
after a week or more. Among 211 cases, while under treatment, 61 
had no convulsions, 106 had less than 5, and only 45 had a larger 
number. Only 3 deaths occurred during this period, 1 from lobar- 
pneumonia, 1 from mitral regurgitation, and 1 from status epilepticus. 
The results were most gratifying, but it is necessary that some thousands 
of cases be treated over a period of years for final determination of its 
value. John Gifford. 


5. Pathology. 

A Study of NissVs Stabchenzellen in the Cerebral Cortex in General 
Paresis , Senile Dementia , Epilepsy , Glioma , Tuberculous Meningitis , 
and Delirium Tremens. ( Jour . Nerv. and Ment. Dis ., March , 
1921.) Noda , U. 

When Nissl, in 1899, ^ rst called attention to these rod-cells, he 
believed them to be glial; but in 1904 both he and Alzheimer, in their 
celebrated works on the general paralytic cortex, rejected the notion of 
a glial origin for these cells and pronounced them mesoblastic, derived 
from the walls of the blood-vessels, an opinion in which these authors 
have been followed by Mott, Ranke, Dupre, Rosenthal, and Rondoni. 
A glial origin was first seriously maintained in 1905 by Cerletti, and 
-afterwards by Straussler, Agostini and Rossi, Ris, Perusini, Marchand, 
Torata Sano, Simchowicz, Fuller, and Uyemaisu. Some observers— 
Achdcarro, Bonfiglio, Cerletti (1910), Martha Ulrich, Alzheimer (1912), 
Spielmeyer, and now Noda—have come to the conviction that rod-cells 
arise from both sources; that some are glia-cells but that others are 
derivatives of vessel-wall elements. 

In this paper (56 pages, 10 illustrations), Noda reviews the literature, 
and reports his observations on rod-cells in 10 cases of general paralysis, 
of senile dementia, 1 of epilepsy, 1 of delirium tremens, 1 of tuber¬ 
culous meningitis, and 2 of glioma. He has been able to confirm 
almost all the grounds of argument in favour of a glial origin for rod- 
cells—the occurrence of various forms intermediate between glia-cells 
and rod-cells, the presence of rod-cells in the glial encapsulation of 
senile plaques and in glia-cell colonies, the occurrence of rod-shaped 
individuals among the glial satellites of the cortical nerve-cells, the 
parallelism between the number of rod-cells and that of proliferated 
glia-cells, and the discovery of glia fibres attached to rod-cells. To these 
considerations he would add the presence of many rod-shaped glia-cells 
in his cases of glioma; such cells were found not only in the tumour, 
but widely distributed over the cortex. On the other hand, he believes 
he finds evidence that some rod-cells are proliferated vessel-wall 


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elements that have become actually or apparently detached in con¬ 
sequence of regressive changes. The fact that the regressive changes 
in the vessels of the cortex in general paralysis have been preceded by 
much proliferation of the cells of their walls, and by increase of 
capillaries, may help to explain why in this disease rod-cells are so 
numerous. In all Noda’s paralytic cases they abounded. They were 
especially abundant in the pyramidal and ganglion cell layers of the 
frontal region and cornu Ammonis. In his case of tuberculous menin¬ 
gitis he says he observed migration of rod-cells into the outer layer of 
the cortex from the pia, but only where there was a pronounced pial 
infiltration. In his cases of senile dementia, epilepsy and delirium 
tremens few rod-cells were found. 

He hazards guesses at the functions of these cells, and why they take 
this shape. Sydney J. Cole. 

The /Etiology of Bacillary Dysentery tn Asylums. {Lancet, July 30 thy 
1921.) Dawson , W. S., and Moody , W. 

Dysentery is shown to cause about 3 per cent, of asylum deaths and 
much ill-health. The authors studied a series of cases of clinical 
dysentery and diarrhoea at Claybury Mental Hospital, from a number 
of which they cultivated a bacillus of the Flexner type of B. dysentence. 
Swabs were taken from faeces or rectal wall, and the specimens plated 
on McConkey’s medium of exactly + 4 acidity, incubated twenty-four 
hours, and for twelve on Russell’s double sugar agar, then agglutinated 
for fifteen seconds with Flexner’s serum. No results positive by this, 
rapid method failed of confirmation by various more detailed tests 
used. 

Contrary to some observers the authors found that agglutinins did not 
appear in the blood till after the fourth week, nor in any case with 
bacteriologically negative faeces. 

At Claybury incidence of dysentery has been greatest in winter, 
suggesting direct contagion. The authors found the organism to re¬ 
appear in the faeces after apparent cure in several cases of mild,, 
transitory relapse, and therefore advocate permanent isolation of 
bacteriologically positive subjects. Marjorie E. Franklin. 


A Study of Some Peculiar Changes Found in the Axons and Dendrites 
of the Purkinje Cells. {Arch, of Neur. and Psychiat., March , 
1921.) Uyematsu , S. 

Peculiar balloon-like swellings of the dendrites of Purkinje cells were 
first described by Schaffer and others, who believed them to be patho¬ 
gnomic of amaurotic family idiocy. Later Straussler found swellings 
on the axons and dentrites in a case of psychosis with cerebellar 
symptoms, and later still in juvenile general paralysis. Other observers. 
noted the same phenomenon in other conditions, some considering it as 
a symptom of degeneration, others as a regenerative effort on the part 
of the cell. 

The author used brains hardened in 14 per cent, formaldehyde solu¬ 
tion, of which frozen sections were stained by the Bielschowsky 


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method. He investigated the changes in senile dementia, arteriosclerotic 
brain disease, general paralysis, congenital brain disease, dementia 
praecox, manic-depressive insanity, alcoholic and toxic psychoses, brain 
tumours and myxoedematous psychosis. Of these, swellings on the 
axons were found in ioo per. cent, excepting in dementia praecox and 
manic-depressive insanity, in which the condition was not found at all. 
Swellings on the dendrites were found in a varying but smaller per¬ 
centage in all except dementia praecox, manic-depressive insanity, brain 
tumours and myxcedema, in which the swellings appeared to be absent. 
He describes various forms of these swellings, e.g., spindle, pedunculated, 
bulb-like, etc., and he attempted to discover the contents by means of 
the staining reactions. Most stained diffusely, and contained some 
homogeneous argentophilic substance, some showed liquid content, a 
few had thickening of neurofibrils and whirl-like structures suggesting 
Alzheimer degeneration. 

He concludes that these changes can no longer be considered as 
specific, but are encountered in cerebella wherever there is a chronic 
degenerative process. He discusses the question whether they are 
regenerative or degenerative, and believes that both the axonal and 
dendritic swellings are a feeble attempt at regeneration. 

L. H. Wootton. 


6 . Sociology. 

Kleptomania from the Medico-Legal Point of View \De la Kleptomanie 
au point de vue m(dico-legat\. {Ann. Mld.-psychol. No. 3, March, 
1921). Wimmer, A. 

The author mentions the conclusion of Marc that the more carefully 
cases of kleptomania are examined the more one is convinced that true 
kleptomania— i.e., an irresistible impulse towards theft for the sake of 
theft—is, if it exists, a pathological rarity. This the author thinks may 
be true in medico-legal practice, but in the psychiatric clinic it is 
common, and is one of the numerous mental stigmata of degenerates. 
He mentions the theory that the theft is a symptom of a repressed 
sexual wish symbolically satisfied, but considers this is only true 
probably for a small number of cases. He believes that in some cases 
it is due to an impulse of an organic nature latent behind the klepto¬ 
mania, and which under the influence of certain disturbances— e.g., 
drunkenness, menstruation, pregnancy—is translated into action; he 
mentions the case of a young girl, set. 18, “ bonne et bonnete fille,” who 
had violent fits of hunger accompanying her impulses to thieve, and at 
these times she would steal eatables—cakes, chocolate, fruit, etc. If 
this patient’s troubles had been reviewed in the court of law rather 
than in the consulting room, he believes it could have been maintained 
that she was the victim of a morbid impulse to theft due to an 
unconscious organic change in her mental state. Many authors have 
noted the connection between sex and theft, and a distinction has to 
be drawn between those who thieve articles which give them sexual 
pleasure—fetichists, not true kleptomaniacs—and those in whom the 
theft itself produces a sexual orgasm. Of the latter, some recognise 
the nature of the pleasure, in others the sexual motive appears com- 
LXVIII. 


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[Jan., 


pletely unrecognised by the patient. As examples of this group he 
refers to several published cases of women who were sexually frigid, but 
who experienced sexual sensations at the moment of theft He mentions 
a woman who practised prostitution when young for the sake of gain, 
and later married a man because she “ respected ” him; she had 
feeble sexual desires, and was generally frigid. During her pregnancies 
she experienced kleptomanic impulses, which if repressed caused attacks 
of vomiting; if she yielded she experienced an orgasm. The author 
considers she was a psychopath of emotional temperament in whom, 
during her pregnancies, the ordinary temperament was accentuated in 
a direction more decidedly pathological; her kleptomania does not 
come in the category of obsessions according to the classic definition, 
but was a symptom of an organic disorder, and became the equivalent 
of a normal coitus; he points out that kleptomanias which only show 
themselves during pregnancy suggest almost irrefutably their dependence 
on pathological causes. He cites the case of a woman of poor in¬ 
telligence who was married and had two children; during both the 
pregnancies she exhibited a depraved appetite, bit her nails, etc. Later 
she was in an accident, and was concussed, after which she became 
very nervous and anxious. When she became pregnant for the third 
time she did not develop her previous eccentric appetite, etc., but had 
impulses of kleptomania. He considers that her depraved appetite and 
nail-biting could be attributed to purely somatic alterations, and these 
were afterwards, during her third pregnancy, replaced by her klepto¬ 
mania, and he believes that the thefts committed by this woman were 
due to a morbid impulse which she would not have been able to resist 
normally, precisely because it was due to an organic cause. 

These observations give to kleptomania a different value than that of 
Marc; but, on the other hand, one can use it with greater precision in 
the small number of medico-legal cases to which it is applicable. 

L. H. Wootton. 


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Part IV.—Notes and News. 


MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN 

AND IRELAND. 

The Adjourned Eightieth Annual Meeting was held on Tuesday, November 
.22nd, 1921, at the rooms of the Medical Society of London, n,Chandos Street, 
Cavendish Square, London, W., the President, Dr. C. Hubert Bond, C.B.E., 
F.R.C.P., in the chair. 

The New Edition of the Handbook for Mental Nurses. 

Dr. Bedford Pierce, Chairman of the Handbook Committee, reported that 
the new edition of the Handbook of Mental Nursing was now ready for the 
publishers. He explained that it had been arranged to correlate the Syllabus of 
Training and the Contents Table of the Handbook, and the first difficulty 
•encountered by the Committee was that of deciding as to the scope of the work, 
and whether it would be possible to cover the whole ground properly in a single 
volume. After considerable discussion it was decided to continue on the former 
lines, though that would mean a serious limitation of the space allotted to anatomy, 
physiology and bodily diseases, as well as nursing details and other subjects. 
Great pains had been taken in writing the book; many articles had been written 
more than once, and some sections had been re-written three or four times. He 
felt free to speak of the labour involved as he had had nothing to do with the 
writing of the book; he had only seen what others had done. Frank criticism 
had been directed on all doubtful points, and when there was a doubtful point 
which needed a decision, the opinion of the Committee as a whole was taken. 
Therefore, the book now presented was not a volume in which one person had 
been responsible for one section and another person for another section, but the 
-responsibility for the whole work was accepted by the Committee as a whole. The 
general aim of the book had been the development of the mental nurse, and 
although this book represented an advance on the previous one, every care had been 
taken to explain technical matters and put them into plain language, so as to make 
them intelligible and clear to the thoughtful nurse. No attempt, however, had 
.been made to write the book down to suit the careless and the illiterate. In its 
compilation the Committee had received valuable assistance by experts. Dr. 
"Sherlock wrote a long and excellent chapter on Mental Deficiency, so that the book 
covered what was required by the Association for the Certificate in Mental 
Deficiency. Prof. Pear, of Manchester, helped in regard to the portion dealing 
with the Mind in Health. The article he sent was not adopted in its entirety 
by the Committee, but what he contributed was used by the member of the 
•Committee who dealt with this very difficult subject. Miss Corke had revised the 
chapter on Sick Nursing as it was felt desirable that an experienced woman 
nurse should help on that subject. Considerable help had also been given 
from a literary point of view, in the simplification of language, etc., by Miss 
Kendal, of York. The book had now been placed on the table, and was ready 
for final editing. The Committee therefore asked the Association if they would 
be willing to re-appoint the Committee, and empower it to print and publish the 
volume. They also asked for sanction to expend ^75, £2 5 of which was to be 
given to Miss Kendal, ^25 to the Medical Editor recommended by the 
Publishers, and ^25 for typing. He hoped the labours of the Handbook Committee 
would be approved by the Association. 

Dr. G. Warwick Smith said he had very little to add to Dr. Bedford Pierce’s 
remarks. Perhaps, however, members would be interested in being reminded of 
the composition of the Committee. Its fourteen members consisted of: 

England : Drs. Bedford Pierce, W. F. Menzies, J. Middlemass, F. R. P. Taylor, 
/W. Daniel, W. Rees Thomas, G. W. B. James, G. W. Smith, O. P. Napier Pearn. 

Scotland : Drs. T. C. Mackenzie, Donald Ross, H. Yellowlees. 

Ireland : Drs. M. J. Nolan, H. R. C. Rutherford, 

Eight were from county or borough mental hospitals, one was from a State 
institution, three from a registered hospital, two from private mental institutions. 


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The Committee had met 13 times, the average attendance having been 8, and the* 
meetings had been held in the places which best suited the members of the 
Committee, in England and Scotland, so as to divide the travelling as fairly as 
possible. Seven times the Committee had met in London, three times in York, 
and once each in Glasgow, Manchester and Carlisle. Dr. Bedford Pierce has- 
already referred to the ambitions of the Committee, the great pains they had taken, 
and the enthusiasm which had been expended on the work ; he had spoken also of 
the correlation of the syllabus of training with the contents of the book. Although 
the syllabus of training was taken as the guide, it had not been possible to adhere 
to every word which was put down in the syllabus ; the authors had to have some 
liberty in choosing their own language. Substantially, however, the contents of 
the book were as put down in the syllabus of training. With regard to the final 
editing, though the contributions were completed, much work still remained to be 
done in avoiding repetitions, and to condense the book into as reasonable a compass 
as possible and to make it one coherent whole. That work will be done if what 
has been done so far was approved. 

The President said the thought uppermost in the minds of members must be 
one of gratitude to the Committee for their labours. The proposals before the 
meeting were (i) That the Association’s Revised Handbook of Mental Nursing 
be approved, (ii) that a grant of ^75 be made for expenses thereof, and (iii) that 
the Association tenders to the Committee its grateful and cordial thanks for the 
work they have so kindly undertaken and brought to so able a conclusion. 

This was carried by acclamation, and terminated the Annual Meeting for 1921. 

The Quarterly Meeting followed, the Council and various committeeshaving 
met earlier in the day. 

The President said it had been ascertained that the minutes of the previous 
meeting were signed by Dr. Menzies at the last Annual Meeting. 

Matters arising out of the Council Meeting. 

The President said the question of the activities of the General Nursing 
Council came up for discussion, and a certain amount of information had been 
obtained as to their proposals, which were not yet published, but would be made 
known shortly. The facts brought to their notice had led the Council to set up a 
committee to consider the situation which had now arisen by the establishment 
of the General Nursing Council in respect to the training and examination in 
mental nursing. That Committee had been empowered to maxe very full 
inquiries, and would, in due course, report to the Association. It was not neces¬ 
sary for him to add more, because he was sure the members present realised the 
possibly somewhat serious nature of the new situation with reference to this Asso¬ 
ciation. The Committee now to inquire into the matter would hope to put 
members in possession of the facts, so that a conclusion could be arrived at. 

Election of New Members. 

The President nominated Dr. J. N. Sergeant and Dr. H. J. Norman as 
scrutineers. 

The following gentlemen were elected members : 

Butcher, Walter Herbert, M.A., M.B., B.Ch.Oxon., M.R.C.S., L.R.C.P. 
Lond., Assistant Medical Officer, City Mental Hospital, Humberstone,. 
Leicester. 

Proposed by Drs. J. Francis Dixon, C. W. Bower, and R. Worth. 

Phillips, Philip Gordon, L.R.C.P., L.R.C.S.Edin., Medical Superinten¬ 
dent, Oulton Hall and Stainbech Ministry of Pensions Neurological 
Hospital, Oulton Hall, Woodlesford, near Leeds. 

Proposed by Drs. J. E. Middlemiss, R. Worth, and G. Warwick Smith. 

Gilfillan, John Aitken, M.B., Ch.B.Glas., Assistant „Medical Officer,. 
London County Mental Hospital, Long Grove, Epsom. 

Proposed by Drs. D. Ogilvy, V. Lindley Connolly, and E. G. T. Poynder. 

Drury, Kenneth Kirkpatrick, M.C ., M.D., B.Ch.Dublin, Senior Assis¬ 
tant Medical Officer and Deputy Superintendent, County Mental Hospital,. 
Stafford; “ Swift Brook,” Corporation Street, Stafford. 

Proposed by Drs. B. H. Shaw, A. Miller, and H. Brougham Leech. 


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Farran-Ridge, Clive, M.B., Ch.M.Syd., D.P.M.Lond., Assistant Medical 
Officer, Darenth Training Colony, Dartford, Kent. 

Proposed by Drs. E. B. Sherlock, J. G. Porter-Phillips, and R. H. Steen. 

McKail, Robert Buchanan Forbes, M.B., Ch.B.Glas., Senior Assistant 
Medical Officer, " Calderstones ” Certified Institution for Mental Defectives, 
Whalley, near Blackburn. 

Proposed by Drs. R. M. Stewart, R. M. Clark, and R. Worth. 

Suffern, Canning, M.A.Camb., M.R.C.S., L.R.C.P.Lond., Junior Assistant 
Medical Officer, City Mental Hospital, Nottingham. 

Proposed by Drs. E. Powell, R. Worth, and G. Warwick Smith. 

Roberts, Edward Douglas Thomas, M.R.C.S.Eng., L.R.C.P.Lond., Assis¬ 
tant Medical Officer, Herts County Mental Hospital, Hill End, St. Albans. 

Proposed by Drs. A. N. Boycott, W. J. T. Kimber, and L. Rolleston. 

McCutcheon, Archibald Munn, M.B., Ch.B.Glas., Resident Medical 
Officer, Monyhull Colony, King’s Heath, Birmingham. 

Proposed by Drs. W. A. Potts, R. Worth, and G. Warwick Smith. 

Riddel, Donald Olson, D.S.O. , M.B., Ch.B.Aberd., Assistant Medical 
Officer, County Asylum, Whittingham, Preston. 

Proposed by Drs. R. Worth, F. R. Gilmour, and G. Warwick Smith. 

Masefield, William Gordon, M.R.C.S., L.R.C.P.Lond., Deputy Medical 
Superintendent, Severalls Mental Hospital, Colchester. 

Proposed by Drs. R. C. Campbell, J. Noel Sergeant, and R. Worth. 

The Dinner. 

Announcing the arrangements made for members to dine together in the even¬ 
ing, the President said it seemed a pity that this practice should have fallen into 
•disuse during the war, and it was his hope that the custom might be revived. 

Paper. 

"The Medical Examination of Delinquents.” By Dr. W. Hamblin Smith, 
Medical Officer, H.M. Prison, Birmingham. 

Discussion. 

The President, in thanking the author for his communication, said that he had 
handled the subject in a way which was readily followed and easily understood. 
He hoped it would be followed by a good discussion. 

Dr. W. A. Potts (Psychological Expert to the Birmingham Justices) wished to 
take the opportunity of thanking Dr. Hamblin Smith very much for his extremely 
interesting paper, which appeared to have covered almost the whole ground of 
this very large subject. During the last two years he, the speaker, had been 
engaged in somewhat similar work, though he was brought into contact with a 
more limited number of cases. He could amply confirm Dr. Hamblin Smith’s 
-contention that every offender was worthy of investigation ; indeed he urgently 
required it. He would also confirm what the author said as to such examination 
proving, in the end, an economical procedure. Whatever the cost of such 
examination might be, it would be sure to be very much less than that involved in 
leaving the case insufficiently examined. He could give one very definite 
instance from Birmingham, which occurred recently. A little boy who was 
convicted of stealing was sent to a reformatory school. He had been placed upon 
probation before, but never had any medical examination. The lad escaped on 
two occasions, and gave much trouble. On the third occasion he stole ^10 from 
the Superintendent of the Institution, and that was regarded as a much more 
serious matter; therefore he (Dr. Potts) was asked to examine him. It was soon 
•evident that it was a case of word-blindness, which placed him for the moment in 
the category of mental defectives, as he could not benefit from the ordinary 
instruction in school. Thus in escaping from this school the lad was obeying a 
healthy instinct: he knew the institution was of no use to him. Arrangements 
were then made for placing him in a school for mental defectives, where he was 
now doing satisfactorily. With regard to the physical side, he saw, two years ago, 
sl very interesting case, that of a young man who was convicted of stealing. He 


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(Dr. Potts) found he was suffering from phthisis, and the Justices consented to 
place him on probation, on condition that he went to a sanatorium for con¬ 
sumptives. He was there three months, and since he left the sanatorium he 
had been an exemplary member of the community: he obtained employment of a 
lighter nature than before, and had remained in it ever since. This was his 
second offence, and had he not been dealt with in the way he was, he might 
have now been on the high road to becoming a confirmed criminal, or else 
have been a continual charge as a definite case of tubercular disease. Dr- 
Hamblin Smith, in his paper, drew attention to the weak point in the Birming¬ 
ham scheme, namely, that a so-called doubtful case was allowed to go through 
the Courts without being examined. The onus of deciding whether it 
was doubtful rested on the Justices. If the person were sent to prison, he was 
examined by Dr. Hamblin Smith, but many cases were placed on probation and 
dealt with in an unsatisfactory manner. The author suggested that a medical 
assessor should sit in Court. Some of the Birmingham Justices, too, suggested 
it would be an advantage if he (Dr. Potts) were to attend the Children’s Court 
and point out the cases which required expert examination. He did attend a 
number of times, and pointed out a considerable number of cases which he 
thought required investigation, but, for some legal or other reason, it was decided 
that such examination should not be carried out. Therefore he considered it 
would be a waste of time for him to continue. To give an instance which 
illustrated the extraordinary blindness of magistrates to the necessity of a special 
examination, he wished to refer to the case of a good-looking girl, set. 18, whom he 
saw in the dock a few weeks ago. On this occasion she was charged with drunken¬ 
ness. She was obviously not a mental defective. On previous occasions she had 
been charged with stealing and with prostitution, and convicted. On this 
occasion the magistrate in charge said severity had been tried in this case, and he 
would now like to try leniency. He inquired about her home, and the reply was 
that it was a satisfactory home. But the Probation Officer’s idea of a satisfactory 
home, as a rule, was : “ Were the parents addicted to drink, and did they go 
regularly to church or chapel ?” It was evident to him (Dr. Potts) that this girl 
must be suffering from some mental conflict. The magistrate told her he would, 
not send her to prison this time, but would place her on probation, and she would, 
have an opportunity of thinking over her future course, when he hoped she would 
behave differently. That young woman must be labouring under a mental 
conflict, and she was not likely to solve it in her own home; hence it was essential 
she should be got away from home as soon as possible. That was the manner in 
which cases were still being dealt with in Birmingham, although there were two- 
doctors available to examine these cases if called upon to do so. Dr. Hamblin 
Smith had referred to the great advantage of examining these cases in an 
institution. He, the speaker, agreed that in many cases this was a great 
advantage, but he would not say it was an advantage in all cases. He examined 
cases which did not go to prison at all, which were remanded out of custody, and 
it was very important that their self-respect should not be injured by their going 
to prison, because one of the great problems in connection with delinquents, which 
Dr. Hamblin Smith mentioned, was the feeling of inferiority. Once a person had 
been in prison, even though he might not be kept there and was there only on 
remand, that could only have the effect of increasing his sense of inferiority. 
With regard to the course of instruction which it was proposed to hold in 
Birmingham University next summer, he might say the course had been definitely 
settled, but it would be a great help if names of one or two who proposed to take 
the course were received. The course would last a fortnight, and it would be 
intensive, consisting of lectures and practical demonstrations. The fee would be 
five guineas. Those taking the course would have to make their own boarding 
arrangements for the time. He asked that names of those intending to take the 
course might be sent to either Dr. Hamblin Smith or himself as soon as possible. 

Dr. J. T. Dunston (S. Africa) spoke of what he saw on the subject during his 
recent visit to America. In the State of New York they had gone so far that every 
individual person who was sentenced to a year or more of imprisonment went 
through a most complete medical examination. There was now being built a 
large and splendidly fitted reception prison, next to it a huge medical institute. 
At the present time the work was being done by Dr. Glueck under more difficult 
circumstances. The whole scheme to be carried out in the new buildings had 


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been devised by the National Committee for Mental Hygiene. On the ground 
floor of this new institute there was provision for, first, the prisoner to be examined 
by a surgeon, then by a physician, finally by a psychiatrist. All the assistance of 
the social workers, the psychiatrists and other people interested was available. 
The medical examination or any one person occupied several hours. The final 
“ say ” rested with the psychiatrist, for it was he who decided whether the prisoner 
was defective, was mal-adjusted, or was actually insane. If the psychiatrist found, 
after consultation with his colleagues, that the man was normal, he recommended 
what he regarded as the right occupation or vocational training or treatment for 
that particular prisoner. Their prisons were divided into groups—agricultural, 
industrial, and so on—and the psychiatrist decided, in conference, into which 
prison the particular felon should go. If he were found to be defective, or mal¬ 
adjusted, or insane, he was certified by the conference for detention during the 
remainder of his life, and was dealt with according to the methods of a mental 
hospital or whatever home or other care was deemed to be necessary for him. As 
regards juvenile offenders he saw work at Boston, New York, Toronto, and other 
places. The method differed very considerably. In Chicago every juvenile 
delinquent was examined by a psychiatrist, who sat as assessor beside the judge, 
whereas in Massachusetts they made a most detailed personality study and only 
formed their conclusions after many hours* study of the child. In America they 
had arrived at the view that it was the individual who really mattered, not the 
crime. 

Mr. Trevor said it had not been his intention to take part in this discussion. 
He came as a humble listener, as he wanted to hear as much as he could from the 
medical side of this most interesting subject. It was impossible for anyone 
to listen to what had been done, either in Birmingham or America or anywhere 
else, in keeping these defective persons out of prison without sympa¬ 
thising with such efforts to the full. What one realised was, that there was 
nothing more futile than the sending of such persons who were not responsible 
for their actions, for short periods of imprisonment. It had only to be 
stated to be appreciated what a real saving was effected by avoiding the sending 
of these people to prison, but detaining them, if necessary, for longer periods. If 
the various branches of the Mental Deficiency Act could be worked for a sufficient 
time, there could be no question that a great saving to the country would be 
effected. 

Sir Robert Armstrong-Jones spoke of an effort being made to found a 
Magistrates’ Association, one object of which would be to secure greater uniformity 
in the dealing with similar offences in the various districts. What had kindled 
this desire was a recognition of the different treatment to prisoners by the various 
benches of magistrates. There was the " lex talionis ” (an eye for an eye and a 
tooth for a tooth), that punishment must be given as a correction and as an example 
to others. Certain benches took that view very strongly. Dr. Hamblin 
Smith took the very sympathetic view that a delinquent should receive special 
treatment, and should be mentally examined, and he, Sir Robert, emphasised 
this at the Guildhall Conference of Magistrates which he attended as a delegate from 
the Petty Sessional Division of Carnarvonshire. At Birmingham they had a special 
medical officer, who gave his opinion in cases of mental defect with a view to improving 
the individual and raising his status. But there were benches which took note of 
neither, but considered that environment was entirely responsible for crime. He 
did not agree with a view which had been given of delinquency, that it was due to 
mental conflicts; and that it was in consequence of these conflicts that anti-social 
conditions arose, the result being the evolution of the criminal. He regarded the 
delinquent in these cases as congenitally weak-minded, with deficient self-control. 
He thought they were not cases of mental conflict, but just a yielding to temptation 
and giving way to instead of resisting the impulses owing to congenital mental 
weakness. 

Dr. J. G. Soutar said that delinquency occurred not only in those who got 
into the hands of the law. Many boys and girls committed delinquencies. 
Thieving, lying, cruelty were very common among young people who were neither 
intellectual defectives nor moral imbeciles. It was the experience of most 
alienists that, under treatment which was directed to adjustment of these young 
people to the facts of life, they ceased to be an anxiety to parents and they grew 
up to be useful members of society. 


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The President remarked that it was with no small amount of self-restraint that 
he forebore to join in the discussion on this paper. He had seen the work which 
was being done at Birmingham, and for that and other reasons he felt great 
interest in it. So great was its importance that he thought it had not received due 
attention from the Association. It was the custom annually to kindly review in the 
Journal the Reports of the Boards of Control. These reviews were very helpful, 
and he thought the same might with much advantage be done as to the Reports 
of the Prison Commissioners. In the American journal, Mental Hygiene, he saw 
details of what was being done in the United States, and to some extent in Canada, 
on this matter. One result of that reading was at first to make him feel impatient 
with his own country. But, in the course of some conversation he had with 
Sir E. Ruggles-Brise, the latter was able to show him what was being done in this 
country, and had been done for years ; but it had not been written and talked about 
much. He was now aware that in the annual reports of the commissioners of 
prisons and elsewhere there was a very large amount of information of value to 
the medico-psychologist, which could be reviewed in the Association s Journal 
every year with mutual advantage. 

Dr. Hamblin Smith, in reply, agreed with Dr. Potts that the weak part of the 
Birmingham scheme was the way in which the cases were selected. But he did 
not at present know how that could be overcome. He (Dr. Smith) was not insist¬ 
ing that every case should be examined in prison, but said that examining a case 
in prison gave, as a rule, more satisfactory surroundings for examination than 
.were available outside. If a case could be examined outside, it was better not to 
send it to prison. And further, in answer to Dr. Potts, it was equally necessary to 
examine before probation, just as before sending to prison. In answer to Dr. 
Dunston, it was a question whether they should examine a few cases intensively, 
or go over very many cases in a more superficial manner. On the whole, he 
thought the former was preferable. With|regard to Dr. Soutar’s remarks, he could 
assure the meeting that on a number of occasions the examination and analysis of 
a case had had a most excellent result in rehabilitating the subjects. He could 
not give statistics of cases, but anyone who would work along those lines would 
feel amply rewarded for his trouble. 


Paper. 

“ Forgetting.” By Dr. H. Davies Jones (Ashurst Hospital, Littlemore, 
Oxford). 

Sir Robert Armstrong-Jones said this question of forgetting was very 
interesting, and there was something paradoxical about it. In order to forget a 
thing, one must first remember it; it must be brought to the focus of attention, and 
then an effort must be made to forget it—two evidently very contradictory aspects. 
He was not sure the description was not good which represented the conscious as 
a little ring the size of a threepenny-bit, resting on the subconscious or the pre- 
conscious mind the size of a shilling, both resting on a table, an extensive reservoir 
which was the unconscious mind, made up of tendencies, possibly inherited, possibly, 
also, the results of education. If anything was forgotten, it was astonishing how 
little links of association helped one to remember. Frances Power Cobbe said the 
power of forgetting was such an extraordinary thing that it was very much like a 
faithful private secretary; leave it alone and it will do its own work in its own 
way. If one had forgotten, the subconscious mind would bring it up. It must 
have happened to all that, having forgotten a thing, it came to mind when least 
expected. He could not see the Freudian aspect, that by definitely focussing 
the power of the mind the thing was forgotton. The more he, the speaker, 
tried to forget certain things, the more they seemed to be present in mind, and he 
had never yet heard a satisfactory explanation of that paradox. Bergson 
referred to the cortex, not as the power of remembering, but as the potentiality for 
forgetting things, otherwise things would come into the cortex and the result 
would be incoherent thought and confusion of ideas. 

Dr. James Stewart said he could remember certain arguments he used to have 
with himself fifty years ago, and he concluded that the senses helped more in the 
way of recalling events than did anything else. For instance, a pretty girl in the 


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West Indies gave him a flower of sweet perfume in the garden of a friend. The 
event and the girl went from his mind, but when, years afterwards, he smelt a 
similar flower, it brought up vividly the image of the girl again. There must have 
remained a glimmer in his mind of the first event, which the smelling of the 
second flower reawakened. During thirty years’ dealing with inebriates he found 
that the memory of these people was invariably affected; he concluded it was a 
result of the damage done to the brain produced by the alcohol. To that, too, he 
attributed in great part the lying indulged in by the inebriate. 

Dr. C. Stanford Read said he found but little to comment upon in the paper, 
as it was only a brief sketch of the Freudian mechanisms of the forgetting in 
every-day life, and giving very good illustrations of it. But it was curious to hear 
Sir Robert Armstrong-Jones talk about 11 the paradox of forgetting,” because 
there were so many illustrations of that fact. How else could hysterical blindness 
be explained ? The explanation was, that a dissociated part of the mind remembered 
something; that something was there, but the consciousness refused to see that 
which the other part of the mind did see. Such experiments could easily be made 
by hypnotic suggestion. While in the dissociated condition the suggestion was 
made to the patient that he would not be able to see this or that, and it could be 
proved that the dissociated part of the mind did see what the conscious mind was 
not allowed to see, and that was merely done by suggestion. Very likely much of 
the forgetting did not come into the unconscious mind, but simply lay in the pre- 
conscious and so might be superficial. He had an illustration of that in his own 
person not long ago. Having arrived at the age in which, though full of ambition 
and enthusiasm he was sorry to know that the years were advancing more rapidly 
than he cared for, he entered a bookseller’s shop and asked for a book the author 
of which he knew very well, but was unable to remember his name. It was some 
time later that he learned by association that it was Jung; it was simply that he 
did not wish to realise he was not now as young as he might be. 

Dr. Bedford Pierce said he would like to ask the author whether he really 
meant that repressed memories must find an expression in consciousness, in some 
way or other. If so, there was an inevitableness about it which he, the speaker, did 
not understand. He spoke on the same point at the annual meeting at Buxton. 
He saw no reason why a repressed memory should necessarily reappear in 
consciousness at some future time. Why could not ideas remain permanently 
latent in a person P Permanent physical things or conditions could remain latent 
many years, why not also mental ? Surely there was no conservation of psychical 
energy which meant that because a thing was pushed out in one place it must 
necessarily crop up in another? Yet psycho-analytical literature was full of 
expressions liked “ dammed back,” and “ it must be appearing somewhere else.” 
That was one of his difficulties in accepting the psycho-analytic theory. He asked 
whether the writer did not think that another analyst, dealing with the same 
symptom, might arrive at a different conclusion. He knew that was a question it 
might not be possible to answer. Sometimes the train of associations was so 
remote and crooked that one wondered whether another analyst would not have 
reached another explanation of the same phenomenon. 

Dr. A. E. Evans said what struck one forcibly in dealing with cases of amnesia 
was the mental upset attending such an affliction. By getting at the individual 
association which was offending and relieving the amnesia, there was evident 
pronounced benefit to the patient. He could recall numerous instances in which 
the amnesia was associated with a condition of real mental agony ; and by recover¬ 
ing memory after memory, by a process of association, and linking memory with 
memory, the mental agony had been relieved. Arguing back, one could say that if 
in these pronounced cases of amnesia there was mental agony, there was probably 
mental distress of a certain degree associated with forgetting. 

Dr. Davies Jones, in reply, said the point raised by Dr. Pierce as to whether 
repressed ideas would express themselves was an important one. With that 
question he coupled another; was forgetting an active or a passive process ? To 
his view, forgetting was an act of repression. There were many varieties of for¬ 
getting ; but in the type he alluded to, repression produced the forgetting. It was an 
active process to begin with, but repeated attempts to repress would render it 
passive. He thought repression would express itself in consciousness in the form 
of a symptom if it had attached to it any emotion ; /.<?., repression must involve a 
conflict, and a conflict must involve pain; and as long as there was pain associated 


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with it, there would always be something present of a painful nature. The term 
“ pain ” was used generally and included any hysterical or emotional condition. 
But if the conflict could be satisfactorily settled, from the patient’s point of view, 
that distress would be no longer present; there would be no manifestation of 
repression coming back into the consciousness. Freud maintained that hysterias 
were unsatisfactory attempts at cure, that satisfactory attempts would not express 
themselves. He wished to thank Dr. Stanford Read for answering the point 
about the paradox, and he endorsed that gentleman’s view entirely. He could 
not see a paradox in forgetting. Dr. Stanford Read’s instance in regard to Jung’s 
name was of the kind he, the speaker, quoted. As to whether different analysts 
would arrive at differerent conclusions on the same cases that depended on the 
analysts. Very much depended on the line adopted towards the patient by the first 
analyst who saw him, as well as on the line the patient adopted towards him. 
Any subsequent interview, whether with the same analyst or another, would 
suffer from the impress made by the first, and it would be a case of the result of 
this second analysis plus the first result. One of the great difficulties in the 
practice was caused by having chronic cases which had undergone tinkering by 
several other people, who often said the patient must try to drown all memories ; he 
was told by one that he had nothing to worry about, and another told him he 
would never get well. It was being realised that work was going to be one of 
the most potent helps for these people, i.e. t a more conscious employment that the 
psycho-analyst could give. He had never yet met with a case in which he could 
—in an inebriate, for example—find out whether the forgetting could be traced, 
and then treated along Freudian lines. 

The Association’s Bronze Medal. 

The President said two essays had been sent in for the Association’s Medal. 
Both of them were able, both showed painstaking work; but those whose duty it 
was to examine them and adjudicate upon them had concluded that neither came 
up to the level demanded by the Association for the bestowal of its medal. One 
of the essays was considered to show so much promise that the writer should be 
invited to enlarge the subject, for, with the addition of a little further work, there 
might be a good chance of securing the medal. 

This concluded the meeting. 


SOUTH-WESTERN DIVISION. 

The Autumn Meeting of the Division was held, by the courtesy of Dr. Blach- 
ford, at the City Mental Hospital, Fishponds, Bristol, on October 28th, 1921. 

Dr. Soutar was voted to the chair, and the minutes of the last meeting were 
read and signed. 

Dr. Bartlett was nominated Honorary Divisional Secretary. 

Drs. Good and Soutar were nominated Representative Members of Council. 

The place of the Spring Meeting was fixed for the Dorset County Mental 
Hospital, and the Secretary was instructed to tender the thanks of the members 
to Dr. Peachell for his kind invitation. 

Dr. Blachford then read a most interesting paper on “ The Functions of the 
Basal Ganglia,” and Dr. Hadfield, Pathologist of the Bristol University, demon¬ 
strated a brain specimen showing a sclerotic patch in the optic thalamus from a 
case with a history of epileptiform fits, increasing in number and severity, for 
three years without permanent motor symptoms. Drs. Soutar, Hadfield and 
Bartlett took part in the ensuing discussion. 

At the conclusion of the meeting a hearty vote of thanks was accorded to Dr. 
Blachford for his kind hospitality. 


SOUTH-EASTERN DIVISION. 

The Autumn Meeting of the South-Eastern Division was held by the courtesy 
of Dr. C. M. Tuke at Chiswick House, Chiswick, on Wednesday, October 12th, 
1921. 


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The members were entertained to luncheon and were afterwards shown round 
the house and grounds. 

The meeting was held at 4 p.m. 

Dr. C. M. Tuke took the Chair. 

The minutes of the last meeting were read and confirmed. 

Dr. D. Bower proposed, and it was seconded by Dr. G. E. Shuttleworth, 
that the Spring Meeting should be held sometime in the month of April. 

At a meeting of the Committee of Management held the same day it was decided 
that the day and place of the Spring Meeting be left to the Hon. Divisional 
Secretary to arrange. 

Dr. Tuke then read his paper “ On Some Points of Historical and Architectural 
Interest in Chiswick House,” and Dr. G. W. Smith gave a short account of a 
case of “ Mania in Myxcedema,” which was followed by a discussion, in which 
Dr. Edwards and Dr. G. F. Barham took part. Dr. Smith replied. 

A vote of thanks to Dr. Tuke was carried by acclamation, and the members 
were then entertained to tea, which concluded this very pleasant meeting. 


PARLIAMENTARY NEWS. 

November 3 rd f 1921 .* Ex-service men in asylums. —In reply to a long question 
by Capt. Loseby, Mr. Macpherson said that he was bound by law to send a 
certified patient to an asylum or some other place approved by the Board of Control. 
The places he utilised for this u nfortunate class of men were very well run indeed. He 
did not ask for any charity. It was an obligation of the State to attend to this 
work. Mr. Macpherson added that he had no personal knowledge of the success 
or otherwise of Chartfield. A report was now being submitted. He should 
consider the individual merits of the place. It was, of course, his duty to see that 
the various institutions under the department were good and were carrying on 
successful work. He refused to send ex-service men to a charity institution. 

Sir Watson Cheyne asked whether it was not a fact the general asylums 
were fully aware of the hope and possibility of treatment, and put that as their 
first object in receiving patients.—Capt. Loseby said he could not follow what 
kind of hardship was held to be inflicted upon the insane by compelling them to 
mix with the sane.—Mr. Macpherson said it was difficult to discuss the question 
of policy by means of question and answer, but he refused to mix insane patients 
with neurasthenics. 

November 8 tk, 1921 : Ex-service men in asylums. —Capt. Loseby asked for the 
number of lunatic asylums approved by the Ministry of Pensions for ex-service 
men and the number of these which were run for private gain.—Mr. Macpherson 
said that approximately 240 institutions were under the control of or had been 
approved by the Board of Control and the Ministry, and of these more than 60 
were private establishments. 

November gth t 1921: Ex-service men in asylums. —Capt. Loseby asked the 
Prime Minister if the treatment allowances upon which some 6000 ex-service 
men depend, were paid strictly on the condition that these men consented to be 
confined in lunatic asylums, whereas the allowance was refused in respect of 
patients being treated and anxious to be treated in certain private institutions of 
the Board of Control; also whether the official figures showed that on January 1st, 
1919, there were 2507 ex-soldiers confined in lunatic asylums ; that the figures had 
risen to 4673 on January 1st, 1921, and to 6435 on October 27th, 1921. He asked, 
further, if the Prime Minister was aware that bitter laments were continually 
emerging from the men so confined, and whether he would consider the advisability 
of setting up a Commission of members of the Houses of Parliament to hear 
complaints and consider whether conditions could be improved. 

Mr. Macpherson, who replied, said that the lunacy law required that every 
person who was certified as insane should be sent to an institution approved by the 
Board of Control, save that under certain conditions a single patient might be 
placed in a private house not specifically licensed for the reception of lunatics. 
Treatment allowances were granted, and the necessary cost of treatment was 
defrayed by the Pensions Department in respect of all certified patients whose 
insanity was due to war service and who were receiving treatment in institutions, 


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whether public or private, approved by the Board of Control and by the Ministry. 
He could not speak for the ex-service men in asylums the origin of whose state did 
not entitle them to Royal Warrant benefits, but as regards certified ‘‘service 
patients ” it was not accurate to suggest that any large number of complaints were 
received as to the conditions of their treatment. On the contrary the number was 
small and they had invariably proved to have been made on unsubstantial grounds 
or to be of minor importance. When a complaint was received the practice was 
for the institution to be inspected and the whole circumstances investigated by 
Pensions Ministry officers, either alone or jointly with Commissioners of the Board 
of Control. Under an arrangement with the Board of Control, asylums were now 
visited by medical officers of the Pensions Ministry, and the service patients 
personally interviewed. Thus he was kept in close touch with the conditions of 
asylums and he did not consider that there was any ground for adopting the sugges¬ 
tion to set up a commission. He could not accept as accurate Capt. Loseby’s 
statement as to the number of certified ex-soldiers in asylums in January, 1919, and 
January, 1920. On the latter date the number was approximately 6000. 

Capt. Loseby inquired whether, if he could produce tangible evidence that some 
lunatic asylums were highly unsuitable for ex-service men and make out a prima 
facie case, the Minister would advise the setting up of a commission.—Mr. 
Macpherson did not think he could do so, but said he would be glad if any 
member of that House would visit any institution under his control. He had taken 
the greatest personal interest in this particular branch of work, and the complaints 
he had received had always been on unsubstantial grounds.—Mr. Gritten asked 
whether it would not cause a large drain on financial resources to place large 
numbers of patients in private institutions.—Mr. Macpherson said that was so; 
the State, in his opinion, was behaving very generously, but he had consistently 
refused to mix patients who had been certified with those who had not. In answer 
to Sir Philip Magnus, Mr. Macpherson added that the private institutions approved 
by the Board of Control, like the asylums, were periodically visited by the 
department. In reply to Mr. Gillis, he said that provision had been made in the 
Ministry’s neurasthenic hospitals for the accommodation and treatment by trained 
medical officers of uncertifiable cases suffering from war injury. 


EDUCATIONAL NOTES. 

The Maudslcy Hospital. —The lectures and practical courses of instruction for a 
Diploma of Psychological Medicine, fourth course, 1922, are announced as follows : 

Part I.—(I) Eight Lectures on the Anatomy of the Nervous System. By Sir 
Frederick Mott, K.B.E., M.D., LL.D., F.R.S., F.R.C.P. On Tuesdays, at 2.30 
p.m., commencing on January 3rd, 1922. The evolution of the nervous system in 
the animal series; physiological levels; macroscopic and microscopic anatomy 
of the nervous system ; the neurone concept—the projection, association and 
autonomic systems; ultimate distribution of the cranial nerves, spinal nerve 
roots and sympathetic nerves ; the meninges—cerebral arteries and their distribu¬ 
tion—the intra-cranial venous and lymphatic systems; the congruence of structure 
and function in the brain ; the congruence of experimental investigation with 
anatomical observation ; the clinico-anatomical methods of investigating the func¬ 
tions of the central nervous system—spinal cord—medulla oblongata—pons— 
cerebellum—mesencephalon basal ganglia—cerebral hemispheres ; the cortex 
cerebri in relation to cerebral localisation, including the cerebral mechanism of 
speech; the structure of the endocrine and reproductive organs. 

Practical Instruction and Demonstrations: Methods of staining nervous tissue 
and preparing it for microscopical examination ; the living nerve-cell—the nerve- 
fibre ; degeneration and regeneration of nerves ; distribution of sections, illustrating 
the principal diseases of the nervous system, for mounting as a permanent 
collection. 

(II) Eight Lectures on the Physiology of the Nervous System. By F. Golla, 
M.D., F.R.C.P., Physician, St. George’s Hospital. On Fridays,at 2.30 p.m., com¬ 
mencing on January 6th, 1922. Reflex action—co-ordination and proprioceptive 
system ; motor system, including muscle and nerve ; sensation—fatigue—localisa¬ 
tion and reference of sensation, normal and abnormal—special senses—mental 


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work and fatigue—methods of investigation—physiology of the emotions—endo¬ 
crinology—the autonomic system—action of alcohol and drugs—physiological 
chemistry—trophic and vegetative functions. 

Practical Instruction and Demonstrations: Physiological Chemistry: Chemistry 
of the nervous system and cerebro-spinal fluid; metabolism ; vitamins and food 
deficiency; physico-chemical methods as applied to bio-chemical research ; blood 
and urine analysis—acidosis, uraemia, uric acid ; gastric contents analysis. 

Practical Physiology: Physical concomitants of emotion; recording reflexes 
and tremors in man ; action of drugs on autonomic system ; the study of reflex 
action in the spinal animal. 

(Ill) Eight Lectures on Psychology. By Henry Devine, M.D., F.R.C.P. On 
Thursdays, at 2.30 p.m., commencing on January 5th, 1922. Definition and scope 
of psychology—behaviour—adjustment—classification of responses—instinct— 
habit—thought—relation of mind and body—the psycho-physical organisation as 
a biological unit—integration—methods of psychological investigation ; analysis 
and classification of modes of consciousness ; cognition—sensation—perception— 
imagination—memory—association—judgment; conation — attention — volition; 
affection—emotion—mood—sentiment; personality — temperament — character; 
sleep— dreams—suggestion—hypnosis — dissociation ; illusion — hallucination — 
delusions—disorders of attention ; fatigue—effects of drugs on reactions. 

Practical Instruction and Demonstration : Sensation—psycho-physical methods— 
statistical methods—reaction times—association—memory—intelligence tests— 
muscular and mental work. 

Part II: Part II will follow in April, 1922, and will include lectures and demon¬ 
strations on the following subjects (a further announcement will be made as to 
times and lecturers): (1) The diagnosis, prognosis and treatment of mental 
diseases; (2) mental defect and crime; (3) the practical aspect of mental 
deficiency; (4) pathology of mental diseases, including brain syphilis, its sympto¬ 
matology and treatment; (5) the symptomatology of mental diseases; (6) the 
psychoneuroses; (7) demonstrations in neurology. 

Fees: For the whole course of Part I and Part II, ^15 15$.; for Part I separately, 
£ 10 10s .; for Part II separately, £ 10 10s.; for one single series of lectures in Part I, 
£4. 4s.; for one single series of lectures in Part II, £2 2s. 

Inquiries as to lectures, etc., should be addressed to “ The Director of the Patho¬ 
logical Laboratory,” Maudsley Hospital, Denmark Hill, S.E. 

The Fellowship of Medicine, 1, Wimpole Street, W., will collect fees from, and 
issue admission tickets to, medical men intending to take the course, who are 
introduced by the Fellowship. 

The Medical Aspects of Crime and Punishment .—Arrangements for a course of 
instruction on this subject are in the hands of the Medical Faculty of the University 
of Birmingham. It is proposed that the course should extend over a fortnight, 
during the summer session. There will be lectures on Psychiatry (by Dr. P. T. 
Hughes), on Mental Deficiency (by Dr. W. A. Potts), and on “ Criminology ” (by 
Dr. M. Hamblin Smith). There will also be practical demonstrations, as may be 
arranged, at the various institutions for defectives near Birmingham, at the Prison, 
and possibly also at Barnsley Hall Mental Hospital. The University Lecturer on 
Psycho-therapy for the year will also deliver two lectures. The course will be 
limited to medical graduates, male and female. 


RETIREMENT OF LIEUT.-COL. T. E. K. STANSFIELD, C.B.E ., M.B. 

The London County Mental Hospital service has lost its doyen in the person 
of Lieut.-Col. Stansfield, who retired from the post of Medical Superintendent of 
Bexley Mental Hospital on July 1st, 1921. He has been a notable figure in London 
lunacy circles ever since his appointment at Banstead as a medical officer in 1890, 
and his work and precepts have had a wide influence in the moulding of the modern 
mental hospital. In his earlier days he travelled extensively on the continent and 
in America, visiting institutions devoted to the care of the mentally afflicted, and in 
1896 published the results of his inquiries, which, together with his observations, 
form one of the most valuable contributions ever made to the subject of the housing 
and treatment of the insane. He has ever been a strong propagandist of the 
colony and villa system of housing, the separate treatment of acute and chronic 


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cases, skilled occupations as therapeutic measures, and the hospitalisation of 
asylum medical administration. Though not the least of his many life-long 
activities, he will be most remembered by the admirable system of. : clinical 
recording which he established at Bexley referred to by the President of our 
Association in his Presidential Address^) which later became general throughout 
the London Mental Hospitals and has been increasingly adopted throughout the 
country. 

His resignation was accepted with much regret by the Asylums and Mental 
Deficiency Committee of the London County Council, and graceful reference was 
made to his valuable services by Mr. W. C. Johnson, J.P., at the Council Meeting 
which received the report. On June 30th at Bexley Mental Hospital there was a 
representative gathering of present and past members of his Committee, former 
colleagues (including Dr. C. Hubert Bond, Commissioner of the Board of Control), 
officers, staff generally, and patients of the hospital, at which Lieut.-Col. Stansfield 
was the recipient of a handsome silver gilt casket containing an engrossed address 
in appreciation of his devotion to his great ideals of work and duty, and the 
success which had been attained in their achievement. 

(*) See page 439, vol. lxvii, October, 1921. 


CONVALESCENT FUND FOR MENTAL NURSES. 

A number of applications for grants from the balance of the Convalescent Fund 
of the late Asylums Workers’ Association have been dealt with by the Committee 
appointed in May, 1920, but a sum still remains to be disposed of. Medical 
Superintendents are reminded that applicants for grants should communicate with 
the General Secretary or Dr. J. F. Powell, Mental Hospital, Caterham, Surrey. 


NOTICES BY THE REGISTRAR. 

Final Examination for the Nursing Certificate, May, 1921. 

List of Successful Candidates. 

* Passed with distinction. 

Birmingham , Rubery Hill .—Richard J. Amphlett. 

Birmingham , Winson Green .—Clara Bullivant, Leah B. Fray. 

Brighton .—Beatrice M. Fidler, Ernest H. Vinehill. 

Cambridge .—Jesse W. Cornell, Vernay Hodgman, Albert F. Minett. 

Canterbury .—Linda V. Mildenhall. 

Chester , Macclesfield Hilda A. Belfield, *Kathleen Hughes, Frances Moss, 
Catherine Thompson, Harry Bannister, Ernest Young. 

Chester , Upton .—Annie C. Manley, Elizabeth O’Keefe, Doris Price, Margaret 
H. Timmis, Harry F. Bromley, Fred Carman, Charles Martin, Thomas Walley. 

Cornwall .—Beatrice A. Bennetts, Norah Maunder, Lucinda Mitchell, Beatrice 
M. Veale, Thomas H. Bligh, Richard W. Bunney, Charles J. Gill, George Hearn, 
♦Thomas J. Roskelly, Alfred J. Stevens, Frederick C. Stevens, Isaac Tiller, 
Alexander R. Weller, Arthur J. Wendon. 

Derby {Borough ).—Edith A. Chambers, Evelyn W. Lee, Dorah Twigge. 

Derby (County ).—Gertrude A. Jeffrey, Sarah A. Radford, Gertrude A. Webster, 
*William H. Hammond. 

Devon .—*Jessie Barrell, Ethel F. Gunn, *Lilian Elisia Warner, Joseph W. Kevern. 

Dorset .—Ivy E. Allen, Dorothy M. James, Mary A. Leslie, Mary Lowman, Hilda 
F. Wadhams, Frank J. Christopher, Theophilus B. P. Dunman. 

Durham .—Mary H. Allison, Ada Clark, Mahalah E. Dyer, # Margaret E. 
Gallacher, Maggie Keegan, Emily Thompson, Ernest W. Davis, James McPhee, 
Ernest Scott, *E. G. Stanley. 

Essex , Brentwood .—Ethel M. Hare, John V. Cressey, Edward P. Gibson, George 
Laundy, William J. Potiphar, Henry J. Richardson, Hatry Whitehead. 

Essex , Severalls .—Elsie A. B. Barton, Alice B. Dawson, Daisy G. Deary, 
Margaret L. Hicks, Florence M. Holmes, *Lilian M. Hull, Elizabeth Kinnimouth, 


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Lily L. Leatherdale, Gwendolen D. Price, Dorothy Whitbourne, Eileen M. Wilson, 
Robert Bessey, George M. Hockley, Frederick Stirling. 

Gateshead .—Joseph Bell, Victor S. Dodds. 

Hants .— # Lilian A. Barting, May Bocher, Samuel H. Giles, Frederick Jones, 
Gwen Whitely Pharoah, Alexander O. Walker. 

Hull .—Hilda E. Watson, Mary L. Willoughby, Tom Wilson. 

Isle of Wight .—Lily Beauchamp, Katherine M. Hayes, Charles E. Brown. 

Kent , Bafming Heath .—Brigid A. O’Donnell, Mary E. Shaw, Lillian A. Wood, 
Bertie Dominey, Anthony Flynn, George W. Goldsmith, William Humphrey, 
Albert O’Kill, Richard Thomson, William J. Wallis. 

Kent t Chartham .—Gertrude M. Best, Alice E. Cork, Winifred M. Kennedy, 
Alice L. Mayes, Harold George, Henry W. Solly, Arthur South, Henry E. 
Weatherall. 

Lancaster , Whittingham .—Mary Blodwen Hughes, Margaret A. W. Lee, Lillian 
E. Milton, # Jane Marsden, *Alice Smith, John W. Barker, Arthur Bracewell, 
John Dickson, R. Fairclough, Thomas Helm, Cornelius McDowell, Edmund 
O’Brien, Thomas O’Brien, Frank C. Turner. 

Lincoln , Bracebridge .—Ivy E. Blow, Edith Bristow, Ada L. Cooper, Edith 
Freeman, Dorothy Jelley, Alicia Kendall, Amelia White, Louisa O. Would, 
George Baumber, Arthur Bott, William Brackenbury, George W. Hough, Frank 
Weldon. 

Lincoln , Kesteven .—Lucy E. Marshall, Charles S. Boddy, Ambrose C. Smith, 
John Taylor. 

London , Banstead .—Mary Browne, Lilian B. Byram, Lucy R. Cutler, Amy 
Farnesworth Flint, Winifred May Fox, Mary G. Glennane, Margaret K. Graves, 
Edith E. Higgs, Charlotte Hooper, Lena Maquire, Antoinette M. Power, Gertrude 

A. Thrupp. 

London , Bexley .—Elizabeth M. H. Allen, Bridget Dowling, Margaret W. 
Flockhart, Lucy M. Gillard, Hetty E. Jolley, Frances C. Jones, Lily M. Jones, 
Phyllis E. Knell, Dorothy McEntagart, Delia McHugh, Lily Maddock, Mabel E. 
.Newton, Florence A. Parucutt, Florence Shaw, Frank S. Allen, John P. Carran, 
Arthur G. Draycott, ♦Albert A. Fackrell, Henry W. Farrant, Sam. M. Hodgson, 
Ernest C. Jeeves, Leo George Knight, Alfred R. Linford, Richard Lunn, Walter 

B. Palmer, Henry W. Pepler, Arthur S. Riches, Archibald Russell, Harry H. 
Ryder, Ernest W. Smith, Frederick C. Thomson, Frederick M. Thorpe, Edwin 
John Waller, Walter E. Yates. 

London , Cane Hill .—Arthur J. Brackenbury, William Scutchings, Charles E. 
Wheeler. 

London , Claybury .—Ellen Burroughs, Evelyn Burdekin, Anastasia Dalton, Julia 
W. Dalton, Alice M. Feeney, Mary Fennelley, Celia M. O’Boyle, Mary Malloy, 
Mary L. Pateman, Annie E. Spokes, Jessie M. Twine, William A. Brown, Fred 
Dawson, Eugene Sheridan. 

London , Colney Hatch .—Emily Ashton, *Mollie Kellaghan, Jennie A. O’Callaghan, 
Harold F. Barnes, Henry Church, William Cooper, Harry S. Diddams, Edgar 
John Hart, Walter J. Hutchings, Walter Robinson. 

London t Ewell Colony .—Emily Moore, Helen O’Sullivan, Cyril Absalom, 
Alexander MacLennan, Michael Reardon, *Sidney Simmons. 

London , Hanwell .—*Katherine L. Chew, Elizabeth Croft, Grace E. Dear, Mary 
E. Frasier, Annie L. Lear, Gertrude A. Leonard, Emma M. Lole, # Primrose Lyon, 
Alice M. Marke, E. Martin, Annie E. Newman, Louisa Stelling, John E. Ayres, 
Alexander Clapperton, Thomas Danby, Charles H.Godden, Frederick W. Hibbert, 
John King, Frederick Mant, Albert Marshall, M. Mihlemsledt, Burt Nicholls, 
William E. Turrell, Harry E. Williams. 

London , Horton .—Jennie Amos, Annie E. Bailey, Ida Bennett, Ada E. W. 
Bramble, Bridget Carolan, Beatrice M. Cox, Catherine McElearney, Florence G. 
Marshall, Mary L. Wadkin, William Lipscombe, Oscar H. Smith, E. Stebbings, 
Albert W. Spong. 

London , Long Grove .—Lily Disbrey, Elizabeth Freeman, Violet I. Foster, 
Grace M. Roffe, Isabella H. Salter, Harriet L. Shingler, William R. Allen, 
Richard Crompton, George H. Riley, Arthur Shrimpton, Richard Smith, Albert 
E. Turner. 

London , Manor .—Beatrice M. Bowen, Harriet Curling, Eliza J. Williams, 
Ronald A. Patrick, Stephen J. Webb. 


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Caterham .—Frederick C. Finch, George V. Gray. 

Leavesden .—Flora Bennett, Annie Harding, Elsie R. Stead, Maud F. 
Ware, Charles Brittain, Herbert Dade, William J. Dean, William H. Horton, 
Arthur J. Palmer, George Rowe, Thomas H. H. Simmons, Joseph Turnbull. 

M.A.B ., Tooting Bee .—Alice M. Hancock, Doris Marmont, Eva A. Rogers, 
Florence M. Townson, Maria Walker, Alfred Barkham, Thomas Barrett, William 

A. Crouch, John Gahagan, William E. Flower, George L. Hammond, William R. 
Humphries, Walter T. Mortley, ^Frederick Shelley, Arthur Taylor. 

Middlesex > Napsbury .—Alice M. Bromley, Charlotte Connor, Elizabeth A. 
Hagon, Elsie E. Lovering, Annie Rose, Jennie L. Whitehead, William H. Rose, 
Charles W. Wells. 

Middlesex , Wandsworth .—Mildred C. Jones, Florence M. Jarvis, Margaret 
Meaney, Hilda K. Picknell, Elizabeth Blythe Reid, Lilian Spray, Gertrude L. M. 
Thomas, Victoria Varney, Edith Wyatt, Walter H. Allen, George A. Hoare, 
* Alfred G. C. Nunn, Edgar Paterson, Francis G. Reardon, William A. Rogers. 
Monmouth .—Ethel L. Davis. 

Norfolk .—Maud A. E. Burrage, Emily A. Housley, Mary MacLellan, Alice E. 
Rimmer, Victor A. Boyce, Francis V. Doggett, Percy G. Elliot, Charles H. 
Sparkman, John W. Whittaker. 

Northampton .—*Frederick C. Coupland. 

Norwich City .—Mabel R. E. Blake, Beatrice Couzens, Charlotte E. Gould, 
Bertha G. Tooke. 

Notts (City ).—Annie L. Bradbury, Harriette Coope, Johanna M. Glennon, 
George P. Barrow, William Briggs, Arthur Smith. 

Plymouth .—Marie A. Moore, Kathleen F. Neve, Rhoda M. Wyatt, John H. 
Moore, Edwin H. Ryder, Arthur J. Worth. 

Salop .—Sarah E. Davies, Alice M. Howells, Alice M. Jones. 

Stafford , Cheddleton .—Lizzie C. Young, Arthur J. Knight. 

Stafford .—Millie Gerrard, George Barker, Frank A. Davis. 

Sunderland .—Margaret E. Bailey, Annie G. Press, Ida Pybus. 

Surrey , Brookwood .—Rachel Chandler, Edith S. D. Denning, Martha M. McLeod, 
Daisy J. Smith, William H. Arthur, Herbert Coleman, James A. Hunt, Joseph 
Seppings, Thomas W. Willoughby. 

Surrey , Netherne .—Dorothy Pitman, Teresa K. Quinn, Alice L. Ward, Charles 
E. Bruford, Arthur F. Thornton. 

Sussex , Hellingly .—Jessie F. Challenor, May P. George, Rose Giles, Rosina 
Holmes, Hilda Peddle, Thomas A. Doick, William J. King, Francis B. K. Knight, 

B. Mitchell, George S. Wallis. 

Warwick .—Alice Maud Hill, Jane Murray, Edith Mary Rainbow, Alfred Hicken, 
Isaac Hinde, Ben Watts. 

Worcester , Barnsley Hall .—Mary W. M. Goddard, Winifred L. Porter, Marion 
Whitehouse, Ernest J. Manton. 

Yorkshire , Beverley .—Harry Crowe, Robert Poole. 

Yorkshire , North Riding .—Florence Morgan, ^Walter Spence. 

Yorkshire , Scalebor Park .—Margaret Ellis, Margaret Wilson. 

Yorkshire , Wadsley .—Louie Bamforth, Hilda R. Barfoot, Albert Bisby. 

York .—Elsie Boynton, Lucy Clare, Leonard Knight, Sarah E. Mant, *Annie 
McKeon, Elizabeth Pickering. 

Bethlem Royal .—Margaret H. Smith, Marian Tweeddale. 

Bootham Park t York .—Janet Guthrie, Helen T. Newbound, Michael J. O’Rourke, 
Harry Rawson, Oscar Shaw. 

Camberwell House .—Helen Buckley, Dorothy E. Cullum, Elsie Everett, Winifred 
D. White. 

Coppice .—Sarah Griffiths, Jessica Waterfield, Arthur E. Elsworth, Frederick J. 
Woolnough. 

Holloway Sanatorium .—Clara C. Lovelock, Harry Evans, Charles W. J. 
Barkham. 

Manchester Royal .—James Loftus, Frank Wood. 

Middleton Hall .—Mary J. Hodgson, Louie Lennard, John W. Kemp. 

Moor croft House .—Fanny Joyce. 

Peckham House .—Emily E. Salmon, George H. I. Bates. 

Retreat , York .—Julia G. Thomson, David I. Roberts, *Fred Wilson. 

St. Andrew's Hospital .—Delia Gibbons, Bessie Olive Goode, Bridget McNally 


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Thomas B. Hawker, Harold G. Bartlett, Joseph H. Faulkner, Harry B. Furn, 
T. A. Rickard, Walter Stafford. 

Ticehurst House .—Christine H. Robertson. 

Warneford Hospital .—Frederick C. Redding, James H. Tutty. 

Aberdeen City .—Jane Beaton, Mary McCurrach, Isabella G. Wilson, George R. 
Burnett, William W. Burnett, William Grant. 

Aberdeen Royal .—Anabella Davidson, Annabella Duncan, Alice M. Fraser, 
Janet R. Sorrie. 

Argyle and Bute .—-Isabella Mackay, Mary McAulay, Mary McLachlan, Elizabeth 
Mitchell. 

Ayr .—Robert F. Geddes, James Paterson. 

Crichton Royal Institution .—Jean Callander, Dorothy I. McDonald. 

Edinburgh , Craig House .—Margaret Bertram, * Agnes Cruse, Annabella Gentles, 
Christina Henderson, Johan Sinclair, Mary Sinclair, Harry Jackson. 

Edinburgh Royal .—Mary Lucas, Janie K. McCargo. 

Elgin .—John Barron, Charles Robertson. 

East Lothian .—Mary G. McDonald. 

Fife and Kinross .—Eliza Allan, Annie W. Anderson, Nellie G. Hampton. 
Agnes C. Mather, Winifred Young, John Grome, James MacKay, George Samson, 
Glasgow Gartloch .—*Jennie L. Mitchell, Elizabeth C. Walker. 

Glasgow , Royal .—Margaret L. Fraser, Ada Mason, Mary McLellan, Teresa 

F. E. O’Hara, Brigid Sharkey, William Inglis. 

Glasgow , Woodilee .—Jean Begbie, Annie Campbell, Mona Cartwright, Nellie 
Edwards, *Sarah Johnston, Mary Kelly, Margaret Kennedy, Alexandrina Melville, 
Annie Mulgrew, Jean O’Rourke, ^Margaret Sim, *Anna E. Thomson, Elizabeth M. 
Wilkie, Cornelius J. Brooks, Murdoch Cameron, Norman Corbett, Thomas 
McAuslan, Patrick McTernan, David McWilliams, Edward Moy, Andrews Orr, 
Thomas Taylor. 

Govan .—jean M. Morrison, Mary Stewart, James Ferguson, James Rae. 
Inverness .—Catherine S. Stevenson. 

Lanark , Hartwood .—Mary J. Titterington, Margaret Winning, Donald Graham, 
David H. Jackson. 

Montrose Royal .—*Mary Balnaves, *Mary Franco, *Florence M. Henry. 

Paisley .—Duncan Campbell, *James Cruickshank, Thomas Matthew. 

Perth t James Murray's Royal .—Jessie Duff. 

Renfrew .—Norman MacKinnon. 

Roxburgh .—Margaret Cameron, Lily Grant, Donald V. MacDonald. 

Stirling .—Mary M. Clapperton, Mary Courtenay, Mary Kennedy, Margaret 
McLennan, * Elizabeth Powrie, George Stewart Cameron, John Macdonald. 
Armagh .—John Devine. 

Belfast .—Johanna D’Arcy, * Helena Feury, Catherine Magee, Adina Martin, 
Maud Moffat, Alexander Murray, Teresa Murray, Martha E. Rowland, Minnie M. 
Stoops, Agnes Young, William J. Flanagan. 

Dublin , St. Patrick's .—Mary Corcoran, Ellen L. Mills, Samuel F. Newman. 
Dublin , Richmond .—Catherine Dunne, Jane Lynch, Joseph Kerrigan, John J. 
Sheridan. 

Mullingar .—Margaret Tiernan, John Creamer, Thomas Fry. 

Omagh .—Bridget Donaghey, Catherine Kelly, Catherine M. McCreary, Rose 
Sharkey. 

Portrane .—Thomas Byrne, John Callaghan, Michael Connolly. 

Cardiff .—Mary Christie, Mary A. Jourdan. 

Denbigh .—Richard Blythen. 

Glamorgan .—Elizabeth Daley, Letitia Davies, Martha John, Mary E. Phillips, 
Annie Roberts, Gertrude Wilkes, Louis Jones, Edward P. Kiernan, Edwin T. 
Williams. 

Newport .—Ada V. Coombs, Martha E. Lewis, Edith Maddocks. 

South Africa , Grahamstown .—Louis Melville Kemp. 

South Africa, Pietermaritzburg .—Robert Henry Brash. 

South Africa , Pretoria .—Martha Jane Mandy, Paulina M. Redlinghuys, Gundina 

G. P. Zeederberg, David Howard de Villiers, Charles F. Marais, Sarel Francois 
Oostheuizen, Francis Statham, Frederick William Sutton. 

South Africa , Valkenberg .—Martha Brider, Elizabeth C. Dreyer, Martha Sophia 
J. van Heerden, Catherine van Jarrsweld, Martha Letitia Koch, Dirkie Connelia 

LXVIII. 8 


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[Jan., 1922. 


Marincowitz, Myrtle Martha du Plessis, Catherine Visagie, Jacoba M. van Zijl, 
Johannes Andries Burger, Hendries Stephanus Lotter, S. F. Steenekamps. 


Final Examination for Nursing of Mental Defectives, May, 1921. 

List of Successful Candidates. 

Stoneyettes Institution , Chryston. —Reginald Clarke. 

M.A.B ., Darenth. —Ada Crawley, Dora L. Dunn, Maud Morley, Louisa Radley, 
Amelia Stone. 

Royal Scottish National Institution .—Janet Bryce, Margaret Macrae, Annie W. 
Rankine. 


NOTICES OF MEETINGS. 

Annual General Meeting .—First week in July, 1922, at Edinburgh. 

Quarterly Meetings. —February 23rd, 1922; May 25th, 1922. 

South-Western Division. —April 28th, 1922, at the Dorset County Mental 
Hospital. 

Irish Division. —April 6th, 1922; July 6th, 1922. 


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THE 

JOURNAL OF MENTAL SCIENCE 

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


No. 281 APRIL, 1922. VOL. LXVIII. 


Part I.—Original Articles. 


Ends and Means of Psychiatric Research .( x ) By Prof. Emii. 

Kraepelin, of Munich. 

The story of the founding of the German Institute of Psychiatric 
Research reveals the astonishing fact that a great enterprise, requiring 
millions of marks, and serving in the first instance purposes of pure 
science, has been carried into execution, even amid the tumult of the 
war, in little over a twelvemonth. The preparatory work dates back, 
of course, to the pre-war period, but the scheme had to give place to 
the great task of the day, until, on January 6th, 1916, with the 
subscription of the first half-million marks, the possibility of its 
materialising came suddenly within reach. Six months later the 
future of the new Institute was firmly^ assured, and on February 13th, 
19x7, His Majesty King Ludwig was able to grant the charter that gave 
it being. On June 10th, 1917, was held the first public meeting at 
which the position of the Institute with regard to the development of 
our science could be made plain, and in April of this year ( 2 ) five of the 
seven departments originally projected had taken up their work under 
the leadership of eminent savants. The others will follow as soon as 
the circumstances of the time permit a satisfactory solution of the 
problem of personnel. 

Quietly has the great result manifest in these facts been achieved, 
without publicity, without aid of the press, and without any organised 
appeal for funds. It would not be incorrect to say that what has thus 
been enacted has to some extent occurred spontaneously. The clear¬ 
sighted determination of a few persons sufficed to raise the requisite 
means, smooth the ground, put aside obstructions and rear the edifice. 
Without their energy and willing sacrifice our object, of course, could 

(') Translated by Sydney J. Cole from “ Ziele und Wege der psychiatrischen 
Forschung,” Arbeiten aus der Deutschen Forschungsansialt fur Psychiatrie in 
Munchen, Bd. i, December, 1919 (Sonderdruck aus der Zeitschr. f. d. ges. 
Neurol, u. Psychiat., Orig.-Bd. xlii, Heft 3/5). [The Journal has acquired the sole 
rights to publish this article in the English language.— Eds.] 

LXVIII. 9 


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116 ENDS AND MEANS OF PSYCHIATRIC RESEARCH, [April, 


not have been attained. But the rapid and almost effortless accom¬ 
plishment of this great work would still have been impossible were it 
not for the conjunction of another circumstance. The time must have 
been ripe for the idea thus realised. The establishment of a psychiatric 
research institute must have become an obvious need of the hour. 

That it is so is unquestionable. With oppressive weight the 
knowledge has forced itself on all public bodies concerned with lunacy 
that they have to do with a monstrous burden, imposing ever greater 
demands on the thrift and productivity of our people—experience 
eloquently set forth in the well-known address of the Prussian Provinces 
(September 25th, 1912), in which the establishing of a research institute 
for psychiatry was recommended; and individuals innumerable have 
had occasion to feel, in their own homes or in the circle of their 
acquaintance, the dire calamities mental illness can bring. That 
soundness of mind is no less important for a nation’s productive and 
resistive capacity than physical fitness has been bitterly brought home 
to us by the affliction of war. To hold before our eyes the necessity 
for the struggle against mental disease there could hardly be a fitter 
moment than this, in which our whole existence is dependent on our 
knowledge and abilities, our powers of adaptation and self-discipline, 
the strength of our will and the steadfastness of our resolve. 

But not even the clearest perception of the dangers with which 
mental diseases threaten the future of our people, any more than the 
strongest determination to avert them, would enable us to discover by 
what means they can be repelled, were not our science also ripe for 
taking up this task with a prospect of success. Only a few decades 
ago it would have seemed hopeless, nor would then the most opulent 
resources have enabled our science to advance one step in the desired 
direction. Not till lately was a point reached from which any sure 
progress in the knowledge of the causes and nature of mental disorders 
could be made. But to-day many lines are open to us by which these 
questions can be approached, and we have also the implements for 
commencing the work. After a hundred years of hard struggle we have 
arrived so far as to be able to draw up plans that are rich in promise, if 
to the right men are granted resources, and the freedom to devote their 
whole energy to the task. 

The instituting of a thorough inquiry in our department of science 
proceeds from the assumption that we have to do with processes of 
veritable disease—processes that will admit of recognition and be dis¬ 
tinguishable with certainty from one another. What at the outset 
presents itself to the alienist’s observation is a jumble of pictures, some 
of them stable, others variable, compounded of the most miscellaneous 
details. The attempt to reduce to order these multifarious exhibitions 
has led inevitably, as in other branches of medicine, to the grouping of 


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cases according to their most conspicuous outward signs. So, down to 
our own day, almost all classifications of mental disorders have started 
from the fact that some patients are depressed, others cheerful; that 
some are dull and self-absorbed, others restless, noisy and violent; that 
here we seem to see a complete absence of mental operations, there 
a restriction of morbid ideas to some particular subject, and so on. 
As for anything beyond this, there was at most a distinction between 
congenital and acquired weak-mindedness—the first shy approach to 
invoking history of onset for the purpose of discriminating between 
different disease forms. 

Innumerable have been the attempts to classify in that manner the 
given cases, and so to arrive at types. But again and again it has been 
found that the diversity of the phenomena makes mock of such imprison¬ 
ment, that the mixed and indefinite forms thickly overgrow the simple 
types artificially stripped of their bark, and that a close examination 
leaves but few cases that will go unmistakably into this or that pigeon¬ 
hole. Observers, of course, have not been blind to the barrenness of 
these incessantly renewed attempts. In particular, they soon saw that 
there can be no distinctiveness in cheerful and gloomy moods, for one 
can be directly exchanged for the other in the same patient. This led 
them, notably in France, to split up disorders showing marked variations 
of mood into a number of forms, according to the various kinds of 
sequence which the cheerful, gloomy, and normal periods exhibit. 

A further breach in the conception of mental disorders as mere 
divergences from a psychic norm was made by the discovery, in the 
twenties of the last century, of a form of illness characterised by post¬ 
mortem appearances—by chronic inflammation of the substance and 
membranes of the brain. This illness, distinguished first in France, 
is general paralysis of the insane, which we now know to be in the 
strict sense a disease. Here, where it can be shown by post-mortem 
examination of the brain that a given case is referable to a definite 
morbid process, it is plain to be seen that the phenomena during life 
are not by any means uniform, but extremely diversified. It is remark¬ 
able how long this clear proof of the deceptiveness of outward appear¬ 
ances, as an index to the morbid process, remained without appreciable 
influence on clinical investigation. The impression made by the obvious 
mental abnormalities was so strong that observers were unable to rid 
themselves of it. 

Another promising opening was offered when Guislain suggested, in 
1838, that the various forms of insanity might to some extent be 
regarded as efforts of the diseased brain to make good a gradually 
spreading damage. The clinical aspects thus became stages in a pro¬ 
gressive affection whose features took shape from the disposition of the 
patient. Although this doctrine, later accepted by Zeller and Griesinger, 


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does not prove to be sound, it contains the apt notion that to a morbid 
process there corresponds a definite course in which a number of 
changing aspects may be displayed. 

The decisive turn to our mode of viewing these things was given by 
Kahlbaum, who not only emphasised in the strongest manner the 
distinction between the manifold changing aspects that attract our 
immediate attention and the morbid processes that pursue their regular 
course beneath, but showed, in 1874, by the example of katatonia, how 
varied, at different periods of the illness, the spectacle presented by one 
and the same patient can be. It was now clear that, in spite of all 
diversity of phases, it is possible by a more refined observation to trace 
through the entire course certain characteristics by which the inner 
connection of the several stages can be demonstrated. Thus the 
important result was reached that, from a given present state, definite 
conclusions can be drawn respecting the stages that have gone before 
and the stages that are likely to ensue—the only certain indication that 
a genuine morbid process has been unveiled. The same holds good for 
hebephrenia (juvenile insanity), already described three years earlier by 
Hecker at Kahlbaum’s instigation. 

With these two forms of disease, and the general paralysis that had 
served as their prototype, a start was made in the discovering of genuine 
morbid processes. To them, since Kahlbaum’s mode of view has 
overcome initial opposition and gained more and more acceptance, a 
number of similar finds have been added. Above all should be men¬ 
tioned the long-known but little-regarded diseases produced by poisons, 
particularly delirium tremens and those other alcoholic mental disorders 
that have only of late years been closely studied, and the insanity brought 
about by cocaine; the various forms of mental disturbance occurring in 
febrile diseases, in injuries of the skull, in uraemia and eclampsia, and in 
cretinism ; the great group of manic-depressive disorders, genuine 
epilepsy, the arterio-sclerotic, senile and syphilitic brain affections, 
hysteria and the manifold forms of degeneracy, and still more numerous 
smaller groups that we have reason to regard as expressions of definite 
morbid processes. 

Many of these diseases, of course, are still very imperfectly under¬ 
stood and insufficiently distinguished; yet a large proportion of them 
offer very useful points of attack for a systematic investigation of their 
causes and nature. So long as disease forms were set up with a sole 
regard to outward aspect at a given moment, an investigation of the 
conditions that produce them could naturally never lead to any useful 
result, for we had always to do with a mixture of the most heterogeneous 
processes, and no uniform causes were present. Hence the hopeless 
obscurity of the old teaching, which for every disease made all possible 
causes responsible, and on the other hand ascribed to the same injurious 


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factors the most diverse affections. To-day, however, we start from the 
principle that behind similar morbid processes there must somewhere or 
•other be a similar noxious influence that has produced them, and that 
from the observed effect we can infer a definite cause. Obvious 
instances of such a connection are tipsiness, which we set down straight¬ 
way to alcohol, general paralysis, for which a syphilitic basis can always 
be demonstrated, and cretinism, which is invariably due to a failure of 
thyroid action. 

At the same time, of course, we have always to take into account the 
influence of mental and bodily peculiarities of the individual. Such 
peculiarities can completely inhibit the action of the morbific factors, or 
they can aggravate it; they can give a special tinge to the clinical 
aspect, allow of the appearance of aberrant forms, and permit unusual 
developments in the course of the illness. It appears, however, that 
the influence of individual peculiarities does not very materially modify 
the leading characteristics in mental disorders produced by noxious 
action from without. It is probably quite otherwise in the misty sphere 
of diseases arising from inner causes; at any rate, there is here an 
immense group of forms whose features are determined solely by 
personal disposition. 

The crudest and most primitive procedure for establishing a connec¬ 
tion between cause and effect consists in observing the time-succession 
of two events. It yields more or less reliable results only where the 
disorders follow immediately upon powerful noxious influence from 
without—for example, head injuries, poisonings, febrile illnesses, and 
childbirth. But even here, apart from the possibility of mere chance 
coincidence, it can often be seen that the outward occasion was not the 
true cause of the disease that has broken out; it has but let loose a 
malady already prepared by inner causes. This holds good for a not 
inconsiderable proportion of mental disorders following febrile illnesses- 
It applies in even greater degree to puerperal insanity. The mental 
illnesses of women recently confined were formerly regarded as all of 
one sort—as the immediate effect of the revolutionary changes then 
taking place in the organism—but wider experience has shown that we 
have to do with a number of totally distinct forms of insanity, of which 
comparatively few have any strict causal connection with childbirth. 

The establishing of a causal connection becomes even more 
precarious if damage and illness are separated by a wider interval of 
time. The general public, like the psychiatrists of former days, are 
only too ready to blame anything specially striking that has happened 
in the past, no matter of what sort, for the mental disorder that has 
now arisen; they profess to trace visible effects of it right back to 
the time of its occurrence. To such caprice there are no bounds. 
This hasty connecting of one impressive incident with another is 


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largely responsible for the terrible confusion in the teaching of causes, 
in psychiatry as in other departments of medicine. Not uncommonly, 
the first indications of the commencing illness, or even its consequences, 
are taken for its cause. This is especially the case with emotional 
excitements, supposed to be so powerful in producing insanity. We 
now know that in mentally vigorous people they can hardly ever lead 
to morbid disturbances. In unstable and excitable persons their 
morbific influence is greater, but even in them the disturbances 
produced have mostly a brief and favourable course. In the vast 
majority of cases the apparent emotional cause—the disappointment 
in love, the worry, the grief, the indignation or the annoyance—proves 
to have been immaterial to the production of the illness, or was its 
first indication. 

The difficulties here pointed out can be surmounted only by the 
search for unitary morbid processes. These we may assume always 
to arise from similar definite causes. Apart from certain clinical 
features often difficult to apprehend, the data for the recognition of 
such a process are chiefly its course and result, and, in certain groups, 
the post-mortem appearances. Whenever a true morbid process is 
ascertained, our understanding of the causation is invariably clarified, 
even if only so far that we become able to reject false causal 
attributions. We see, for example, that a certain definite morbid 
process is frequently associated with a particular damage; but if we 
see that far more frequently this damage has no such consequence, 
we obviously cannot regard it as the true cause. By such experiences 
our knowledge of the true causes of insanity has been enormously 
increased. In a great number of morbid processes the physical and 
mental causes are now so well known that from the clinical picture 
the nature of the preceding damage can be inferred. This is especially 
true for the illnesses produced by poisonings and by syphilis, for 
uraemic deliria, cretinism, hysterical disorders, traumatic and war 
neuroses, and, with certain limitations, the acute forms of insanity 
produced by head injuries and febrile illnesses. Here also, of course, 
there are many pitfalls; for, owing to gradual shadings and to the 
personal colouring of the phenomena, the relevance of different clinical 
pictures to a particular morbid process is not always easy to perceive. 

Even more reliable than the mental states there are often physical 
signs from which, in certain circumstances, the nature of the malady 
is immediately evident. Chief among these are the Wassermann 
reaction, the cell-count and albumen content of the spinal fluid, and 
inactivity of the pupils to light; from these we may safely infer the 
presence of syphilis and its invasion of the brain and spinal cord. 
Important signs also are the neuritis in alcoholism, the myxoedema 
in cretinism, the increase of the residual nitrogen of the blood in 


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uraemia, and many others. The keen desire to increase the number 
of such aids has led, moreover, to an extensive application of the 
Abderhalden dialytic procedure to psychiatric questions. From the 
circumstance that the blood fluid in certain cases exhibits the power 
of disintegrating the tissue of such or such organs, there is believed 
to be some ground for assuming that the latter are materially concerned 
in the morbid process. Unfortunately the extravagant hopes that have 
been set on such findings have not been realised; it does not appear 
that from those disintegrative phenomena we can draw any far- 
reaching conclusions. The process itself being extremely wayward 
and unreliable, the deductions from its results have but a weak 
foundation. 

Although the improved resources of advancing science have served 
to clear up many points respecting the ways in which mental disorders 
are produced, there is still a very wide sphere in which we are no nearer 
to a solution of the question—a sphere in which, indeed, we feel less 
assurance than before, as connections that on a rough examination 
seemed obvious have turned out to be deceptive. This applies 
especially to the bulk of the disorders assigned to dementia praecox 
and manic-depressive insanity. We know well that inherited disposition 
plays here an important part, that the frequency and the forms of the 
disorder are greatly affected by time of life, and that noxious influences 
from without, emotional excitements, childbirth and bodily illness have 
sometimes a precipitating effect, but of the causes that really engender 
the malady we are ignorant. It is much the same with epilepsy, to 
whose production influences deleterious to the germ certainly often 
contribute, though of the nature of their action we can give no account. 
We are equally in the dark as to the origination of degenerative insanity, 
of the various defects of personal disposition that lead, as life goes on, 
to derailment in this direction or that, and for the most part also of 
states of congenital weak-mindedness. Here, too, we have to take into 
account hereditary factors and germinal injuries, but also manifold 
morbid processes that invade the brain in youth. 

The disclosure of the causal relations is an important step towards 
an insight into the essence of the morbid processes, and an understand¬ 
ing of the changes that take place during the malady and represent its 
elements. Even if we have recognised with certainty the causal 
dependence of a mental disorder upon a particular damage, we may 
still be far from understanding their deeper connections. A typical 
instance is afforded by delirium tremens. So certain is it that this is 
produced through prolonged alcoholic excess that from the clinical 
picture we can tell at once what the cause is. But delirium tremens is 
no direct expression of alcohol poisoning, for its phenomena are quite 
different from those presented by this; to tipsiness it has not the 


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122 ENDS AND MEANS OF PSYCHIATRIC RESEARCH, [April, 

slightest resemblance. Here we get a hint from the striking relation¬ 
ship it shows to the deliria occurring in uraemia—retention of urinary 
constituents in the blood. In delirium tremens there may similarly be 
an auto-intoxication, by metabolic products whose formation or insuffi¬ 
cient excretion is conditioned by the chronic alcoholic state of the 
body. This supposition, which of course needs verification in detail, 
would remove an important objection to the opinion here maintained 
that it is possible, even in our department, to reason from particular 
morbid signs to particular causes and reversely. The multifarious* 
ness of the mental disturbances brought about by alcohol is often 
adduced against this opinion. Close examination shows, however, 
that among effects of alcohol we must distinguish between two 
series of disorders, exhibiting apparently quite different causal rela¬ 
tions to the poison. To the first group belong the ordinary and 
the excited forms of tipsiness, alcoholic hysteria, with perhaps 
also the so-called habitual epilepsy of drunkards, as well as simple 
alcoholic thickheadedness and alcoholic jealousy ; to the second, 
delirium tremens, alcoholic delusional insanity, Korsakoff’s psychosis 
and alcoholic epilepsy. The first-mentioned forms can be traced 
without much difficulty to the direct action of the alcohol. For those 
in the second group (which occur only after prolonged heavy drinking) 
this is not possible; and since among these we observe transitional 
and mixed forms, they have all perhaps a common mode of origin 
through poisoning with products of a morbid metabolism to which 
chronic alcoholism gives rise. 

Similar difficulties confront us when we try to picture the relations of 
general paralysis to syphilis. That syphilis can attack the brain was 
known long before the origin of general paralysis was divined. Brain 
syphilis, however, is a disease that is in many respects quite different 
from general paralysis. The latter usually arises much later after 
infection, and is almost always fatal within a few years, while brain 
syphilis often leads to a protracted mental illness, and may end in 
complete recovery. Moreover, the behaviour of the spinal fluid, the 
post-mortem appearances and the susceptibility to treatment differ in 
the two cases, and the two conditions can usually be distinguished by 
their clinical aspects. In spite of their common origin from syphilis, 
their modes of production must therefore be in some respect dissimilar ; 
but how it happens that in one person a brain syphilis develops, and 
in another a general paralysis, the vigorous investigations directed to 
this point have not yet been able to explain. 

From such examples, which could easily be multiplied, we may learn 
what a long way it is from a bare recognition of causal connections to 
a real understanding of them. Even where at a first glance things seem 
clearly displayed, on close inspection numerous difficulties present 


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themselves. We know definitely that failure of thyroid action in early 
life produces cretinism, and that we can prevent this by timely adminis¬ 
tration of dried thyroid; but we still do not know what noxious 
influence causes the atrophy of the thyroid in endemic cretinism, or 
what those ingredients of the thyroid secretion are whose deficiency 
occasions the cretinous disturbances in the growth of the bones, the 
cutaneous and metabolic changes, and the weak-mindedness. With 
every attempt to penetrate deeper into the nature of the morbid pro¬ 
cesses we are confronted with fresh questions, for whose solution many 
sciences must be invoked. 

The problems thus arising demand in the first place a study of the 
effects which a morbific influence produces in the body, up to the point 
at which it attacks the brain. We must follow this process carefully 
through all its intermediate links. The final aim will then be to make 
clear what alterations the malady eventually produces in the structure 
and function of the brain tissue. Here we have to consider not only 
the destructions and impairments produced by the last link of the 
morbid process, but the defensive and compensatory efforts of the 
diseased parts, and the results that ensue in spheres dependent on these. 
It is needless to say that for an approach to these questions we have 
nowhere yet got beyond the most meagre preliminaries. 

But until we have obtained some insight into the essence of the. 
morbid processes, it will be difficult to take up, with any prospect of 
success, the second great problem that awaits us—the question what 
relations exist between the ascertained disturbances of brain function 
and the mental changes presented in the clinical pictures. To this 
highest and perhaps never quite attainable end there is still a further 
distance to travel. The connections between the normal mental life 
and the brain processes that constitute its basis must first be made 
clear. For the requirements of our science we can be content with 
purely empirical demonstrations, without touching the ultimate funda¬ 
mental question of the essential nature of the connection. The 
immensely developed structure of the brain and especially of the cortex, 
the facts of ontogeny and comparative anatomy of the brain, the study 
of focal brain lesions and malformations, and the results of experiments 
on animals, show more and more clearly that, corresponding to diffe¬ 
rences in structure of individual portions of brain and differences in 
their arrangement, there must be differences in function. In other 
words, we have every ground for assuming that the brain is composed 
of an immense number of individual implements and mechanisms, all 
of which possess definite importance for the fulfilment of the total 
function. Moreover, it is extremely probable that manifold safeguards 
are provided, so that the same purpose may be achievable in many 
independent ways and with different means, yet without its being 


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124 ENDS and means of psychiatric research, [April, 

possible, as was formerly supposed, for one part to take over, in the 
strictest sense, the function of another. We need but remember that 
speech symbols can be apprehended not only through the medium of 
hearing, but by vision, and by perception of the appropriate speech- 
movements, and that disturbances of bodily equilibrium are notified 
through vision, through sensations from muscles and joints, and through 
the semicircular canals. 

If these conceptions are just, it would be necessary, in order to 
understand the relations between brain function and mental expression, 
to obtain first a clear picture of the fashion in which the brain is 
constructed of its countless individual implements and groups of imple¬ 
ments. It must then be ascertained what purposes all these different 
implements serve, how they act together, and in what ways they are 
dependent one upon another. For working out these questions, how¬ 
ever, we require a deep and detailed knowledge of our mental life. 
We must know from what primitive constituents the mental processes 
are built up, and how they combine with one another for higher and 
more elaborate performances. It would then become possible to 
discover more general and perhaps gradually more detailed relations 
between brain structure and mental operations, in the development of 
the growing man, in the animal series, and, in the direction that has of 
late been followed with some success, the thorough investigation of the 
peculiarities exhibited by different races and different individuals. But 
the most fruitful source of knowledge will be the circumscribed brain 
lesions offered by experiments on animals and by an imposing array 
of clinical material. We know that many poisons have the peculiarity 
of seizing upon quite definite territories of brain, and of causing mental 
disturbances that correspond to these and are likewise sharply defined. 
There is always the possibility that the connections between circum¬ 
scribed portions of brain and particular mental operations may in that 
way be revealed. But our object is much more approachable by investi¬ 
gation of the defect phenomena resulting from brain injuries, if we can 
ascertain also what regions of the brain are affected in the particular 
cases. The war has unhappily multiplied such cases to a frightful 
extent. If we could manage to utilise the experience gained from these 
cases, so as to widen our knowledge of the relations between particular 
brain regions and particular expressions of mind, the unspeakable 
misery of brain wounds could at least contribute towards arming our 
science with weapons for combating future ills. 

By such researches the foundation would be laid for a knowledge 
of the connection between morbid changes in the brain, so far as they 
leave demonstrable traces, and the morbid phenomena observed during 
life. Post-mortem investigations in cases of insanity have hitherto 
yielded at most a disclosure of the occurrence of this or that morbid 


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process in the brain, with perhaps some general idea of its greater or 
less extent; but as to what members of the brain structure are implicated, 
and what effect their implication must have upon the mental life, we 
still know practically nothing. At the present time it is therefore quite 
impossible to draw, from the character of the disturbances during life, 
any conclusion as to the seat and extent of the morbid processes, if we 
except certain gross disturbances of sensory perception, of voluntary 
movement, and of understanding and use of speech. 

It will certainly not be easy to advance along the road here indicated. 
Besides all other difficulties, residing in the nature of the thing, we 
shall have to reckon with personal peculiarities, by which we may easily 
be misled, and which in the immensely elaborated structure of the 
brain should find their freest expansion. As has already been pointed 
out, we have at our command, for achieving a purpose of any sort, 
several different brain mechanisms, of which sometimes this one is 
preferred, being perhaps more finished, and sometimes that. The 
impairment or failure of a particular performance can accordingly be 
conditioned by a disturbance, now in this brain region, now in that. 
We may mention, by way of example, the personal differences in 
respect of preferential use of visual, auditory or speech-movement 
presentations, for the formation of concepts and for the fixing of 
memory impressions. But far beyond such elementary forms of mental 
work there are differences in other personal inherited or acquired 
characters, in endowment or deficiency in circumscribed spheres, wide 
or narrow, in the operations of conception, memory or intelligence, and 
in temperament, volitional capacity and accomplishments. The 
problem of estimating the importance of personal peculiarity, not 
merely in the clinical picture but in relation to distribution of brain 
changes, certainly appears, so far as we can see at present, quite 
insoluble. Meanwhile, the considerations here adduced are to be 
regarded as indicating, not an attainable end, but a general direction in 
which scientific work is possible. 

If from these highest ultimate problems, so inaccessibly remote, we 
turn our gaze to the prosaic world of facts, we see a number of paths 
that we can already follow with a hope of gradually penetrating further 
into the subject of our science. First, we must persist in our endeavours 
t& find out genuine processes of disease, since they only can provide 
the basis for future research. Among cases that do not admit of being 
ranked with already known and firmly established forms, we shall be 
able to find groups of cases resembling one another in mode of onset, 
phenomena, course and result, and, where the point arises, in post¬ 
mortem appearances. Such cases must be tentatively gathered into a 
new disease form. Experience shows that, to such a provisional group, 
other cases always attach themselves—cases which, though somewhat 


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different, exhibit in their general behaviour a similarity to the type 
that has been set up. Since such aberrations are observed in all unitary 
affections, it is to be assumed that at least some of these cases will 
have to be allotted to the original group. For a final decision we 
must be guided by the upshot of the case and, in the event of death, by 
the finer post-mortem appearances of the brain ; also, in certain circum¬ 
stances, by the history of onset, but only in a minor degree by the 
details of the clinical picture, for these, as we know, can in the same 
morbid process be quite different and may even appear contradictory. 

If in this way the original picture has widened itself, it will have to 
be proved where its limits lie. We keep adding, by way of trial, fresh 
similar cases, throwing them out again if a divergence in their outcome 
and post-mortem appearances shows them to have been included 
erroneously. Disease pictures more or less divergent in their expres¬ 
sions are in this way gradually comprehended in a unity, so that we are 
enabled to make at least a definite prediction. Probably we have 
succeeded thus in grasping a unitary morbid process ; we have certainly 
succeeded if we find that from the changes demonstrated in the brain 
after death the general features of the antecedent clinical picture can, 
as a rule, be correctly inferred. Among the various clinical phenomena, 
certain signs, perhaps inconspicuous, will usually by this time have 
been noticed, common to all cases in all stages of the malady, and 
hence characterising in some degree the newly constructed disease 
form. If we have succeeded in discovering such leading signs, often 
demonstrable only by some special artifice, we may perhaps become able 
to include, in the new disease form, cases that in course and in 
outcome diverge from the main group, since the same thing occurs with 
morbid processes that have been surely defined. We must proceed, of 
course, with extreme caution. A really satisfying assurance in the 
recognition and demarcation of a newly distinguished form of disease 
can be reached only by long experience and after many disappoint¬ 
ments. Our errors of prediction are really the handholds for our 
advance. They show us that we have over-estimated the worth of some 
particular sign, misconstrued another, and overlooked or insufficiently 
valued a third. So they enable us again and again to amend our views. 

How enormously important for the progress of our science is 
anatomical investigation of the brain, both in health and in disease, ss 
evident from the foregoing considerations. What we require above all 
is a clear characterisation of the post-mortem appearances of the brain 
in as many morbid processes as possible. That the indispensable 
pre-requisite for this is an exact knowledge of all component parts of the 
tissue, and of their structure in all its details, including chemical 
constitution, needs no elaborate proof. But even when this condition 
is approximately fulfilled, and when the morbid abnormalities can thus 


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with certainty be detected, new difficulties arise, especially as the 
microscopic appearances in an individual case show us, in every 
instance, only a particular state of the tissue, not how it has come 
about nor how it would shape itself further. Side by side in the same 
brain there may doubtless often be seen portions which exhibit the 
same morbid process in different stages of its development, so that by 
a comparison of these a picture of the succession of the changes can 
be obtained; but in other instances an attempt must be made, from 
the various fortuitously available cross-sections of the morbid process, 
to deduce a longitudinal section—not always an easy thing to do, for 
the sequence, and even the relevance, of the several appearances may 
be very dubious. 

Even if he has succeeded in following a morbid process through its 
changing stages, the anatomist is still in danger of confusing different 
kinds of morbid processes, or of failing to recognise the essential 
oneness of pictures outwardly differing. Since, in the morbid changes, 
a whole series of tissue-elements connected with one another can be 
affected sympathetically, various pictures may be produced, differing as 
this or that element is in greater or less degree affected, and these 
pictures are prone to alter in the course of the same morbid process. 
On the other hand, it is sometimes extremely difficult to perceive the 
dissimilar significance of similar anatomical findings, for these consist, 
time after time, in alterations of the same tissue-elements. The sources 
of error that here confront us resemble those that we are to beware of 
in interpreting the mental phenomena, where likewise we have to gather 
into a unity appearances that are diverse, and to separate others that are 
seemingly alike. In the anatomical sphere, as in the clinical, a review 
of the whole course of the changes, so far as this is possible, may afford 
us some fixed points. A deeper insight also into the finer details of the 
morbid process, particularly by aid of stains and chemical reactions, 
will often materially facilitate the unification of things that belong 
together, and the separation of those which, though similar, are essen¬ 
tially different. And lastly, a most important part in the elucidation of 
the anatomical changes is that which is played by experiments on 
animals. However little it may be possible to identify human with 
animal brain-functions and illnesses, yet, from the effects produced by 
particular noxae in the brains of animals, conclusions can be drawn as 
to the issue of like processes in man. We are thus enabled to trace 
accurately the course which the changes pursue, and to apprehend the 
connection of their several stages. The acute and the permanent 
effects of manifold poisons, the results of concussions and demolitions, 
and finally, the changes evoked by pathogenic agents or by ablation of 
organs—whatever morbid processes, in short, are producible artificially— 
can in this way find elucidation. 


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Specially important in this connection is the study of the injuries 
brought about in nervous tissue by the spirochsete of syphilis. It 
appears that by experiments on animals some part of these changes can 
be imitated—those in which the so-called brain syphilis consists. Of the 
metasyphilitic affections, general paralysis and tabes, artificial production 
in animals appears at present impossible, but in our department, at any 
rate, an explanation of the conditions for the vitality of the spirochaete, 
the fates that attend it in the body, the changes it undergoes, and the 
changes it produces, must be striven for with all our might. 

As soon as we have by such means succeeded in defining in detail 
the anatomical characters that a brain affection exhibits, the far more 
toilsome work begins of determining its local distribution in the brain. 
This has hitherto been undertaken only in the rudest outline ; for, besides 
an exact knowledge of every phase in the course which the changes 
pursue, it necessitates complete investigation of the whole of each indi¬ 
vidual brain—a task that demands the utmost skill and patience. Such 
work, occupying sometimes many months, acquires significance only in 
proportion to the progress made in demarcating the various cortical 
regions. We know as yet no more than that in one disease certain lobes 
are especially affected, in another certain cortical layers, while in others, 
again, the changes are spread over the whole brain evenly, or are 
parcelled out in the form of foci. The laying of sure foundations for 
a doctrine of seat and distribution of cortical affections entails a labour 
that is immense, but necessary if the connection between brain changes 
and clinical phenomena is ever to be more fully understood. 

Groups of mental diseases exist that certainly or probably have their 
origin, not in injuries affecting the brain cortex immediately, but in 
disorders that are seated primarily in other regions of the body, and 
whose influence on the brain is only indirect. According to our present 
notions, the part of intermediary in such instances is played principally 
by the fluid component of the blood; In the composition of the blood, 
those organic diseases in which the brain is implicated sympathetically 
must, as a rule, find expression. Disturbances of blood supply, and 
disordered blood states, have engaged the special attention of alienists 
from time immemorial. In the production of insanity the characters of 
the pulse, formerly studied with such care, its frequency, regularity, 
volume and hardness, may perhaps be rather of secondary importance, 
and the same may well prove true of blood-pressure, although, like the 
pulse variations, it bears to certain forms of mental illness a recognisable 
relationship. We may assume, however, that for the functioning of the 
brain it is the chemical composition, of the corpuscular elements of the 
blood as well as of the fluid element, that is chiefly important. Apart 
from the circumstance that only through the medium of the blood can 
the brain be reached by poisons introduced from without, and that the 


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Active excretions of pathogenic organisms often take the same route, we 
know that the blood receives all secretions of ductless glands, besides a 
great quantity of metabolic products by which the brain tissue can be 
influenced. Some few such morbific substances appearing in the blood 
can be indicated offhand; for example, the urinary constituents retained 
when the renal function is suppressed. Others we can infer from their 
effects, as in Graves’s disease and in cretinism. By reason of its precious¬ 
ness, comprehensive chemical investigations of the blood in the living 
soon encounter insuperable obstacles, but a systematic testing of its 
composition, and, above all, a search for morbid admixtures, must 
nevertheless be undertaken ; micro-chemical methods, in particular, may 
yield valuable discoveries. It is to the more intimate changes that our 
attention must be directed chiefly. The new science of serology has 
shown what a profusion of complicated anabolic and katabolic processes 
is continually going on in the blood, and how closely these are bound 
up with the vital conditions of the tissues. The phenomena of immu¬ 
nity, with all its defensive adaptations, particularly in the blood fluid, 
have opened a wide prospect over new fields of research, which for 
psychiatry also have probably far-reaching importance. 

So far as we can at present judge, it is on the nature of illnesses of 
internal origin, leading slowly to severe damage or even annihilation of 
the mental personality, that serological research is most likely to throw 
light. The onset and course of these maladies, which include epilepsy 
and that most important of dementing diseases dementia praecox, seem 
to show that in them the influences injurious to the brain arise from 
disturbances of co-operation of the mechanisms that protect the body 
from deleterious products of metabolism. The same may be true for 
some forms of arterial sclerosis. That alterations of a special kind in 
the behaviour of the body fluids can be evoked by external influences 
is shown by the Wassermann reaction. The circumstance that the 
corpuscular elements of the blood can be influenced in a lively manner 
by processes going on in the serum must attract our attention also to 
the appearances presented by the blood microscopically, even if for our 
department the results obtained in this direction have as yet been 
slender. 

For obtaining a conception of the chemical changes occurring in the 
body there is still another way open to us—that provided by investiga¬ 
tions of metabolism. Although by these we can usually observe only 
the last links in long chains of related processes, it is possible thus to 
get some clue to gross deviations from the normal, and to infer, 
from the nature of the dross that comes to light, the disorder that has 
led to its formation. Owing to the difficulty of extensive investigations 
of this sort, with which a study of the gaseous interchange should be 
combined, their employment in our department has hitherto been 



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quite inadequate. It cannot be doubted, however, that in a number of 
severe mental disorders valuable discoveries are to be expected from 
such research. In epilepsy and in general paralysis, in cretinism and 
in Graves’s disease this is already evident. But alcoholic disorders 
and manic-depressive insanity, with its regular and pronounced fluctua¬ 
tions of body-weight, may equally repay study on these lines, and so, 
too, may dementia praecox. 

In many of these questions it will be possible to import for our 
enlightenment experiments on animals. Serological research especially 
is at every step dependent on them—indeed, without their employment 
on a large scale, altogether impossible. But the study also of the 
injuries occasioned by deficiency or morbid alteration of certain 
glandular activities rests principally on the data that animal experiment 
affords. Without this mightiest of all engines of research we should 
be powerless before the very questions whose solution offers the best 
prospect, not only of a deeper understanding of insanity, but of further 
possibilities for its treatment. 

In our department, of course, the step from animal to man is 
especially great, and on this account a simple translation to man of 
knowledge obtained from animals is admissible only within narrow 
limits. Above all, it is impossible, especially from the lower animals 
commonly utilised for experiment, to form a judgment upon the mental 
effects of artificial damage. The gap can to some extent be filled by 
experiments on man himself. By the elaborate methods of experi¬ 
mental psychology we can obtain a more exact picture of the changes 
produced in the mental life by natural processes of disease. So far as 
the patient is at all amenable to such experiment, we may be able to 
make out whether and in what degree the perception and understanding 
of external impressions, their retention in the memory, the rapidity of 
processes of thought, the content of ideas, the aptitude for improvement 
through practice, the susceptibility to fatigue, the release of voluntary 
impulses, the execution of simple movements, and the finer perform¬ 
ances of speech and writing, are affected and altered by morbific 
influences. Such observations are specially valuable in those rare cases 
in which the influence at work is fully known, for then we can directly 
trace the connection between the morbid process and its mental 
expression. This holds, roughly, for the acute poisonings, for cretinism, 
for Graves’s disease, and for focal brain lesions, particularly those in 
which there is a circumscribed destruction of tissue. Such minute 
psychological investigation has already, in cases of war wounds of the 
brain, yielded many valuable observations. Its only serious drawback 
is that, in the living, the extent of the brain damage can never be 
estimated with certainty. 

Although, for observations that are unequivocal, we are thus dependent 


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mostly on chance, we are not entirely debarred from producing mental 
disorders artificially in man, and from following by psychological experi¬ 
ment the details of their development and results. Of course we must 
confine ourselves to very slight and rapidly curable disturbances, but 
even from these it is sometimes possible to draw conclusions as to 
corresponding disorders of greater severity. Such investigation of the 
mental effects of poisons, of alcohol, hypnotics and narcotics, tea and 
coffee, tobacco, morphia and cocaine, has proved especially fruitful. It 
has thus been shown that the mental states produced by poisons, like 
those produced by diseases, are distinguished from one another, not so 
much by any features that are peculiar, as by diversity of combination 
of recurring details, and that each exhibits a characteristic and distinctive 
mixture of disturbances. The prosecution of such researches is urgently 
desirable, for, besides affording a more exact knowledge of toxic effects 
themselves, it may help to clarify our general notions regarding slight 
-differences observed between morbid states that broadly resemble one 
another. 

Further, it is possible within bounds to imitate experimentally some 
other kinds of harm to which the causation of mental disorder has in 
many instances been ascribed, especially overwork (protracted physical 
or mental activity) and exhaustion, where the overwork is accompanied 
by loss of sleep and by want of food and drink—factors that should be 
considered separately. In these directions some researches have already 
been carried out, by which our conceptions of the mental derangements 
produced by overwork and exhaustion have been materially influenced. 

For the production of a disease, and especially for the moulding of 
its clinical aspect, the state of the patient himself, apart from the 
influences at work upon him, is decisive. This is especially true in 
insanity, for a large proportion of mental disorders arise from morbid 
-disposition, though this may be first set up by unfavourable conditions 
-of life. For our science it is therefore extremely important to obtain a 
fuller understanding of the various forms of phenomena that constitute 
human personality. In the first place, the modifications which the 
individual undergoes in the course of his life find expression in the 
frequency and form of the mental troubles of the different age-periods. 
Whereas in early childhood the chief danger is from invasion by infective 
organisms, in the years of development, and during the work of repro¬ 
duction, an important part in pathogenesis is played by internal revolu¬ 
tions in the bodily economy. Later, the injuries resulting from life’s 
accidents preponderate, till age itself at last becomes disease. In the 
child insanity bears in particular the features of an arrest of develop¬ 
ment, later supplanted by states of confusion with lively emotional 
oscillations, clouding of consciousness, excitement or depravity; in 
middle life a tendency to formation of delusions becomes pronounced ; 

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132 ENDS AND MEANS OF PSYCHIATRIC RESEARCH, [April,. 


still later a sense of shortcoming; and finally, a breakdown of the mental 
powers, especially of memory. Differences are seen also in the behaviour 
of the two sexes. These naturally are most marked in the interval 
between development and involution. In the man morbific damage 
occurs chiefly from alcoholic excess, from syphilis, from head injuries 
and other accidents, from morphia and cocaine, or from the wearing 
effect of hard struggle for a livelihood, interfering with sleep and nutri¬ 
tion and exhausting the bodily strength. Woman, on the other hand, 
is imperilled chiefly by the physical and mental demands of reproduction,, 
by the emotional shocks incidental to love, and by the burden of unhappy 
family conditions or of an unsatisfied, stunted and defenceless existence. 

If the study of these differences, as yet in its infancy, affords so helpful' 
an insight into such conditions for the production of insanity as aro 
inherent in the mental constitutions proper to age and to sex, such 
study must be widened, that we may know what special psychiatric 
characters pertain to different races, and what influence is exerted on. 
frequency and form of mental disorder by town and country life, by 
calling and habits, by culture and civilisation. A grappling with these 
questions can for the first time be contemplated now that our concep¬ 
tions of disease are beginning to grow clear, but is still attended with 
great difficulties. Above all there is the difficulty of extricating in a 
recognisable shape from the tangle of co-operating influences the results 
of any particular one. The groups we would compare diverge from one 
another, not in a single respect, but in many, and are never in themselves 
so homogeneous as could be wished, for the establishment of sure con¬ 
clusions. Yet it seems possible even now, from the frequency of the 
most important forms of disease in individual groups of people, to 
obtain some general picture, and to draw conclusions respecting the 
causal conditions operative in them. It needs but suitable workers 
carefully and patiently to collect the multitude of trustworthy observa¬ 
tions necessary for this, and to guard against fallacies by wary apprecia¬ 
tion of the various sources of error. 

Even more enticing, though certainly more thorny, is the problem 
of relation of the outward aspects of mental disease to the mental 
characteristics of different human groups. There can be no doubt, 
not only that the world reflects itself differently in different minds, but 
that peculiarities of mental constitution must find expression in the 
phenomena of disease. It has been shown that in widely separated 
peoples the composition of the asylum populations can be very different,, 
and the same morbid processes can produce very different pictures. 
Folk psychology offers here an untilled field for research, from which 
we may reap, as regards the mental make-up of different races, 
knowledge undreamed of, which may well become of salient importance 
for those ultimate psychiatric questions that turn upon the connection. 


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between mental expressions and the structure of the brain. The 
mental differences are most striking, of course, between peoples most 
divergent in their descent and in their conditions of life. Unhappily, 
such investigations, which should range over primitive peoples and 
highly civilised, over the virile and the effeminate, over the artistic 
and the intellectual, over those with eyes for the world around and 
those given to brooding and introspection, have been made impossible, 
for we know not how long a time, by the world war. And besides 
the great cost and the linguistic and mental obstacles to a mutual 
understanding, there is the circumstance that truly comparable results 
can be furnished only by one and the same observer. Nevertheless 
such study of the manifold configurations of the folk-mind, in health 
and in disease, offers tasks for the future as profitable as they are 
attractive. 

Inquiries of this sort are feasible also within a narrower range. 
Much work has already been done upon the mental affections of the 
Jews in this country, as compared with the rest of our people, and 
has yielded notable results. But no one of experience can escape 
the impression that the composition and behaviour of asylum 
populations differ a good deal in different parts of Germany. This 
impression is strengthened for any who have had occasion to visit 
asylums in other European countries. Although such differences are 
much slighter than those met with in a comparison of widely separated 
races, they are probably easier to observe in detail. Here, however, 
where we are concerned with finer distinctions, the influence of 
external circumstances will be weightier, so that, in attributing 
observed differences to constitutional peculiarities of the various stocks 
and peoples, we shall have to exercise special caution. 

The ultimate problem of comparative psychiatry is the determination 
of the influence of personal disposition on liability to insanity and on 
the forms that insanity assumes. Of prime importance in both these 
respects is the original mental make-up of the individual, his intellectual 
development, his temperamental disposition and the qualities of his 
will, which to some extent, however, can be altered by his conditions 
of life. For characterising the personality in all these aspects we 
must invoke the analytical and mensural resources of psychological 
experiment. This enables us, in some directions at any rate, to resolve 
our general impressions into clearly defined details. Least accessible 
by such means are the emotional processes, though even here, by 
examination of the various kinds of expressive movement, of speech 
and writing, and of involuntary expressions, as well as of the pulse, 
the blood-pressure and the respiration, there is some prospect of 
obtaining valuable results. 

Such investigations will help to provide a survey of the various modes 


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of composition of healthy personalities. By so determining the range 
of normal variation, we shall obtain a standard for measuring morbid 
deviations—a standard that will be of value, not merely for pure 
science, but for many practical purposes, as for estimating school 
capacity, military fitness, business talent, and responsibility. A first 
attempt in this direction is seen in the procedure devised by Binet and 
Simon for gauging the mental efficiency of children of different ages 
by quite simple tests, chosen on grounds that are purely empirical. 
The scale so obtained serves also for determining degrees of feeble¬ 
mindedness ; and, as it rests on very extensive studies of healthy 
children, it provides data for estimating grades of mental maturity. 
Unfortunately it fails after the thirteenth year of life, for then such 
simple tests, which permit no exact measurements, cannot keep pace 
with the rapid increase of individual differences arising under the 
influence of education, of culture, and of experience of life. Moreover, 
the demands made by these tests are addressed almost exclusively to 
the intelligence, other sides of the mental life being hardly taken into 
account. For a really useful insight into the mental performances of a 
developed personality, we must institute a plan of investigation that 
will as far as possible comprise the most various performances and be 
capable of yielding clearly definable results. Thus we may gradually 
learn, not only to characterise numerically the various grades and kinds 
of intellectual defect, but to obtain more exact expressions for in¬ 
sufficiencies and aberrances in other mental spheres. Only thus can 
the important forms of psychopathy that fade into one another be more 
clearly outlined. This work raises once more the problem of relation 
of individual mental defects to those physical bases that are to be 
explored by other means. 

The study of causation here obtruding itself presents certain special 
difficulties, because the noxious influences that have produced the 
observed result lie far back in the past and are withdrawn from direct 
inspection. At the outset we can say only that inferiority of inborn 
disposition is mainly referable to two great groups of causes—hereditary 
degeneracy and germinal injuries. An explanation of the connections 
involves far-reaching problems. Studies of heredity in long series of 
families will illumine the laws by which morbid dispositions arise and 
die out. So far as transmission of insanity in man is concerned, our 
knowledge is dependent on the laborious collection of observations 
through decade after decade, though, as regards general questions of 
vital significance, particularly that of inheritance of acquired characters, 
we can be assisted by experiments on animals. 

No less important is the study of germinal injuries. These, we may 
assume, express themselves not so much in particular morbid dis¬ 
positions as in general inferiority of the growing creature. We know 


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135 


that here alcohol and syphilis come especially into account; but 
probably also all other general injuries of the body, so far as they affect 
the sex glands, can exert an unfavourable influence upon the new germ. 
In this connection especially arrests of mental and physical develop¬ 
ment (infantilisms) present a wide field demanding exploration. Since 
we have reason to suppose that many phenomena of degenerative 
insanity are to be regarded as relics of primitive adaptations that have 
not, as in the normal, become thrust into the background or put out of 
action, the study of developmental arrests from the point of view of 
their causation by germinal injuries may prove even more fruitful than 
might at first be expected. Further, we may be justified in ascribing 
similar effects to damage, not of the sex glands, but of the growing 
germ in the earliest stages of its development. Unfortunately our 
knowledge of these things is still very fragmentary. 

In this sphere also we must have recourse to experiments on animals. 
What Nature presents to us in casual and ambiguous observations we 
can imitate artificially by experiments, arbitrarily modified to eliminate 
accidental sources of error. Experimental investigation of germinal 
injuries, if conducted on a large scale, will fix the general lines for the 
interpretation of observations on man. In particular spheres, especially 
those of alcoholism and morphinism, blinded and weak-willed men 
place themselves voluntarily within the range of experiment, so that it 
needs only a more systematic carrying out of corresponding experiments 
on animals to demonstrate the nature of the causal relations concerned. 
In this connection, too, the artificial production of syphilis in animals 
will furnish data for some conclusions, though the widely divergent 
behaviour of animals towards the pathogenic agent offers considerable 
impediments. 

The effect of injuries apt to influence unfavourably the mental 
disposition of man expresses itself, as we may well understand, not 
exclusively, nor even perhaps most seriously, in the occurrence of 
pronounced mental illness, but much rather in the numberless more or 
less striking phenomena of everyday life in which the mental consti¬ 
tution of the members of the community is manifested. Important 
among these are suicide, crime, vagrancy and prostitution, the frequency 
and the motives of marriage, the tendency to produce and rear offspring, 
and the results of education in elementary and higher schools ; to some 
extent also military fitness, certain manifestations of political and 
religious life, migration from rural districts into towns, business enter¬ 
prise, and much else. Although factors of other kinds, especially 
economic conditions, play everywhere a large and often decisive part, 
original mental state cannot be immaterial, and deficiencies of mass 
endowment must here and there show themselves in unfavourable issues. 

The investigation of such phenomena affords insight therefore into 


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136 ENDS AND MEANS OF PSYCHIATRIC RESEARCH, [April, 

the metamorphoses of the popular mind. We can conceive that there 
are two kinds of processes continually going on, the one constituting 
progressive development of productive and resistive power, the other 
inducing qualities obstructive to the attainment of life’s ends. The 
study of such manifestations of the popular mind furnishes a means of 
recognising betimes, and so perhaps of counteracting, untoward and 
dangerous changes in its behaviour. 

The psychiatric importance of such investigation on the large scale 
cannot be over-estimated. A mass psychiatry, having at its disposal 
statistics in their widest scope, must provide the foundations for a 
science of public mental health—a preventive psychological medicine 
for combating all those mischiefs that we group under the head of 
mental degeneracy. It will enable us to judge the extent of existing 
damage, the rapidity of its spread, and the efficacy of the steps taken to 
meet it; it will advise us of approaching danger, spur us to action, and 
reassure us when the menace is averted. Our economic life has long 
provided itself with organisations for keeping world-wide watch on pro¬ 
cesses important for its prosperity, and provision has been made also 
for procuring medical and criminal statistics, statistics of population, 
and the like. What we in our department need is such collective 
inquiry as will permit a survey, from a uniform standpoint, of the 
fluctuations of public mental health. 

Until such inquiry is organised, it is impossible to answer the all- 
important questions in this sphere in which our whole future fate will 
in a sense be decided. The prosperity of a people depends evidently 
on whether the injurious or the strengthening influences continue to 
predominate. In the one case it will sooner or later forfeit its position 
in the world, in the other it will enduringly flourish. There is 
notoriously no lack of voices to tell us that the former fate is a 
necessity of nature; they support their opinion by many historic 
examples suggesting that the rise of every people is succeeded even¬ 
tually by a decline. As such a fate must be determined chiefly by 
the people’s mental constitution, it is supremely important to know 
whether the morbid mental phenomena that in no people are entirely 
absent keep within moderate limits and can be restrained, or whether 
they spread and grow. 

This matter urgently needs testing, for it has often been supposed 
that the very progress of civilisation favours the appearance of such 
phenomena. If this were so, we should be driven to the terrible 
conclusion that the pursuit of our highest aims leads inevitably to ruin. 
There are, indeed, several arguments for this notion. It is clear that 
our civilisation actively opposes the natural selection by which the 
fittest alone survive and propagate. All the efforts of human pity to 
preserve the lives of the sick, the weak and the unfit, and to mould 


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192 2.] 

them into worthy human beings, have doubtless the unsatisfactory 
result that an ever-widening stream of inferior stock mixes itself with 
•our offspring, to the deterioration of the race. The more we succeed 
in fulfilling our duty to the wretched, the erring and the helpless, the 
■more persistently we impair the strength of our nation. 

We must also consider whether the higher culture of a people may 
not itself directly favour the appearance of morbid mental phenomena. 
There can be no doubt that the complete devotion to lofty and 
unselfish aims, required of us by religion and morality, is apt to weaken 
the basis of our existence—the instinct of self-preservation. So arises 
the danger that the best and noblest sacrifice their health and strength 
for those who are by nature most careful of themselves and their own 
wants ; for the former class, the conditions for existence and reproduc¬ 
tion tend to become specially unfavourable. In this connection it 
cannot be overlooked that the church’s restrictions on marriage deprive 
the race of valuable offspring. Moreover, we may assume that an 
organ of the body becomes more sensitive the more its performances 
are elaborated and refined; the slightest damage will then induce 
disorders more striking and harder to make good. Development 
directed to higher mental aims naturally represses those adaptations 
that primarily serve for the maintenance of life and health. So, in 
persons of specially high endowment, we commonly find not only one¬ 
sidedness, but also some defect, which can greatly impede the attain¬ 
ment of life’s immediate and general ends. The repression of our 
animal impulses, which are the foundation of our existence, is effected 
through a striving for something beyond the satisfaction of immediate 
needs. Those primeval and well-tried guides through the perils of life, 
the self-preservative and reproductiveimpulses, the need of food and sleep, 
and the desire for liberty, lose, for men of culture, their constraining 
power, without always being sufficiently replaced by other mental forces. 

Advancing civilisation has considerable influence also on the 
development of the will. As it largely guarantees the satisfaction of 
simple wants and the protection of life, it saves us that daily struggle 
for mere existence that repeatedly stimulates the self-preservative 
instinct. On the other hand, from earliest youth it restricts the 
expressions of our will by education, schooling, precepts of religion 
and morality, rules of conduct, customs, laws, regulations and duties 
of every kind at every step and turn, so that in human intercourse we 
can go no other than strictly prescribed ways, without some instant 
rude reminder that we must consider our fellows. This taming is 
possible only through the formation of a multitude of inner restraints, 
which resist unceasingly the explosive force of the will. From them 
proceed the sense of duty, and conscientiousness, and also one of the 
most wide-spread characters of civilised man—anxious hesitancy—as 


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138 ENDS AND MEANS OF PSYCHIATRIC RESEARCH, [April,. 


well as the host of paralysing doubts and self-reproaches that in our 
disease-pictures, in contrast with those of uncivilised peoples, hold so 
prominent a place. 

On the other hand, it may well be urged that whatever importance 
these considerations may have is quite impossible of assessment, and 
that, corresponding to the mischiefs alleged, civilisation confers certain 
advantages, by which such tendencies to impairment of national 
efficiency may perhaps be more than compensated. Among the weaklings 
whom to-day our pity keeps alive many a valuable personality is to be 
found ; but the value of the extended operation of our social care lies 
so much more in the raising of the general state of the people, that in 
comparison with this the propagation of the fittest is perhaps of no 
importance at all. Thus it is that higher moral powers are evoked in 
the mass, and these in their turn strengthen the safeguards against great 
common dangers. Religious and moral training have a similar effect, 
inspiring the individual to place all his powers, even life itself, at the 
service of the community, and so to promote its welfare. The higher 
brain development and the division of labour associated with it allow 
of far higher and more varied achievements, and so afford a more 
complete protection against the dangers of existence than the blind 
sway of natural impulses could ever provide. Lastly the subjugation 
of the will of the individual enables action to be directed systematically 
along paths conducive to the common good, and so gives to the will 
of the community a sureness of aim and a momentum otherwise 
unattainable. Who can say offhand whether, in the mental life of our 
people, the degenerative or the invigorative effects of all these influences 
preponderate ? 

The importance of some further circumstances connected with the 
progress of civilisation is less difficult to estimate. The refinement of 
the outward conditions of life, the easy attainment of every possible 
pleasure and comfort, accustoms people- to a host of superfluities, the 
loss of which is felt as a serious disturbance of bodily and mental well¬ 
being. Thus arises effeminacy, coddling, shiftless dependence on 
others, and a sapping of the will, by which it becomes more and more 
incapable of meeting new requirements, of overcoming difficulties, of 
repairing injuries, and of fending for itself. Thus the natural defences 
against life’s hardships are undermined—a process that cannot but 
interfere with the preservation of mental stability. 

The pendant to this picture is pauperism, which in its worst forma 
is essentially an accompaniment of civilisation. Poverty and need, of 
course, have existed in all times, and destitution is certainly worse 
among uncivilised peoples than among our poorest. But the deplorable 
feature of pauperism among people of culture is the loss of freedom, 
of close contact with Nature, of rich enjoyment of light and air. This- 


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stunting process has evidently a direct relation to the growth of large 
towns, which during the last hundred years has progressed with such 
alarming rapidity. The life of the worker in the crowded city, wearing 
himself out in the struggle for a living, and almost entirely deprived of 
free movement in the wide spaces of Nature, in sun and wind, is far 
removed indeed from the essential requirements of bodily and mental 
health. The evil results of such conditions are aggravated by other 
features of town life, by the continual temptation to unseasonable 
delights that poison body and soul and to antisocial acts, and by 
venereal disease and alcoholic excess. The growth of large towns in 
their present form entails ills that gravely threaten not merely the 
physical, but certainly also the mental health of the people. 

Another unfortunate result of economic progress is the undue 
importance attached to wealth. As money-making becomes the supreme 
object of endeavour, it leads to unscrupulous exploitation of the powers 
of our own and other peoples, and not only conduces to effeminacy, 
but exercises a very undesirable influence on natural selection. In the 
contracting of marriage the personal qualifications of the partner as 
regards health and fitness are very commonly subordinated to social, and 
especially financial, considerations. This disregard of the prime requisites 
for the business of reproduction must lead to a deterioration of the 
race, and promote the transmission of characters that are unsuitable. 

It is well that in modern civilised life there are many factors by 
which these unfavourable influences are opposed. There is the 
establishment of institutions, where detention prevents the severely 
diseased in mind from propagating. And although the increasing care 
bestowed on the sick, the weak and the injured preserves many unfit 
persons, it often prevents the severer grades of damage and procures 
many complete recoveries. The organised campaign against alcoholism 
and venereal disease is certainly not unavailing ; and the same can be 
said of the efforts for relieving poverty in large towns, for creating 
garden cities and small holdings, for establishing holiday camps, for 
encouraging cottage gardens, and for the betterment of housing con¬ 
ditions. In improving the physique and morale of our people universal 
military service has been very effective; and a similar purpose is served 
by athletics and physical exercises of every kind, by the Wehrkraft and 
Wanderoogel movement, and by country homes for children. 

The mental health of our people is thus determined by the 
simultaneous action of a great number of complicated, co-operating, 
interacting and conflicting influences, and no one can say whither the 
resultant of these forces is tending. On the one hand, we can point 
to the rarity of mental illness in animals and in uncivilised peoples; 
to the enormous increase in the number of insane persons requiring 
care in all civilised nations; to the increase of suicide, crime, drink 


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and syphilis in the great centres of civilised countries; and to the 
manifold artistic, religious and political extravagances that in this age 
are so rife. On the other hand, it can be pleaded that disease and 
poverty were formerly perhaps more severe and wide-spread than now, 
only less noticed and less combated ; that the great mental epidemics 
of the middle ages would to-day be impossible; that many distressing 
phenomena of our social life are due to intensification of the struggle 
for existence rather than to mental degeneracy of the people; that super¬ 
stitions and crazes have played in bygone times a far greater part than 
in our day; and that the unparalleled achievements of this present age in 
every sphere of human activity, and especially our efficiency in war, 
must at once dispel every suspicion of decadence of our mental qualities. 

For a decision of these questions so important for our national 
existence we can rely only upon facts, of which as yet we have only 
an altogether insufficient quantity at our disposal. Many inquiries 
indeed have been instituted by various authorities—inquiries that for 
the estimation of public mental health are of great importance. Thus, 
besides the lamentably meagre statistics of lunacy, we have returns 
of births, marriages and deaths (including infant mortality and suicide), 
the reports of education authorities, military returns, criminal records, 
and police and law reports, all representing an inexhaustible mine 
of information as to manifold morbid phenomena of the body politic; 
the reports of hospitals and sick funds, and of institutions for nervous 
and mental diseases, for alcoholism and syphilis; and the census 
returns as to classification of the population, mortality rates, and com¬ 
parative figures for urban and rural districts. Besides all these there are 
many other sources of information, especially as to economic conditions 
by which the state of the public mind can be influenced or reflected. 

The disclosures that a personal study of circumscribed sections of 
the population can yield in reference to the questions here considered 
may be briefly indicated. The emergence and disappearance of 
particular stocks, their rise and fall, the fates that attend them and 
the transformations that in process of time they undergo, afford often 
a deeper insight into the causal relations between external influences 
and mental welfare than any that we can derive from numerical 
presentations of the behaviour of the mass. 

At present, unhappily, we are not in a position to talk of collecting 
the information already extant regarding the mental state of our people. 
But psychiatry should not grow tired of insisting that here an immense 
task lies before us, whose accomplishment is an urgent necessity. By 
careful verification and collation of all obtainable facts we must secure 
a clear and permanent picture of the effects of the degenerative and 
invigorative influences of modern life, so that we may formulate rules 
for meeting the dangers that threaten us. What people shall fare forth 


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upon the uncharted ocean of the future, without a compass to show 
it when it is off its course and is heading for destruction ? 

The highest aim of medical research is the vanquishing of disease, 
and the surest road to this is the discovery of causes. When these are 
known, we are faced with a clear question of the measures we are to 
employ. Already there is a large sphere in which an answer is forth¬ 
coming. This is the case with the habitual poisonings by alcohol, 
ether, morphia and cocaine. Here nothing is necessary for restoring 
health but to prevent further introduction of the poison. We are 
assuming, of course, that no permanent or incurable results have yet 
been produced. It follows that intervention is the more promising the 
earlier it is effected. The action that we must take is indicated, and 
all that remains for research is to ascertain in detail the relation between 
causes and phenomena, so as to demonstrate the necessity for medical 
interference. Similar, though less simple, is the position as regards 
cretinism, Graves’s disease and syphilis; the steps to be taken are known, 
though we still do not thoroughly understand the processes going on. 
In syphilis especially the efficacy of our curative methods does not 
come up to our wishes ; even if we can intervene early, which of course 
is the main condition for successful treatment, our weapons often 
misfire. By the systematic investigations associated with the name of 
Ehrlich, aided by animal experiments, great progress has been made, 
and we may justifiably hope for further advances in this direction. 

When the cause of a disease is known, a more effective and satisfac¬ 
tory way of combating it is often open to us, that of prevention. The 
problems connected with this extend, of course, beyond the province 
of the physician, and require united action of the community. Although 
the measures to be taken are in themselves simple and intelligible, as in 
the prevention of poisonings, syphilis and hereditary degeneracy, their 
application encounters great obstacles in established custom, prejudice, 
ignorance, vested interests, and opposition to interference with personal 
liberty. As such resistances commonly spring, not from reasonable 
considerations, but from sentimental likes and dislikes, they are less 
easily overcome than we could wish by scientific argument. The 
personal experience of the individual is far more persuasive, but is of 
little help where united action is required. It is here perhaps that 
demographic research, by displaying the phenomena of disease observed 
in the mass, may be effective in bringing before the eyes of each 
member of society the dangers to which he himself is exposed by 
deterioration of the race. 

The problem is much harder when we are dealing, not with obviously 
injurious influences that are to be combated by simple and definite 
regulations, but with causes whose removal requires a general ordering 
•of the whole conduct of life. Besides many general diseases such as 


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rickets, scrofula and chlorosis, which may participate in the production 
of mental disorders, premature failure of physical and mental powers, 
and the arterial sclerosis often associated with this, may be specially 
promoted by conditions of life that have shaped themselves with or 
without the connivance of the individual. Here we have to deal with 
slow and insidious causes whose effects are difficult of recognition 
and proof; still, one of our tasks is to establish a doctrine of mental 
health that shall show us how to develop the powers of the mind 
and preserve them from life’s dangers. Besides animal experiments, 
which enable us to some extent to resolve into their details the 
effects of complicated conditions, we shall make use of psychological 
experiments on man, for by these the first slight mental disturbances 
resulting from particular noxious influences can be revealed long before 
they reach morbid proportions. 

Even when we know the causes of the insanity, we are often unable 
systematically to remove or prevent them. But a far more serious thing 
is the fact that in most of the severe mental diseases we have no 
knowledge, often no inkling, of the conditions for their production. 
Ignorant of the cause, we have no clue to treatment, and are reduced to 
making random shots, which obviously have little chance of hitting the 
mark. Yet that they do now and then succeed is shown in the case of 
epilepsy. The means of treatment hitherto most effective in this 
disease, bromides and luminal, were not discovered through our 
knowledge of its causes and nature—knowledge which is still extremely 
meagre—but by pure accident. Probably this is why the results of 
treatment, though undeniable, are so unsatisfying. Complete failure 
has hitherto dogged all attempts at treatment of the form of insanity 
that more than any other fills our asylums—that dementia praecox whose 
causation is so obscure. The conjecture that this is due to faulty 
composition of the blood, consequent upon some endocrine disorder, 
has not been upheld by the results of administration of glandular 
extracts. We are not much better off with respect to that severest of 
all mental diseases, general paralysis, though its relationship to syphilis- 
is now beyond doubt. All attempts to fight the disease with the means 
useful in syphilis have as yet been in vain. Only the one hope, and 
that not assured, remains to us, of being able to prevent its occurrence 
by timely radical treatment of syphilis on a more extended scale. We 
shall never, I believe, find any really reliable way of combating general- 
paralysis until we are quite clear as to the nature of its connection with 
.the underlying syphilis. 

In these circumstances we must, for the present, and perhaps for a 
long time to come, be content in most cases to treat symptoms. This 
applies especially to one of the largest groups of those who seek our 
help—the sufferers from manic-depressive disorders. Since we have as- 


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yet no insight into the bodily changes, often very stormy, that occur in 
these cases, we are unable to influence them decisively. Yet, where we 
cannot eradicate symptoms but only mitigate them, research must not 
stand still. The long series of sedatives and hypnotics and other means 
of alleviating the sufferings of our patients have been discovered by 
experimental gropings, which, though they have wandered into many 
wrong paths, have yet often struck the right one. We must extend our 
knowledge of the mode of action of our therapeutic agents by more and 
more refined experiments on animals and man. With the help of such 
experience we shall be able to find out new procedures more adapted 
to the purposes in view and possessing greater efficacy without the 
inconveniences and dangers of our present methods. 

While we must be zealous in our immediate task of relieving symptoms, 
we must not lose sight of our main object—the struggle against the 
causes of insanity. No one can at present foresee whether, or how 
far, our efforts in this direction will be successful. But it is not to be 
supposed that if any progress is made it will be by some lucky accident 
or inspiration. We must be prepared to face the fact that every step of 
the way will have to be trodden, and with untiring care and thoroughness. 
Nor is it thinkable that any one man, however outstanding his ability, 
will ever solve the riddle unaided. In any circumstances a detailed 
division of labour will be needed and a union of forces for attacking 
the great problems of our science from every side. 

These requirements have hitherto been quite inadequately met. 
There was but a handful of investigators who, in clinics and asylums, 
in the midst of harassing daily tasks, found leisure for research, and at 
the same time had the ability to find their own road. Their positions 
were mostly subordinate, ill-paid, and never meant to be held for any 
long time. Regard for their future career usually prevented them from 
devoting themselves very much to research, for whose prosecution, 
moreover, little time was left to them when once they had reached 
some measure of official and economic independence. They had at 
their disposal insufficient space, slender means, and inadequate material 
and equipment. In all these directions the establishment and expected 
completion of the German Institute for Psychiatric Research will effect 
a change. So far as the preliminary conditions for fruitful investigation 
are here fulfilled, we can look with confidence to the future. Though 
the solution of the problems before us may be harder than we anticipate, 
we can at least set about it systematically. Those extraneous hindrances 
that daunt the spirit and drain the strength can thus be in great part 
removed, while upon the intrinsic difficulties of the subject our powers 
will exercise themselves and grow. What is anyhow attainable can so 
be attained, whether scientific knowledge or saving deed. 

(*) i9‘8. 


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VENOUS STASIS. 


[April, 


Venous Stasis.( l ) By Theo. B. Hyslop, M.D., F.R.S.Edin. 

In order to understand venous stasis in its several relationships to 
the functions of the brain, it is advisable to refer to some of the 
problems which have been the most difficult with which neurologists 
and psychiatrists have had to deal. The aspects of the problems 
studied have been so varied, and the interpretations of the phenomena 
so widely different, that it has hitherto been almost impossible to 
obtain any degree of unanimity of opinion. In dealing with the 
aetiology and pathology of disease one of the first considerations ought 
to be to determine, if possible, the existence of physical or mechanical 
factors of causation. 

Functional integrity of the various systems of the body depends 
upon the maintenance of balance between stimulation, chemical change, 
metabolism, nutrition, and excretion. For present purposes, however, 
I propose to exclude from consideration all problems of chemistry and 
metabolism, and to confine my attention merely to those of the 
mechanism of “ supply and demand ” occurring within the skull. 

It would appear to be almost useless to attempt to unravel some of 
the complex problems of intracranial physiology, neurology, and 
psychiatry, until we have first come to a more definite agreement 
concerning the nature of the actual mechanism involved. 

(i) Is the brain a generator, or merely a transmitter of energy ? 

The living organism, as in the case with matter generally, can neither 
create nor destroy energy. The nervous system can only serve as a 
transmitter or transformer of energy. The attribute, “ sensibility,” is a 
superposed phenomenon, and although its physical manifestations may 
be expressed in terms of energy, it cannot act as a substitute for the 
energetic phenomena of matter. The excitability and sensibility of 
living matter provides us with the first elements or rudiments for 
adaptive reaction for the preservation of life in the substance stimulated. 
The stimuli are derived from the external world, and the reaction of the 
organism to them is obtained by physico-chemical activities, which 
become more highly elaborated as the organism becomes more highly 
evolved in complexity. 

It is probably true that the nerve cell does not initiate energy, but 
serves as a mechanism for the support, protection, and nutrition of its 
fibrillar elements, which are concerned with the propagation and 
direction of energies developed elsewhere. In fact, the role of the 
nervous fibrillae is to transmit an impulse from one point to another. 
Morat (Physiology of the Nervous System, p. 48) has stated this very 
clearly : “ The body of the cell of the neuron is an organ necessary 

(') A paper read at the Spring Meeting of the South-Eastern Division, May 5th, 
1920. 


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for the organisation and conservation of the latter, but it takes no 
necessary and direct part in its power of functional activity so-called." 

From these remarks it will be gathered that the statical and dynamic 
unit of nerve is to be sought in the nervous or fibrillar substance 
proper, and any observations derived from experiment on the nerve 
cell or medullated fibre must be imperfect so long as they do not 
exclude the organotrophic energies. The true static unit of nerve must, 
in common with other units, possess chemical, caloric, and electric force 
which undergoes transformations when the specific energies of the 
nerve units are called into play; but of the nature and source of these 
energies and excitations of their transmitted and localised effects, and 
of the possibility of their being held in reserve, nothing is definitely 
known. As a matter of fact, the experiments of Rolleston, Stewart, and 
Boeck (who endeavoured to estimate by means of an apparatus sensitive 
up to 1-5,oooth of a degree the amount of heat given off by an isolated 
nerve trunk) gave no results. Similarly, many physiologists agree with 
Hermann that electric nerve currents do not pre-exist, any currents 
which do occur having a chemical source and arising under entirely 
artificial conditions. The various modifications of the body of the cell 
during repose and functional activity and the phenomena of chromato¬ 
lysis pertain to the trophon and not to the static units of the nerve 
proper, which are relatively almost incapable of fatigue. 

(2) Is the sum total of the intracranial contents capable of variation 
in amount ? 

In a paper read before the Hunterian Society (Hunterian Lecture on 
“Intracranial Murmurs in their Relationship to Tinnitus Aurium," 
Lancet October 14th, 1911), I there stated that the term “cerebral 
pressure ” really means either undue preponderance of one or other of 
the cranial contents, partial displacement of one or other constituent, 
acceleration of the arterial or retarding of the venous circulation, or 
alteration in the compensatory movements of the cerebro-spinal fluid. 
Arterial, venous, lymphatic, and other forms of pressure due to injury 
or disease, etc., are but terms used to signify alterations either in the 
position or in the relative quantities of the cranial contents. The 
intracranial contents being in the sum incapable of expansion or 
contraction, it is of importance to note the mechanism whereby the 
“ give and take " between them is affected. The brain itself is passive, 
and depends upon arterial, venous, respiratory, and peristaltic move¬ 
ments for its metabolism and activities. Its substance may be 
displaced, contracted, expanded, or destroyed by injury, disease, new 
growths, or finer interstitial degenerative changes. The arterial system 
may preponderate unduly in its activities, the relative amount of arterial 
blood being greater than in health. This is due either to excess of 
propelling action in the arterial system or defect in resistance of the 


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VENOUS STASIS, 


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venous or lymphatic systems. The arterial blood may be diminished, 
on the other hand, owing to defect in the propelling mechanism or to 
increase in the resistance offered by the venous or lymphatic systems. 
Similarly, the arterial and venous systems may be concurrently hyper¬ 
active or deficient owing to diminution or excess of the lymph cisterns. 
Perfect balance of the relative quantities of the cranial contents thus 
presupposes certain activities or movements, which are also essential to 
proper metabolism. The skull thus regulates the pressure of the fluid 
within its cavity, and any functional increase in the arterial blood would 
be possible only upon one of two conditions, viz., a corresponding 
collateral arterial diminution, or a transfer of venous blood in the 
direction of the venous sinuses. A venous transfer would be altogether 
too slow, and there could not be any continuous action, for the 
repulsion of the venous current—dependent upon the respiratory 
movements—would give rise to a frequently interrupted flow of venous 
blood in the brain. The cranial cavity is not, however, entirely filled 
by the brain; it includes, in addition, a number of spaces filled with 
lymphatic fluid. 

The Monroe-Kellie doctrine, that the intracranial contents are, in 
the sum, a fixed quantity, has not yet been fully conceded. If, 
however, we can start with the acceptance of this doctrine, a vast 
field of possible explanations of intracranial phenomena becomes open 
to us. 

Alexander Monro (Secundus) wrote as follows (Observations on the 
Structure and Functions of the Nervous System, p. 5): “ As the 
substance of the brain, like that of other solids of our body, is nearly 
incompressible, the quantity of blood within the head must be the 
same, or very nearly the same, at all times, whether in health or disease, 
in life or after death, those cases only excepted in which water or other 
matter is effused or secreted from the blood-vessels, for in these a 
quantity of blood equal in bulk to the effused blood will be pressed out 
of the cranium.” 

Many other observers have, from experiments and reasonings founded 
on the mechanical construction of the cranium, concluded that the 
absolute quantity of blood within it is at all times nearly the same, and 
were the other intracranial contents, such as the extravascular serum, 
the connective and nervous tissues, fixed quantities also, the quantity 
of blood would be absolute and invariable. Thus it might be conceded 
that any variation in the relative quantities of the fluid constituents 
must consist in a “give and take” between extravascular and intra¬ 
vascular contents, one acting as compensatory to the other. 

Were we to attempt to drain the cranium of its fluid contents by 
aspiraiion of its veins at their points of egress, we would find that we 
could not really diminish the sum-total, for there would always be 


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•compensatory filling of the cranium by fluid unless, of course, the 
mechanical forces were sufficient to create a vacuum. 

The next principle to recognise and acknowledge is that, in accor¬ 
dance with the law of pressure of fluids, the tension throughout the 
nerve structures which are supported and everywhere permeated by 
fluid must be equivalent, or nearly so, at every point. The disposition 
of the solid tissues is, of course, determined by the volume, strength and 
direction of the blood currents. The mechanism whereby one set of 
vessels feeds and another drains the capillaries, and whereby the balance 
between lymph supply and metabolic change in the nerve structures is 
maintained, will be more fully comprehended if we bear in mind this 
fundamental principle. When we speak of local congestion, or local 
pressure, as occurring within the skull, we mean, therefore, that there is 
a relative preponderance of one or more of the constituents, with com¬ 
pensatory diminution of one or more of the other constituents, this 
diminution being affected by displacement which, when viewed in its 
external manifestations as an extension through one or more of the 
cranial apertures (along lines of least resistance), becomes, strictly 
speaking, extracranial, and causes conditions which bear a certain 
homology and analogy to conditions of hernia. Thus it is that all the 
apertures for the ingress and egress of vessels and nerves, to and from 
the cranium, become the sites at which the compensatory mechanism 
of give and take must necessarily find the greatest strain, and it will 
readily be understood how under disturbed conditions of balance 
between the relative proportions of the intracranial contents the various 
sensory and other structures attached to the cranium may become 
mechanically and also pathologically affected. 

Of late years Leonard Hill, Baylis, Elder, Bradbury, Geigel, Hurthle, 
Roy and Sherrington, Cavazzini, Pusateri, Acquisto, d’Abundo, Mosso, 
Duke, De Sarlo and Bemardini, Ford Robertson, and many others, 
have contributed very valuable observations to the discussion. Any 
•divergencies of opinion which may have arisen have been (i) from 
imperfect comprehension of the real nature and mechanism of the 
•contents of the cranium; (2) from faulty interpretation of the anatomy 
and physiology of these contents; and (3) from experiments conducted 
upon structures and mechanisms which are really extracranial. 

It is essential to recognise that the brain is mainly of fluid consist¬ 
ence, i.e., of arterial, capillary, and venous blood, and also of lymph 
which occupies not only the ventricles and cisterns, etc., but which 
also circulates in the perivascular canals and permeates everywhere, 
even within the nerve-cells, and possibly even to the nuclei and 
nucleoli. Under these circumstances it is evident that we are dealing 
with what is, to all practical purposes, a fluid medium which must 
•conform to the ordinary laws of hydrostatics. Hence the incnmpressi- 
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148 VENOUS STASIS. [April r 

bility of the brain, replete as it is with fluid, is imaginary and not real. 
It seems obvious, therefore, that the term “pressure,” as applied 
hitherto to the intracranial mechanism, requires modification. 

The cranial cavity may be compared to that of a hose syringe, the 
perforations at its nozzle corresponding to the usual points of egress 
for the fluids ( i.e ., the normal channels into the veins, lymphatics, and 
the spinal column). If we close some of the numerous orifices at the 
base of the skull normal conditions are able to resist the outflow of 
fluids from the cranium. Any displacement of fluid takes place along 
the lines of least resistance, and it will pass out of the skull (in physio¬ 
logical conditions of health). If, however, this process of displacement 
is arrested, the fluid then seeks to escape from the points of lesser 
resistance, and the phenomena of dizziness, ringing in the ears, flashes 
of light, rhinorrhcea, choked discs, etc., are occasioned, the intracranial' 
fluid seeking to escape by unusual channels. In any experiments to 
determine intercranial pressure it would appear to be fallacious and 
misleading to deal solely with conditions of pressure outside the skull. 
This objection is obvious when we reflect that the mechanical, 
anatomical, physiological, and atmospheric conditions outside the skult 
are totally different from those within it. 

The doctrine of the incompressibility of the brain-tissue being a 
myth, it seems necessary to find some means by which the brain may 
best react mechanically to the expanding influences brought to bear 
upon it. In the absence of any direct influence derived from atmo¬ 
spheric pressure, the arteries, arterioles, and capillaries are provided with 
a relatively greater amount of elastic tissue than exists in these vessels- 
elsewhere, and it is by means of this elasticity of the vessel walls that 
resistance to their undue expansion and also their power to contract 
become possible. Under the general laws of hydrostatics it is incon¬ 
ceivable that increase of local pressure can occur or bear any significance 
other than as being an increase in volume of one constituent at the 
expense of the volume of other constituents, any actual conditions of 
pressure or tension being the same throughout the whole of the intra¬ 
cranial contents. Needless to say, the presence of tumours or other 
foreign bodies may not only cause alterations or displacements of 
structure, but also alterations and displacements of the sum-total, or 
alterations in the relative proportions of the fluid constituents. 

Excluding spatial or mechanical encroachments from without (as in 
depressed fractures), or from within (due to intracranial tumours, 
foreign bodies, etc.), the sum-total of the intracranial contents is not 
only constant and invariable, but the pressure throughout the sum-total 
of the contents is also universal and equivalent. 

The intracranial mechanism being thus passively dependent upon 
extracranial factors, there becomes no need for a special vasomotor 


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nerve-fibre mechanism such as pertains to vessels of the body, and the 
long-continued dispute as to the presence or absence of special vaso¬ 
constrictor and vasodilator fibres within the cranium can probably be 
finally settled if this assumption be true. 

It would seem that the various intracranial movements due to 
pulsatory and respiratory factors are entirely extracranial in origin and 
force; and it will probably be conceded that any evidences of intra¬ 
cranial vascular peristalsis are merely evidences of propagation of the 
peristalsis common to the arterial system right up to the points of 
ingress of the arteries to the skull, i.e., the intracranial waves owe their 
peristaltic variations more to the variations in volume of the arterial 
waves propagated from without than to any actual vasomotor influence 
acting on the vessels within the skull itself. 

In speaking thus of intracranial local tension it must, of course, be 
conceded that there may be, under pathological conditions, a struggle 
for supremacy between different contents. It is also to be noted that 
no account is here taken of osmotic or other influences which serve to 
preserve the balance between fluids of varying consistency. 

The usefulness of applying mechanical and mathematical principles 
for the explanation of intracranial disease is evidenced in a remarkable 
degree when we study the disturbances from which the brain and its 
adnexa are prone to suffer. Thus arterial inflammatory affections, 
capillary engorgements, and increase of serous exudation and diapedesis 
of leucocytes, with ultimate formation of connective tissues, can be 
represented by more or less definite formulae. Similarly alterations in 
the relative proportions of the lymph as a whole, or in its relationship 
to individual units such as the neurons, can be defined in mathematical 
terms; and lastly the processes of excretion by the lymphatics, the 
venules, veins, and sinuses may be considered either separately or in 
their entirety. Intracranial physics has not yet elaborated the 
mechanism of backward pressure in the vascular structures, and seldom 
do we find anything in treatises on diseases of the brain which tends 
to throw much light upon the mechanism or results of backward venous 
pressure. We know that venous congestion and stasis do occur, and 
that the surface veins of the brain are in almost immediate juxta¬ 
position to various brain centres, but the variations in venous pressure 
and their effects on the cortex as occurring in health and disease have 
as yet been scarcely touched upon. We have here, therefore, an 
almost unexplored field for research. 

It should be recognised that the cranium and its contents are 
dependent upon the blood for nutrition and repair, and that the 
processes of nutrition and repair are dependent not only upon an 
adequate mechanism of arterial supply, but also upon an adequate 
mechanism of venous drainage. The cranium and the pelvis hold 


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a somewhat similar relationship to the general circulation, and their 
contents are dependent respectively on similar conditions of arterial 
supply and venous drainage. This being the case, and recognising 
the close similarity between the two departments, it becomes evident 
how, under certain mechanical defects in the circulation, a double 
series of phenomena becomes manifest. It is an old observation that 
congestion of the pelvic contents is apt to be simulated in the brain, 
as evidenced by the nervous and mental symptoms associated with 
constipation. The comparison could be carried still further so as to 
include, on the one hand, the numerous troubles arising from congestion 
of the various pelvic viscera, and, on the other hand, the almost 
innumerable varieties of symptoms arising from delay of the venous 
return, not only from the various orifices of the skull, but also from 
the cerebral convolutions themselves. Such conditions as haemorrhoids, 
which are extrapelvic in site, are simulated by the various conditions 
of extracranial congestion occurring at the orifices of egress of the 
cerebral and cranial veins, either singly or in relationship to the cranial 
nerves and the special organs of sense. It will readily occur to all 
present how, under conditions of lowered blood-pressure, a tendency 
to venous stasis might readily occur, and, viewed from the purely 
mechanical standpoint, the indications for treatment are evident. In 
his Croonian Lectures on the “Degeneration of the Neuron” (1900),. 
Mott made some extremely valuable obervations in regard to the part 
played by venous congestion in the production of various forms of 
nervous and mental disease. He there pointed .out the means whereby 
a vicious circle becomes established by conditions which tend, on the 
one hand, to perpetual venous congestion in certain regions, and, on 
the other, to increased excitability of the neurons, these factors 
mutually interacting. It seemed to be a remarkable fact, that whereas 
much attention has been paid to the question of the arterial supply 
to the brain, the venous drainage from the various convolutions has 
been somewhat neglected. This is all the more remarkable in view 
of the close relationship between the veins and their surface of drainage 
from the various convolutions. When one considers the question of 
the vital importance of an effective drainage from the various sensory 
and motor regions, it becomes difficult to avoid recognising that many 
of the groups of symptoms met with in neurasthenia are not only of 
localising value, but also form indications as to the treatment necessary. 

I think, however, that this is not the occasion to elaborate the 
observations of Mott with regard to the part played by venous 
congestion regarded from a regional point of view, but I believe the 
time is not very far distant when many of the types of neurasthenia 
will come to be regarded as being due to local conditions of a 
mechanical nature, and dependent upon laciors which are entirely 


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BY THEO. B. HYSLOP, M.D. 


1 5 1 

extracranial in origin. The tendency to perpetual venous congestion 
in certain regions, referred to by Mott, is markedly exemplified in some 
parts of the course of the superior longitudinal sinus and in the 
area drained by the great anastomotic vein of Trolard. Just as the 
left middle cerebral artery is the artery of greatest wear and tear, 
so certain veins are subjected to greater exercise of function than 
others, and it is to the efficient drainage from these veins that more 
attention might with benefit be given. Speaking generally, I might 
state, with some degree of truth, that oftentimes what has come to 
be regarded as a familial neurotic taint is merely a familial defect in 
the bodily mechanism, whereby individual members of the family, 
whilst possessing finely evolved brains, are prone to neurasthenia 
because their brains are but imperfectly served by the bodily 
mechanism. The practical indications for the treatment of such cases 
are very clearly defined, and I have found benefit to accrue from 
complete rest of the areas which are drained defectively. One general 
principle of treatment is to increase the force of the arterial wave by 
cardiac stimulation, and to favour the venous return by aiding the 
inspiratory venous suction by forced inspiration, plus passive pressure, 
or massage, extending from the occiput downwards. Abdominal 
massage is also of considerable value, and more especially so when 
it serves to stimulate intestinal peristalsis. With regard to the special 
senses, I would give only one example of the effects of treatment by 
complete rest. The temporo-sphenoidal convolutions are particularly 
prone to suffer from venous stasis, and in order to give them complete 
and absolute rest, and more especially when auditory disturbances are 
present, I recommend for that purpose plugging of the meatuses by 
suitably devised plugs of paraffin wax. By this method I have afforded 
relief from hallucinations of long standing. 

In presenting to you these views on cerebral congestion and its 
results, I venture to hope that I have not only afforded material for 
discussion, but that I have also helped to throw some light on certain 
aspects of cases which are not only remarkably frequent in their 
occurrence, but which are also most difficult of explanation. It must 
not be assumed that my remarks apply to all cases of cerebral congestion, 
for there is of course another series of morbid phenomena due to 
high tension with arterial capillary fibrosis and the usual series of 
pathological changes ranging from sclerosis to actual haemorrhage and 
paralysis. 

Risumi. 

Active congestion is due to: 

(i) Over-action of the heart and whatever increases the force 
of the heart. 


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VENOUS STASIS. 


[April, 

(2) Sudden contractiota of the arterioles elsewhere—as, for instance, 

in the skin from exposure to cold or during a rigor—causing 
transient over-filling of the cerebral vessels together with 
those of other viscera. 

(3) Dilatation of the arterioles, and consequently an increase of the 

blood-supply, produced by certain toxic agents, especially by 
nitrite of amyl, nitro-glycerine and alcohol. In exophthalmic 
goitre vascular dilatation is associated with cardiac over¬ 
action. In some young neurotic persons periodic congestive 
disturbances are frequent. 

(4) Active congestion occurs as the first stage of inflammation. 

Convulsions may be due to active or passive congestion. 

(5) Sunstroke is said to be not infrequently attended by active 

congestion, but in my opinion the congestion is generally 
passive and due to extracranial and hygrometric causes. 

(6) In acute febrile diseases the delirium is usually due primarily 

to toxins and secondarily to congestion. 

(7) Plethora in adults with an increase in the total quantity of 

blood in the system, when attended by the suppression 
of an habitual discharge, especially haemorrhagic, as from 
piles or catamenia, or rhinorrhoea, epistaxis, etc., is apt to 
be attended by congestion, and in this relationship many 
chapters could be written. 

(8) In many instances the active condition of congestion may be 

local, as in connection with tumours, focal lesions, etc., but 
with these there is no need to deal. 

Passive congestion is always produced mechanically by some 
obstruction to the return of blood. It occurs in heart disease when 
there is over-filling of the venous system ; in conditions of pressure on 
the superior vena cava, or on the innominate veins, or on the veins 
of the neck in tumours, etc.; in obstruction to the flow of blood through 
the lungs in coughing, playing wind instruments; in strangulation from 
tight collars, in suffocation, and in spasmodic muscular conditions 
affecting the throat, as in epilepsy, etc.; in causes due to gravitation 
and the various types of asphyxiation, but most commonly of all to 
deficient arterial pressure. 

Of the various symptoms of the plethoric and adynamic types there 
is no time to devote to their further elaboration. Gowers, after having 
fully elaborated the pathology and symptomatology of the various 
cephalic sensations, states that there is not the slightest justification 
for attributing them to congestion of the brain, and he states con¬ 
temptuously that when such patients consult many doctors, as they 
usually do, they are told that their symptoms are due to congestion of 
the brain, or even (with a precision that is evidence only of profound 


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3922 .] THE FUNCTIONS OF THE BASAL GANGLIA. 


153 


ignorance or of actual charlatanry) to “ congestion of the base of the 
brain ”—a condition that probably never exists but in a pathological 
niagination. Needless to say this sweeping assertion is consistent 
neither with his own findings nor with those of any other observers 
who have studied the conditions to which he refers. 

. I have referred frequently to the value of massage of the base of the 
skull, the neck and spine, to ensure free movement in the veins and 
lymphatics. This should be conducted rhythmically from above down¬ 
wards to synchronise with expiration and the draining of venous fluid 
from the skull. It is sometimes remarkable how this relieves stasis in 
the basal veins, the petrosal and cavernous sinuses, and not infrequently 
an anaesthesia, more or less general, improves rapidly with draining of 
the straight sinus, thereby relieving the intra-commissural areas con¬ 
cerned with cutaneous sensation. 

I have also found that rhythmic exercises relieve conditions of venous 
•stasis which hitherto have not yielded to any other form of treatment. 
In many cases I believe it to be essential to aid the circulation by 
•careful estimation of the internal secretions and adjustment of the 
balance between the thyroid, pituitary, adrenal, ovarian, and testicular 
functions. 


The Functions of the Basal Ganglia.t 1 ) By J. V. Blachford, 

C.B.E ., M.D.Durh., Medical Superintendent, City Mental Hospital, 
Fishponds, Bristol, and Lecturer on Mental Diseases, University of 
Bristol. 

In the Journal of Mental Science , vol. xlviii, T902, p. 53, I described 
a case of degeneration of the optic thalami in a male patient, and 
pointed to the fact that the symptoms were chiefly those of very 
advanced dementia. 

Some years later a female patient, who had been resident in the 
asylum for a number of years, died. The following is a short history 
•of her case and the conditions found post-mortem : 

E.T—, a female patient, set. 78, had two or three attacks of partial aphasia; the 
last and worst occurred some months before her death. There was no paralysis, 
•but patient complained of feeling giddy and at the same time was at a loss to 
•remember certain words in conversation. From the first attacks she recovered 
completely; as regards the last, her aphasia had much improved but she was 
■evidently becoming more childish, and her death was certified as due to old age. 
Post mortem,: The vessels at the base of the brain were noted as very atheromatous, 
the grey matter pale and firm, the white matter pale and firm, and ependyma of 
ventricles smooth. There was a fairly large patch of softening in the right corpus 
striatum and a smaller one in the left. In this case the only lesion to account for 
the aphasia was softening in the corpora striata. 

I have searched the post-mortem records of this asylum for the past 
twenty years, and in all cases in which the lesion could be localised in 

(i) A paper read at the Autumn Meeting of the South-Western Division on 
October 28th, 1921. 


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154 the functions of the basal ganglia, [April, 

the basal ganglia, have ascertained from the case-books, as far as 
possible the symptoms presented by each, before and after admission. 
Including the one just described, there are seventeen in all, and the 
following is a rlsume, giving the seat of the lesion and the symptoms : 

Optic thalamus. —Three cases: All dementia—no paralysis noted—no 
convulsions or fits. 

Optic thalamus and corpus striatum. —Three cases: i dementia ; i 
seizures—paralysis—dementia—speech much affected ; i seizure— 
strong convulsions. 

Corpus striatum. —Ten cases : 4 speech affected ; 1 hallucinations of 
sight and hearing; 1 epilepsy—dementia—destructive; 1 fits, two or three 
years before admission ; 1 left-sided convulsions; 1 epileptiform fits;. 
1 pupils normal—knee-jerks present. 

Internal capsule. —One case : Aphasia—hemiplegia—loss of sensation. 

From this analysis it will be seen that in lesions involving the optic 
thalamus alone, the chief symptoms were those of dementia, or inability 
to appreciate one’s surroundings without epileptiform seizures or con¬ 
vulsions, which, however, sometimes occurred accompanied by dementia 
if a striate body was also involved; that injury to the corpus striatum 
led to epileptiform convulsions, or difficulty of speech ; and that in the 
only recorded case of involvement of the internal capsule alone, the 
symptoms were motor and sensory paralysis, but unaccompanied by 
convulsions or any marked degree of dementia. 

The optic thalamus is connected with the centre for sight through its 
posterior peduncle, with the auditory centre through its inferior peduncle, 
with the fronto-parietal cortex through its anterior peduncle, and with 
the olfactory centre through the bundle of Vicq d’Azyr. It is also 
intimately connected with the mesial fillet, is older than the corpus 
striatum, and no doubt chiefly concerned in those associations of the 
primary sensations of sight, touch, hearing and smell which enable us 
to form perceptions, a perception being the result of the association 
of two or more sensations, hence in lesions of this ganglion the most 
elementary appreciation of things in the outside world including our 
own peripheral parts is at fault, leading to pronounced dementia. 

The corpus striatum, on the other hand, is connected chiefly with 
the optic thalamus and cortex; with the former through the ansa 
lenticularis connecting the thalamus with the lenticular nucleus, and 
fibres passing through the anterior part of the internal capsule con¬ 
necting the optic thalamus with the caudate nucleus; with the cortex 
through the cortico-caudate fibres connecting the frontal cortex with 
the caudate nucleus, and by three bundles connecting the lenticular 
nucleus with the frontal region, the insula and the temporal region. 

Lesions of the corpus striatum give rise to convulsions, epileptiform 
seizures and difficulties of speech and but little permanent muscular 


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1922.] BY J. V. BLACHFORD, M.D. 155 

paralysis, unless the lesion is sufficiently extensive tQ involve the internal 
capsule. The anatomical connections and pathological considerations 
appear to point to the fact that it is the centre for the association of the 
muscle sense with the other centres of primary sensation, probably 
already associated amongst themselves in the optic thalamus. 

(a) We can only think in terms of muscular energy ; in other words, 
all thought is an incipient muscular contraction, due to the mild stimu¬ 
lation of those cells which receive the sense of muscular contraction 
when certain muscles are used, either to pronounce the name of the 
thing thought, or to adjust the eyes or other parts of the body in 
perceiving the object, or, performing the action. 

(b) This stimulation, if carried still further, issues in action, viz., 
the contraction of those muscles used in pronouncing the name or 
performing the act, of which these cortical cells are the sensory 
representatives. 

(c) Associated sensations giving rise to a perception leave the 
thalamus and reach the corpus striatum. Here they are associated 
with the muscle sense, which arises whenever the object is perceived 
and its name pronounced, a mental picture consisting of this muscle 
sense being thereby projected on to the cortex. In lesions of this body 
giving rise to a disassociation, or rather to want of association of these 
sensations, no picture is so formed, and so there is a forgetfulness of the 
name required, although the object and its use may be recognised, 
hence visual aphasia. In the same way, should the part concerned with 
the association of sound and the muscle sense be involved, word- 
deafness will result, though the patient hears perfectly well what is said 
to him, the failure being in that part of the nervous centre in which the 
sound is associated with the muscle sense, so that the muscle sense 
cells in the cortex corresponding to the sound are not stimulated and 
the consequent mental picture is not formed. In those cases in which 
the lesion is irritative we should expect contraction of the muscles 
whose sense cells were over-stimulated. But as some of the association 
cells in the corpus striatum will have been destroyed by the lesion while 
others are unduly stimulated, instead of an orderly co-ordinated con¬ 
traction of the corresponding muscles there will arise irregular, unequal 
contractions; and should the irritation be sufficiently severe these will 
spread to other parts, giving rise to one-sided, and sometimes even to 
general convulsions. 

The muscle sense is the most revivable in consciousness ; it is almost 
impossible to recall a taste, or smell, and, as to sight, colours are very 
faintly revivable, and then only by thinking at the same time of the 
name (and so incipiently pronouncing it). The shape and form of 
objects are much more revivable, this being due to the revivability of 
the muscular feeling experienced through the musculature of the eye- 


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156 THE FUNCTIONS OF THE BASAL GANGLIA. [April, 

balls, etc., when the object has been observed. Musical sounds are 
easily remembered, but only by that faint feeling of muscular sense which 
hs experienced by the muscles of the larynx, lips, tongue and cheeks 
when the same tune is sung, hummed or whistled—in fact, whenever a 
melody is thought over there is always a distinct feeling of strain in the 
laryngeal muscles. On the other hand a loud report, which cannot be 
imitated by the voice, is quite incapable of revivability. If, then, the 
■muscle sense is the only sense immediately revivable, the others being 
not so, or only indirectly through the muscle sense, it follows that it is 
our only medium for recalling past experiences or forming ideas—in 
other words for any kind of thought. It is not uncommon to meet with 
patients having some of the above-mentioned symptoms, especially the 
-difficulty of naming objects, and of calling to mind the words they wish 
to say, this symptom being frequently recovered from, and, as these 
symptoms correspond very closely with the cases mentioned, especially 
that of E. T—, there does not seem to be any reason why the lesion should 
not be of a similar nature. 

To sum up, then, it would appear that: 

(1) The optic thalami are chiefly the association centres of the primary 
-senses of sight, touch, hearing and smell, and their involvement is 
accompanied by impairment of those associations which give rise to the 
perception of things in the outside world. 

(2) The corpora striata are essentially the centres for the association 
of the muscle sense with the others giving rise to a great part of our 
subject consciousness, making speech and thought as we know it 
possible. 

In lesions of these structures we have the phenomena of visual 
aphasia, word-deafness, inability to call up words and names at will, 
and various difficulties and irregularities of speech and thought due to 
want of association of the primary senses with the muscle sense Divided 
up as these bodies are into nucleus, caudatus, putamen, and globus 
pallidus, it is probable that they have other functions as well, almost 
certainly associated with the motor system. Only careful and prolonged 
investigation will enable this to be solved; experiments are useless, and 
we shall have to rely on clinical, pathological and anatomical research. 

There is one other point: we are in the habit of speaking of the special 
senses as five in number—sight, hearing, touch, taste, and smell—omit¬ 
ting the muscle sense, which is of such importance, for without it, 
thought, as we know it, would be impossible. 

There is also a seventh sense, which, though recognised by the 
physiologist, is seldom mentioned—the sense of position of the body 
and its parts. It is well known that the special organ for this sense is 
situated in the vestibule and semicircular canals, and that in disease or 
injury of these structures there is intense vertigo and inability to stand. 


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CLINICAL NOTES AND CASES. 


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The axons of the vestibular nerve pass to the dorso-internal nucleus, the 
nuclei of Dieters and Bechterew in the fourth ventricle, and thence fibres 
pass directly to the cerebellum. The maintenance of the various positions 
of the body and its members is intimately connected with the association 
of the sense of position with the muscle sense. 

Cortico-pontic fibres, anterior and posterior, reach the pontic nuclei 
from the fronto-parietal and temporal regions and these fibres pass up to 
the cerebellum, the latter in all probability being the centre for these 
associations. 


Clinical Notes and Cases. 


Paraphrenia.^) By M. J. Nolan, Medical Superintendent, District 
Asylum, Downpatrick. 

I am sure it has been the experience of many other observers to 
come across certain unusual highly-coloured cases of mental disorder, 
difficult to place correctly in the jig-saw puzzle of insanity. We take 
very careful note of such cases and try to fit them into their proper places, 
but here and there the outlines do not correspond and the colour-tones 
do not blend in, so it is only after great patience we at last get them 
to fall exactly into the vacant spaces. And so it was with Kraepelin, 
who revived and restricted the term “paraphrenia” as suitable to 
designate “the morbid forms which are distinguished in their whole 
course by very definite manifestations of peculiar disturbances of 
intellect, while lacking enfeeblement of volition and especially of 
feeling, or at least such symptoms are only feebly indicated.” 

Prof. Kraepelin, at the close of his classical work on dementia 
praecox, points out that there is a comparatively small group of cases 
—paraphrenia—in which, in contrast to that wide-spread disease, there 
is a far slighter development of the disorders of emotion and volition 
cases in which the inner harmony of the psychic life is considerably less 
involved, and in which at least the inner unity is essentially limited 
to certain intellectual faculties. The marked delusions, the paranoid 
colouring of the morbid picture is common to all these clinical forms, 
which cannot everywhere be sharply separated. At the same time 
there are also abnormalities in the disposition, but, till the latest periods 
of the malady, not that dulness and indifference which so frequently 
form the first symptoms of dementia praecox. Lastly, activity also 
frequently appears morbidly influenced, but essentially only by the 
abnormal trains of thought and moods; independent disorders of voli¬ 
tion not connected with these, such as usually accompany dementia 

(*) Paper read at the Autumn Meeting of the Irish Division, November3rd, 1921 


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15$ CLINICAL NOTEis AND CASES. [April, 

prsecox in such multifarious forms, only come under observation by 
indication once in a while. 

Having stated these facts, Kraepelin, with characteristic modesty and 
reserve, proceeds in a first tentative attempt at delimitation. He 
makes four groups of these paranoid cases as follows : (1) Paraphrenia 
systemica, (2) paraphrenia expansiva, (3) paraphrenia confabulans, and 
(4) paraphrenia phantasiica. 

As the cases so grouped are not very numerous, even in large asylums, 
and as some of those which have come under my observation happen 
to be singularly well defined, I desire to briefly record them as striking 
examples of clinical entities, and to offer a few observations on some of 
the special features they present. 

Case i. Paraphrenia systemica .— I. Y —, tailor. Disease first showed itself 
when he was 35 years old. It commenced with mild mistrust, then definite delu¬ 
sional jealousy of his wife, followed by considerable depression. During five 
years he remained in this state, working in the tailor’s shop, and showing little 
disorder of conduct, but adhering to his jealous delusions, and stating his condition 
was due to his enemies. He then became suspicious of everyone he came into- 
contact with. One day he announced that he heard heavenly voices giving him 
spiritual revelations, under the influence of which he became excited and refused 
to work. Later he stated he had finished the work he had come to do, and that 
he had 44 cast down Satan.” He became aggressive when spoken to, and refused 
to converse with his inferiors. This state continued for five years, when he stated, 
44 1 can do anything I wish; I got all my powers from God. Do you wish to be 
made a king ? If you do, just say the word, and I will crown you where you 
stand ! ” Later he said 44 1 am King James II of Great Britain. What do you want 
annoying me with your own questions ? ” He spoke a good deal of himself, sometimes 
as if in response to hallucinations, and said aloud, 44 Who are you P ” 44 How dare 

you speak to me.” Two years later he still refused to work as he 44 needed no 
clothes, all were provided for him,” but to keep him from 44 thinking long,” he 
made a garment which I exhibit (vide illustration, p. 158). You will see it is a 
work of great labour, showing a well-thought-out design, worked with considerable 
artistic ability, a marvel of patient execution under difficult conditions and with 
a limited selection of materials. Wrought in amongst the web of symbolic orna¬ 
ment we find the following : 41 The most High Ruler ’’—indicating the rank of the 
maker and wearer— 44 Mighty deliverance, Glorious Victory,” 44 Faith,” 44 Bible,” 
44 Pray Brothers Pray,” “ Naught against that prevail,” 14 Must be born again,” 
44 Glory to God in the highest, and Peace to W. (sic) and to men,” 44 Power of 
Prayer,” 44 Lord if Thou wilt Thou canst make me whole,” 44 Look and Live,” 
44 Behold he smote the Rock,” 44 Begun and finises (sic) a table in the wilderness.” 
He now said he was in the institution twenty years, and announced, 44 I am the 
dress King of Germany ! I will not instruct ignorant people. I thought you were 
qualified to understand.” 

For four years he remained in this exalted state, very imperious in manner, now 
and again asserting his power and position, but never referring to the old persecu¬ 
tory delusions. The spiritual revelations still influenced him, and he had visual 
hallucinations. His general habits, appetite and sleep were normal. He developed 
phthisis, of which he died twenty-three years after the onset of his mental disorder. 

This case is clearly stamped with the characteristics which dis¬ 
tinguish the cases grouped under the term “ paraphrenia systemica ”— 
the insidious development of a continuously progressive delusion of 
persecution, to which are added later, ideas of exaltation without decay 
of the personality. A slow, progressive continuous course has issued 



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To illustrate Dr. M. J. Nolan’s article on “ Paraphrenia.” 


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Vestment designed, and worked in coloured symbols, texts and ornaments by “ I. Y— ” 
—“ The Most High Ruler ” : a case of paraphrenia systematica. 




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CLINICAL NOTES AND CASES. 


159 


1922 .] 

in a psychic decline with persistent delusions, also hallucinations, but 
without specially independent disorders of volition and without emo¬ 
tional dulness. Hallucinations, auditory, visual and sensory have been 
manifest, and ideas of influence (spiritual) have operated. Pseudo¬ 
memories play a minor part. Perception had never been disordered. 
The mood has changed from anxious, depressed and despairing phases 
at the initial stage to an intermediate stage of suspicious, strained and 
hostile, and finally he became self-conscious, haughty and scornful. 
Exaltation as to personal powers, attributes, etc., over-ride the persecu¬ 
tory depression. The patient’s activities are influenced in the most 
decided way by the delusions, but in contrast to the paranoid forms of 
the larger group the psychic personality is well preserved; there is in 
fact no loss of the inner unity of the activities of intellect, emotion and 
volition—there is no annihilation of the intra-psychic co-ordination. 

Case 2. Paraphrenia expansiva. —H. G. C. G—, recently deceased at age of 
71, was insane for the greater part of his long life, which was spent in unceasing 
and unprofitable travel in pursuance of his ever-changing and chimerical projects; 
but owing to special circumstances and self-control he escaped certification until 
some two years before his death. He came of an old family stock, many members 
of which had shown much ability. His life-history is one long succession of 
impracticable schemes and undertakings of world-wide ambition. From an early 
age his conduct, though restrained sufficiently to permit of his residence outside 
an asylum, was distinctly under the influence of hallucination and delusion. These 
found an outlet, and to a large extent support in his associates, many of whom in 
America were well known as reformers, philanthropists, investigators of spiritism, 
advocates of the “simple life,” and promoters of “settlements,” where curious 
religious and erotic doctrines prevailed. A man of some little means, consider¬ 
able culture, great enthusiasm, vivid imagination and marvellous energy, united 
to a soft disposition with expansive kindly feelings towards all men, he went 
through the world with a charming smile on his handsome face, illuminated by 
eyes of sparkling intelligence. An intense Nature-lover, he represented a com¬ 
pound of Walt Whitman and William Blake, expressing himself in something of 
the realistic language of the one, and the symbolic artistry of the other. His ideas 
originated from wide desultory reading, and strange personal experiences were 
thrown into the crucible of his delusional melting-pot, and transmitted into a 
pseudo-inspiration. His appearance, manner, and even dress became fantastic, 
his language and writing equally so. In adolescence and maturity he was a 
sensualist of a refined erotic type, but he did not in public permit himself to dis¬ 
regard conventions, which were antagonistic to his convictions, and which in secret 
he never respected. But he was always happy, expansive, and exalted, tolerating 
all those who, in his opinion, missed the joys of the mystic realm in which he 
revelled. While he fell short of being even a minor poet or a missionary with a 
following of his cult, he was at least a poetic dreamer, and possessed a personal 
magnetism which brought him into touch with strange and often more bizarre 
intellects than his own. Towards the close of his life he was an outstanding 
character in the country-side where he resided, and being a great pedestrian 
rambled round, calling on some trivial pretext on all the residents, gentle and 
simple. Garrulous, picturesque, hale, hearty and temperate, no one disliked or 
resented the odd visitor, whose eccentricity always interested and never offended. 

Glancing back over the records of his life, we find this gentleman constantly 
contributing letters to the press in support of all that appealed to him, and con¬ 
demning all that he objected to. At the same time he sent various poetic effusions 
on subjects that touched his emotions. Moreover he advocated by voice, pen and 
example many projects, among which may be named : The “ Universal Republic,” 
“ The Simple Life,” Henry George’s “ Land Theory,” “ Special Colony Schemes,” 
“The Brotherhood of the New Life,” “ Municipal Reform Schemes,” “The Doc- 


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trines of Dr. Sivartha and Mrs. Lightfoot,” and 44 The Happy Home Colony/’ He 
was the 44 Vice-President of the World’s Arbitration League,” described as “an 
organisation that in time will bring about a sort of millenium by abolishing wars 
and quarrels of all descriptions.” He launched a band of Messians for the purpose 
of realising “ The Messiance Life,” and any group coming to the colony were 
offered twelve acres of the tract for twenty-five dollars. He also launched 
41 G—n’s W—t All,” described as 44 a perfect standard food for muscle, brain and 
nerve, with a special action on man’s social qualities—marriage, religion, home 
and family.” It was advertised with highly diagrammatic sketches of the said 
qualities located in the brain. He obtained much public notoriety by his scheme 
of “ Lost and Found,” described in sensational headings in newspaper articles as 
“ Lost and Found. C— G—’s brilliant scheme to benefit mankind.” 44 Self- 
appointed Waif-Master-General. He proposes to establish a system by which 
everything lost may be found.” The scheme was to be worked by means of 
stamps, designed and issued by C. G—, who, being 44 Waif-Master-General/' 
proposed to appoint local Waif-Masters at each post office. The United States 
Government, however, took exception to the issue of the stamps, hence the news¬ 
papers had the following headings : “ 4 H. C—’s Waif-Master-General ’ officiaL 
designation of a man arrested yesterday. Scheme to find anything in which a 
little green stamp is used.” “ Deputy United States Marshall gathers him in, but 
he is released on his own recognisances.” 44 World's Arbitration League,” and 
44 C. G—held.” “Proposal for a Waif Office.” The stamp is described: “On 
said waif stamp may be seen a photo-engraving of G— himself, and above his. 
head in a halo is the beautiful engraving of Christ before the doctors when he was 
twelve years old. Pointing to this, Mr.G — smilingly said, 4 So we may imitate Christ's 
picture, words, works and ways, but if Caesar’s, then arrest and nous verrons 4 ” 
The report goes on to say : 41 This very morning a lawyer offered Mr. G— $40,000 
for the goodwill of his scheme, but he declined, saying his figures were $100,000, 
and a twelfth interest in all countries that would adopt it.” Subsequently Mr. 
G— was fined, and the stamps suppressed, and so the great scheme is extinguished. 

But C. G— is soon very much before the public again, this time in connection 
with domestic matters. He married the daughter of a lady who herself was in the 
public eye. She was a school teacher and married a preacher, and it is said, says 
the newspapers’ report of the day, that he was instrumental in having his wife sent 
to an asylum 44 because she differed from him in religious matters.” While in the 
asylum this lady wrote some books on the care and treatment of the insane. After 
her release she worked arduously to secure the passage of laws in the interest of the 
insane. Through her influence, it is said, Bills were passed by the legislature of 
nearly every State in the Union. Some years ago she took a special interest in 
lobbying for a Bill in Iowa. She followed the measure until the Bill was signed by 
the Governor. She succeeded in getting through a Bill to place the inmates of 
insane asylums under the protection of the laws by securing to them their postal 
rights. This lady’s daughter, who became Mrs. C. G—, fell ill mentally, and her 
malady and its treatment were prominently discussed in the papers, where we find 
the following headlines : 44 Romantic Courtship.” 44 Mr. G— has been a faithful 
husband and also a poet.” 44 Mrs. G— case: a lady friend thinks she is being well 
cared for.” 44 Out of an insane asylum.” 44 Mrs. G— released from A—w’s by 
her husband.” 44 Mrs. G— case. The Marshall and Health Officer do not think 
it calls for interference.” This refers to the fact that C. G— and Mrs. P— 
removed Mrs. C. G— from the asylum and placed her in a house in a cage 10 feet 
high, 8 feet long and 4 feet wide. Meanwhile C. G— writes to the papers— 44 Now 
what is the cause of all this fearsome increasing insanity ? Lack of love, lack 
of charity, lack of heart-felt sympathy, lack of national every-day life, lack of 
national religion. My wife's case was simply feeling intensely for these evils, and, 
trying to do too much for others, which a merciful Providence cut short by taking 
her into forgetfulness for a time.” And in his scrap-book under a cutting headed' 
44 A case for the Humane Society,” describing the condition of his wife after six 
weeks’ continuous confinement in the cage, he writes in red ink: 44 Strange that the 
little wounded lamb delighted in her cage, and objected to anyone coming into it 
but W—t All G— 4 Angelo ’ ” (“ Angelo ” being his nom de plume). At this time 
we find in the press that C. G— was an artist going ahead with a 44 cycloramic 
painting for the World's Fair”; that 44 as artist W—t All manufacturer, poet,. 


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preacher and philanthropist, he had a ten days’ camping tour, returning with a, 
series of sketches of the valley all round the horizon.” He also had an exhibition 
at the Great Fair—an ingenious reflecting instrument for reproducing objects 
on a level surface. He at some time sought to solve the problem of cheap* 
housing by making his little houses, advertised at $3 a month, keeping them 
inland in winter and taking them to seaside in summer. As already stated, all 
went well until at the age of 69, some year and eight months before his death, he 
was certified as “ suffering from periodical outbursts of mild maniacal exaltation, 
is restless and shows unnatural energy, wandering abroad, often insufficiently 
clothed in all weathers, shows some morbid eroticism, speaking of marrying young* 
girls. He has some delusions of grandeur, seems unable to take proper care of 
himself. Goes about talking nonsense, being King of Ireland.” The excitement 
passed off soon after his admission to the asylum. He became perfectly happy, 
beaming with delight on everything and everyone. When not reading and 
expounding what he read, he was engaged in writing love-letters. Though 
suffering some inconvenience from prostatic disease he rejoiced in his symptoms, 
regarding them as evidence of his virility. Love in the abstract and sexual 
relation were his constant theme, and it was difficult to determine the actual 
experiences from his imaginations, which were of a picturesque and graphic but 
never coarse type. His pseudo-memories anticipated his birth, and he vividly 
described his own procreation with details as to manner, time and place, and the 
advent of a butterfly from the garden into the room bearing his soul, which it 
released for its corporeal habitat at the physiological moment. Photographs 
show him in some of his exalted moods—leading simple life in the settlement; 
beside one of his monster oil paintings; as a bridegroom; bedecked with symbolism 
as a preacher; pointing with pride to the decorated tomb of his ancestors; and 
finally as one of a group in a u spirit photograph,” the “ spirit ” being one of the 
disciples of Laurence Oliphant, a man who had been killed years before in 
a cyclone. 

C. G— was nominally a Unitarian, but in fact was one of a small set called 
“ Aggressive Optimists,” who held that each one of us carried his own hell or 
heaven in him, and could alone make either for himself in this life. He attributed 
the “ spirit influences ” working in him as due to souls awaiting re-incarnation. 
He lived up to his belief and connected his life-long failure into a cause of most 
perfect happiness, enjoying to the last his unceasing but ever-changing delusions. 
He passed away painlessly in his sleep, so even his transition was a continuance of 
his dreamy visionary life. 

It would be difficult to meet a case of more characteristic symptoms— 
an exuberant megalomania, with predominantly exalted mood and 
slight excitement. The hallucinations appeared early and were of the 
u dream-like ” vision type, and coloured by religio-erotic associations. 
His perception, orientation, memory and retention were never essentially 
disordered, though he sometimes indulged in pseudo-memories. His 
mood was always self-conscious, cheerful, unrestrained and irresponsible, 
and his activities were not always dominated by his delusions. There 
was a steady course with little change and no destruction of his psychic 
personality, in strong contrast to the ruin entailed by dementia 
praecox. Delusional occurrences were kept in the background, not 
brought forward and reinforced by others as in systematised paraphrenia. 

Case 3. Paraphrenia confabulans. —R. McG—, aet. 44, single. Has been odd 
since he went to America some eighteen years ago, when he felt “ things were not 
right at home.” In U.S.A. he worked at mining, bridge building, lumbering, meat 
packing, ship building, concrete work, brick making, and farming. “ Things were 
not right,” so he returned to Ireland some seven years ago, and lived with his father, 
a farmer in fairly comfortable circumstances, doing little work of any kind. He 
became suspicious of his family and his neighbours, and made many delusional 


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statements of an alarming kind. He said numbers of men beat and murdered him, 
but that he was waiting to find out all their names so that he might deal with each 
one of them separately. He said he had great wealth in America, and proceeded 
to make a road for a motor car he did not possess. After a period of brooding he 
launched into a narration of extraordinary experiences, a mixture of persecutory 
and exalted delusion. When brought to the asylum he stated he was sent to another 
house to commit an immoral act with another man, and insisted on his right to 
see the American representative. Since then he has told long tales of retrospective 
persecution and exalted reminiscence. Each day he has a fresh narrative which 
he tells in a cheerful mood. When questioned definitely on the point he declares 
he is 44 quite happy.” He is very loquacious, and if not led into conversation 
becomes desultory, breaking off suddenly with a laugh, or a feeble attempt at a 
play on words. Each succeeding day his narratives, from a loose association of 
ideas, are more or less linked up. He is usually quiet and conducts himself 
rationally. Coming into my office for an interview he starts off and runs on as 
follows: 44 Here we are, Doctor, very old friends. Why, when I first met you I 
wasn’t quite four years old. I remember as well as yesterday you met me on the 
garden walk, and what a hot day it was! We went all round the place. I wasn’t 
here again for seven years. Then it was Mr. S. W— (an official dead several 
years, and whom the patient never saw), a fine old man, took me over. I had been 
badly bruised and beaten. Now they have been at the old bad tricks again, and I 
am here to get my head fixed up. Well, we may have a trip this time to Mount 
Stewart again, and if Lord L— does us as well as our first visit, we shall have 
a right old time. What a crossing of the ferry we had that day!—how the 
current caught the poor old boat; why, I had been in the sea if you hadn’t made 
me sit tight. But he made up for it at lunch—he knew who I was, so we fared 
well. My memory is coming back; you know that bad bash in of the skull I got 
broke my memory. Ah 1 but it’s coming back. You are making a good job of me, 
but it will take six months yet. I know 1 am insane, but I’m getting better. 
Having plenty of money I won’t need to work again. The badness is going 
through me, but you doctors must make a clean job of my head. By the way, 
what have you done with my photograph ?—I don’t see it here. You stood it on 
your table for many a day. It was a good one, the expression fine 1 A dear one 
too—I paid well for it. What was that you said the day I gave it to you ? Oh! 
I remember—* David, it is indeed yourself I’—and the way you looked at it, and 
smiled at me, before you put it on that very spot, I shall never forget. You say 1 
imagine all that, Doctor. Do I really ? Well, perhaps I do. Will you come over to the 
garden where we first met, anyhow—you weren’t more than ten years old then. I 
had to get away over the wall, and hurt myself badly too. The head was hurt 
most, but the marks didn’t show in the photograph. Doctor, you have put it away 
—I miss it still.” The patient is quite well conducted, and a willing worker in the 
wards, but says it is only until he is cured, and 14 he really is not R. McG., but 
someone else—he can’t say who—a mystery, but it will come right some day. 
Some things one can’t be too sure of.” 

This case illustrates a very distinct type, distinguished by the domi¬ 
nant role which pseudo-memories play in it. These pseudo-memories 
are of a widely diversified nature, reflecting in fact all the circumstances 
of life; they do not materially affect the condition of the patient, who 
recounts them with the reminiscent air of a raconteur . Now and again 
“the confabulatory springs of megalomania flow abundantly.” Con¬ 
sciousness is never permanently troubled. He perceives without 
difficulty, gives clear and connected information, and behaves himself 
reasonably. His mood, in spite of persecutory ideas, is cheerful, 
exalted and quite happy. He is very accessible, loquacious, verbose 
and desultory. He has a silly tendency, and sometimes plays on words. 
All these features are given as forming the clinical picture of this group 


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of cases of paraphrenia, and the characterisation of the group delimits 
it from the vast mass of dementia prsecox and from the smaller groups of 
paraphrenia. 

Case 4. Paraphrenia phantastica. —Patient, F. E—, set. 43, has been insane for 
some twenty years, and has been all that time resident in asylums in Malay States, 
Switzerland, England, Scotland, and Ireland. Well born and well educated, he began 
life as a Civil servant, having had private school and London University educa¬ 
tion. He is of mixed descent—Scotch, English, French and Italian, his paternal 
great grandfather belonging to the ranks of nobility of the latter country. He 
attributes all his troubles to over-education by his stepmother and to family 
surroundings. States that at the age of 11 he lay awake at night thinking of the 
loss of his soul. “ What else could you expect with a father a missionary and a 
grandfather one of the Plymouth Brethren ?” He was first legally certified insane 
in 1905, but says he was himself conscious from 1901 that his nerves had given 
way. He felt then that as a junior official he was made to do “dirty work” in 
connection with the enforcement of Pahang law in matters antagonistic to his Non¬ 
conformist conscience. He felt “ out of sorts,” and finally became an inmate of 
an asylum in 1905. Since then he has been almost continuously resident in 
asylums, spending his time in miscellaneous reading and the study of languages 
and social problems. He considers all his confinement has been illegal, and that 
the disturbance of his brain, classed by all the doctors as “ insanity,” is “ no more 
than nerves injured in childhood by overstrain, and now reacting rapidly in a too 
highly organised brain, consequent on a family history of insanity on both sides.” 
The intense jealousy of his father and brothers has also operated against him at 
all ti,mes. His father was just an accidental male progenitor, with feelings of 
Herod ; his brother, a “ false friend,” “ hated him like Esau hated Jacob, or worse.” 
When he came under the writer’s notice he was excited, denouncing the world as 
all wrong in every respect, more particularly European royalty and officials. Rape 
was so habitual to those persons—Kings, asylum doctors and asylum attendants were 
the worst offenders—he would reform society and introduce polygamy. His 
varied reading and personal experience have resulted in the formation of a tissue 
of paranoid delusion, chiefly religio-sexual, and this mental state is reinforced by 
very frequent auditory hallucinations. The delusional growth is indeed” luxuriant, 
highly extraordinary, disconnected and changing.” It would be impossible to 
convey any adequate idea of its area and diversity in anything less than a bulky 
volume, so I can but briefly touch on the more outstanding delusions and hallucina¬ 
tions at the present time. The not infrequent confabulations of non-personal 
experience may be mentioned ^as existing and as padding in his daily recitals; 
they are usually unimportant and ephemeral. The patient’s mood is generally 
exalted, though he frequently assumes in conversation an air of gloom and strain, 
but on the whole he is vivacious and accessible. His actions are always under 
control, and he is orderly, clean, and he is a “busy idler,” finding the days all too 
short for his many occupations, writing his autobiography, a novel, and his 
magnum opus , an “ Exposure of the Asylum System,” drawing in crayons, talking 
to patients specially selected as “good listeners”—a blind, senile melancholic, 
a broken-down farmer, he is instructing so that he may be fit for the position of a 
Minister in the Northern Parliament at a future date—taking long walks “ on 
parole ” through the country, swimming, hockey playing, carpentry work, attend¬ 
ing religious services of the Unitarian church. He protests against his registration 
as a member of the Church of England, and expresses his intention when at 
liberty to join the Brahamo-Somaj, at the services of which the Bible, the Koran 
and the Veda are used as the celebrant may desire. He takes a vegetarian diet 
well, and is in perfect health, but complains of some degree of sleeplessness and of 
dreams and nightmares. In many of his dreams scientific subjects are set before 
him, “ with a few carefully introduced errors to undermine his judgment.” 

Hallucinations. —At first were visual, “ lewd and spiritual,” chiefly the inferno, 
but the visions have ceased for some time. Then the auditory hallucinations 
commenced as vague, indefinite whispering, which was followed by voices, some 
of persons he knew, others unknown to him. These voices sometimes revile him 
by calling him opprobious names; at other times they suggest evil and error to 
his mind. Now and again they adopt a pseudo-friendly tone in order to entrap 

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him. He recognises them as hallucinations, and believes they are the work of 
evil spirits who seek his destruction in this way. Sometimes they seem to be 
inside, and at other times external to his head. They give him much trouble 
when they suggest to him to do good things, as they know his disposition is to go 
strongly against any suggestion from them, and as a result he would be driven to 
evil doings. Knowing their motive he does the right thing to annoy them. He 
has then known them to argue with each other irrespective of him. At one time 
he distinctly heard two highly-placed officials argue as to time and place and 
method of his execution ; he felt quite apart from them, yet had to listen to the two 
voices in his head. This latter class hallucination is a good example of “ Les 
hallucinations verbales psycho-motiv,” as described by Seglas: " 11 s’^tablit alors 
une veritable conversation intlrieure (conversation mentale) participant de tous les 
caract&res des hallucinations motrices verbales. Tant6t le malade n’a nullement 
conscience qu’il intervienne en quoi qui ce soit dans cette conversation k laquelle 
il ne fait alors qu’assister, et qui lui semblent tenir entre deux individus ayant pris 
possession de lui m£me.” 

He complains of “strange feelings in his genitalia—not normal, sometimes 
1 feverish * and sometimes * frigid.’ ” This may be due to some influence at work. 
He also gets hyperesthesia of hearing, and has other strange feelings in various 
parts of his body. Sometimes he had to lie as if paralysed. He was also made 
to perceive very disgusting smells which had no human source of origin. Particular 
parts of his body sweated at times, and the odour of the sweat was unpleasant. 

Delusions .—Patient states: “ I am F. C—, Carnegie hero, poet, scholar, philan- 
trophist, 1 The Unlucky.’ When at liberty I shall try to set the world right. 
Marriage laws must be put on an eugenic basis. It shall have State endowment. 
The best men must get many wives each, and one inferior woman must take several 
inferior men. Personally I shall be class Ai, but owing to the bad treatment I 
have had at hands of Europeans I shall take native women. So far I have only 
had consciously relations with three native women—one a concubine, one a mistress, 
and one a native’s wife. An effort was made to induce me to take a Japanese 
mistress, but I refused as they wanted me to go for a night’s trial. The native 
woman left me ; I did not seem satisfactory. When about twenty I was drugged 
by a servant who took advantage of me and gave me disease—I was unconscious 
like Lot’s daughter. I wish to reform morals; I hope to be protector of Sakai. 
I shall start a magazine for all classes and ages and nations, chiefly aimed against 
royalty and so-called religion. I shall have a special Hindustani edition for 
India; also a vegetarian sanatorium on the Nilgiri Hills. My present knowledge 
of languages being limited to English, French, Spanish, Dutch, Italian, Greek, 
Latin, Ido and Esperanto, I must make up native languages in the East. I am 
now studying Irish, but find it difficult; the spelling is archaic and is a millennium 
and a half behind the times. It is more akin to Hindustani, hence Irish and 
Scotch do better in India than English officials. The Irish and Indians say 4 1 
have no fear,’ for example, and the Englishman says * I am afraid.’ General 
Smuts would make me his private secretary; in time I would not only write his 
letters but give him the ideas. I am afraid some one is impersonating me now, 
reaping great advantages of wealth, position and influence. In order to win me 
over, overtures, which I rejected, have been made to me to have immoral relations 
with a princess. I have been described as the bastard son of a royal duke, and 
also as the rightful Duke of Normandy, but I prefer my own noble descent. I hope 
to do away with all property and to nationalise the land, moderate compensation 
to be given to the owners. Asylums as now constituted must be abolished. At 
present decent men and women are certified by medical perjurers for love of money. 
Wrongs unspeakable are performed with impunity by doctors, attendants and pet 
patients. Attendants are largely the scum of lower, and doctors the dregs of the 
upper classes. So long as medical men declare that anyone who hears voices, 
will do anything in the bidding of the voices, and that those who consider them¬ 
selves persecuted are always suffering from nerves, and the public take it all in 
without inquiry, is it not fit to drive one to despair, doing nothing, even writing 
nothing. That is why I write in shorthand—for general illegibility, for speed, for 
small space, for cheapness. All political parties fight shy of the medical profes¬ 
sion—the old are weary, the young are heedless. I have failed in my duty as a 
potential husband and father. May I at least succeed in denouncing the plague of 


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plagues of Britain. I am on in years now, and may go as an anti-Christian 
missionary for a small salary to Malay. The visions have stopped and the voices 
I am resenting. I attribute them to the fact that my grandfather’s grandfather, who 
was a Roman Catholic priest, joined the Church of England and married. Or they 
may be due to the revenge of the Hindoo Deities who were offended by my father at 
Muthra. Or it is quite possible they are due to the jealousy of Sir H. C—, who 
was once my chief, and who was a student of demonology, and it was said had 
secretly become a Mahomedan. The evil spirits are very often put into the bodies 
of other living men and women, who carry out the work of persecution, or they 
may be disembodied in some higher state than man, as we must conclude there is 
so much below man in the scale of development, there must be as many grades 
above him, between him and God. Yes, I can resist their influence. Once only I 
was overcome by it, and that was to save a life. A voice once said to me, 4 If you 
tell Dr. F— that we threatened to take your life, we will kill Dr. F— as well as 
yourself,’ so in the circumstances 1 did not tell.” 

Now we have in this case a good example of the final group. It is 
marked by a luxuriant growth of highly extraordinary disconnected and 
changing delusions. An unhappy childhood is followed by an unhappy 
and introspective adolescence, and later still by marked ill-humour and 
discontent with surroundings. Ideas of persecution now begin, and 
later hallucinations of sight and dysaesthesia. Next come delusions of 
personal influence —“ evil spirits ”—and these take up a large share of 
the morbid picture. Sexual troubles are also prominent. Pseudo¬ 
memories are not infrequent, and the confabulations are of non-personal 
experience. The patient’s mood is indifferent, gloomy, strained, 
exalted or threatening according to the delusion in dominance at the 
moment. There is little injury to volition; mental activity remains 
strikingly well preserved. Conversation is sometimes somewhat 
confused, is always vivacious and accessible, and as there is an absence 
of volitional disorder he acts quite reasonably, though the delusions 
are extremely luxuriant. 

The student of morbid psychology cannot afford to disregard the 
close examination of cases which exhibit disorder of certain definite 
paths of mentality. In the cases under review there is a very distinct 
disturbance of the intellectual faculties as in contrast to the emotional 
and volitional so very definitely affected in dementia praecox. 
ICraepelin, indeed, when presenting his series of morbid pictures, 
claimed only that they were the first steps of a preliminary inquiry. 
We all know, however, how far those steps have taken us in a scientific 
understanding of mental disease. They have brought us face to face 
with types heretofore crowded out by reason of their comparative rarity 
in the vast masses of common mental disorder. In this recognition we 
come to a closer understanding of the working of that most intricate 
complex and mysterious organ, the brain as an organ of mind. In 
following up such cases we are not only viewing the ravages in the path 
of the storm, but we trace the damage along the lines of least resistance, 
and this enables us to judge to some extent the relative importance of 
the mental attributes in the maintenance of normal mentality. 


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The Use of Luminal Sodium in Epilepsy .( x ) By J. Tylor Fox, 
M.A., M.D.Camb., D.P.M., Medical Superintendent, Lingfield 
Epileptic Colony. 

The history of the drug treatment of epilepsy is not an encouraging 
one. “There is scarcely a substance in the world,” says Sieveking, 
“ capable of passing through the gullet of man that has not at one time 
or another enjoyed the reputation of being anti-epileptic,” and it 
appears rather an impertinence to report upon yet another drug to be 
eulogised, tested, doubted, and perhaps ultimately discarded like so 
many of its predecessors. This paper is, indeed, no more than a 
preliminary note on the use of luminal sodium, and much more extensive 
trials over long periods are required before the value of the drug can 
be finally estimated. 

Luminal was first tried in Germany in 1912, and has been fairly 
widely used, but I have not come across any record of the results 
obtained from it in England or America. 

Luminal is phenylethylmalonylurea, or a derivative of veronal in 
which one of the ethyl groups is replaced by a phenyl radicle. 
Luminal sodium is a soluble derivative of luminal, and I have given 
it in solution, with hot milk or water, in doses of 1 to 2 gr. once 
a day, usually at bedtime. The dosage is small as compared with that 
of continental observers, who consider that 3 to 4J gr. can safely be 
given to adults over prolonged periods, provided that the patients 
are under adequate supervision. For the purposes of investigation 
sixteen cases of ordinary epilepsy in children or adolescents were chosen; 
the patients were all liable to major attacks at fairly regular intervals, 
and none showed signs of marked mental defect or deterioration. It is 
essential to confine statistical investigation to patients whose fits show a 
regular incidence, unless very long periods of time are under review. 
Most of the patients were taking bromide when the luminal was started, 
and the daily dose, which in no case exceeded 30 gr., was continued. 
This course was, no doubt, open to some objection, but had it not been 
followed, it would have been impossible to say whether any modification 
of the fit-incidence was due to deprivation of bromide or to the luminal 
sodium. In this connection it is perhaps worth mentioning that I have 
known stoppage of bromide to be followed by a considerable lessening 
in the number of fits. All the patients were under the continuous 
supervision, both by day and night, of experienced nurses or attendants, 
so that the fit statistics should be complete. 

The accompanying table shows the age of each patient, the daily dose 
of luminal sodium, the number of attacks recorded in each of the last six 

(*) A paper read at the Spring Meeting of the South-Eastern Division, 
May 4th, 1921. 


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I922.] CLINICAL NOTES AND CASES. 167 

months before the commencement of the administration of the drug, and 
the number recorded in each of the first three months of its administra¬ 
tion, the average number of fits per month during those two periods, 
and the gain in weight during the three months of the drug treatment. 


Table Showing the Effect of Luminal Sodium upon the Fit Incidence 
of Sixteen Young Epileptics. 






Average fit incidence. 



Sex. 

Age. 

Daily dose. 

Six months 

Three 

Gain in 
weight. 





prior to 
administr. 

months of 
administr. 


A. E. S— . 

M. 

18 

2 gr. 

4*3 

ro 

8 lb. 

Y. L—. 

M. 

22 

2 „ 

6*8 

o*o 

8 

C. J. F— . 

M. 

l6 

2 „ 

7*5 

4 *o 

8 „ 

A. E. C— . 

M. 

*7 

2 „ 

9*7 

2‘3 

7 » 

L.J.H- . 

M 

13 

2 „ 

reduced to 

4*5 

3*3 

2$ it 




1 gr- 




E. G. T— . 

M. j 

21 

2 gr. 

60 

07 

Lost 5i lb. 

c. w. s— . 

M. 1 

19 

2 „ 

87 

5*3 

Gain 7 lb. 

L.T. H— . 

M. ! 

15 

2 „ 


2*3 

6 lb. 

E. A. O— . 

M. j 

11 

I* „ 

7*3 

o *3 

5 i »» 

C. H. C— . 

M. 

12 

2 „ 

1 8-3 

4*7 

5 * ,, 

R. G. S— . 

| M. 1 

12 

ii 

4*2 

00 

1 „ 

R. S—. 

1 M. 

l 

11 

ii iy 

reduced to 

88 

47 j 

5 >» 




* gr. 




N. E. P— . 

F. 

14 

2 gr. 

60 

4 *o 

2^ it 

L. C. D— . 

F. 

15 

2 „ 

6*2 

5*3 

1 ,t 

A. G— 

F. 

15 

2 „ 

7*5 

20 

10 „ 

H. H— 

1 M - 

20 

2 „ 

2*3 j 

0*7 

7 t, 


Attention may be particularly called to two points in the figures 
shown. In the first place there is a marked reduction in the fit inci¬ 
dence in every case. This uniformity of reaction to the drug places it, 
I believe, in a category apart from other anti-epileptic remedies. I have 
drawn up and published elsewhere similar tables dealing with the effects 
of belladonna, digitalis, and of borax upon epilepsy, and they show no 
such uniformity of reaction. Borax, indeed, is the only one of the three 
which appears, when the figures are studied in bulk, to have any effect 
at all in the reduction of fit incidence. Various statistics of the fit 
incidence under the influence of bromide have also been published, 
but in none that I have seen have the beneficial results been so uniform 
as in this table. This point is worth stressing, because it is a matter of 
common knowledge that marked benefit, or even a complete arrest of 
fits, may follow the adoption of any new line of treatment, therapeutic or 
dietetic, or from a chance change in the environment of any individual 


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patient. Secondly, the considerable increase in weight that occurred in 
almost every case can be no mere coincidence. The average increase 
of the sixteen cases works out at just under five pounds, and it will be 
noted that only in one case is a loss of weight recorded. 

So much for the advantages of the drug. Are there any drawbacks 
to its use ? Careful observation was made of the mental and physical 
conditions of all the patients. In no case was complaint made of 
headache or abdominal pain; nor were there any acute outbursts of 
excitement such as have been recorded by continental observers. In 
five of the sixteen cases the general mental condition of the patients 
was apparently unchanged ; in three the patients were reported as rather 
more irritable than formerly, while in four they were evidently more 
cheerful and alert. One case, L. C. D—, a girl, aet. 15, has become 
distinctly more dull since taking luminal sodium ; her speech is hesi¬ 
tating, and she appears to have trouble in finding her words. It is to 
be noted that her fit record shows less improvement than that of any of 
the other patients, and that her increase in weight is correspondingly 
small. Two boys, L. J. H—, aet. 13, and R. S—, aet. 11, became 
sleepy after taking the drug for a few days. In both cases the dose 
was probably too large, and improvement followed on its reduction. 
Finally, in the fourth month of administration, one boy, C. H. C—, 
aet. 12, became very dull and lethargic, and could only with difficulty 
be persuaded to eat his food. The drug was stopped and the boy began 
to get back to his normal condition some days later, but as he had an 
exactly similar attack some time ago, it does not seem reasonable to 
ascribe his condition to the luminal sodium. 

As in the case of other drugs, luminal sodium seems to give best 
results in cases liable to major epileptic attacks ; cases who suffer from 
momentary losses of consciousness, or from periodic short attacks of 
altered consciousness with automatism, are notoriously inaccessible to 
drug treatment. Nevertheless there is recorded a diminution of 
momentary attacks in three of the patients in the table who were liable 
to them; and one of the most satisfactory cases we have had is that 
of a boy, jet. 9, who was liable to very frequent psychic attacks with 
automatic movements, the number and duration of whose attacks have 
been very greatly diminished by three months of luminal treatment, and 
who has become, as a consequence, very much brighter mentally. 

The modem view of the psycho-genetic origin of epilepsy has led some 
writers to discount the value of any treatment directed to reducing the 
fit incidence or arresting the fits. Fits are said to be protective reactions 
away from an environment to which the epileptic, with his egocentric 
sensitive temperament, cannot adapt himself, and to stop fits is to court 
further mental trouble. I have seen mental disturbance follow the 
sudden cessation of fits in an old-standing case of epilepsy, but more 


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commonly the patient becomes more alert and cheerful when his fits 
stop, and I have no fear that in using a drug that will arrest fits we are 
doing the patient any disservice, provided that we are satisfied that the 
drug itself has no prejudicial effect upon him. 

It is, of course, not claimed that luminal sodium, or any other drug, 
has any curative effect upon the disease; at best it only arrests or lessens 
the frequency of the convulsive attacks. 


Mental Disorder resulting from Encephalitis Lethargical) By 
H. D. Macphail, O.B.E., M.A., M.D.Edin., Medical Superin¬ 
tendent, Newcastle Mental Hospital, Gosforth, Newcastle-on-Tyne. 

The following brief notes refer to a case which I think presents 
certain features of interest. It is quite a common thing for children of 
tender years to be sent to mental institutions, but it is somewhat unusual 
for mental disorder of such a degree as to require certification to occur 
in a boy set. 10 who had previously been of sound mind. For this 
reason it is thought that a few details about such a case may be worth 
recording. 

The patient, set. 10, was certified and admitted to the Newcastle 
Mental Hospital on December 29th, 1920, the medical certificate 
stating that he was irresponsible, subject to frequent and sudden periods 
of excitement, when he became unmanageable, that he had tried to 
jump over the window, to put his head in the fire, and to stab his 
mother with a knife. 

There is no previous family history of mental disorder. The patient 
did well at school, and was regarded as perfectly normal in every way 
until he had an acute illness in the summer of 1920. This illness began 
about July 8th, the first symptom being pain in the head. Two 
days later twitchings affecting the whole body developed. About this 
time he became very drowsy, and on one occasion slept continuously 
for sixteen hours. His medical attendant diagnosed epidemic cerebro¬ 
spinal meningitis, and had him sent to the local fever hospital. 

He was admitted to the fever hospital on July 12th. Here the 
case was kept under observation, and the diagnosis of encephalitis 
lethargica was subsequently made. Lumbar puncture was performed 
on fifteen occasions, temporary improvement resulting from each 
puncture. Nothing was found in the cerebro-spinal fluid to justify 
either a tubercular or septic meningitis. The patient was discharged 
on August 25th apparently fit and well, and with no mental derange¬ 
ment. 

(') Paper read at the Spring Meeting of the Northern and Midland Division on 
May 12th, 1921. 


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On his return home he came under the care of his own doctor, who 
says: “ When he came home he had some inversion of the left foot, 
but his mother tells me he was then normal mentally. About the 
beginning of October he began to give way to uncontrollable temper in 
which he threatened violence both to himself and others, and he also 
developed twitchings of the left side. I have never seen these attacks 
of violence, and so depend entirely on the mother’s description; but I 
can answer for it that the whole family is terrified.” 

His mother tells me that since coming out of hospital he slept badly, 
and refused to stay in bed. He was excitable, unable to control 
himself, and had violent fits of temper. She states that this violence 
occurred by night, her description of an attack being that “ he becomes 
restless, runs about, loses control of himself, shrieks, and becomes 
violent. Next morning he is depressed, quiet, has little appetite, but 
is then no trouble.” Ultimately he became quite unmanageable at 
home, he took a knife to his mother, and threatened to cut his brother 
up. He was sent to the workhouse on November 6th, where he remained 
till December 6th. His mother states that on his return home he was 
in no way improved—he took a hatchet to his sister. He was again 
sent to the workhouse on December 20th, where he remained till his 
certification. 

On account of his violence the day-school authorities refused to have 
him at school with the other children; and I can quite imagine that it 
was rather a difficult problem for those concerned to know where to 
send him. 

On admission his general appearance struck one as being different 
from that of the patients usually admitted. He looked a bright, 
intelligent boy, rather pert and forward in manner. There were certain 
features of note in the nervous system. There was inversion of the left 
foot, with some liability to trip while walking. The plantar response 
was flexor, knee-jerks normal. There was twitching of left arm and leg. 
This was most marked in the arm—an involuntary sudden movement 
of the whole limb occurring at frequent intervals. As regards his mental 
state, the prominent feature was lack of self-control. He was restless 
and kept getting out of bed and interfering with the other patients. 
At night he became very troublesome and was a source of great 
annoyance to his fellow patients. He persistently asked to be sent 
home. His intelligence as estimated by the usual education tests 
is quite good; he has a fair knowledge of the elementary subjects, but 
there is marked lack of power of concentration, his attention being very 
easily diverted. There also appears to be some loss of the moral sense. 

There is one feature in which he differs considerably from the 
imbecile and the commoner type of mental case, namely his general 
alertness to things about him. 


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So far there has been no real improvement in his general mental 
condition; he is, as one might anticipate, rather more easily managed 
after some weeks’ residence, but from the point of view of permanent 
improvement the outlook does not appear hopeful. 

To summarise, the points of interest in this case appear to be that 
we find definite acquired mental disorder occurring in early life, 
following on an acute disease which has quite recently been described 
and which has attracted a good deal of attention; that the mental 
disorder is associated with manifestations of cerebral lesion, and that 
the disorder itself differs in several respects from imbecility and the 
commoner forms of insanity. 

Since writing the above a second case of a somewhat similar nature 
has been admitted. This was a boy, set. 15, who was sent to the fever 
'hospital on January 19th, 1921, suffering from encephalitis lethargica, 
.and was there for ten weeks. He developed mental symptoms while 
at the fever hospital, and was sent from there to the Union Hospital. 

He was admitted to the Newcastle Mental Hospital on April 27th. 
The prominent features in this case are childishness, irresponsibility, 
•and a marked loss of the proper fitness and proportion of things, well 
shown by his contradictory statements about ordinary events. In this 
oase there are no physical manifestations to note. He is described by 
his mother as being always a “ nervous ” boy, but he did quite well at 
school, and the acute illness would appear to be the cause of the mental 
•breakdown. 


Occasional Notes. 


The Trend of Psychiatry in England and Wales. 

The Journal published by authority of our Association would be 
■singularly incomplete did it fail to chronicle some recent occurrences 
affecting the world of psychiatry in England which may have perhaps 
more than a passing effect on lunacy administration and the care and 
treatment of the mentally afflicted. 

Our Association has never been unmindful of the defects in the 
.present Lunacy Acts, and for many years has steadily pressed for 
reform, especially in the direction of some better method of dealing 
with cases of insanity in its incipient and acute stages. 

In 1911 it appointed a committee to consider the “Status of 
Psychiatry, etc.,” the outcome of which was a valuable report issued in 
1914(1) advocating the establishment of clinics in connection with the 
universities, medical schools, and general hospitals, admission thereto 
to be on a voluntary basis, except in certain cases where it might be 


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desirable to have power to detain for a limited period on notification to 
the Board of Control; the admission of voluntary boarders to all public 
mental hospitals; the abolition of Poor-Law intervention ; the establish¬ 
ment of research laboratories and teaching centres; study leave for 
medical officers; facilities for medical officers to be married men, etc. 
Another recommendation was that a conference of persons and repre¬ 
sentatives of authorities interested and concerned in psychiatry and 
asylum management be convened. 

In January, 1918, an English Lunacy Legislation Sub-Committee of 
the Association commenced its labours and produced a report in 
November of the same year. Its purpose was to show how and in what 
directions the Lunacy Acts should be amended to carry out some of 
the recommendations of the Status Committee. The establishment of 
diplomas in psychological medicine and courses of training in psychiatry 
at the universities and medical schools is chiefly due to the initiative 
and efforts of our' Association ; and its Parliamentary Committee has 
ever been active and strenuous in guiding any proposed lunacy legisla¬ 
tion in the right direction. 

All this movement in the direction of reform and advancement has 
gone on solidly and unceasingly, and were the real facts of the situation 
known more generally, the unhappy impression that the mental services 
require waking up to their responsibilities created by some recent 
publications and by the activities of certain irresponsible and self- 
constituted reformers would not have prevailed. As an actual fact it 
was the public that needed awaking and not the mental services ; and 
just as it has happened in other matters, a crusade of exaggeration, 
calumny, and alarm has done as much, perhaps even more, to stimulate 
the present revival of public interest in the welfare of the insane than 
legitimate propaganda based on hard fact and careful thought. It is 
true, as Dr. Claye Shaw (2) recently wrote, that such outbursts against 
the Lunacy Acts and their administration are periodical and commonly 
bum themselves out without advancing matters, but we are hopeful that 
the general public are at last really roused to the necessities of the 
situation and on this occasion mean business. The danger is that the 
chief instigators may overdo it, and kill the interest they have success¬ 
fully evoked. The mental hospital medical and nursing services have 
for years been subjected to suspicions, neglect, discouragement, even, 
thinly disguised aversion, so much so that they have developed a hide 
of almost armadillo-like texture. A further instalment, even of an extra 
virulent variety, is a small matter if thereby the public can be brought 
to give more constant and serious thought in the work of mental 
hospitals and welfare of the insane. 

We need the sympathy, encouragement, and co-operation of the 
public. We invite inquiry and investigation, for we are confident that 


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the closer the treatment of the insane and the administration of the 
mental hospitals are looked into, the more apparent will it be that the 
chief hindrance to progress is the still archaic knowledge of people 
generally as regards mental affliction, and their ignorance of the work 
and aspirations of those fellow citizens whose life’s work is the care and 
treatment of the insane. 

Fortune has not favoured either the Association or such pioneers of 
fairly recent times as Brudenell Carter and Cooper of the London 
County Council in their efforts to secure greater efficiency in the 
treatment of mental diseases. It is only now that the behests of the 
late Dr. Henry Maudsley are definitely coming to pass after an 
unavoidable delay of nearly fifteen years; the several Bills that have been 
promoted in Parliament with the same or similar objectives have all 
come to naught chiefly through failure to agree on the modus operandi; 
nor have the praiseworthy efforts of such recent reforming agencies as 
the Mental Hospitals Association met with any better success. 

Without, however, going too far back into history, we may record 
that some general interest was aroused by the appearance in the 
autumn of 1918 of a book, A Plea for the Insane , by Dr. L. A. 
Weatherley. Much of it members of our Association could cordially 
agree with, and it no doubt did good in some quarters, though, as the 
British Medical Journal (3) remarked, it was marred by the way in 
which the subject was handled: “ Personal feelings are expressed with 
extravagance and some bitterness, and opinions are put forward with a 
lack of moderation which will not add to the strength of the case in the 
eyes of serious readers.” About the middle of last year another book 
on the same subject appeared, The Experiences of an Asylum Doctor , 
by Dr. Montague Lomax. 

Both these publications were addressed to the general public. The 
latter author in his introduction says: “ Had it been addressed to 
the medical profession, it would have been very differently written,” 
which presumably means that greater care would have been taken in 
presenting the legal and administrative data, an accurate knowledge of 
which is expected from even a junior medical or lay officer of an asylum. 
The former book had the advantage of being written by a medical man 
with long experience in dealing with the insane and not unknown to 
psychiatry, but no such claim can be made by Dr. Lomax, who confesses 
that his sole experience of aslyums was two months in one and nearly 
two years in another, and that his facts are chiefly taken from his 
experience in the latter; and this, too, was during the war, when few if 
any of our civil institutions were functioning normally. As Mr. Keene 
pointed out in a letter to our Journal (4), Dr. Lomax even fails to quote 
accurately the very Act of Parliament the provisions of which he set 
himself out to amend; and other writers have pointed out serious mis- 


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[April 

statements regarding the duties of the Lord Chancellor’s Visitors, the 
appointment of Commissioners of the Board of Control, the certification 
of pauper lunatics, etc. His imperfect knowledge and brief experience 
of his subject is betrayed on almost every page, and what might have 
been a valuable contribution to the only too scanty reliable literature on 
the organisation and management of mental hospitals will be chiefly 
remembered by the acute controversy it aroused, and the fillip it gave 
to the growth of a miasma of slander and mendacity regarding the 
character and conduct of mental nurses and the treatment of patients in 
the mental hospitals, and which has put the relatives and friends of 
patients to much unnecessary anxiety, even alarm. 

As a guide to mental hospital reform Dr. Lomax’s recommendations 
are either thoroughly reactionary and almost as medieval, if correctly 
reported (4), as his views on the nature and origin of mental disease, or 
have been the established practices at the great majority of mental 
hospitals for years, or again matters which the much-criticised medical 
superintendents have already urged. “A little knowledge is a dangerous 
thing ” is again true, and Dr. Lomax can be as little complimented on 
his recent book as on his adoption by the National Council of Lunacy 
Reform, a body which so far has distinguished itself chiefly by its cruel, 
cowardly, and contemptible attacks on the mental hospital workers. In 
another place we report the appointment by the Minister of Health of 
a Committee “ to investigate and report on the charges made by Dr. 
Lomax, etc.” Dr. Lomax, was invited to give evidence, and after 
consenting withdrew on a plea we consider trivial, having regard to the 
gravity of his statements. Perhaps, however, it is true of him that 
“ He who fights and runs away, lives to fight another day,” and there 
may yet be an opportunity of refuting his allegations. The National 
Asylum Workers’ Union also declined to appear, for reasons which 
many will sympathise with. 

However, to leave this unsavoury aspect of the subject, we can next 
record that the recommendation of the Status Committee in 1914 
regarding the convening of “a conference of persons and representatives 
of authorities interested and concerned in psychiatry and asylum manage¬ 
ment ” materialised early this year, when Sir Frederick Willis, K.B.E., 
C.B., chairman of the Board of Control, convened a conference on 
lunacy administration and the treatment of persons suffering from mental 
diseases, between the Commissioners of his Board and Medical Superin¬ 
tendents and Chairmen of Visiting Committees of County and Borough 
Mental Hospitals, and Medical Superintendents and Chairmen of 
Managing Committees of Registered Mental Hospitals and certain others. 

The Conference met on January 19th and 20th, 1922, at the County 
Hall, Spring Gardens, London, and Sir Frederick Willis is to be con¬ 
gratulated on the satisfaction it gave and the success it achieved—a 


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success in no small measure due to his tactful and business-like conduct 
in the chair, a success, we hope, which will lead to such reunions 
becoming annual occurrences. The proceedings (6) were afterwards 
published, and should act as a sedative to the feelings of many people 
lacerated by other recent publications and press utterances, while at 
the same time pointing out directions which true and sound reform 
should take. The Right Hon. Sir Alfred Mond, Bart., M.P., Minister 
of Health, opened the proceedings with a speech showing a fairness of 
mind and a breadth of view which, we trust, is a happy augury for the 
future of psychiatry in this country. 

The most recent event we desire to chronicle is the steps which are 
being taken to form a National Council for Mental Hygiene, and 
announced through the columns of the Times by Sir Courtauld 
Thomson, K.B.E., C.B. (7) Our friend and ally France has already 
taken this step, and the communication on this matter by Dr. Henri 
Colin at the last annual meeting assumes even greater importance. (8) 
A meeting of the inauguration committee has been called for May 4th, 
1922, at the Rooms of the Royal Society of Medicine, at which, it is 
hoped, there will be a good attendance of members of our Association. 
In the meantime communications should be addressed to the Hon. 
Secretary, National Council of Mental Hygiene, 51, Green Street, W. 1. 

As to how far this project can be fitted in with a similar proposal 
made by Lieut.-Col. J. R. Lord at the recent Conference on Lunacy 
Reform (9) remains to be seen, but no doubt the strong advisability of 
seeking the sympathy and co-operation of the local authorities in actual 
charge of the welfare of the insane will receive due consideration. 

References. 

(1) Journ. 0/Merit. Set'., p. 667 et seq., October, 1914. 

(2) The Times , January 10th, 1922. 

(3) Brit. Med. Journ., p. 605, vol. ii, 1918. 

(4) Lancet, p. 828, October 15th, 1921. 

( 5 ) Journ. of Ment. Sci., p. 572, October, 1914. 

(6) London : His Majesty’s Stationery Office, price 2 s. 6 d. net. 

(7) The Times, March 29th, 1922. 

(8) “ Mental Hygiene and Prophylaxis in France,” Journ. oj Ment. 
Sci., p. 459 et seq., October, 1921. 

(9) Vide Proceedings, p. 104 et seq. 


Progress of Psychiatry in the Union of South Africa. 

As announced in the July number of the Journal, 1921, we had 
received the first report of the Commissioner of Mentally Disordered 
and Defective Persons for the Union of South Africa, which covered a 


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period, 1916-18. Dr. J. T. Dunston, who has held this post since 
November, 1916, was given a cordial welcome by the Association at its 
Annual Meeting in 1921, when he read a very interesting and instructive 
paper on “The Problem of the Feeble-minded in South Africa.” We 
have since received his second report, which is for the year 1919. We 
are therefore in a position to appreciate the progress psychiatry is 
making in the Union of South Africa under the guidance of this able 
administrator and alienist, and the encouragement of successive 
Ministers of the Interior (now Mr. Patrick Duncan) and Col. H. B. 
Shawe, the permanent head of the Department. 

At the date of the Union, the lunacy laws of the several States and 
institutions for the treatment of the insane were placed under the 
administration of the Minister of the Interior. It soon became apparent 
that a consolidating law was urgently needed to secure uniformity of 
procedure, and to bring the various laws into line with modern legislation 
elsewhere regarding the care and treatment of the mentally disordered 
or deficient. What was more urgent still was the problem of proper 
accommodation for the patients, which was lamentably inadequate to 
requirements and for the most part highly unsuitable, chiefly in the Cape, 
where four out of the five institutions for the insane were originally 
convict stations or military barracks. Patients were kept in gaols and 
other unsuitable places for long periods awaiting vacancies at the mental 
hospitals, and all kinds of expedients resorted to at the latter institutions 
to increase their accommodation, especially for acute cases. 

No less than 144,000 was spent on buildings and repairs during 
the first three years of the Union, but it became obvious in 1912 that a 
much larger sum would need to be expended before it could be said 
that the position was satisfactory. 

In April, 1913, a definite move was made when the House of 
Assembly appointed a Select Committee to inquire into the adequacy 
or otherwise of the provision in the various Provinces for the accommoda¬ 
tion and treatment of persons of unsound mind. With amazing eelerity 
this committee presented its report in a month’s time, with fruitful 
results. 

The sum of ^350,000 was voted to be expended over a period of four 
or five years in carrying out a carefully prepared scheme for extensions to 
existing institutions and the establishment of new institutions and 
the closing of others. Two new mental hospitals were to be established. 
The extensions covered the provision of admission blocks at the mental 
hospitals, at which early and acute cases could be received and treated 
without the necessity for admission into the ordinary wards of the 
institution, also ample grounds for exercise and recreation and to afford 
opportunities for dairying and farming. Criminal patients were to be 
segregated in one institution. It was proposed to close three of the 


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older institutions to mental patients, but later it was found possible to 
■adapt two of them as industrial colonies for the mentally defective. 

Lastly, and not least, the Legislature passed an Act (The Mental 
Disorders Act, No. 38 of 1916) which embodied all the recommenda¬ 
tions of the Select Committee on the care and treatment of the mentally 
■disordered and deficient. Examinations of the provisions of this Act, 
which came into operation on November 1st, 1916, show that psychiatry 
in South Africa proposes to advance along sound lines, and that it is 
ahead of the mother country inasmuch as it has managed to place on 
its statute book an enactment which embodies progressive ideals we 
have long aspired to in this country without material success. 

The Act covers • all cases of mental disorder or defect, and thus 
recognises the unity of the problem of the insane and mentally deficient. 
The medical administration of these services is united in the person of 
the Commissioner of the Mentally Disordered and Defective Persons. 

It sanctions the treatment in general hospitals of incipient cases of 
mental disorder. The object was threefold. In the first place it was 
intended to give medical practitioners an opportunity of treating and 
following up their own cases of mental disorder and defect; secondly, 
that definite clinical departments for study and research should be 
established in large hospitals with medical schools; thirdly, by 
removing the stigma attached to admission to the mental hospitals, it 
was hoped it would lead to adequate treatment being sought at an 
earlier stage of the mental illness. Though it has not yet been found 
possible to give effect to this provision, South Africa is to be envied 
in that it has removed all legal obstacles in the way of the most 
enlightened and effective treatment being readily available for occurring 
insanity in its incipient and acute stages. 

Under this Act discretion is given to commit patients to “ single care ” 
instead of to a mental institution; voluntary boarders are admissible to 
all mental hospitals, and there is power to send for observation to a 
mental hospital persons awaiting or during trial who show evidences 
of mental derangement. 

Feeble-mindedness as defined by the Act excludes imbeciles and 
idiots, but, in addition to the usual defect who cannot “make good,” 
etc., it includes children permanently incapable of receiving proper 
benefit from instruction in ordinary schools by reason of mental defec¬ 
tiveness. Feeble-minded persons thus defined were brought under the 
control of the State for the first time. Investigations by Dr. Dunston 
and his collaborators show that they are to be found in ordinary schools 
(•84 per cent.), orphanages (13 per cent.), industrial schools (7 per 
cent, to 14 per cent.), reformatories (10 per cent, to 25 per cent.), mental 
hospitals (13 per cent.), rescue homes, etc. (25 per cent.). Similar 
investigations regarding criminals, prostitutes, and those in receipt of 


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poor relief have yet to be made, but in other countries the percentage 
of feeble-minded has been found in these classes of the community to 
be 10, 50 and 21 respectively. South Africa is fully alive to the 
importance of this problem as affecting the mental health of its people 
and the material prosperity of the country generally. Steps have been 
taken to deal with the feeble-minded in reformatories and industrial 
schools, and for this purpose these institutions are now regularly 
inspected by the Commissioner himself or by deputy. 

South Africa, like other countries, has felt the economic stress 
engendered by the Great War, which has delayed the putting into 
operation of the full programme of psychiatrical advancement sanctioned 
by its legislation. Although much remains to be done it can be con¬ 
gratulated on the progress already made. The problem is complicated 
in that it involves both white and native races, but the remedies 
proposed in both cases are based upon the same enlightened ideals, 
though the treatment will need to vary to suit the circumstances of 
each. We foresee a great future for psychiatry in South Africa and our 
Association will watch future developments with the keenest interest. 


The Resignation of Sir James Crichton-Browne. 

There is something pathetic in the connotation of the term “resigna¬ 
tion.” It implies an acquiescence in or a submission to the inevitable 
lapse and flow of the years, reminding some earlier and others later of 
the finality of human efficiency. In this instance, however, the chariot 
of time has borne its distinguished occupant beyond the allotted span, 
but has nevertheless preserved his mental and physical activities without 
any sign of failure or flagging. 

In some instances, as Lord Lytton said, resignation is interpreted as 
“ our day is come and with bitter thoughts,” but on this occasion there 
is the realisation that the task of fulfilling a responsible and dignified 
office, however congenial, may, if unduly prolonged, involve a strain at a 
time when Nature demands repose. Thus Sir James Crichton-Browne 
surrenders an office which he has greatly dignified, and which he has 
also maintained with sympathy, tact, courtesy and skill, and this for a 
period of 47 years—a longer official service than has been rendered by 
any of his distinguished predecessors. The first physician to become 
the Lord Chancellor’s Visitor in Lunacy was Sir Donald Hood, of 
Bethlem Royal Hospital; another was Dr. Robertson, of Haywards 
Heath Asylum, the translator of Grissinger’s German Text-book, and a 
third was Sir John Bucknill, F.R.S.; but Sir James Crichton-Browne, 
M.D., F.R.S., LL.D. (Aberdeen and St. Andrews), D.Sc. (Leeds), adds 
a further lustre and distinction to the office he now relinquishes. 


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Some of the older medical superintendents realise with gratitude that 
they hold their posts through the support and recommendation of Sir 
James. It was his special interest in research work that helped Darwin 
to complete his most valuable work on the expression of the emotions, 
and it was his interest in pathology that kindled the enthusiasm of his 
colleagues and assistants at the West Riding Asylum, where he and 
Ferrier, Bastian, and Bevan Lewis first investigated the physiology of the 
cortex of the brain upon an experimental and scientific basis. He has 
always been interested in matters of health, and was until this year the 
President for 20 years of the Sanitary Inspectors’ Association, his annual 
oration being an event which was always keenly anticipated in health 
circles and being related to prevention rather than cure. His chapter 
in the Book of Health , edited by Sir Malcolm Morris, has been widely 
read in every English-speaking country. 

One of his most marked accomplishments has been his public 
speaking. He has always been regarded as the modern Demosthenes, 
not only without his physical disadvantages, but on the contrary his 
eloquence has been aided by an impressive personality, a convincing 
reasoning and a choice of language which has adorned his style and 
oratory, his great abilities in this particular direction having made him 
an appreciated and popular figure at many public functions. The first 
Maudsley oration delivered in 1920 at the Royal Society of Medicine 
will long be remembered by those who heard it. 

Sir James Crichton-Browne has contributed extensively to the litera¬ 
ture of our time and his medical writings have also been numerous. 
His work on the over-pressure of school children will remain a classic. 
It was his privilege to be the first Lecturer upon Mental Diseases to the 
Newcastle Medical College as well as to the Leeds School of Medicine, 
and he was on the staff as Lecturer to St. Mary’s Hospital. His 
Presidency of the Medical Society of London and of the Medico- 
Psychological Association, as well as of the Neurological Society before 
its amalgamation with the Royal Society of Medicine, will be in the 
memory of many of the members. 

Sir James Crichton-Browne has secured the respect, the admiration 
and gratitude of many of the wards in Chancery, to whom for so many 
years he has been the intimate friend and faithful guardian. 

All who are engaged in the work of relieving the mentally afflicted 
will follow Sir James Crichton-Browne into his retirement with happy 
memories, and will wish him the freedom and leisure which he has so 
well deserved. 


LXVIII. 


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[April, 


Part II.—Reviews. 


The English Prison System. By Sir Evelyn Ruggles-Brise, K.C.B. 

London: Macmillan & Co. Pp. 275. Price 7 s. 6 d. 

Sir Evelyn Ruggles-Brise, who has just retired from the position of 
Chairman of the Prison Commission after twenty-five years of service, 
has in this book published an account of the English prison system 
which is of wide interest. 

In the preface and early chapters he traces the steps by which 
throughout the civilised world the severity of the old penal laws have 
been mitigated, and modern ideas of the uses of punishment have been 
generally adopted. In the light of modern opinion a system has 
been evolved which, while upholding the coercive, deterrent, and 
retributory attributes of punishment, recognises the principle that it 
must also be as far as possible reformatory, the problem being how far 
the rights of the State must be asserted without involving unnecessary 
and irretrievable damage to the individual. The days of treating 
criminals in the mass have gone, and it is now universally recognised 
that each case must be dealt with on its merits and after study of the 
individual delinquent. This question has been well dealt with in 
America by Dr. Healy in his valuable book on The Individual 
Delinquent. Modern criminologists also thoroughly realise the futility 
of short sentences of imprisonment for minor offences. 

Much valuable work in educating public opinion has been accom¬ 
plished by the International Prison Commission at their quinquennial 
congresses, one of which was to have been held in London in 1915 
under the chairmanship of Sir Evelyn Ruggles-Brise, had not the 
Great War intervened. 

The story of the gradual development of the English prison system 
is admirably told in the chapters relating to penal servitude and 
imprisonment. At the present time both convict and local prisons are 
under the control of the Prison Commissioners, who act subject to the 
direction of the Secretary of State, who is himself responsible to 
Parliament for their administration. As the result of the report of an 
Inquiry in 1895 the Prison Act of 1898 was passed. Under this Act, 
with the subsequent improvements embodied in the Criminal Justice 
Administration Act, 1914, the whole prison system has been placed on 
a humane and progressive basis. This country can no longer be 
accused of callousness or inhumanity to the criminal. During his 
incarceration he is under close observation physically, mentally, and 
morally, and every effort is made to reform him from his evil ways. 
The important position held by the Medical Officer of the prison is now 
fully recognised. 

The legislation of 1908 deserves more than a passing mention. In 
this year the Children’s Act was passed, which practically forbids 
imprisonment before 16 years of age, and thus withdraws all persons 
under 16 almost entirely from the control of the prison authorities. 
The Prevention of Crime Act, with which the name of # Sir Evelyn 
Ruggles-Brise will always be closely associated, also became law. This 


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very important statute deals with two categories of evil-doers who 
represent the opposite poles of criminality, namely, the juvenile offender 
and the habitual criminal. Under what is now familiar as the Borstal 
system, juvenile offenders between the ages of 16 and 21 who, by reason 
of their criminal habits, tendencies, or evil associations, require deten¬ 
tion under such instruction and discipline as may be most conducive to 
their reform and the repression of crime, can receive a sentence of 
detention in a Borstal Institution for a term of not less than two nor 
more than three years. During this period they receive training and 
instruction with every encouragement to reform, and on discharge are 
assisted to keep on the straight path by the aid-on-discharge societies. 
When an offender is found to be an habitual criminal, the court 
has power to pass a special sentence ordering that on the determination 
of the sentence of penal servitude, he may be detained for a period not 
exceeding ten nor less than five years under “preventive detention.” 
Whilst undergoing this sentence special endeavours are made towards 
the reformation of the individual, and to convince the most professional 
of criminals that crime does not pay. Borstal Institutions have been 
started for males at Borstal and Feltham and for females at Aylesbury. 
For habitual criminals of the male sex a new prison has been constructed 
at Camp Hill, in the Isle of Wight. The institution appears to be 
making good progress. 

The salient features of the prison system under modern legislation 
may be summarised under the following heads : 

(a) The concentration of attention on the juvenile offender 
under the Borstal system. 

(b) The organisation of a system of aid-on-discharge both for 
convicts and short-sentence prisoners. 

( c ) The provision of “preventive detention” for the habitual 
criminal, with various incentives to reform. 

To readers of this journal the most interesting chapter in the book 
will probably be that which relates to the criminological inquiry con¬ 
ducted by the late Dr. Goring, and his report entitled “The English 
Convict—A Statistical Study.” Sir Evelyn Ruggles-Brise gives a careful 
analysis of this work, with the conclusions to which Dr. Goring arrives. 
Without accepting Dr. Goring’s views of “ the criminal diathesis ” in 
their entirety, everyone agrees that a very large number of the inmates 
of our prisons are mental defectives, and that consequently their men¬ 
tality is the important factor in deciding whether they ought to be dealt 
with as criminals or as defectives. The Mental Deficiency Act, 1913, 
contains provisions which enable certain classes of defectives to be 
taken charge of and dealt with more appropriately than in prison, 
orders made under the Act authorising their detention for such period 
as may be necessary. The operation of this Act has been sadly ham¬ 
pered by the War and the resulting financial stringency, but there can 
be little doubt that when every local authority has its special school, 
under the Elementary Education (Defective and Epileptic Children) 
Acts, 1899 and 1914, as well as its certified institutions, under the Mental 
Deficiency Act, and when the Education and Mental Deficiency Com¬ 
mittees are properly functioning, the numbers of defectives who find 
their way to prison will be very considerably diminished. Sir Evelyn 


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Ruggles-Brise fully recognises the importance of the Mental Deficiency 
Act in promoting the rational and scientific treatment of the criminal 
problem. He notes with approval the growing appreciation on the part 
of magistrates and the public generally of the close and often undis¬ 
covered association between crime and mental deficiency. It remains 
largely for the medical profession to foster and encourage this apprecia¬ 
tion. The problems presented by the “ moral imbecile,” as defined in 
the Act, are often full of difficulty, and their solution calls for the 
closest co-operation between the medical officers who in their various 
capacities have to deal with them. It is only by intimate personal 
knowledge of the complex mentality of many of these social misfits that 
accurate diagnosis can be arrived at. 

The chapter on vagrancy and inebriety merits careful attention, especi 
ally in view of the inadequacy of short sentences of imprisonment. Persons 
committed to prison for offences under the Vagrancy Act, or as the result 
of drunkenness, are the cause of much anxiety to the prison authorities ; 
in neither case can short terms of imprisonment, followed by unrestricted 
discharge, effect permanent improvement. These offenders only go 
to swell the ranks of recidivists and habitual criminals. Sir Evelyn 
Ruggles-Brise states that of the women sent to prison annually nearly 
two-thirds are committed for drunkenness and prostitution. The 
figures relating to female committals for drunkenness given on p. 115 are 
especially appalling. The difficulties are immense, but it is quite time 
that fresh legislative effort was made to deal with these offenders on a 
more satisfactory basis. 

The statistical table of committals to prison on conviction in the 
year 1918-19, as compared with 1913-14, shows a reduction in the 
numbers of such committals amounting to 81 per cent. This reduction 
is attributable to a great extent to conditions arising out of a state of 
war—such as the general call upon the manhood of the nation for 
service under the forces, the endless opportunities for employment for 
those who in ordinary times would not be eligible for want of the 
necessary qualifications, and the drastic restrictions on the sale of 
intoxicating liquor. But the decrease in grave as well as in the less 
serious forms of crime had been proceeding for some years before the 
war. Further, the Criminal Justice Administration Act, 1914, which 
gave new facilities for the payment of fines, came into operation in 1915, 
and it is interesting to note that whereas before the operation of this 
Act between 75,000 and 100,000 persons had been committed annually 
in default, the numbers so committed in 1918-1919 had fallen to about 
5,300 only. This low number is probably to be accounted for by the 
high wages prevalent, thus affording means to pay the fines imposed. 
It is devoutly to be hoped that these improvements will not prove to be 
transient. 

As regards the population in convict prisons, the great bulk of whom 
are classed as recidivist, only about 700 are so classified at the present 
time, as compared with 2,000 at the beginning of the present century ; 
while the supply of the juvenile adults sentenced to penal servitude has 
almost ceased. These results of modern legislation are very encouraging 
and satisfactory. 

For the future Sir Evelyn Ruggles-Brise seems to suggest the possi- 


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bility of further development of “ the indeterminate sentence ” as a 
punishment for grave crime in lieu of penal servitude. A resolution in 
favour of this principle was, at the last International Congress in 
Washington, carried unanimously by delegates representing most of the 
countries of Europe and the civilised world. He also considers that 
there is further scope for the organisation of probation on large and 
well-considered national lines, and for the co-ordination of all organised 
efforts, collective and individual, now existing in the country, with a 
view to the prevention of crime. A. H. Trevor. 


The Manner of Man that Kills. By L. Vernon Briggs, M.D. 

Boston, U.S.A.: Richard G. Badger, 1921. 8vo. Pp. 440. 

In this volume Dr. Briggs details the life-histories along with the 
mental and physical abnormalities of three men—Spencer, Czolgosz 
and Richeson—the perpetrators of the three most sensational murders 
of recent years in America. The only one of the three likely to be 
familiar to British readers is Czolgosz, who shot President McKinley. 
Dr. Briggs’ knowledge of the cases is first hand for he was employed 
as mental expert at the trials. He was, however, satisfied in his 
own mind, notwithstanding that they were all three condemned and 
executed—that they were mentally irresponsible for their actions. He 
accordingly set himself the long task of a thorough investigation into 
their life-histories and the elucidation of facts pointing clearly to the 
morbidity of their mental constitutions. He has succeeded in proving, 
on apparently indisputable grounds, that Spencer was a defective from 
birth whose conduct should have demonstrated that he was not a safe 
individual to live unguided in society. Czolgosz was, from the evidence 
adduced, a case of simple dementia praecox (hebephrenia), who was not 
medically—probably not legally—responsible for the death of the 
President. Richeson, a clergyman, was a hysteric who suffered from 
hallucinations, delusions, amnesic phases, and occasional delirium. He 
had been nervously affected for years and had been treated by numerous 
physicians. 

The book, which is of great interest to medical jurists, is popularly 
written with the avowed intention of enlisting public opinion in favour 
of a change in the laws affecting the supervision of the insane and 
mentally defective living uncared for and unrecognised in the community, 
as well as the methods of procedure in criminal trials. The author 
considers that the medical profession, as a whole, requires a more 
thorough training in psychiatry than it at present receives. He also 
believes that, in chronic cases at any rate, the distinction between 
medical and legal insanity should be abolished. He further urges that 
in all criminal trials where there exists a prima facie suspicion of mental 
unsoundness the accused should be placed by the court under 
competent observation and examination for such time as may be 
necessary, in order to ascertain the true state of his mind. 

John Macpherson. 


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184 EPITOME. [April, 

The Psychology of Medicine. By T. W. Mitchell, M.D. London: 

Methuen & Co., Ltd., 1921. Crown 8vo. Pp. 187. Price 6r. 

Dr. Mitchell is peculiarly well fitted for the task he has undertaken 
in this little volume, as he was first interested in psychotherapy at a 
time when the subject was scarcely recognised by the medical profession. 
Most of the pioneer work was done by the Psycho-Medical Society and 
the Society for Psychical Research in this country, and interest was 
then mainly directed to hypnotic states and hysterical dissociations along 
the lines of Janet’s researches, first published in Automatisme Psycho- 
logique , and followed up by the studies of Morton Prince and Boris 
Sidis. Since these days much progress has been made, and Dr. Mitchell 
has followed closely the transformations in psychopathology during the 
last twenty years. The development of his own attitude enables him ta 
give an excellent historical account of his subject, and he here traces the 
trend of thought from the time of Mesmer to the work of Braid, Charcot, 
Lieubault, Bernheim and Pierre Janet, up to the more modern concep¬ 
tions of Freud and Jung. As the book is definitely didactic and 
elementary in its aims its contents do not call for special comment. 
It includes an even and well-balanced account of opposing schools of 
thought, and may be safely recommended as a useful introduction to 
psychopathology. H. Devine. 


Part III.—Epitome of Current Literature. 

1. Psychology and Psycho-Pathology. 

On Testing the Intelligence of Normal Persons [ Ueber Intelligenzpru- 
fungen an Norma!en\ {Kraepelitis Psychol. Arl>., Bd. Z'ii, Heft 1, 
1920.) Lange , fohannes. 

The main object of this investigation was to obtain a standard for 
use in testing the intelligence of defectives and hebephrenics at the 
Psychiatric Clinic at Munich. The performances of such patients to 
a test of their intelligence cannot be safely judged unless it is known 
what result a corresponding test will yield in a normal person of the 
same stock. 

In 1905, at Kraepelin’s instigation, a list of 170 questions in use 
at the Clinic was therefore set as an examination paper to 500 recruits 
in the Munich garrison. The questions were to be answered in writing, 
at two sittings with an interval of a week. The first part of the 
examination comprised 19 questions as to name, age, and simple 
matters of personal and family history, 28 as to orientation in time 
and as to simple time concepts, and 22 as to spatial orientation 
and spatial concepts. The second part compirised 27 very simple 
arithmetical questions, 64 elementary questions on natural history, 
religion, history, geography, military service, social life and purely 
practical matters, and 10 questions involving ethical concepts and 
judgments. The answers have come into the hands of Lange, who 
in this interesting paper of 158 pages gives an elaborate analysis of 
the results. 


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185 

He found that 31 of the questions made their appeal chiefly to 
the examinee’s judgment; the answers to these were subjected to 
special study. Other questions, involving more or less subsumption, 
were taken as affording some measure of the stock of ideas. Lange 
considers first the numbers of right and wrong answers to the 
questions taken severally, and on these he makes many observations 
too miscellaneous to be fairly sampled. Let us note, however, 
that the request to name towns in Upper Bavaria brought replies 
averaging only 2 ‘5 towns, that 144 men were far out in their estimates 
of the length of the middle finger, and that 100 could not give the 
length of a kilometre. These three results, Lange says, show three 
kinds of wide-spread defect: a miserable narrowness of the geographical 
horizon, an inability to apply the simplest natural instrumental aids, 
and an absence of concepts that we might have supposed to be 
indispensable. Only 195 men could give approximately the date of 
the founding of the German Empire; 190 did not know who Bismarck 
was. As for questions on social life, though 327 men gave passable 
answers to the question what police are for, far below 50 per cent. 
could indicate the kinds and purposes of courts of law, or the purposes 
of taxation. For ethical concepts and judgments the results were 
somewhat better, but many men failed where a thing was not quite 
self-evident; thus, only 173 could give any ethical reason why it would 
be wrong for a man to set fire to his own house. But the questions 
that yielded the worst results were questions of difference, and 
questions appealing directly to the judgment; none of these, except 
the question why houses are built higher in towns than in the country, 
brought more than 40 per cent, of right answers. Only 48 men could 
give an appropriate answer to the only question involving definition 
of a concept—the question what faithfulness is. 

The investigation showed that most of the men could be trusted 
only for such knowledge as touched their most immediate personal 
conditions of life and was indispensable for immediate practical 
purposes. Anything beyond this is in the possession of a percentage 
that is the smaller the less necessary such knowledge is for protecting 
the individual against daily risks. So we find lack of interest, laziness 
of thought, want of adaptation to the question, inability to enter into 
any question where daily need does not compel. The poorness of the 
results is due, not to sheer inability, but to absence of intellectual 
needs. We can now see what those questions are that we may expect 
to be answered correctly by a normal man. The questions that brought 
over 90 per cent, of correct answers numbered 71, of which over 
20 may be ignored as relating merely to personal particulars of the 
simplest sort; of the other 40 odd, there is hardly one that was 
answered correctly by everybody. There is no single question where 
failure to answer indicates weak-mindedness. We must judge not by 
details but by the total performance. 

Yet we must not judge solely by total marks. Identical totals may 
be produced in different ways. One man may score on the informa¬ 
tion he possesses, another on his judgment. Men equal in information 
may differ as regards judgment, and vice versa. Lange plots a curve, 
representing information results and judgment results by ordinates and 


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EPITOME. 


[Aprjl.il, 

abscissae respectively. For each value of total marks for informatici ; >n 
he plots the corresponding judgment average. Similarly for each val<f oe 
of total marks for judgment he plots the corresponding informatir k| jn 
average, and so obtains a second curve. The curves show that the\re 
is some amount of correspondence between the information results anon 
the judgment results. But how much correspondence is there ? This\ 
can be expressed as a coefficient of correlation, according to a mathe- \ 
matical formula that has been given by Spearman. The coefficient \ 
for the correlation of information with judgment is thus found to be ' 
071. (If the correspondence were exact the coefficient would be 1.) 

In the same way Lange obtains coefficients for correlation of informa¬ 
tion with total performance, and of judgment with total performance. 
These work out at 0*94 and 0*83 respectively. The figure 0*94 has 
little importance, and is very much what we should expect, seeing that 
the information questions composed the great bulk of the paper. But 
the figure 0*83 is very noteworthy ; it is remarkably high, if we consider 
how few judgment questions there were; it shows in a striking manner 
the great value of such questions as a test of intelligence. In any 
future investigation of this kind the questions that appeal to the 
judgment should form a greater proportion of the whole; and, as it is 
important that we should be able to disentangle the judgment results 
from the information results, the judgment questions should necessitate 
as little information as possible. If there are sufficient well-designed 
judgment questions, it is not necessary to put very many information 
questions. We gather that where we find a fair amount of judgment 
there we must expect to find also a sufficiency of information for that 
person’s conditions of life. 

Lange makes other criticisms of this list of questions, and he adds a 
proposed list of his own. This comprises 30 questions on school 
knowledge; 20 questions on practical matters (e.g., price of bread), 
economics {e.g., health insurance cards), politics {e.g., the process of 
legislation, the aims of the Social Democrats), and the administration 
of justice; 7 questions on ethical ideas; 8 definitions of concepts 
(plough, uncle, courage, etc.); from a list of 21 words group together 
those of similar meaning; name as many forest trees (beasts of prey, 
metals) as you can; what, collectively, are hammer, anvil, saw, tongs and 
drill ? (2 questions of this type); name all the red things, all the trans¬ 
parent, all the elastic things you know; name all the properties of 
sugar, and of water; name all thejparts of a tree, and of the human body ; 
arrange, in a rational order of time, “doctor, football match, cure, 
bandage, broken leg, convalescence, fall” (4 such puzzles); of 10 given 
proverbs, group together those of somewhat similar meaning ; mention 
the differences between ox and horse, glass and wood, etc. (7 pairs); 
arrange the following jumbled words so as to form a sentence (2 
examples); in the following passage mark the places where the words 
do not make sense; supply the missing words (nouns and verbs) in 
the following narrative; in the gaps in a second narrative insert 
appropriate connecting words (prepositions and conjunctions). 

With the help of tables and curves, Lange considers the results of 
the present investigation in various other ways. Among other things 
he considers the results in relation to the different kinds of schooling 


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that the 500 men had enjoyed, the different kinds of previous employ¬ 
ment in civil life, and the inevitable processes of selection that had 
been at work to produce this batch of 500 men—processes by which 
men more highly endowed had been reserved for higher walks of 
military life, and by which, on the other hand, obvious imbeciles had 
been excluded. He considers, in various lights, the possibility that 
some of these 500 should be regarded as weak-minded. He gives 
some brief critical remarks on some conclusions that would be reached 
by applying to this material certain supposed criteria of weak-mindedness. 

Sydney J. Cole. 

On the Biological Basis of Sexual Repression and its Sociological 

Significance. (Brit. Journ. of Psychol., Med. Sec., July, 1921.) 

Flugel, J. C. 

Psycho-analysis has shown that repression is due to intraphysical 
-conflict; the exact nature, however, of the forces which produce the 
repression and the circumstances under which they act have hitherto 
not been adequately studied. Freud speaks of the ego-trends as con¬ 
stituting a source of instinctive energy which frequently acts in opposi¬ 
tion to the sexual trends, but light has not been thrown upon them to 
anything like the same extent as upon the libido. By the study of 
repression from the biological point of view a deeper insight into its 
-nature can be determined. 

The biological factor, which is the thesis of this paper, consists “ in 
the existence of a necessary biological antagonism between the full 
development of the individual and the exercise of his procreative 
powers—between individualism and genesis, to use the terms employed 
by Herbert Spencer—an antagonism of such a kind that (other things 
being equal) the energies devoted to the life activities of the individual 
vary inversely with the energy devoted to the production of new indi¬ 
viduals. The relative amount of energy devoted to the two ends is 
determined (within the limits imposed by individual modifiability and 
racial variability) by the action of natural selection , there being some 
influences which favour the devotion of energy principally to purposes 
of individuation, while other influences favour the devotion of energy 
principally to purposes of propagation; so that there is brought about 
{within the individual and within the race) a struggle between the two 
lines of development corresponding to the two conflicting influences of 
the environment, this struggle manifesting itself within the mind as a 
conflict between sexual tendencies on the one hand and the self-pre- 
serving and self-regarding tendencies on the other; a conflict as the 
result of which there takes place the general sexual inhibition with 
which we are here concerned.” The true meaning of the antagonism 
between individuation and genesis only becomes manifest when we bear 
in mind the tremendous influence of the struggle for existence, as 
revealed by Malthus in its operation on the human race and by Darwin 
in its application to all forms of life. On the psychological side the 
sexual (and parental) instincts correspond to genesis, and the sublima¬ 
tion of these to individuation. At present the human reproductive 
tendencies and capacities are greater than is biologically advantageous. 


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Malthus’ remedy for over-population, with its attendant evils of 
poverty, war, disease and premature death, is the postponement of all 
sexual relations till relatively late in life. This requires a very extreme- 
degree of sexual inhibition; under the Neo-Malthusian practices of 
contraception the sacrifice of sexual satisfaction is far less. 

The effects of the recognition and application of these principles are 
traced. The writer considers that “in birth control we possess a 
weapon for rendering the individual human being longer lived, more 
amply provided for with the necessaries of life, and less exposed to the- 
rigors of the struggle for existence—in other words, for attaining those 
ends which the majority of social and political reformers have principally 
in view.” Rational insight and conscious control will be substituted 
for methods of blind prohibition and taboo. The inhibitions due to 
over-reproduction will be entirely removed, but the need for sublimation 
will remain and will continue to necessitate a considerable degree of 
sexual inhibition. 

This enlightening article deals in detail with the many sides of the: 
problem, only the fringe of which can be touched upon in this epitome. 

C. W. Forsyth. 


a. Neurology. 

The Hereditary Transmission of Huntington's Chorea \Chorea degenera- 
tiva\ ( Zeitschr. f. d. ges. Neur. u. Psychiat., Bd. Ixvi, April,- 

1921.) Harms zum Spreckel , H. 

The author gives a genealogical tree of certain agricultural families 
in the Erzgebirge (Saxony), showing the incidence of Huntington’s, 
chorea in four generations of descendants of a woman (A), who was 
born in 1785 and who herself at the age of 43 became affected with 
the disease. The taint seems to have originated with her, for though 
there was some question whether her mother may not have had the 
disease, the evidence that the author has unearthed leads him to reject 
a diagnosis of chorea in that instance, and none of A's 4 grandparents 
was affected. Besides 2 children who died young, A had 2 sons 
( 3 , C) and a daughter (D). C and D had chorea ; B escaped the 
disease, but died at the age of 37, i.e., before expiry of the age-period 
of liability to it. Seven of A’s 20 grandchildren, at least 10 of her 43 
great-grandchildren, and, up to the present, 2 of her 51 great-great¬ 
grandchildren, have become choreic. They are: 1 of B's 5 sons (but 
none of this son’s descendants); 3 of C's 10 children, and 2 of his 
9 grandchildren; and 3 of D's 5 children, 8 of her 25 grandchildren, 
and 2 of her 25 great-grandchildren. Ten of the cases have occurred 
in men, 12 in women. In ten instances the author has been able to 
confirm the diagnosis by personal study of the patient. He adds that 
among A’s great-grandchildren, besides the ten here reckoned as 
affected, there are 3 others in whom slight choreic movements have 
been noticed by relatives, though he himself in his personal examinations- 
has hitherto failed to detect them. In twelve cases the disease has been 
inherited from the father, in 9 from the mother. Except in the solitary- 
instance of B’s son, the transmission has always been direct, without. 


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any skipping of a link, i.e., if a member of the family has escaped the 
disease, none of that member’s descendants has become affected; the 
single apparent exception to this rule—that afforded by B's son—seems 
sufficiently explained by the fact of B’s dying from other causes before 
expiry of the critical period of life. Further, it may be noted that the 
three doubtful cases referred to with slight choreic movements, in which 
the diagnosis is not yet confirmed, are all in offspring of affected 
children of C and D. 

The onset of the disease is commonly insidious. It occurs mostly in 
robust persons who have married and had families, and it begins at 
ages varying from 26 to 51 years. The author does not find any 
evident raising or lowering of the average age of onset in successive 
generations, such as some writers have alleged. In particular instances 
the illness has been ascribed by members of the family to various 
causes, but the only causal factor whose influence is at all clear is the 
hereditary factor. Sydney J. Cole. 

Global Aphasia and Bilateral Apraxia due to an Endothelioma 
coinpressing the Gyrus Supramarginalis. (Arch, of Neur. and 
Psychiat., June, 1921.) Bremer , F. 

Two cases are described where a knowledge of Marie and Foix’s 
syndrome of the supramarginalis—slight paresis of the right arm with 
marked sensory disturbances, global aphasia and ideo-motor apraxia— 
enabled the localisation of the tumours to be correctly made. In each 
case the symptoms disappeared after the removal of the tumour. 
Pressure on the corpus callosum was impossible as the tumours were so 
small. A lesion of the left gyrus supramarginalis was found responsible 
for a true bilateral apraxia in thirteen cases out of forty-one (von 
Monokow). 

In two other cases a small gliomatous cyst of the frontal region 
produced the type of aphasia characterised by an intensity of dysarthria 
contrasting with a relative conservation of the understanding. This 
represents the syndrome anarthrique of Marie and Foix, which they 
showed to be produced by a lesion in the posterior part of the second 
frontal convolution and the adjacent part of the ascending gyrus. 

C. W. Forsyth. 

Reflex Epilepsy \Uber Reflexepilepsie\ (Zeitschr. f. d. ges. Neur. u. 
Psychiat ., Bd. Ixiv , February 1921.) Rosenhain, E. 

In 1850 Brown-SCquard divided a guinea-pig’s sciatic nerve, and 
after some weeks observed the development of an epileptic condition, 
and of an epileptogenous zone on the injured side. The attacks 
occurred sometimes spontaneously, but they occurred regularly when 
the epileptogenous zone was stimulated or touched. From the spasms 
of a guinea-pig to human epilepsy is a big jump ; nevertheless, a number 
of cases of convulsion in man were described as analogous to what 
Brown-SCquard had observed. For example, in 1871 Westphal reported 
the case of a girl, set. 17, in whom pressure on the left supraorbital 
nerve regularly produced a tonic spasm, which ended with vigorous 
weeping and howling. 


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[April, 


The conception of reflex epilepsy requires the existence of a kind of 
epileptic condition, distinguished from other forms of epilepsy by the 
circumstance that, in consequence of a local disease somewhere outside 
the brain, convulsive attacks are released, on a reflex path, by stimula¬ 
tion of a centripetal nerve. In criticism Rosenhain sets forth the 
following considerations : (1) The fits do not follow at once upon the 
incidence of the local disease; there is an interval, sometimes of years. 
(2) An aura in the region of the affected nerve has been supposed to 
be further evidence of the reflex nature of the disturbance; but the 
occurrence of such an aura may be a mere coincidence; or it may be 
due, in cases of Jacksonian epilepsy, to a chance affection of a spot 
of cortex corresponding to the injured limb ; or the aura may have been 
merely referred to a locus minoris resistentia of the periphery of the 
body; or, if the aura were dependent, in accordance with the notion of 
reflex epilepsy, on a morbid functioning of the injured nerve, it would 
be fair to assume that, wherever an aura is located, there there is to be 
found the seat of production of a fit—which is absurd. (3) It has been 
said that in some cases, after treatment of the local affection, or after 
extirpation of the epileptogenous zone, the epilepsy has been cured; 
but this is no proof of its reflex nature, for the cure may have been due 
to removal of a toxic source, or to amelioration of a neuritis ascending 
to the subarachnoid space. (4) If, by suitable stimulation of a centri¬ 
petal nerve, an epileptic fit were regularly induced, the reflex nature 
of the condition would be clear ; but in many of the cases the fits were 
induced psychically ; in many the fits were not epileptic at all, but 
hysterical; there is no record of any exact observations on the delimi¬ 
tation of the epileptogenous zone, the strength of the stimuli employed, 
or the time interval between the application of the stimulus and the 
release of the fit; and, further, it is necessary to exclude many cases of 
local affection of the cortex in which, in consequence of a focal brain 
lesion, a local stimulation of the corresponding limb produces convul¬ 
sions. (5) As the conception requires that the malady should be a 
veritable epilepsy, the possibility arises that not merely major fits but 
various epileptic equivalents might be evoked in the same way ; in this 
connection equivalents have never been considered. (6) How is it 
that among the entire epileptic material of the Breslau clinic during 
the last ten years there has not been a single case, and! that at the 
Wurzburg clinic no case has ever been known ? If a reflex epilepsy 
were possible, the war would have yielded many cases. 

The conception of reflex epilepsy arose in an age when epilepsy was 
very imperfectly distinguished from other affections, but it still drags 
out a shadowy existence in the literature. Rosenhain’s paper may help 
to lay its ghost. Sydney J. Cole. 


3. Clinical Psychiatry. 

The Study of the Trend in a Group of Dementia Prcecox Cases. {State 
Hosp. Quart., May , 1921.) Wright, W. W. 

Seven cases showing two trends are discussed ; four in which the 
incest phantasy is evident, and three where the union with the father 
has a more symbolic representation in a setting of religious exaltation, 


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191 


tbe father being replaced by God, the Pope, priest, president, king or 
some wealthy or renowned person. In all these cases a conflict or wish 
is evident, and the solution is a wish realisation, the variation in their 
phantasies depending upon the individual need. In some the phantasy 
is openly crude, in others subterfuges and substitutions are employed 
to make the situation compatible with the individual’s moral concepts. 

The mental mechanisms in these two groups are similar. In the 
past we have been led to believe that we were dealing with two distinct 
groups, the one said to represent the infantile, the other the adult 
trend of thought. When the first was present the prognosis was said 
to be poor, when the latter it was said to be good, and the case one of 
manic-depressive type. The designations of “ infantile ” and “ adult ” 
as applied to trends are here shown to be misleading and of no prog¬ 
nostic value, and that instead of two groups of cases there is in reality 
but one. C. W. Forsyth. 

The Significance of Certain Symptoms in the Prognosis of Dementia 
Prcecox. {State Hosp. Quart., May , 1921.) Williams, R. R., and 
Potter, H. W. 

From this study of 200 cases of dementia praecox the following 
conclusions may be drawn : (1) The shut-in type of personality may 
be regarded as one of the points for a favourable prognosis. (2) The 
presence of infantile sexual ideas is of grave significance. (3) The 
outlook is poor where hallucinations are present; if, however, they are 
of the visual type, the outcome may be regarded as more favourable. 

(4) The presence of a reactive mood change as shown by perplexity, 
anxiety, apprehension, depression or elation would portend a more 
favourable prognosis; conversely, an acceptance of the situation with 
an attitude of apathy and indifference is of serious prognostic inference. 

(5) A consistent and adequate emotional response may point to a 

favourable outcome; when a proper affective tone is lacking, the odds 
are greatly in favour of a protracted chronic course. (6) Regression 
and projection are the essential mechanisms of dementia praecox. 
Regression, if the sole mechanism, usually points to a deterioration with 
little hope of adjustment. If in combination with any of the accessory 
mechanisms the prognosis becomes less grave, when combined with 
projection it is not materially helped. Where projection is the sole 
mechanism the outlook is more favourable. (7) If the accessory 
mechanisms of wish fulfillment, repression, compensation or atonement, 
etc., are active, the prognosis is improved. C. W. Forsyth. 


4. Treatment of Insanity. 

Occupational Therapy at Kankakee, Illinois, State Hospital. {The State 
Hosp. Quart., August, 1921.) Sutton, Bess E. 

This is an account by the chief educational therapist of eighteen 
months’ work. The purpose of this department is to hasten recovery, 
lessen deterioration, improve the deteriorated, and to make the patient, 
generally, a happier and more useful member of society, whether outside 
or inside the hospital. Economic advantage is incidental. Efforts are 


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made, according to individual needs, to promote initiative, interests, 
contact with reality, self-expression and cheerfulness; to increase 
concentration, control, self-respect, sociability, to direct energy; to 
substitute good habits for bad; to diminish self-consciousness, and 
to give definite sensory and motor training. The means employed 
include training in personal habits, purposeful constructive work of 
graduated difficulty, games and amusements likewise graduated, walks, 
picnics, dancing, music, physical drill and gymnastics. 

The work supplements that of the industrial departments to which 
some of the unrecovered cases from class A, who are taught, e.g ., carpet¬ 
weaving and furniture making, etc., are drafted. 

The patients are classified, and an interesting enterprise is the 
adaptation of a disused building as an attractive ward, with dormitory 
and day room, in which intensive re-educational work is done with 
twenty at a time of the most deteriorated, untidy women in the insti¬ 
tution. Another class is for 125 disturbed patients. “At first they 
seemed impossible,” but rapidly improved. Music and exercise were 
important here. 

Class-rooms are being established in the hydrotherapy department, 
so that reduction of psycho-motor activity may be followed by directed 
employment. 

Twelve hundred men and women patients now attend classes (in 
addition to those in industrial departments). The personnel comprises 
a chief and five assistant trained occupational therapists, a physical 
director, fourteen charge attendants. They attend weekly lectures. The 
author looks back on slow, steady progress in spite of frequent 
discouragements. Marjorie E. Franklin. 


5. Pathology. 

Spirochates, Serum and Spinal Fluid: Studies Relating to the 
Pathogenesis of General Paralysis \Spiroehdten, Serum und 
Liquor: Studien zur Pathogenese der Paralyse ]. ( Zeitschr . f. d. 

ges. JVettr. u. Psychiat., Bd. Ixiv, February , 1921.) Schamke 
and Ruete. 

The writers report observations of the action of serum and spinal 
fluid upon spirochaetes obtained direct from cases of primary or 
secondary syphilis. An actual agglutination can hardly be said to 
occur, but in many instances the motility of the spirochaetes is 
abolished or impaired. Such an immobilising action is possessed in 
a very marked degree by fresh non-inactivated serum, even of healthy 
persons. If the serum is inactivated by heat, or even if it is merely 
allowed to stand for some hours, it loses this power. Syphilitic serum, 
however, whether of positive or of negative Wassermann reaction, 
retains this power in some degree even when it is inactivated or stale. 
Even in cases where under treatment the Wassermann reaction has 
become negative, the immobilising power of the serum remains. 

The conditions for the occurrence and persistence of a similar 
immobilising power in the spinal fluid are less clear. Spinal fluids 
are met with that, though fresh and non-inactivated, are inert; but 


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3 922.] 

usually the fresh spinal fluid of a healthy person has an immobilising 
action, though this is slower than that of fresh serum. Spinal fluid of 
negative Wassermann reaction from healthy persons, if it is inactivated 
or stale, is inert Spinal fluid of positive Wassermann reaction from 
a case of secondary syphilis with severe headache, even when left to 
stand for thirty-two hours, had an instant immobilising effect. The 
immobilisation is especially rapid when the spinal fluid, even if of 
negative Wassermann reaction and inactivated, is that of the patient 
from whom the spirochaetes have been obtained. The action of spinal 
fluid from cases of general paralysis is usually very rapid and complete. 
A slower action was observed in two paralytic fluids of negative 
Wassermann reaction. The immobilising power of paralytic fluid is 
very little reduced by inactivation. In many paralytic cases the 
immobilising action of the spinal fluid is much more rapid and 
complete than that of the serum. A complete absence of immobilising 
power in the spinal fluid almost certainly excludes a diagnosis of 
paralysis. 

As there are so many complicating factors and sources of fallacy, 
it is desirable that these observations should be checked by other 
workers; but the results so far obtained have confirmed Scharnke and 
Ruete in the opinion, formed already upon other grounds, that in 
general paralysis the brain is left to fight the spirochaetes single-handed 
with such antitoxins as it can itself produce, unassisted by supplies 
from other parts of the body, and that treatment should consist in 
stimulating the production of antitoxins in the body generally by 
oft-repeated introduction of small doses of syphilitic virus. 

Sydney J. Cole. 

The Pathogenesis of Epilepsy from the Historical Standpoint, with a 
Report of an Organic Case. (Arch, of Neur. and Psychiat., June, 
1921.) Kasak , U. 

A short account is given of the various theories which have been 
held to account for epilepsy. The only reference, however, to Pierce 
Clark’s monumental work is the following : “ It is significant that these 
mental factors have been recently re-emphasised.” 

It is pointed out that there are no anatomical changes in the central 
nervous system pathognomonic of epilepsy. Brain tumours form an 
interesting group of organic conditions causing epilepsy. A case is 
described, apparently one of idiopathic epilepsy, which post-mortem 
proved to be a psammoma of the left frontal lobe, with hydrocephalus. 
Excellent macroscopic and microscopic photographs are reproduced. 

Psychic disturbances are present in two-thirds of the patients who 
suffer from cerebral tumour. In tumours of the bulb symptoms are 
present in one fourth of the cases, of the cerebellum in one-third, of the 
hypophysis in two-thirds; in all cases of the corpus callosum without 
exception, and in most cases of frontal lobe tumours. Among other 
disturbances fits of unconsciousness with convulsions are frequent in 
cerebral tumours apart from cortical epilepsy. In rare cases general 
epileptiform convulsions may for some time be the only symptom. 
It may be impossible to distinguish them from idiopathic epilepsy 
until headache, double neuritis, or other signs appear. Other mental 


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disturbances of frontal lobe tumours are “ indifference, unpunctuality, 
mental enfeeblement, loss of memory and power of attention, change 
in disposition, with more or less marked irritability or taciturnity, 
or obstinacy or jocularity, etc., rambling speech, lack of realisation 
of illness, change in general conduct of life, habits of untidiness.” 
Kraepelin considers that these disturbances are due to destruction 
of brain substance, to pressure impairing cerebral circulation, and 
possibly to traction and displacement of the tissue, and in some cases 
to absorption of decomposition products. C. W. Forsyth. 


Part IV—Notes and News. 


MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN 

AND IRELAND. 

The Quarterly Meeting of the Association was held in the rooms of the 
Medical Society of London, 11, Chandos Street, London, on Thursday, February 
23rd, 1922, at 2.45 p.m., Dr. C. Hubert Bond, O.B.E., President, occupying the 
Chair. The Council and various Committees met earlier in the day. 

The minutes of the last meeting, having already appeared in the Journal, were 
accepted as read, and duly signed. 

Matters arising out of the Council Meeting. 

The President said the Council had had a long meeting, but there was not 
much business arising out of it to report to this general meeting. It was a 
great regret to learn of the illness of Sir Maurice Craig, who it had been hoped 
would have been present at the meeting. Sir Maurice had been, and was still, 
seriously ill, but it was satisfactory to know that his condition was no longer 
causing anxiety. He suggested that if the members would sanction a letter of 
sympathy being sent in their name by the Secretary, it would be some gratification 
to the patient. 

This was unanimously agreed to. 

The President said that at the Association’s previous general meeting the 
question of the cost of printing the Journal arose, and the senior Editor (Colonel 
Lord), Dr. Edwards, and the Hon. Treasurer (Dr. Chambers), were asked to look 
into the matter and report. They had delivered their report to the Council, and 
he would ask Colonel Lord to give a condensed purport of it now. It would be 
seen that the result of the inquiries was satisfactory. 

Colonel Lord said that, following the instructions given at the Annual Meeting, 
the small Committee had collaborated on several occasions, and finally a form of 
tender was sent to seven printing firms of repute, used to this style of work, 
including the present printers of the Journal. The form of tender had not proved 
an easy matter. There was much work in connection with the production and 
issue of the Journal which it was impossible to tender for, and there was a great 
variation in its contents from time to time. Estimates for the reproduction of 
plates had to be obtained separately on each occasion. And again in the printing 
of statistics, some were easy to set up, others were difficult and complicated. 
There was also the business connected with the advertisements, which was carried 
out by the printers, which could not be tendered for; also the exchange of 
journals, which involved a good deal of correspondence. The Register of names 
and addresses of members had to be kept up to date by the printers, and changes 
in addresses recorded, and the regular despatch of the Journals could not be put 
out to tender. Therefore the tender had finally to be restricted to the bare printing 
of atypical issue of the Journal, and samples of pages and types were sent with 
the form of tender. These forms had to be returned by February 15th, and it was 
satisfactory to note that the present printers gave the lowest tender, and members 


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195 


could now feel assured that the Journal was being printed on the most economical 
terms which could be obtained. 

The President said the thanks of members were due to the Committee, who had 
gone so carefully into the matter, and had relieved the anxiety felt about it. 

Dr. Bower asked whether the price now quoted by Messrs. Adlard was less than 
that which they had been charging for printing the Journal P Had the action 
taken by this Committee secured more favourable terms ? 

Dr. Edwards said that the Auditors reported a charge of nearly ^100 more 
than the present tender. 

Dr. Bower said that showed that benefit had resulted from the inquiry. 

The President said it should be remembered that trade prices had been 
coming down for some time, and were still declining. 

Colonel Lord said it was clear that the Journal was being printed by the firm 
who would charge the Association the lowest, which was the object of the inquiry. 
The cost of printing had gone down since the matter was raised, but the tenders 
obtained were all based on an imaginary journal at present prices, so that com¬ 
parison with former charges was impossible. The cost of printing would, however, 
now be checked from time to time. 

The President said that, also arising out of the meeting of the Council, members 
would remember that a sub-committee had been appointed by the Council to 
watch, and with power to act, the position which had arisen in the relationship 
of this Association to the General Nursing Council. That sub-committee had 
met, and had forwarded a letter to the Minister of Health on the matter, and the 
Council had re-appointed the sub-committee, with the same duty as heretofore. 
As the position was still obscure, the Council thought it would be wise to pause 
for a short time and note the action which would be taken by the General Nursing 
Council when it re-assembled under its new chairman. 

A further item was the resignation which the Council were sorry to receive from 
Dr. W. R. Dawson as one of the co-editors of the Journal. And though, under 
the circumstances, the Council had no option but to accept it, it was a pleasure to 
know that the reason was one on which they could offer their hearty congratula¬ 
tions to Dr. Dawson, as he had been appointed to the important position of Chief 
Medical Officer in the Ministry of Home Affairs, Northern Ireland. It was a 
satisfaction to know that the holder of that post would by his previous identifica¬ 
tion with the specialty always be interested in the progress of psychological 
medicine. 

Election of Candidates for Membership. 

The following were duly elected members of the Association. 

Wootton, L. H., Af.C., B.Sc., M.B., B.S., M.R.C.S., L.R.C.P.Lond., Second 
Assistant Medical Officer, Bexley Mental Hospital, Bexley, Kent. 

Proposed by Drs. G. Clarke, J. R. Lord, and John Brander. 

Webster, William Leckie, Capt. (Bt.-Major), R.A.M.C. , M.B., Ch.B.Edin., 
18, Minto Street. Edinburgh, c/o Messrs. Holt & Co., 3, Whitehall Place, 
London, S.W. 1. 

Proposed by Drs. G. M. Robertson, J. G. Porter-Phillips, and Thomas 
Beaton. 

Wilson, Ambrose Cyril, M.R.C.S., L.R.C.P.Lond., Physician, London 
Neurological Clinic, Ministry of Pensions. Union Club, Trafalgar Square, 
London, S.W. 

Proposed by Drs. G. W. B. James, A. F. Grimble, and R. Worth. 

Casson, Elizabeth, M.B., Ch.B. Bristol, Assistant Medical Officer, Holloway 
Sanatorium, Virginia Water, Surrey. 

Proposed by Drs. W. D. Moore, R. Worth, and C. Rutherford. 

Dunscombe, Nicholas Dunscombe, M.A., M.B., B.Ch.Camb., L.M.S.S.A. 
Lond., Assistant Medical Officer, Royal Earlswood Institution, Redhill. 

Proposed by Drs. Charles Caldecott, R. Worth, and G. Warwick Smith. 

Segerdal, A. McM. W., M.B., B.Ch., D.P.H.Belf., Assistant Medical 
Officer, Winwick Asylum, Warrington. 

Proposed by Drs. F. M. Rodgers, G. Warwick Smith, and R. Worth. 

Dearden, Harold, B.A.Camb., M.R.C.S., L.R.C.P.Lond., 45, Curzon 
Street, W. 

Proposed by Drs. J. C. Woods, J. G. Porter-Phillips, and Thomas Beaton. 

LXVIII. 14 


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Guppy, Francis Henry, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, 
Bexley Mental Hospital, Bexlev, Kent. 

Proposed by Drs. G. Clarke, J. R. Lord, and John Brander. 

Jarrett, R. F., L.M.S.S.A.Lond., Assistant Medical Officer, Springfield 
Mental Hospital, Tooting, S.W. 17. 

Proposed by Drs. R. Worth, G. Warwick Smith, and E. H. Beresford. 

The President, in asking for names of members who would be present at the 
Dinner in the evening, said that these Dinners fell practically into abeyance during 
the war, but he was now most anxious to see them revived, as they enabled members 
to renew friendships and to compare notes in the course of informal conversation. 
Cost had been a considerable factor in the past, but as they would see, a very low 
quotation had been obtained, and he hoped as many as possible would meet at 
dinner. 


The Album of Past Presidents. 

The President reminded members that the album of photographs of Past 
Presidents of the Association was on the table ; it contained the portrait of every 
Past President down to Dr. Charles Mercier. He was sure it was the desire of 
members that this should be kept up to date. Dr. Outterson Wood, whom all 
were delighted to see present, had most kindly stated that as this album was full, 
he would defray the cost of a new one, and he, the President, had undertaken to 
procure the photographs of Presidents since that date. In the name of the 
members, he had tendered their warm thanks to Dr. Outterson Wood for his 
promised gift. 


International Congress of Mental Hygiene. 

The President said the General Secretary and he had received a communica¬ 
tion from Paris inviting members to a double event in Paris on the last two days 
in May and the first four days in June, the events being to celebrate the Bayle 
Centenary of the identification of general paralysis, and to attend the First Inter¬ 
national Congress of Mental Hygiene. Announcements would appear in the next 
Journal regarding each of these projects. 

Paper. 

** The Use of Analysis in Diagnosis.” By Dr. T. S. Good, Ashurst Hospital, 
Oxford. 

The President said the Association was much indebted to Dr. Good for having 
put this highly interesting paper together at a time when he was exceedingly busy, 
and for coming from Oxford to read it. Dr. Good was discussing both the cases 
set out in the paper with him, the speaker, when he was recently at Oxford, and 
the author yielded to his persuasion to give the Association the benefit of hearing 
about them. From time to time one met with advocates of what some liked to 
term the two schools, the materialistic and the psychogenetic, and to speak of them 
as if they were opposed to each other. One thing the present paper did was to 
harmonise these two aspects, and it emphasised that there should not be a one¬ 
sided way of looking at cases. These two cases had been adequately examined 
physically, yet by the means employed the physical condition was elucidated, 
and it did not become so until the way had been pointed out by psychotherapy. 
Hence this contribution could be looked upon as a shaking of hands of those 
two lines of investigation, which many so unfortunately regarded as opposed to 
each other. 

Dr. F. H. Edwards said the great point in the paper seemed to him to be the 
great rapidity with which Dr. Good had been able to reach his diagnosis. The 
method pursued was not the one usually seen practised in psycho-analysis, in 
which the patient had to submit himself to a process of analysis extending up to 
even three months. It was the form known as the open method, one of which he 
himself had had very little opportunity of seeing the results. He had had many 
conversations with those who had been treating war neuroses, and he had been 
astonished at the statements made by certain experts, namely, that—particularly 
in the treatment of such conditions as mutism—recovery had invariably taken 
place within, at the outside, one hour from the commencement of the treatment. 


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It was therefore obvious that there were two schools, or methods, of practising 
psycho-analysis, yet one would think from the terminology that it was one 
method. He felt convinced that psycho-analysis in the hands of Dr. Good would 
be, from his own standpoint, much more satisfactory than the methods employed 
by other members of the profession. 

Dr. C. W. Barr asked how soon after the receipt of their injury the patients 
mentioned had come under the treatment. As a rule, it was not so easy to bring 
about recovery from the amnesias when there was a somewhat long interval 
between the causal accident and the commencement of the treatment. 

Dr. Bedford Pierce asked if the patients dealt with in the paper had been in 
any of the recognised war psychopathic hospitals, as it seemed somewhat singular 
that their physical defect had not been discovered before. 

Dr. A. W. B. Livesay said that, from the surgical point of view, it seemed a 
lightning diagnosis, and he asked whether there was any X-ray evidence of the 
injury. The operation of decompression seemed to have been a severe one on the 
rather slight evidence available, and such a long time after the receipt of 
the injury. He hoped the reply would give more information on that point. 

The President said the brevity of the discussion must not be taken as the 
criterion of the interest the paper had aroused; there had been some important 
•questions asked. He looked forward with great keenness to the day when 
Dr. Good would be at work again and the institution after its return to its normal 
function; then we should have a chance to see the results of Dr. Good’s very 
great experience during the war brought to bear upon cases of mental disorder of 
the type ordinarily admitted to mental hospitals. 

Dr. Good, in reply, said he was aware the cases he dealt with in his paper were 
regarded as rather startling. He then discussed the teachings of Freud, Ardler 
and Jung. Continuing, he had been asked what form of analysis he used. 
Surgeon-Captain Livesay said he, the speaker, had made a lightning diagnosis, but 
he had been three weeks at the man, giving up to him two hours at a time. In 
tackling the amnesias, it did not take long once a move was made. Dr. Edwards 
referred to it as the open method, but it was used by both Freud and Jung. Jung 
admitted that the cause might be one which did not reach back as far as childhood. 
The Harvard Lectures and recently published writings of Freud showed that he 
had altered his ideas as to war neuroses, for he said the self-preservation instinct 
might account for a good deal. The cases he, the speaker, had narrated did not 
go back to childhood, therefore they would not be so difficult to get at. It was 
better, in either bodily or mental diseases, to try everybody’s methods than sticking 
to one school or set method to the exclusion of others. It was far preferable to 
fighting among themselves. He could remember hypnotism being looked upon as 
an awfully weird matter, and not so very long ago a commission was appointed 
by the British Medical Association to report whether hypnotism and suggestion 
were of the slightest use in medicine. Hypnosis was not a treatment, but a 
condition, the reason it was assumed being that it strongly resembled sleep. 
Another contest had raged on whether treatment by psycho-analysis was sugges¬ 
tion. An integral part of our mental make-up was that we were suggestible, but 
he did not think we were conscious of suggestion. He could not answer 
Dr. Bedford Pierce’s question, but he invariably put down on the case-sheet 
everything on the physical side. The facial paralysis might have been a slight 
Bell's palsy. The diagnosis of the injury was made before any operation was 
undertaken, and at the operation the surgeon found the condition present. One 
of the men had not had any more epileptiform convulsions since; the other now 
understood his condition and certification had been avoided. In answer to a 
further question, one case was treated four years after the original accident, and 
the other, he believed, was three years after. 


NORTHERN AND MIDLAND DIVISION. 

The Autumn Meeting of the Northern and Midland Division was held, on the 
invitation of Dr. J. R. Gilmour, at the West Riding Asylum, Scalebor Park, 
Burley-in-Wharfedale, on Thursday, October 27th, at 2.30 p.m. 

Dr. Gilmour presided and 20 members were present. 

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The Minutes of the last meeting were read and confirmed. 

The following candidate for ordinary membership was balloted for and duly 
declared elected : Ernest William Jones, M.D., M.R.C.S., L.R.C.P.Lond., the 
Manor House, Aldridge, Walsall, Staffs. (Proposed by Drs. F. P. Selwyn 
Thomas, W. F. Menzies, and R. G. M. Ladell.) 

On the motion of Dr. Eades, seconded by Dr. Mackenzie, the following 
members were re-elected to the Divisional Committee : Drs. B. Pierce, E. G. 
Mould and T. Stewart Adair. 

Dr. C. Wilfred Vining then read a paper on “The Relationship of the- 
1 Bilious Attack * and certain other Morbid Phenomena to the Epileptic State/’ 

Having briefly reviewed the relationship of migraine and epilepsy Dr. Vining 
gave the results of his observations on a series of 240 cases of epilepsy. Ii> 
approximately, one-third of these series there was a well-defined history of the 
“ bilious attack.” This “ bilious attack ” associated with epilepsy had certain 
characteristics. The attack nearly always commenced in the morning, the patient 
waking with a prostrating headache, accompanied by extreme nausea and distaste 
for food, lasting for a period of hours and frequently terminating in vomiting, 
which appears to bring the attack to a close. The headache is generally frontal 
and rarely hemicranial in character, visual phenomena being rare. In 88 cases 
out of the 240 these “ bilious attacks ” were well defined. They had preceded the 
epileptic period and had continued as an associated phenomenon in 48 cases ; had 
preceded, ceased before or on the outset of epilepsy in 25 cases; and in the 
remaining cases had been an associated phenomenon throughout. In 73 cases the 
attacks commenced before 13 years of age, in many cases from infancy. Females 
were more frequently affected, 66 out of 156 females against 22 out of 84 males. 
It happened that the bilious attack had little to do with the digestive system, anci 
was probably a “ nerve storm ” with the same setiological foundation as epilepsy. 
An epileptic heredity was present in 32 cases, a “ bilious attack ” heredity in 30 
cases. Dr. Vining then gave statistics concerning “ faints ” and nocturnal 
enuresis, which was present in his series in 43 cases apart from the incontinence- 
due to the epileptic fit. A history of somnabulism was present in 12 cases and in 
9 preceded the fits by some years. These evidences emphasised the possibility of 
the “bilious attack” and other phenomena occurring in the child being an 
expression of a potentially epileptic nervous system, and other recognition with 
active and prolonged treatment may prevent the development of the convulsive- 
state. 

Dr. Rees Thomas asked how many of the cases were associated with organic 
changes; Dr. Pierce asked about the effect of a purin-free diet in the cases ; ancL 
Dr. Eurich emphasised the fact that true migraine is very rarely associated with 
epilepsy. Dr. Vining replied that all the cases were of the idiopathic type and 
that diet had apparently little effect. 

Dr. Eurich then read his paper on “The Treatment of the Criminal.” He- 
pointed out that crime might be looked at from the historical, ethnological and 
even anatomical standpoints. This opened up a review of Lombroso's work, but 
Dr. Eurich pointed out that the conception of crime varied with the centuries, and 
that it would be an absurdity to look for anatomical features characteristic of the 
criminal. This did not mean that the criminal was not a subject for biological 
study. After showing how physical defects and diseases can affect the working of 
the mind, Dr. Eurich suggested that, given the circumstances, each one of us 
might become a criminal. He then passed on to the treatment of the criminal on 
punitive lines, and showed from the statistics of recidivism, from the considered 
opinions of clergy, prison doctors, visitors and judges that the punitive system is a 
failure. Punishment has been justified on the plea that it is retributive, but there 
could only be true retribution if the principle of “an eye for an eye” were 
followed. Punishment is supposed to be deterrent, but again recidivism and the 
results of the barbarous treatment of 100 years ago showed that punishment did 
not so act. Punishment is alleged to be curative. In children it is curative and 
deterrent—the punishment being effective in direct proportion to the amount of 
love existing between the punishing parent and the child. This element falls 
away in the presence of a judge. Consequently the criminal looks on the punish¬ 
ment as an act of vengeance. Finally Dr. Eurich stated that it seemed to him 
that the function of judge and jury should be the determination of facts and of the- 


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guilt or innocence of the prisoner. If found guilty the function of the judge should 
•end and the prisoner be treated along biological lines, using this in the widest 
sense. Dr. Eurich gave many examples of the opinions and facts brought forward 
in the papers. 

Dr. Rees Thomas, in discussing the paper, put in a plea for the Borstal system, 

•classifying delinquents as (a) feeble-minded (b) psychoneurotic and physical. He 
claimed 90 per cent, of cures for the system. The punitive methods in Borstal 
-were merely a system of discipline. He advocated also permanent medical officers 
ior prisons and courts. 

Drs. Bedford Pierce, Geddes, Eades and others also spoke. 

After a full discussion the following resolution was passed : 1 

“ That this Division desires to place on record that the attack on Mental 
Hospitals made by Dr. M. Lomax in his book The Experiences of an Asylum 
Doctor is not justified, and is calculated to cause a great deal of unnecessary 
pain to the relatives of patients; and that the accusations contained in the 
summary at the end of his book are untrue. 

u Further that Dr. Lomax's letter to the Daily Telegraph of 25th October 
makes grave charges of systematic cruelty on the part of male and female 
nurses, against which the Division protests in the strongest terms.” 

This resolution to be sent with the suggestion that the Council of the Association 
•should deal with the matter. 

This concluded the meeting. 


SCOTTISH DIVISION. 

The Autumn Meeting of the Scottish Division of the Medico-Psychological 
Association was held in the Royal College of Physicians, Queen Street, Edinburgh, 
*>n Friday, November 18th, 1921. 

Prof. G. M. Robertson occupied the Chair. There was a good attendance of 
Tnembers, and Drs. Brock, George Kerr and Murray Lyon were present as guests. 

The minutes of last Divisional Meeting were read and approved, and the 
Chairman was authorised to sign them. 

The Secretary submitted letters of acknowledgment from the relatives of 
Dr. David Yellowlees and Dr. Maxwell Ross, thanking the members of the 
Division for the kind letters of sympathy. 

The Secretary reviewed the steps taken since last meeting regarding the 
Division's amendments to the Asylums Officers* Superannuation Act, and reported 
•that in England the Sub-Committee had been unsuccessful in securing an interview 
with the Minister of Health on the subject. It was remitted to the Business 
Committee to consider, and take any local action that might be thought expedient 
towards obtaining the desired amending legislation. 

The Secretary submitted a letter from H.M. Inspector of Anatomy for Scotland, 
directing attention to the serious shortage of subjects in the anatomy rooms of the 
teaching schools, and asking the co-operation of the members in increasing 
the supply. After discussion it was agreed that each Medical Superintendent 
•should, as far as he could, help when circumstances made this possible, and the 
Secretary was instructed to reply accordingly. 

The Business Committee was appointed, consisting of the Nominated Member 
•and the two Representative Members of Council, along with Dr. R. B. Campbell, 
Dr. McAlister, and the Divisional Secretary. 

Drs. Donald Ross and N. T. Kerr were nominated by the Division for the 
^position of Representative Members of Council, and Dr. W. M. Buchanan was 
nominated for the position of Divisional Secretary. 

The following candidates, after ballot, were admitted to membership of the 
Association: 

(1) Robert Dick Gillespie, M.B., Ch.B.Glasg., Junior Assistant Physician, Royal 
Asylum, Gartnavel, Glasgow. (Proposed by Drs. D. K. Henderson, Oswald, and 
Buchanan.) 

(2) David Yellowlees, M.B., Ch.B.Glas., 5, St. James's Terrace, Glasgow, W. 
^Proposed by Drs. D. K. Henderson, Hotchkis, and Buchanan.) 

Dr. Haydn Brown (London) read a paper entitled “ Psychotherapy,” which 

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contained an exposition of his method of restoring disorders of nerve and brain 
functioning by 44 neuro-induction a method which he claimed to be new to 
science. The technique of the method was then demonstrated on a patient. The 
discussion which followed was taken part in by a very large number of members 
and guests, who all, without exception, vigorously criticised the paper. The chief 
grounds of criticism were that 44 neuro-induction," as demonstrated, was simply 
the use of suggestion in a state of complete relaxation, akin to the hypnoidal state 
of Boris-Sidis; that the introduction of a new term like 44 neuro-induction " was 
not justified; and that Dr. Haydn Brown’s psychology was confusing, through the 
use of new terms without exact definition, and the use of old terms in new 
meanings. 

A vote of thanks to the Chairman for presiding terminated the meeting. 


IRISH DIVISION. 

The Autumn Meeting of the Irish Division was held on Thursday, November 
3rd, 1921, at the Royal College of Physicians, Kildare Street, Dublin. 

Dr. W. R. Dawson took the Chair. 

The Minutes of the previous meeting having been read and signed, an apology 
for unavoidable absence was read from Dr. J. O’C. Donelan. Before the next 
ordinary business was proceeded with, the following resolution was proposed by 
Dr. Rainsford, seconded by Dr. Greene and passed unanimously, and the Hon. 
Secretary was directed to forward a copy of it forthwith to Dr. Colles: 

44 That we, the members of the Medico-Psychological Association, having 
learned of the resignation of John M. Colles, K.C., LL.D., Registrar in 
Lunacy and Honorary Member of this Association, desire to place on record 
our keen sense of the loss which we, in common with the speciality in Ireland, 
sustain by his relinquishing the office of Registrar in Lunacy which he held 
* for so many years. During his long and efficient term of office Dr. Colles 
has been at all times unequalled in his ability in administering the affairs of 
Chancery lunatics, to whose interests he was devoted, and his visits to the 
Institutions, public and private, marked as they were by zeal and courtesy, 
will be much missed by physicians and patients alike. 

44 We desire to tender to Dr. Colles our most heartfelt wish that he may 
enjoy for many years his well-earned retirement. He carries with him our 
highest esteem and regard." 

Communications from Dr. Mills and Dr. Hetherington, with reference to the 
correspondence recently addressed to them, were communicated to the meeting 
{vide p. 390, vol. Ixvii, July, 1921). 

It was left to the Hon. Secretary to arrange for a suitable place to hold the 
Spring Meeting. 

The Hon. Secretary explained to the meeting that, owing to unforeseen 
circumstances, it was not possible for him to arrange for or hold the Summer 
Meeting of the Division. His explanation was considered satisfactory. 

Owing to the regrettable and unavoidable absence of Dr. Donelan, it was 
decided to postpone the discussion on the subject of 44 Parole " until the next 
meeting of the Division. 

Dr. M. J. Nolan next proceeded to read his communication on 44 The 
Paraphrenias " {vide p. ). The paper was rendered doubly interesting by the 
exhibition of photographs and collection of autograph letters and albums compiled 
by the patients whose cases were dealt with in the paper. The Chairman 
complimented Dr. Nolan on his most interesting communication, and especially 
upon the four perfect examples of the paraphrenias which he had described. The 
paper was discussed by Drs. Rutherford, Mills, Rainsford, Greene and 
Leeper, and all expressed their appreciation of its great interest. The 
connection between the paraphrenic and the paranoid patient was considered, and 
an effort to draw lines of symptomatological demarcation between the two 
conditions was referred to by the speaker. All the members expressed their 
appreciation and thanks to Dr. Nolan for the valuable contribution he had 
brought before the Division. 

This terminated the proceedings. 


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PARLIAMENTARY NEWS. 

February gth, 1922: Asylum administration .—Mr. T. Thomson asked whether, 
in view of difficulties in securing some of the evidence necessary to enable the 
Departmental Committee of the Ministry of Health to investigate completely 
charges made as to the treatment of asylum patients, Sir Alfred Mond would 
reconsider the desirability of recommending the appointment of a Royal Com¬ 
mission with full powers both of investigation into the present system and a 
recommendation as to the future treatment of all types of mental disorder. 
—Capt. Loseby asked a question on the same subject.—Sir A. Mond, in a written 
answer, said that the question of the appointment of a Royal Commission was 
under due consideration. It would, however, necessarily involve a long delay 
before any practicable steps could be taken, and would postpone reforms which by 
general agreement he hoped might be introduced at an early date. In view of the 
necessity for an expeditious investigation into the allegations made by Dr. Lomax 
he had appointed a Departmental Committee. He was informed that neither of 
the medical members was, nor had been, associated with any asylum maintained 
out of public funds, nor was it correct to say that the chairman was in any sense a 
representative of the system criticised. He feared that it was impossible for him 
to obtain the services of any expert who had not already shown interest in Dr. 
Lomax’s criticisms. He regretted that Dr. Lomax was not prepared to substan¬ 
tiate before the Committee the charges he had publicly made, and that the National 
Asylum Workers’ Union had refused to defend their members against Dr. Lomax's 
charges; but he could not admit that either Dr. Lomax or they were entitled to 
dictate the composition of any tribunal or inquiry on the issues raised, for the 
appointment of which the Minister was solely responsible. 

February 1 $th, 1922 .* The asylums inquiry .—Capt. Loseby and Mr. Mills 
asked further questions of Sir A. Mond in regard to the departmental inquiry into 
lunatic asylum administration.—The Minister repeated that in his opinion the 
tribunal appointed to investigate the allegations made by Dr. Lomax was quite 
impartial, and that it was now for the latter to substantiate his charges or to with¬ 
draw them. In reference to the refusal of the Asylum Worker's Union to be 
represented at the inquiry, Sir A. Mond said that his information was that they 
refused because they wanted to have a representative on the Committee. Con¬ 
sidering that they were the people who were mainly attacked by Dr. Lomax, it 
obviously would not be proper to put them on the Committee. 

February 1 6th, 1922; Mental deficiency .—Mr. Leslie Scott asked whether the 
Minister of Health had been able, in consultation with the Board of Control and 
the Treasury, to reconsider the position created by the circular of the Board of 
Control of August last in relation to the financial limitation of local authorities in 
dealing with urgent cases of mental deficiency. He asked whether the circular 
would not be withdrawn, as its operation would prevent large numbers of cases 
being dealt with under the Act, with results to the rates and taxes that would be 
far more expensive.—Sir A. Mond said that in view of the economy which it should 
be possible to secure on the mental deficiency service generally, he hoped that 
local authorities could now make such provision as was essential to enable new 
urgent cases to be dealt with, and he was causing the Board of Control to issue a 
circular accordingly. 

February 23rd, 1922 : Asylum administration inquiry .—On further question by 
Mr. R. Richardson, as to the refusal of the National Asylum Workers’ Union to 
submit evidence before the Committee on Asylum Administration, Sir A. Mond 
said that in the first instance the Union made a verbal request for representation on 
the Committee. When he refused this the Union declined to give evidence, and 
sought to justify its action on the ground that representatives of the Medico- 
Psychological Association predominated on the Committee. 


EDUCATIONAL NOTES. 

London County Council: The Maudsley Hospital .—Lectures and practical 
courses of instruction for a Diploma in Psychological Medicine, fourth course, 
1922: 

Part II.—Six Lectures on the Pathology of Mental Diseases, including Brain 
Syphilis, its Symptomatology and Treatment. By Sir Frederick Mott, K.B.E., 


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[April, 


M.D., LL.D., F.R.S., F.R.C.P. On Mondays, at 2.30 p.m., commencing April 3rd, 
1922. 

Eight Lectures on the Psychoneuroses. By Bernard Hart, M.D. On Mondays, 
at 4.30 p.m., commencing on April 3rd, 1922. 

Twelve Clinical Demonstrations in Neurology. By Sir Frederick Mott, K.B.E., 
M.D., F.R.S., F.R.C.P., and by F. Golla, F.R.C.P. On Tuesdays, at 2.30 p.m., 
commencing on April 4th, 1922. [The first six demonstrations will be given by 
Dr. Golla at the Hospital for Paralysis and Epilepsy, Maida Vale. An announce¬ 
ment will be made later regarding the six clinical demonstrations by Sir 
Frederick Mott.] 

Eight Lectures on the Practical Aspect of Mental Deficiency. By F. C. 
Shrubsall, M.D., F.R.C.P. On Wednesdays, at 2.30 p.m., commencing April 5th, 
1922. 

Six Lectures on Crime and Insanity. By W. C. Sullivan, M.D. On 
Wednesdays, at 4 p.m., commencing April 5th, 1922. 

A Course of Lectures on the Differential Diagnosis and Treatment of Mental 
Disorders—Legal Relationships of Insanity. By C. Hubert Bond, D.Sc., M.D., 
F.R.C.P., and E. Mapother, M.D., M.R.C.P., F.R.C.S. On Thursdays, at 2.30 p.m., 
commencing April 6th, 1922. 

University of London Extension Board .—A Course of Post-Graduate Lectures 
on Mental Deficiency supplemented by a Course of Clinical Instruction. The 
course will be of two weeks 1 duration, beginning on Monday, June 12th, 1922, and 
ending on Saturday, June 24th, 1922. The course will be based on the require¬ 
ments of the Syllabus for the University of London Diploma in Psychological 
Medicine. The University will grant a certificate of attendance to those who 
have attended the whole course regularly, taking both theoretical and practical 
work. 

Lectures on mental deficiency .—Unless otherwise stated lectures will be delivered 
at the University of London, South Kensington. 

Ten Lectures by A. F. Tredgold, Esq., M.D., M.R.C.P., F.R.S.Ed., on Mental 
Deficiency, Causation, Classification, Histology, Differential Diagnosis, etc. 

One Lecture by W. C. Sullivan, Esq., M.D., B.Ch., B.A.O., Medical Superin¬ 
tendent, H.M. Criminal Lunatic Asylum, Broadmoor, on the Relationship between 
Crime and Mental Defect. 

One Lecture by E. Prideaux, Esq., M.R.C.S., L.R.C.P., on Psycho-Neuroses in 
Relation to Mental Deficiency. 

Five Lectures by F. C. Shrubsall, Esq., M.A., M.D., F.R.C.P., on Administrative 
Procedure. 

Three Lectures by Cyril Burt, Esq., M.A., on Psychological Tests. 

Two Lectures by Lucy Fildes, B.A., Holder of Board of Control Research 
Studentship at the Psychological Laboratory, Cambridge, on Methods of Training. 

Clinical work. —Each student will visit one special school and one large 
certified institution for defectives, and will attend demonstrations by the 
lecturers (Dr. Tredgold, Dr. Shrubsall, and Mr. Cyril Burt) and other experts. 
Arrangements will also be made, if desired, for individual students to visit other 
special schools or homes. 

Fees and applications. —Registration fee, £\ is. ; fee for the course, £5 5s. 
The course will only be held if a sufficient number of students are registered. 
Intending students are therefore asked to send in their applications as soon as 
possible. No applications will be entertained after Monday, May 22nd, 1922. 
The registration fee of one guinea must be paid at the time of application, and 
the fee for the course must be paid by May 22nd. If applicants withdraw from 
the course before May 29th, 1922, the fee of five guineas will be returned, or 
carried forward to another course, as preferred. After that date no fee can be 
returned. A detailed syllabus of the course may be obtained on application at 
the end of March, 1922. Cheques should be made payable to Miss Evelyn Fox, 
C.A.M.W., and crossed Barclay’s Bank, Ltd. All communications with regard to 
the course should be addressed to Miss Evelyn Fox, at the University of London, 
South Kensington, S.W. 7. 


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THE MENTAL AFTER-CARE ASSOCIATION. 

The Annual Meeting of the Mental After-Care Association was held in the 
Apothecaries 1 Hall on February 24th, 1922, under the Presidency of Dr. W. F. R. 
Burgess, O.B.E., the Worshipful Master. Sir Claud Schuster, K.C.B., K.C., 
Secretary to the Lord Chancellor, in moving the adoption of the annual report 
^presented by Dr. Henry Rayner, Chairman of the Council, said: 

It falls to my lot to move the adoption of this report. 

I could have wished that the task had fallen to other hands. Someone, who had 
actual personal experience of asylum administration or of the cure of mental diseases, 
could have from the depths of his knowledge impressed upon you the lessons of the 
report with greater power of conviction. 

Someone who was not in any way connected with the administration of the 
lunacy laws could have spoken with greater freedom. 

Someone who was trained to speech rather than to silence could have pleaded 
the cause with an eloquence which I cannot summon to my aid. 

It is my fortune and your misfortune that I have to address you as a bureaucrat— 
that is to say, a person, as I gather from the papers, of limited mental horizon, small 
intelligence, and closely restricted sympathies, or to speak more frankly, one whose 
acquaintance with this subject is derived in the main from books and papers and 
reports and the conversation of other men. 

Now to one who depends for his knowledge in the main on the reports of the 
Lord Chancellor’s Visitors and of the members of the Board of Control, what would 
be in this respect of the subject the most salient characteristic ? 

There is an old and hackneyed quotation which should be inscribed in the room 
of every bureaucrat, in letters I sometimes think of gold, and I sometimes think of 
1 lead. 

" For forms of government let fools contest; 

What e’er is best administered is best.” 

I do not suppose that even when those lines were written they were intended to 
be—and I am sure that they now could not be—taken without some qualification. If 
you include in forms of government those rigid rules which appear in the Statute 
Book as regulating the law relating to lunacy, many of you think, I know, that they 
are capable of improvement—that in their endeavour at once to safeguard the 
- community and to provide efficient protection for the liberty of the subject, they lay 
insufficient stress upon those curative influences to the use of which modern science 
looks forward with so much hope. On these matters I must touch but lightly, and 
I only do so at all for a purpose which will appear hereafter. 

But with regard to the second limb of the maxim, in lunacy administration, as in 
many other fields of administration, it is certainly capable of being expressed slightly 
differently. Perhaps the poet would have expressed it differently had he not been 
* constrained by the exigencies of metre. I think it might read—“ What e’er is 
administered in the best spirit is best.” 

What strikes me in the reports of the men of whom I have spoken is the spirit 
in which their work is approached, and the intense sympathy, descending even to 
the most trivial detail of personal comfort, which they evince in everything which 
concerns the welfare of those unhappy beings who are under restraint. 

Such a spirit is the first essential—whether the restraint be exercised at home, 
in private institutions, or in the largest public mental hospital. No one says that the 
. administration is not capable of improvement—that there is no carelessness, no 
hasty word, no neglect. In so difficult and anxious a service it would be wonderful 
if there were never cause for complaint. When we are dealing with creatures so 
helpless it would be tragic if no complaint were ever made. 

Still, the essential fact remains that so long as a mental patient is under the 
charge of the law, his every act and deed is watched, his every need provided for. 

Consider what it means when a human being, who has passed through a paroxysm 
of this awful disease and is pronounced cured, or sufficiently recovered to be 
discharged from custody, receives his liberty. Think how helpless he must be 
when he re-enters the world from which he has been secluded. If he was engaged 
in business, he has probably lost it during his seclusion. If he was a worker with 
his hands, he has lost touch with his old associations, in some sense he has lost 


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some of his former skill, and if this stood alone, he would then find it more diffieult 
than most men in obtaining employment. 

Unhappily, it is not these causes alone which retard henceforth his progress in 
the world. There clings to him the stigma of lunacy. He was probably a trouble 
to his family and to his friends before they had to have recourse to the law to take 
his guardianship. 

And then such patients—even those who have partially, or perhaps wholly, 
recovered—are not as a rule the most efficient citizens; they are not pleasant persons 
to deal with. They are too often whimsical, uneasy, restless and exacting. Some* 
times the temptations to which they gave way and which led to their affliction are 
unpleasant in their consequences, and those temptations are only too ready to 
present themselves again when the restraint has been removed. Again, lunacy, 
through all the ages, has been looked upon by the world at large, who suppose 
themselves not to be lunatics, with an almost equal mixture of disgust and derision. 
When Shakespeare or Eurypides present us with the great tragic figures of Lear or 
of Hercules, they do indeed tend to purge our emotions with pity and with terror. 
But it needs the hand of some such great master to rethind most of us of the awful 
nature of the affliction, and of the share which those so afflicted have in our common 
humanity. 

Lastly, think how over all these poor people there hangs the personal fear of a 
recurrence of the malady. Think what this means. When some great shock, 
some great sorrow or bereavement comes upon any of us, the first unconscious cry 
is “ 1 shall go mad,” deprecating the extreme calamity which can fall upon a sentient 
being. Think what it must mean to go on day by day with the knowledge that in. 
the past one has gone mad, with the haunting fear that one may go mad again, and 
to do this while struggling, with enfeebled frame and reduced resources, to earn 
one’s own living, to recover one’s self respect, to make oneself again an efficient 
and respected member of the community. 

It is for these people that this Society exists and to their service that the efforts 
of its workers are devoted. There are many of them. In the last year for which 
figures are available, 7,206 persons were discharged from restraint as recovered, and 
3,276 were discharged not recovered. Many of these people depend—if they are 
to retain the sanity which they have recovered—upon such assistance as the Society 
can render to them to put them on their feet again, and set them on their road to 
normal life. 

Nor is this all. Medical science, as I understand, is more and more sanguine of 
the possibilities of recovery if the patient is treated in the early stages of the malady.. 
If medical science is right in reaching that conclusion, an inestimable boon will 
have been conferred upon humanity, when opportunity offers to put the theory to 
the test. We shall have fewer permanent inmates of mental hospitals and homes,. 
and fewer in single care. But, from the point of view of the Society, we shall 
greatly increase the numbers of those who are discharged and who have become 
objects for the Society’s care. It may be said that, to some extent, they will not 
suffer the same disabilities as those who are discharged from certificates. I am not 
wholly confident that that result will follow. The mere association with the 
mentally afflicted, the mere fact that it has been found necessary to place a man— 
even at his own request—under institutional care, will, I greatly fear, put him under 
disadvantages in after life. 

For all these people, then—those who have been already discharged, those who 
are now under care and will be discharged hereafter in due course, and those who, if 
the new system is put into operation hereafter, return to the world after but a short 
period of treatment—we appeal for help, and with that object I now move the 
adoption of the report. 

Other speakers were—Sir James Crichton-Browne, F.R.S., Lieut.-General Sir 

J ohn Goodwin, K.C.B., Dr. C. Hubert Bond, C.B.E., Mr. C. Marriott and Mr. 
«ionel Faudel-Phillips, and grateful references were made to the work of the - 
Secretary, Miss E. D. Vickers, to whose untiring efforts the successful working of 
the Association is largely due. 


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NOTES AND NEWS. 


205. 


LUNACY REFORM. 

The conference on Lunacy Administration which was called by Sir Frederick 
Willis, the Chairman of the Board of Control, ended its sittings yesterday. 

The conference was attended by practically the whole of the medical superin¬ 
tendents and chairmen of visiting committees of county and borough mental 
hospitals in England and Wales, the medical superintendents and chairmen of 
managing committees of registered mental hospitals, and the superintendents of 
some of the licensed houses. 

Sir Alfred Mond, in his opening address, mentioned that the chance of getting 
legislation would be very much increased if there was unanimity as to the alteration 
of the law which was desired, so as to permit of the treatment of early cases 
without certification. This subject was very fully discussed at the conference, and 
they arrived at the following unanimous conclusions: 

(1) That early treatment without certification should be legalised. 

(2) That by early treatment very many cases would be prevented from suffering 
permanently from mental breakdown. 

(3) That such early treatment should only be given in institutions or homes- 
approved for the purpose by some Government department. 

(4) That the Government department upon whom the duty of supervising this 
work should be placed should be the Board of Control. 

The conference did not desire that any hard-and-fast lines should be laid down 
as to where early treatment should be provided. Sometimes it might be best if 
provided at a general hospital, sometimes at a public mental hospital, and some* 
times in an approved home. The essential thing was to secure the best arrange¬ 
ments possible in any area. 

The conference also unanimously agreed that the law should be altered so as to 
allow of the reception of voluntary boarders in public mental hospitals, and that 
local authorities should be empowered to contribute towards the expense of early 
treatment when it was carried out by some one other than themselves. 

Another subject which was discussed was the great importance of research and 
pathological work. The amount of this work which is at present being conducted 
is not realised by the general public, but a strong desire was expressed by various 
speakers that it should be still further extended, and that local authorities should 
be authorised to combine for this work wherever it seemed to them desirable. 

It was generally agreed that there should be women members on all visiting 
committees, but there was no unanimity on the suggestion that every institution in 
which there were women patients should have women doctors on the staff. A 
number of speakers, however, urged this. 

As to the medical staff generally, a strong feeling was expressed that the 
medical superintendent should delegate his non-medical duties as far as practicable, 
and that visiting committees should be prepared to provide medical superintendents 
with sufficient lay staff to carry out the business arrangements for the institutions. 
The general view was expressed that the position of an assistant medical officer 
should be made more attractive, and that these officers should be encouraged to 
take up post-graduate courses and to take the Diploma in Psychological Medicine. 

Several members urged the value of the employment of visiting specialists, such 
as dentists, surgeons, bacteriologists and radiologists, at mental hospitals. 
Already many public mental hospitals have the advantage of the services of such 
specialists. 

As to the nursing staff, it was generally agreed that the matron and those nurses 
who occupy the more important posts should all have had not only special 
training in the nursing of mental cases, but that they should have undergone a full 
general hospital training. Many of our public mental hospitals already have such 
trained nurses. 

In regard to general improvements in lunacy administration, it was urged that it 
would be an advantage to divide England and Wales up into some eight or ten 
areas, and to have an advisory committee acting for these areas for an interchange 
of ideas and discussion of the problems apd difficulties arising. 

The conference closed with a vote of thanks to the London County Council for 
their kindness in allowing the conference to use the County Hall, Spring Gardens; 
and a vote of thanks to Sir Frederick Willis for having convened the conference.— 
Vide The Times , January 2ist, 1922. 


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NOTES AND NEWS. 


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CHARGES AGAINST ASYLUMS. 

The Minister of Health has appointed a Committee consisting of Sir Cyril 
Cobb, K.B.E., M.V.O. (Chairman), R. P. Smith, Esq., M.D., F.R.C.P., Bedford 
Pierce, Esq., M.D., F.R.C.P., with Mr. P. Barter, of the Ministry of Health, as 
secretary, “ to investigate and report on the charges made by Dr. Lomax in his 
book, The Experiences of an Asylum Doctor , and to make recommendations as to 
any medical or administrative improvements which may be necessary and practi¬ 
cable in respect of the matters referred to by Dr. Lomax without amendment of 
the existing Lunacy Laws.” 

The Committee will ordinarily hear evidence in public, and the time and place 
of meetings for this purpose will be announced in the Press. The Committee will, 
however, reserve the right to hear evidence in private in any case where they con¬ 
sider such a course desirable. 

The Committee will hear such evidence as is necessary for the investigation 
specified in the terms of reference, and cannot undertake to hear evidence in 
regard to the amendment of the existing Lunacy Laws.— Vide The Times , January 
9th, 1922. 


THE GEDDES REPORT. 

Board of Control, England and Wales. 

1913-14, audited expenditure, £21,464; 1921-22, net estimate, £511,364; 1922- 
23, provisional net estimate, £535,968. 

Since the provisional estimate was submitted a revised estimate has been put 
forward, showing a reduction of .£5,528. 

The number of places provided at present in the institutions to which the State 
contributes is 15,000 and there are now 9,000 patients in those institutions. We 
were told that there was a large number of mentally defective persons outside the 
institutions. If this were not an activity which we regard as essential to the 
physical and moral health of the nation, we would have recommended a substantial 
reduction in the vote in order to enforce economy. In the circumstances we 
refrain from any reduction, pointing out, however, that a larger number of these 
afflicted persons could in our opinion be taken into these institutions within the 
limits of the estimates. There are at the present time 6,000 places unoccupied. 

We recommend that the necessary steps be taken to change this grant from a 
“ percentage ” basis to a “ per capita ” basis coupled with provisions to ensure 
adequate treatment and economical management. 

Scotland. 

1913-14, audited expenditure, £6,139; 1921-22, net estimate, £71,733 ; 1922-23, 
net estimate, £76,333. 

Since this estimate was prepared it has been intimated that the amount to be pro¬ 
vided for 1922-23 will be increased by £28,325. 

The average cost per head is lower than in England. We recommend no reduction 
in the sums asked for, but, as recommended for England and Wales, the grant 
should be on a “per capita ” basis, and all necessary steps should be taken to ensure 
economy.— Vide The Times } February nth, 1922. 


BOARD OF CONTROL COMMITTEES OF INQUIRY. 

The Board of Control have, with the approval of the Minister of Health, 
appointed the following committees : 

Dietary .—Dr. R. W. Branthwaite, C.B. (Chairman), Commissioner of the Board 
of Control; Dr. M. Greenwood, Medical Officer (Medical Statistics), Ministry of 
Health; Dr. R. Worth, O.B.E., Medical Superintendent, Springfield Mental 
Hospital; Dr. L. O. Fuller, Medical Superintendent, Three Counties Mental 
Hospital, Arlesey, Beds. 

Clinical Records , etc .—Dr. A. Rotherham (Chairman), Commissioner of the 


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1922.] 

Board of Control; Dr. H. A. Kidd, C.B.E., Medical Superintendent, Graylingwell 
Hospital, Chichester; Dr. S. J. Gilfillan, O.B.E., Medical Superintendent, Colney 
Hatch Mental Hospital. 

Nursing Service. —Dr. C. Hubert Bond, C.B.E., F.R.C.P. (Chairman), Commis¬ 
sioner of the Board of Control; Dr. G. F. Barham, Medical Superintendent, 
Claybury Mental Hospital; Mrs. E. How-Martyn, M.Sc., Chairman of the 
Springfield Mental Hospital Committee; E. A. Medus, Esq., Chairman of the 
Netherne Mental Hospital Committee; Mrs. Hume Pinsent, Commissioner of 
the Board of Control; Dame Louise Gilbert Samuel, D.B.E., Member of the 
Chelsea Borough Council; E. Sanger, Esq., J.P., L.C.C.; Miss M. M. Thorburn, 
R.R.C., Matron, Horton Mental Hospital; Dr. H. Wolseley-Lewis, F.R.C.S., 
Medical Superintendent, Barming Heath Mental Hospital. 


THE ASSOCIATION REGISTER: A CORRECTION. 

Owing to an unfortunate misunderstanding the name of Dr. Alexander Ninian 
Bruce was struck off the Association register published in the January number. 
A letter of apology and regret has been addressed to Dr. Bruce by the General 
Secretary and his name restored to the register. The number of ordinary 
members was thus 632, bringing the total membership up to 667. (Vide p. xxix, 

January number, 1922). 


OBITUARY. 

Henry Kingsmill Abbott, B.A., M.D., B.Ch.Dublin, D.P.H. 

Dr. Abbott, a member of the Association since 1900, died on February 27th, 1922, 
at Fareham Asylum, of which he was the Medical Superintendent. He was born 
at Monkestown, Co. Dublin, in September, 1863, being the eldest son of a well- 
known scholar, the late Rev. Thomas Kingsmill Abbott, Litt.D., D.D., Senior 
Fellow of Trinity College, Dublin. He was educated at the old Kingstown 
Grammar School and at the Evesley College, Dublin, and entered Trinity College 
in 1881. He obtained term honours in Natural Science and Logic, and graduated 
B.A. in 1885. He obtained the degrees of M.B., B.Ch. in 1887 and the degree of 
M.D. was conferred upon him in 1887. He took his D.P.H. with honours in 1898. 

During his university career Dr. Abbott was fond of all kinds of athletics. He 
rowed for the old Dublin University Boat Club and was keen on both cricket and 
football. His interest for sport was maintained throughout his life, and until quite 
shortly before he died he bicycled over regularly from Fareham to Hayling Island 
Golf Club to indulge in his favourite game. He was an excellent bridge and 
billiard player and was a much respected member of the Royal Albert Yacht Club 
at Southsea. After serving a short time as surgeon on one of the shipping lines 
to India, Abbott was appointed in 1890 as Assistant Medical Officer at Hants 
County Asylum, and in 1906 he succeeded the late Dr. Worthington as Medical 
Superintendent. He was also for a time Stewart Lecturer on Mental Disease in 
Trinity College, Dublin, and Examiner in Psychiatry for the University. 

He was a man of wide culture and a great reader, but he was an extremely 
reserved and unassuming man and few people suspected the extent of his knowledge. 
He went quietly about his work and administered his asylum conscientiously and 
with conspicuous ability. He was extremely just in his decisions, sound in his 
judgments, and the writer often found his advice of great value in administrative 
problems. He was a man of remarkable will-power, and this was seen particularly 
in the fortitude and courage with which he bore the prolonged illness which 
terminated fatally. He made no difference whatever in the routine of his life, and 
scarcely ever referred to his illness even to his most intimate friends. Almost up 
to the end he played golf and did his work, and he only took to his bed a few days 
before his death. He was buried in the Asylum Cemetery, according to his wishes. 
His funeral was attended by his brother, Canon T. F. Abbott, B.D., and other 
relatives, members of the Visiting Committee, the Staff, and a number of his 
personal friends. He will be much missed in the asylum, to which he gave 
thirty-two years of faithful service. 


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208 NOTES AND NEWS. [April, 1922. 

In Abbott the writer has lost a personal and greatly esteemed friend, and he is 
glad to have an opportunity of paying a tribute to his memory. H. Devine. 


John Turner, M.B., C.M. 

We regret to announce the death of Dr. Turner, late Medical Superintendent of 
Essex County Mental Hospital, Brentwood. An extended obituaiy notice will 
appear in our next number. 


NOTICES OF MEETINGS. 

Annual General Meeting *. At the Royal College of Physicians, Edinburgh. 

Monday, July 17th: Committee meetings at 3 p.m.; Council Dinner in the 
evening. 

Tuesday, July 18th : Council and committee meetings. 

Wednesday, July 19th : Council meeting concluded; general meeting—morning 
session ; at 1 p.m. the Managers of the Royal Hospital at Morningside invite 
members at 3 p.m. to lunch ; afternoon session, Presidential Address; 8.30 p.m., 
" At Home” at Craig House. 

Thursday, July 20th: At the University—subject, “ /Etiological Factors of 
Insanity”; Association Dinner in the evening. 

Friday, July 21st: Open Discussion on the Treatment of Insanity. 

[British Medical Association (Section of Neurology and Psychological 
Medicine) at Glasgow. Tuesday, July 25th : Discussion on Psychotherapy will be 
opened by Drs. Mitchell, Brown and Crichton Millar. Wednesday, July 26th: 
Discussion on Neuro-syphilis will be opened by Sir James Purves Stewart and Dr. 
Kinnier Wilson. Thursday, July 27th : Papers. President of the Section, Prof. 
*G. M. Robertson.] 

Quarterly Meeting .—May 24th, at n,Chandos Street, London, W., Council and 
Committee meetings in the afternoon. May 25th, in the morning, paper by 
Sir F. W. Mott, K.B.E.; afternoon, the 3rd Maudsley Lecture by Sir Maurice 
•Craig, C.B.E. 

South-Eastern Division. —May 2nd at the East Sussex Mental Hospital, 
Hellingly, Sussex. 

South-Western Division .—April 28th, 1922, at the Dorset Mental Hospital. 

Northern and Midland Division .—April 27th, at the Derby Mental Hospital, 
Rowditch. 

Irish Division .—April 6th, 1922; July 6th, 1922. 


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JOURNAL OF MENTAL SCIENCE 


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

No. 282 [To."""’] JULY, 1922. VOL. LXVIII. 


Fart I.—Original Articles. 


The Third Maudsley Lecture. Delivered by Sir Maurice Craig, 
C.B.E., M.A., M.D.Camb., F.R.C.P., at the Quarterly Meeting 
of the Medico-Psychological Association of Great Britain and 
Ireland, held at the County Hall, Spring Gardens, London, on 
Thursday, May 25th, 1922. 

SOME ASPECTS OF EDUCATION AND TRAINING IN 
RELATION TO MENTAL DISORDER. 

We are met to fulfil the behest of one of the most distinguished 
physicians of psychological medicine of recent times. Maudsley 
was a leader in his lifetime, and he lit a lamp for research which it 
is our duty and that of the generations which follow after to keep 
burning. He was a man with a great insight and practical withal, 
for he has left behind him benefactions which are endowed by his 
inspiration and which must live with increasing benefit to mankind. 
The acuteness of Maudsley’s vision is demonstrated by the method 
in which he founded these lectures; he perceived, and perceived 
rightly, that mental disorder was not purely a medical problem, but 
that there was a lay side to it which was of vital importance, and in 
consequence he directed that in alternate years a scientific and a 
popular lecture should be given. He wrote that “ there are not many 
natures predisposed to insanity but might be saved from it were they 
placed in their earliest days in exactly those circumstances and sub¬ 
jected to exactly that training most fitted to counteract that innate 
infirmity.” No doubt this connotes much, and to some it may seem 
an overwhelming task. For it would appear to include a full appre¬ 
ciation of how mental disorder is brought about; what, if any, are 
the precursory indications, and what symptoms, when present, should 
be regarded as potentially dangerous to the future welfare of the mind 
of an individual. The inquiry is a fascinating one, and the problem 
can be more quickly unravelled by the working of physician, psycho¬ 
logist and educationalist in close collaboration. Mental disorder 
LXVIII. 


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210 THE THIRD MAUDSLEY LECTURE, [July, 

unfortunately, as things are at present, only becomes a medical matter 
when it has advanced a considerable distance, but this must be 
changed, and it must be our endeavour as physicians to control its 
very beginnings. Whilst it is right to devote time and energy 
to examine scientifically every means by which the recovery or the 
alleviation of mental disorder may be brought about and to use them 
to the full, in the end the return for these labours must be limited; 
to control its gateways and to prevent its occurrence far out-rivals 
any treatment of disorder that has once become established. In fact 
it is doubtful whether a complete recovery ever does take place in 
the sense that the patient is free from any scarring from the experience 
he has passed through. Preventive medicine is the side of medical 
science which is most attractive, offering as it does benefits of infinite 
value both to the individual and to the nation. Investigation tends 
more and more to establish the view that many disorders have their 
inception in childhood and experience confirms that this is true of the 
more common types of mental disturbance. It is on this account 
that I have decided to take as my subject for this lecture “ Some 
Aspects of Education and Training in Relation to Mental Dis¬ 
order.” The term “ education ” will be used in its widest sense and 
will connote the instruction and upbringing of the child both at home 
and in the school. 

Controversy has always centred round the question whether mental 
disorder is in the main psychogenetic or physicogenetic, and each 
theory has its able exponents. Experience has satisfied me that there 
is truth in both views and that it is unwise to disregard the potentia¬ 
lities of either of them. No doubt there is a mental instability in the 
majority of those who develop psychoneuroses or psychoses, but 
lowered physical health may be the final determining cause of the 
breakdown, and I would go even further and suggest that in many 
of these cases, had the bodily health remained satisfactory, no serious 
nervous disturbance would have occurred. We cannot separate 
mental and physical processes, and it would seem unwise to attempt 
to do so when we appreciate how strong is the evidence of the inter¬ 
action which takes place between them. Therefore, in the theme 
before us it will be necessary to consider the child as a whole and to 
give due heed to both its physical and mental development. To 
regard it otherwise is to fall into the error too frequently encountered 
which not uncommonly results in faulty diagnosis. Further, let me 
predicate that the infant referred to in this thesis is the apparently 
normal, and not one who would suggest mental enfeeblement from 
birth. 

It is not my intention to discuss the laws of inheritance further 
than to remind my hearers that, though the child tends to inherit 


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1922.] 


BY SIR MAURICE CRAIG, M.D. 


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the attributes of its parents, fortunately it is nothing more than a 
tendency, and to be forewarned is to be forearmed, and the knowledge 
of any weakness can and should be used to the benefit of the child. 
To ignore the possibility of any known weakness developing is to 
court disaster, whereas to appreciate it and to take steps to lessen 
its influence will in many instances repay the effort which has been 
expended. 

Our first step must be to consider if there are any mental factors 
■whose presence is conducive to the development of mental disorder. 
As I am addressing an audience largely consisting of laymen, I must 
tell you that there are types of insanity which, like some physical 
diseases, are intrinsically part of the organism, and for which, with 
our present knowledge, little can be done either to prevent or to 
remedy. Fortunately these form by far the smaller group, whereas 
the larger includes the many which result from nerve exhaustion 
and emotional states. Therefore it must be to the latter that attention 
should be first directed on account both of the number of cases and 
of the greater possibility of prophylactic measures. 

Maudsley writes: “ Insanities are not really so different from 
sanities that they need a new and special language to describe them, 
nor are they so separated from other nervous disorders by lines of 
demarcation as to render it wise to distinguish every feature of them 
by a special technical nomenclature. The effect of such a procedure 
can hardly fail to be to make artificial distinctions where divisions 
exist not in nature, and thus to set up barriers to true observation 
and inference.” It is these artificial barriers that have in the past 
so encumbered the way of progress. When one appreciates that in 
a given individual nothing more than exaggerated and uncontrolled 
normal characteristics may constitute mental disorder, we realise 
how narrow is the margin between those whom we call the sane and 
the insane. 

Mental evolution should take place in a definite order and within 
certain recognised periods and any delay should be noted, but even 
more important is it to watch for any regressive symptoms which 
may indicate a failure or a dropping back to an earlier phase in the 
child’s life-history. Unless the observer has a keen perception, he 
will usually miss the beginning of any regression and in this way 
lose valuable time. Neither must he permit himself to fall into the 
common error of explaining away all mental changes as matters of 
no importance. Symptoms may be positive in the form of some new 
and unwonted mental characteristic, or they may be rather of the 
negative type, including conditions such as apathy, inattention and 
the like; they are often protective in purpose, being an effort on 
the part of the organism to defend itself from any undue stress. 


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212 THE THIRD MAUDSLEY LECTURE, [July, 

When one reviews a large number of patients who are suffering 
from nerve exhaustion in varying degrees, there is one symptom 
which appears early and which stands out in strong relief, and that 
is hyper-sensitivity. This state is observable not only as a physical 
sign in the nervous system demonstrable by various tests, but it is 
a condition which also affects the mental processes. It is to me the 
symptom of all symptoms which gives rise to many others which in 
time may so disturb personality as to occasion definite unsoundness 
of mind. Here we have a symptom which is common to many 
children, but which in some, by its ever-widening embrace, slowly 
but surely undermines the whole mental fabric. It leads to unhealthy 
emotion, to pre-occupation, and to false reasoning; it heightens 
introspection, and by its presence it aggravates all the normal charac¬ 
teristics of the individual; it disturbs the relationship of self to 
surroundings, and with this failure of adaptation a sense of inferiority 
or of irritation may result. It will be appreciated how baneful this 
hypersensitivity may become, and how by its intensity or by its 
duration it may injure the mental life of the individual. Nature 
has its own way of lessening the trying effects of heightened sensi¬ 
tivity, and the recording of acute sensation may suddenly cease and 
its place be taken by a psychical anaesthesia in which mind may 
become a blank or in some other way become disordered. Now if 
hypersensitivity can do all this, it behoves us to treat its advent 
with an appreciative recognition, and to bring all our knowledge to 
bear in an endeavour to defeat its progress. We must discover, if 
possible, how and why it arises, and then the conditions which favour 
its development, and lastly how it may be remedied or at least 
mitigated. 

Some children are naturally hypersensitive, whereas with others 
it is acquired. Over-stimulation is probably its most common cause 
in childhood, and this may be effected in many ways. Some children 
become over-excited by parties or by passing their days in unsuitable 
surroundings, and the harm that is being done may declare itself in 
irritability, querulence, gastric upsets, or disturbed sleep. The 
naturally quick child is more liable to become over-stimulated than 
the dull one, and its ease of learning delights both the parent and 
the teacher in instructing it. The early ability to read has an un¬ 
doubted danger attached to it, for once it can do this the regulating 
of the time spent in the study of books can only be carried out with 
the co-operation of the child. During the early school days the 
danger of over-stimulation increases, and the brilliant boy develops 
a new and legitimite ambition to outstrip his schoolfellows in 
knowledge. The result of this may be a scholarship, and from then 
onwards his course is fixed, and he must live up to his acquired standard. 


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BY SIR MAURICE CRAIG, M.D. 


213 


not infrequently without consideration of the injurious effect that 
close concentration is having upon his mental and physical health. 
Now it must be borne in mind that brain exhaustion is often of slow 
development and that it may not declare itself until school-days are 
over, and the mental failure may be in varying degrees of severity. 
Some authorities hold that the real blame for the competitive system 
largely rests with the Universities, for these seats of learning are the 
goal for which the boy strives and for which the parent and the master 
prepare the way. I cannot do better than quote Dr. Herbert B. Gray, 
late Headmaster of Bradfield College, who writes in his book on The 
Public Schools and the Empire the following weighty words : “ Most 
physiologists would admit that the mere fact of such competition 
at such an early age involves a strain more or less harmful in after¬ 
life. Apart from the unnatural stimulus of the mental powers, there 
is the excitement of the premature competition, which is opposed 
to all sound biological principles. Physiology contends that over¬ 
strain in mental effort hastens the period of adolescence, whereas the 
more highly organised the creature, the slower is he, or he ought to 
to be, in coming to completed growth. Scientific investigations have 
in fact proved that the delicate mechanism of brain structure forbids 
such premature efforts of brain evolution. Inductive reasoning tells 
the same tale. The writer has been in close touch as boy and master 
with public schools for forty-five years. He is, therefore, familiar 
with many life-histories, and is at least not ‘ entirely ignorant of the 
subject.’ At some of the famous schools where scholarships are 
most valuable, and therefore most eagerly sought after, statistics go 
to show that winners of such prizes have in a large proportion of 
instances ' tailed off ’ either in the stage of early adolescence or soon 
afterwards. The brain in all these cases is proved to have produced 
premature results by early forcing. Some boys have shown no lasting 
power after two years of continued competition at their public school; 
others of less delicate brain organisation or otherwise more bounti¬ 
fully nourished * stay * till half-way through their University course ; 
while others of still stouter mould do not begin to fail in power until 
they enter the competition of outer life; but only a comparatively 
small percentage fulfil the promise of their earlier years. The mental 
growth has become stunted and shrivelled ; the plant atrophies, and 
if it brings forth fruit, it brings forth no fruit to perfection in the 
maturer years. It is a wasted life.” I have quoted Dr. Gray fully 
-on this matter, as his evidence is of the greatest importance, coming 
as it does from a man of long and wide school experience. 
Now what is true of the brilliant boy is true in a relative degree of 
others whose lessened physical stamina renders them more liable to 
over-stimulation; defective circulation, respiratory disorders and 


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214 


THE THIRD MAUDSLEY LECTURE, 


[July, 

zymotic disease all accentuate the danger, and any one of these may 
be the determining factor in bringing about the collapse of an already 
over-strained nervous system. Further, if in addition to work the 
brilliant boy is also successful in games, his risks of breaking down 
are correspondingly increased. We are apt to forget that it is the 
same nervous system which serves both mind and body, and first 
to over-stimulate it on one side and then on the other is to court 
disaster. I have known not a few child prodigies who have excelled 
in games and who have in consequence deteriorated mentally before- 
the age of twenty. Physical fatigue may be damaging in several 
ways, but one of the most important is violent exercise occurring in 
a comparatively short space of time. I can recall the case of a young 
girl who developed an exhaustion delirium after running in a paper- 
chase and who remained in a confused state for several months. 1 
need hardly remind my hearers that such a delirium is almost certain 
to leave behind it a lowered nervous resistance for very many years. 
Children who are about to take part in any severe test of endurance 
should be inspected beforehand, and any who for either physical or 
other reasons are below their usual health standard should be debarred 
from the contest together with those who are constitutionally frail. 
The spirit of many a child far exceeds its power of physical endurance, 
and this high spirit may be raised even further by a powerful herd 
instinct which calls for an unusual effort for the good name of some- 
school house or other school division. Further, apart from the actual 
physical strain, there are some forms of sport which in some young 
persons lead to an extreme bracing up of nervous tension. Anyone- 
may observe this in the trembling of the muscles of the young aspirant 
to athletic success; of course, this is in itself not harmful but even 
beneficial when such effort is kept within limits, but over-stimulation 
of the kind may be very damaging if by prolonged effort the nervous- 
energies are over-taxed, or if even a moderate strain is placed upon 
a physically or nervously reduced child. 

Time will not permit me to make an exhaustive inquiry into the 
various circumstances which give rise to hypersensitivity, for the 
causes are numerous, including as they do physical diseases and 
disorders, defective sleep, and the over-action of various mind pro¬ 
cesses. On the other hand its existence is easy of discernment, and* 
its influence on the growing organism should not be overlooked. F 
am fully aware that there will be critics who will point to the mentaP 
hospitals which draw their patients from the country village and say 
that these cannot be the victims of over-stimulation. But surely 
this is no answer, for the problem of mental disorder in the town is- 
not necessarily that of the country and we find conditions in the- 
rural districts which are rare in the urban. Intermarriage with alt 


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its degenerating influences is rife in villages compared with cities, 
and also a narrowed life has a deteriorating influence of its own. 

Failure of power to concentrate attention is quite one of the earliest 
symptoms of over-stimulation and exhaustion, and the symptom 
should be quickly discernible in the child. Attention is one of the 
attributes of normal mind which appears when the normal child 
reaches a certain age, and if it fails to develop, the faculty for acquiring 
knowledge is correspondingly diminished, the totally inattentive 
child being uneducable. On the other hand, if the capacity to attend 
has once been acquired, to lose it indicates a regression and its import 
must not be lost sight of. Nevertheless the loss of power of con¬ 
centration is of value as a means of protecting the nervous system 
from mental work which might be harmful to it. Unfortunately 
this symptom rarely secures the recognition it demands, and it is 
this failure to observe and understand that leads to the development 
of more serious disorder in later life. 

Again, as over-stimulation may in time give rise to inertness, it is 
necessary to refer to laziness. Owing to the untrained outlook of 
the lay mind, mental attitudes are apt to be classified in one category 
without any distinction as to how and why that attitude has come 
about. “ A lazy child is a lazy child," and too often that ends the 
investigation, and having reached this verdict the sentence is passed 
in due course. But laziness is a proper mental reaction to a definite 
debilitated state of mind, and to ignore it or to punish for it would 
be considered little removed from cruelty if the real circumstances 
were known. To appreciate the pathological significance of laziness 
it is only necessary to read the term reports of a number of school- 
children and to note how frequently we read that this child and that 
has shown indifference and inattention to his studies during the latter 
part of the term, and for this he comes in for condemnation. Yet 
in many cases the condemnation, if any is to be allotted, should be 
on the writer of this report for his lack of insight and knowledge of 
mind and its working. In support of my statement I will again 
quote Dr. Herbert Gray, who writes: “ Every schoolmaster knows 
that the most reproductive work of the term is done during the first 
half of it, and that both masters and industrious boys * tail off ’ in 
energy about the ninth week through sheer brain-fag.” That this 
is true there is ample evidence, but that it should be permitted 
to continue is less easy to understand. It cannot be argued that 
“ brain fag ” is a benign state even in the adult, but to produce it 
in the plastic nervous system of the growing child is little short of 
culpable, and to prevent it must lessen the incidence of nervous and 
mental disturbances. When laziness is to be observed, search for 
any legitimate causes that may be giving rise to it, and only find 


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216 the third maudsley lecture, [July, 

fault or punish when these have been eliminated. It is, unfortunately, 
more common to condemn first, and only when correction has failed 
to produce the desired results, to investigate in other directions. 
To follow such a course not only increases the mental damage to the 
child, but it injures personality by establishing a sense of inferiority 
in the good and a callous indifference in the bad. 

As defective sleep is a common cause of the development of hyper¬ 
sensitivity, it will be well to consider it before we leave this subject. 
All living organisms require proper time for repose, and it is safer to 
permit of a longer rather than a shorter one, especially during the 
early and growing years of childhood. The child should be trained 
to sleep during the day if possible until it reaches the age of five, 
and to neglect this part of the training not infrequently permits of 
too rapid development which brings with it restlessness and over- 
stimulation. Children up to the age of sixteen should have at least 
ten hours* sleep and from sixteen to twenty, nine hours should be 
allotted for rest. When considering sleep it is necessary to give 
weight to the quality as well as the quantity. A restless sleep full 
of dreams and broken by nightmares is unrefreshing and indicates 
an unsatisfactory condition of health, and the child who persistently 
exhibits such symptoms is not in a fit state for the ordinary work 
of school. The nervously over-stimulated child fails to sleep, and when 
this happens it indicates that the organic side of life is being disturbed, 
and this will shortly declare itself in loss of body-weight and other 
symptoms if steps are not taken to correct it. Again, sleep is rhythmic, 
and it can easily be broken by interrupting the rhythmic habit by 
evening dances, theatres and the like. There is little doubt that 
some parents permit of serious damage to their children by giving 
them this type of pleasure. Broken sleep is not easily re-established, 
and even at best once it has been disturbed in this way it is easy to 
relapse into a sleepless state again. Evening school preparation work 
has always seemed to me to be of doubtful value, and it is definitely 
harmful to some children. The work before retiring to bed should 
be of the lightest, and probably in time we shall see with advantage 
the hours after tea being devoted to light lectures or instructive 
games. Some schools are open to criticism for the way that the 
younger boys are disturbed by the older ones as they go to bed at 
a later hour. The nervous apparatus for hearing must always be 
active and alert, as it is largely on this special sense that the sleeping 
person relies for warning of impending danger. If you doubt this, 
watch the restless movements that are produced in a sleeping infant 
by sudden sounds, and these movements are the translation of sensa¬ 
tion into action. Some children are definitely awakened, others 
merely disturbed, by sound, but practically all must be affected by 


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it. Further, sudden noises not only awaken but startle some 
persons—this is known to all anaesthetists—and the disturbance 
•created may not quickly subside. Therefore this matter is of practical 
importance and cannot be brushed aside as a frivolous observation. 
For a time some children, like some adults, do not appear to suffer 
irom defective or deficient sleep, but because there is no gross objec¬ 
tive sign it does not necessarily follow that deterioration is not taking 
place, and experience teaches that it is the wiser course to treat the 
•condition seriously rather than to venture a hazard that all will be 
well. Broken sleep of short standing can easily be remedied, but if 
•once established it is a far more difficult proposition. 

I will now proceed to consider emotion. We owe to D6jerine a 
■debt of gratitude for the emphasis he has laid on this attribute of 
mind and how it may affect the mental health. Everyone knows 
how devastating is passion and how exhausted it leaves the subject 
■who has been enduring it. But emotion exists in varying degrees, 
•and although in its more severe forms its physical concomitants of 
pallor, flushing, tears, tremors and the like are in evidence, some of 
the more subtle types are less easy of discernment owing to the 
■apparent absence of somatic signs, and yet they may be working 
steady and untold havoc. Emotion becomes attached to ideas and 
.groups of ideas, and if the emotion is an unhappy or an unpleasant 
one, it very readily leads to a “ preoccupation ” which may slowly 
.absorb attention until it seems to fill the whole field of thought. 
“ Dreads ” and “ fears ” belong to this order and these are not un¬ 
common in childhood. Many fears are unreasonable but this does 
not lessen their power, and the inability to drive them away is both 
■depressing and terrifying to the sufferer. He must be helped by a 
sympathetic and philosophic understanding. Unless relieved, a fear 
•of this kind may affect the sleep and produce bodily disturbances 
and lessen mental activities by setting up a hyperattention on one 
subject, instead of the normal state of being able to turn the attention 
in any direction. Now emotion of this or a similar kind may result 
in the development of a sense of inferiority—a feeling of being unlike 
others. When this takes place introspection begins to play an impor¬ 
tant part. The healthy mind is largely extroverted ; thoughts are 
.projected outwards, but in certain morbid emotional states the process 
is reversed and everything is turned inwards. This leads to unhealthy 
.reasoning; it interferes with the relationship of the child to others 
■and not infrequently results in a solitary existence. The child who 
has formerly been fond of companionship and who in course of time 
•becomes lonesome is usually evoluting into an abnormal mental state, 
.and every effort should be made to clear away the difficulties. Unless 
••this can be done, the morbid outlook, which at first is scarcely dis- 


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218 the third maudslev LECTURE, [July, 

cemible, becomes, over extended time, a factor of such importance 
that life is almost unbearable. For this feeling of inferiority gives 
rise to suspicions, ideas of persecution and resentment, any of which 
are factors of no mean importance in the mental make-up of an indi¬ 
vidual. Some children develop this sense of inferiority from being 
laughed at by their school-fellows. I do not wish to convey that 
“ chaffing ” is not in the main a healthy mental exercise, but it may 
stultify, if not worse, the intellectual growth of some children, and 
it is these whom we ought to save if we observe as we should do. I 
have heard a well-known training officer in the Army say that a man 
who was “ gun-shy ” and who was clumsy at games has ultimately 
excelled in shooting and in sport by steady encouragement, whereas 
experience has shown that were this not given him and were he allowed 
to be unduly chaffed, he would drift, as many have drifted, into a 
solitary, useless person, full of grievances. Remember that mind is 
never stationary and in the course of evolution factors which are 
of small moment to-day may in time become of absorbing importance. 
Maudsley recognised this, for in speaking of extreme shyness which 
is the unfortunate disqualification of some nervous temperaments, 
he writes : “ Only those who have it can know how sore an affliction 
it is and how great a let and hindrance to them through life. Nay, 
it sometimes wrecks a life. For as the unamiable proclivity of 
mankind, as of other animals, is to set upon and persecute any indi¬ 
vidual of the species which differs from the conventional type, it 
happens that when a nervously sensitive and shy boy is sent to school 
he is teased and bullied there because he is not like other boys. If 
he meets with no one to understand him, to show him sympathy and 
kindness, he gets more and more estranged from his fellows, more 
and more he feels himself a peculiar and separate being, suffers, 
mopes, and pines in solitude, and in the end is so shattered mentally 
perhaps as never in after life to get over the injury which has been 
done to him.” Those who have children in their keeping and who 
believe that boys are best left to themselves to find their own places 
among their fellows, to statements such as I have just read make 
answer,” Yes, we know all this, but the few must suffer for the good 
of the majority." My reply must be, “ Is this necessary ? ” The 
educationalist does not keep back the brilliant child; he bestows 
upon him his special attention for reasons which are obvious. My 
experience goes to show that the rewards will be as great for a more 
careful study of other types. 

Repression is a mechanism which has attracted increasing attention 
with the advent of what is commonly spoken of as the new psycho¬ 
logy. Freud laid down that forgetting is not necessarily a negative 
process but a positive one, and that experiences of an unpleasant 


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character do not fade away with time, but are definitely repressed 
out of consciousness. This is probably only partially true; some 
natures undoubtedly have to treat unpleasant experiences in this way, 
but many do not do so. Freud realised that there must always be 
a danger of a conflict taking place between the primitive instincts 
and the demands of the community, and further that a termination 
of such a conflict may only be possible by the active repression of 
the former, which' usually entails emotion and is in consequence fraught 
with danger. If the individual is successful in fully repressing the 
unpleasant experience, it passes out of the realm of consciousness; 
nevertheless Freud has shown that it may remain as a dissociated 
portion of the mind, with the potentiality of becoming active under 
certain conditions on account of the original emotion attached to it. 
According to Freud and others its harmful effect is in the amnesia 
(loss of memory) occasioned by it. Wingfield, in his book on hypno¬ 
tism, lays special stress upon the preceding emotional state of a 
repressed painful experience. He gives instances in support of his 
view that the emotion always precedes the rising of the repressed 
thought into consciousness, and thus the emotion leads to an automatic 
shutting out of the incident until in time it is entirely forgotten, the 
emotion alone remaining. On the other hand, there is no doubt 
that many so-called repressions are not fully repressed but remain 
more in the realm of consciousness than some authorities would 
suggest, but nevertheless they have a very wearing effect upon the 
nervous system and in the course of time begin to have a deleterious 
effect upon the mind of the individual. Repression takes place 
during all ages, but the struggle with authority is more common 
during certain periods of childhood and the damaging effect of a 
conflict is more serious upon the growing plastic brain of the young. 
That Freud was wrong in believing that most of these repressed 
complexes were sexual in character is becoming increasingly evident, 
and I have long felt that when this is dropped as an intrinsic part 
of the Freudian theory the latter will greatly benefit. To me Freud’s 
teaching is valuable, not in its methods of psycho-analytical treat¬ 
ment, but because it emphasises an important factor which had been 
overlooked—how conflict with subsequent repression may injure the 
mind. The knowledge of this alone must make parents and edu¬ 
cationalists pause for reflection and to examine whether their attitude 
towards the young in their charge is in accordance with it. It is 
not my intention to convey that all repression is harmful, for indeed 
repression is a normal mental process, but like the “ will,” some 
persons try to use it for unsuitable purposes. Repressions that are 
harmful usually tend to centre round some morbid thought or some 
particularly disturbing experience. It is the psychological atmosphere 


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in which the child develops that leaves its mark upon its future life, 
and therefore its later welfare is dependent upon those conflicts, 
repressions and any other mental conditions leading to unrest being 
especially guarded against. If this were fully known and appreciated 
I believe that greater consideration would be given to the conduct 
of the home. Children, and especially the sensitive ones, are far 
more perceptive than many adults give credit to; they note the 
gesture, the conduct and the language of those about them and they 
rationalise in an elemental way, but it is none the less leaving its 
impress on their evoluting minds. Further, it is all-important to 
bear in remembrance that it is not the subjects which are freely 
talked about by the child that are usually harmful, but those upon 
which he introspects in silence. To the observant person gesture- 
language will convey as much, if not more, than words, and no one 
can claim to be an efficient trainer of children unless he is equipped 
with the faculty of reading it. Words may be misleading, but gesture 
is seldom so, for the latter is complex and is the outward and 
visible sign of inward sensation and emotion. As Maudsley once 
wrote: “ What is mind-reading but muscle-reading through move¬ 
ments so fine as to be discernible only by a practised sensibility ? ” 
Every adult knows the effect exercised by the environment of an 
unrestful house and its influence upon a child must be infinitely 
greater, and when to unrest there is added apprehension or definite 
fear, it does not call for a great effort of the imagination to appreciate 
the damage that is being done. The undisciplined man is a burden 
to himself and a thorn in the side of his fellows, but the child who 
has to live with him is in danger of mental ruin. This may appear 
to be forcible language, but thirty years of experience of nerve work 
forbids me to soften it. The greatest hope for the lessening of the 
incidence of mental disorder lies in a fuller awakening to the duties 
of the parent to the child. There is one thing that the State can 
never effectually perform and that is the office of parent, and those 
who wish that it should do so either have a very small insight into, 
what is really meant by parental care, or they must feel that the 
thoughtlessness of the average parent is such that the child is safer 
out of his keeping. Had we but the vision to see, there is no reason 
why either of these views should remain active, but to escape from them 
there is only one way, and that is to increase the sense of responsibility 
of the parents and not to lessen it, otherwise the natural consequences 
must follow. Those who call for larger families without seeing that 
the parents who have them appreciate their duties are incurring a 
grave responsibility. The stability and happiness of the mass are 
the combined effect of these virtues in the individual and it is to 
parental care that we must look to lay their foundations. 


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The child who is naturally repressed is without doubt more diffi¬ 
cult to train than the one whose temperament is open and frank. 
It is less easy to understand and is usually more resentful of inter¬ 
ference, and for this latter reason punishment not infrequently does 
more harm than good unless it is carried out with great circumspec- 
spection. On the other hand such a child may develop into a fine 
character if training has been judicious, for it is often capable of 
much reasoning power and its intelligence may be above its years. 
When and in what way to punish the child become problems of 
increasing perplexity as more is known of the working of mind. 
The crude rule-of-thumb methods of the past must be more and more 
challenged. We now know that in apparently correcting a fault we 
may damage the mental development of the child unless we keep 
this actively in mind when meting out the sentence. Take, for 
example, the matter of corporal punishment—in referring to this I 
do not wish to be misunderstood ; I am not one of those who believe 
that all punishment is wrong, for whilst human nature is what it is 
punishment in some form or other will be necessary—my criticism 
is that it is too often administered according to tradition and custom 
rather than by the exercise of a wise judgment. For example, it 
is difficult to understand how caning and corporal punishment are 
so commonly left in the hands of prefects, whose knowledge of mind 
development must be non-existent, and this being the case it is the 
crime that is punished and not the author of it, and the effect that 
it may have upon the latter is left on the lap of the gods. I have 
known of a young boy caned by prefects several times in his first 
term for minor offences until finally he ran away in a high state of 
nervous excitement, and this at one of our best public schools. Such 
treatment may claim to make some boys into fine men, but un¬ 
doubtedly it also causes some to become nervous wrecks, and I cannot 
help feeling that it ought not to surpass the wit of man to evolve 
some scheme of punishment which should have all the benefits of 
the present system and less of the disadvantages. Government by 
prefects has, when properly carried out, a highly beneficial effect 
upon a school, but duties should not be imposed upon them which 
are clearly beyond their powers of full appreciation. Dr. Herbert 
Gray, in writing on corporal punishment, says that he has “ no 
hesitation in maintaining that it should be confined, when adminis¬ 
tered at all, to offences of a moral or quasi-moral character, such as 
lying, cheating, evil language, and misconduct of similar type.” Now 
that it is known how damaging is emotional shock to some individuals 
—and this must be more likely to occur in a child—it behoves those 
in authority to re-survey the grounds for and the methods of adminis¬ 
tration of corporal punishment from the psychological standpoint. 


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THE THIRD MAUDSLEY LECTURE, 


[July, 


I am not aware to what extent the writing of “ lines ” is still prac¬ 
tised in schools, but it is a form of punishment to which there are 
•serious objections. To write out hundreds of “ lines ” is to fatigue 
the hand centre in addition to other parts of the nervous system, 
and when it is imposed for “ inattention ” which may be due to brain¬ 
fag, the result is obvious. Speed alone in a mental exercise is excep¬ 
tionally fatiguing, and what boy does not write his “ lines ” with 
the greatest despatch at his command, and what master does not 
know this, for does he not intend to keep the boy at it for a definite 
time, and to do this he must be guided by possible pace rather than 
by slowness ? I know that many school authorities are taking a 
more scientific out-look in the treatment of delinquents, but much 
has yet to be done, for traditions die hard, and it is apt to be said 
that “ what was good enough for us is good enough for the boys of 
to-day.” 

There is another type of child to which I might refer, not because 
of the frequency with which it is met, but rather on account of the 
very damaging effect it usually has upon its fellows. Fearlessness 
is an attribute which rightly holds a high place in character, but like 
all virtues it may lose its value unless it is tempered by judgment. 
To train a child to be fearless unless at the same time it is acquiring 
experience is to court very definite danger. The fearless child becomes 
independent above its years, and with independence it may develop 
-a dictatorial and bullying spirit. Many of these children when puberty 
is over pay less and less heed to authority and become quite insensible 
to kindness or severity, and not a few fall into the hands of the police 
for breaking the law. This all goes to prove that mind development 
should be a homogeneous whole, and although interest and aptitude 
may tend to quicken growth in certain directions, these tendencies 
must be watched and kept within reasonable limits. 

During recent years much has been written regarding phantasy— 
not that it was a fresh discovery, but on account of its place in the 
new psychology. Now make-believe is a normal characteristic in all 
young children, but some have it much more fully developed than 
others, and these are usually of the sensitive type. As with reality 
there are two large classes of phantasy: the one includes all that 
stands for brightness and happiness and the other all that is ugly 
and forbidding. That the latter should play so formidable a part in 
the child’s story- and picture-book has always been an enigma to me, 
for to the sensitive child it may do much harm and its power for good 
must be very small. Nevertheless phantasy is good, as it smooths the 
path of the child on its way to the stern realities of life. Whatever its 
troubles, it can soon forget them in the land of fairies. But as years 
pass it is necessary for phantasy to be slowly replaced by realities, 


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and it is incumbent upon the teacher to prepare the way for this 
transition. Realities must not be made too hard, otherwise the child 
is driven back into phantasy, or in silence it may fret until the rising 
emotion shows itself in varied forms of nervous disturbance, or if it is 
made of tougher material it may slowly harden into an attitude of 
•careless indifference or open rebellion. One child easily slides over 
the difficulties which mark the opening years of its life, whereas another 
requires help, and it is urgent that this help should be given. What 
I have already described as a wise, philosophic, yet sympathetic 
understanding is what is called for, and not the enervating “ sloppy ” 
•sympathy which is apt to be given, interspersed from time to time 
with an undisciplined display of irritability. 

Although phantasy is a marked feature of the mind during early 
childhood, it may persist or re-appear in the later school days. If 
so, it will call for inquiry as to why it is there. The adult has his 
day-dreams, but they ought merely to be an outgrowth of reality— 
a visualising of some ambition that is as yet far off but the contempla¬ 
tion of which affords encouragement in the present and a vision of 
hope for the future. On the other hand, phantasy which has no 
normal relationship to life indicates that an older child has either 
regressed or that his mind is not developing normally. At this point 
I may be met by those who believe that “ self-expression ” in whatever 
form it may take is the factor of overwhelming importance through¬ 
out a child’s life, and that what some may regard as phantasy is nothing 
more than the unfolding of a creative mind, which may easily be 
■stunted by careless handling or failure to appreciate the condition 
in its true light. I agree, as I suppose most would agree, that self- 
expression has been sadly neglected in the past and that schools 
have been conducted to meet the requirements of a standardised 
child which, to avoid any difficulties in differentiation, has been 
termed the normal child. Those whose mentality did not permit 
of their fitting into this charmed circle either risked becoming chronic 
failures, or, having weathered the contempt to which they may have 
been exposed in early life, have developed, when once freed from 
the system, into successful men in whatever sphere of work they may 
have taken up. But because “ self-expression ” has been a neglected 
factor in the past, there is no reason why it should be granted too free 
a place in the education of the future. Sooner or later the instinctive 
impulses of the child must meet and, if untrained and unconditioned, 
must clash with the social regime ; he is unable to free himself from 
the herd. What he thinks of others and what they think of him are 
musings which, if allowed to run riot, may entail his downfall, but, if 
rightly directed, may lead to the development of a character where 
self is almost lost in interest for others. It is this adjusting to the 


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224 THE THIRD MAUDSLEV LECTURE, [July, 

demands of the herd which is often so difficult, and when one appre¬ 
ciates what it means, the adaptation of an ever-changing being to 
an equally kaleidoscopic world, it is remarkable that misfits are not 
more common. But apart from actual misfits we are still far behind 
in what could be done to make the best of life and to equip the young 
for the work that they have to do. The normal child is extroverted, 
and if introversion is noted every care must be taken to develop its 
ease of expression. It is frequently the sensitive child who is intro¬ 
verted, and he may otherwise be one who is endowed above the usual 
with powers of perception, and, given suitable care and training, is 
often capable of fine development. If, on the other hand, by any 
misfortune it finds itself under the care of unimaginative and common¬ 
place persons, its life will become increasingly cramped by the conflicts 
within and the cruel pressure from without. Nothing is more tragic 
than to see the introverted child suffering mental anguish more 
exquisite than physical pain, and in consequence closing the way to 
mental development and in many cases all because it is not under¬ 
stood. But a child may be too extroverted, and in this case also 
its mental future is in jeopardy, but in a different way. Its danger 
is in the limelight, and in an undue appraisement of its ability. If 
its fibre is tough it may at first trample its way through or over the 
herd until it ultimately breaks down, a victim of its own conceit. 
Nevertheless if the dangers of such a child are appreciated early enough 
and if it is handled with judgment, it will be found in many ways 
one who is more easily led than the introverted one; but time is against 
the teacher, and once puberty is reached the task becomes infinitely 
more difficult. 

As childhood advances all the natural instinctive impulses must 
become conditioned, and by this we mean that experience must modify 
them. Impulse is an unconditioned reflex, whereas a volitional act 
is an action which has been toned by experience to the environment 
in which we live. The instinctive impulse of a man who is exposed 
to danger is to run away, but training and experience teach the soldier 
that this is contrary to the opinion of the herd, and in consequence 
the fundamental law of self-preservation is conditioned and annulled 
by the dictates of the social order. Untruthfulness and other moral 
delinquencies belong to this category, but just as many men who 
ultimately turn out to be trustworthy soldiers cannot be trained 
any intensive system, similarly certain children require long and 
careful handling. By harshness the normal sensitive child may 
become confirmed in its lying, for falsehood is a defence of the fearful, 
and once it is consciously established, it becomes an active detri¬ 
mental factor in its future mental welfare. 

In this way we reach what is and ever must be the goal of all mind- 


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training—self-discipline. By this I do not mean a mere clicking of 
heels to authority, right as this may be in its proper place, but 
true discipline, connoting the right proportional working of all 
the attributes of mind in an even way. The undisciplined nervous 
system is one which reacts impulsively and violently on slight pro¬ 
vocation. Persons who are undisciplined and querulous not infre¬ 
quently vent their displeasure in spiteful acts; they are highly 
unreliable, and yet they may be possessed of a personal charm which 
throws their defects into singular relief. There is no unhappier 
state than that of instability when a man finds himself reacting 
abnormally to thought and environment. Ultimately he finds that 
there is no place for him in the world, and rationalise as he may 
that his so-called undisciplined outlook is a proper reaction to an 
unfriendly community, his own uncontrolled language and actions 
alienate him from the herd. Many of these individuals end their 
days in mental hospitals, their nervous system having finally broken 
down under the strain of contending with men and things, and yet, 
when carefully analysed from the psychological standpoint, there can 
be discovered no intrinsic reason why such a state of mental unsound¬ 
ness should have been brought about, had reasonable care and super¬ 
vision directed the earlier years of their life. All children are undis¬ 
ciplined, and though the majority acquire controls by the education 
and training which they receive, some lag behind in gaining them. 
The child that does not become disciplined at the usual age is often 
quite intelligent and may even attain to a high standard of knowledge, 
but when a child shows defects in the matter of control it is necessary 
to focus the immediate training upon these defects, for knowledge 
is useless to the possessor of an unbalanced mind ; far wiser is it first 
to obtain stability and then to impart knowledge. The irritable 
child, like the irritable man, must not be regarded as in good mental 
health, but the brain of an adult takes longer to damage, and although 
it is true that each outburst of irritability is gradually undermining 
the mental power of the man, its effect upon the plastic growing 
brain of the child is vastly more injurious. Further, the child forms 
habits with extraordinary ease, and once established they are infinitely 
difficult to displace. Discipline is not a product of short training, 
for it is not elemental; its component parts are highly complex, and 
in consequence its development is slow and subtle, but once estab¬ 
lished its reward is stability, and it protects its possessor from the 
effects of undue strain of conflicts within and irritation from without. 
As we acquire knowledge, thought and acts which at first were 
accompanied by a feeling of effort grow to be automatic. Right 
thoughts should become associated with proper actions. Sound 
experience means that we instinctively do the right thing at the right 
LXVIII. 


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moment; the adult mind should be stored with judgments which 
have been tested by experience and can be called up more or less 
automatically when occasion requires it. It is not the knowledge 
that we have acquired that counts so much as with what other things 
this knowledge is associated. The knowledge of finance associated 
with extravagant or penurious thoughts is of ill-value; cleverness 
and much learning when associated with conceit are singularly un¬ 
attractive ; business capacity when associated with an intolerance for 
others often is a valueless possession. When we come to test a man’s 
endurance or what he has made of his life it is rarely pure learning, 
it is knowledge added to something else which gives it its value, and 
it is this “ something else ” which either makes or mars the history 
of that life. It is outside the purpose of this lecture to discuss all 
that goes to make character, but just as the good morale of troops 
keeps an army in a high state of efficiency, so with the individual it 
is the fundamentals that count. 

It is remarkable what apparently insignificant factors may so 
increase the burdens of life that, starting as a small nucleus, they 
may form a centre which in course of years may collect round it 
other factors, until the cumulative effect is greatly to disturb the 
mental equilibrium of the individual. What for want of a better 
term may be called “ sloppy-mindedness ” is an example of this. 
Some parents give so little heed to the future welfare of their offspring 
that they bring them up indifferent to principles and untidy in thought 
and action. The innate intelligence of the child may permit of its 
acquiring knowledge maybe above its fellows, and when it starts on 
its life-work all goes well until responsibilities have to be accepted. 
It is then that the “ sloppy-minded ” training begins to tell, for it 
may and often does so handicap the man’s progress that troubles 
which might easily have been prevented overtake him, and these 
and the unhappiness which is associated with them become so dis¬ 
turbing as to render him a mentally broken and disappointed man. 
There is another group of cases which are particularly sad, as it is 
often the break-up of a life which from the earliest of days has been 
devoted to close application to work; this group includes those who 
have risen from the ranks and who through scholarship or unceasing 
study have acquired some good position, only to find that their per¬ 
sonality is unsuited for the post. The issues of life cannot and must 
not be lightly faced ; phrases like “ equal opportunities for all ” have 
a fascinating sound to the uncritical mind, but if you carry this 
assumed truth into general practice, your kindly attention will bring 
about the mental downfall of many of those whom you intended to 
help. The tendency of the age is to standardise everything, but 
when this system is carried into the management of human affairs 


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the results cannot but be disastrous. Although it may be true that 
men whose mental capacity is nearly equal can be arranged in groups, 
and although, further, it is true that a certain number may be capable 
of being transferred from lower to much higher grades, the majority 
must be content to move within narrow limits. Evolution is at all 
times slow and to attempt to hasten it is not only unwise but disap¬ 
pointing. The natural laws plough on with an unmerciful regularity, 
for ever heedless of the ever-changing fashions in the opinions of men. 
It is proper to see that the want neither of money nor of position 
should stand in the way of the advancement of those whose natural 
gifts permit of this, but to regard it as the normal right of the majority 
is to think a vain thing. I know that my critics will say that this 
is precisely the difficulty—to know who has natural gifts and how 
such can be gauged. To these my reply must be that this is the duty 
of the educationalist, for he must search until he finds some reliable 
test which shall decide this problem, but to attempt what some would 
have us do, to give all a standard chance, is too wasteful in practice 
and too hurtful to those who fail. The problem is full of perplexities, 
and no doubt there are many who are striving to find the right solution, 
but unfortunately the claimants who demand to be heard are many, 
and each regards the proposition with a distinct bias of his own. 
There is first the parent who sees in his offspring the qualities which, 
if given opportunity, are pregnant with possibilities; and next the 
schoolmaster, kindly and hopeful, fully aware of the limitations of 
his pupil, but always ready to give him the benefit of any doubt. 
Next in order comes the array of examiners and school inspectors, 
men whose outlook is largely concerned with a standard of knowledge, 
the human element only entering into the scheme as a means of 
expressing that knowledge. Next come the Universities and great 
seats of learning, whose duty it is to indicate the educational needs 
of men and to hold out as their highest aim, irrespective of individual 
characteristics, the attainment of pure scholarship. Finally we come 
to the Legislature, the mouthpiece of popular opinion, who are willing 
to fling education into the maelstrom of political notions, careless of 
the effect so long as it appeals to the masses and in consequence 
strengthens some party at the polls. If only each claimant would 
wholeheartedly view the proposition from the standpoint of the 
child and his future welfare and put away from his mind all other 
considerations, the problem should be capable of a right solution. 

Psychological medicine has been progressing rapidly during recent 
years, and with this one of the most satisfactory features is that the 
word “mental” is being used more and more freely with reference 
to normal individuals. At one time any reference to a mental state 
had a terrifying effect upon the lay mind, and it is all to the good to 


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THE THIRD MAUDSLEY LECTURE. 


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find that the public is learning that mental processes are common to 
the normal as well as to the abnormal. We now await the time when 
the Legislature will show its appreciation of the advance that has 
been made by relaxing the law so that the knowledge that has been 
acquired may be the more readily used for the benefit of the people. 
In the meantime we must go on teaching that the mental health of 
the nation is largely dependent upon a wide-spread knowledge of the 
requirements for keeping a mind in health. The position is in every 
way comparable to the problem of attaining a high standard of physical 
fitness. The onus must ultimately rest with the people ; the medical 
profession can but point the way. If the present writing on the wall 
is correct, that the early years of life are the important years for 
determining the stability of the mind of the adult, it behoves us to 
put this knowledge into practice. The country is learning that the 
greatest asset to a nation is good health and that a small number of 
Al men count for infinitely more than a crowd of the C 3 class. 
To attain this end we must look to education, not merely from the 
narrower standpoint of learning, but where*Jearning is superimposed 
upon a stable mind. I would close, as I began, oma^note of hopefulness. 
The criticism that is often made against prophylactic measures is 
that it is pure hypothesis to say that such and such a condition might 
have arisen, and that the claims of having prevented it are in conse¬ 
quence mere assumption. We at least shall be free from such un¬ 
certainty, for we shall be able to point to fewer and less populated 
mental hospitals. We know that this result can be attained, even 
with our present knowledge, and all we ask is that those restrictions 
which hinder us should be removed, and that the lay public should 
bear in mind that mental disorder is rarely of sudden development 
and that much more can be done to prevent it than they at present 
appreciate. For ourselves, we who work in the sphere of mental 
medicine must keep widening and ever widening our vision as our 
knowledge advances. In our struggle to repair disease, we must not 
lose sight of the other matters which belong to our inheritance, for 
our work lies in no narrow scope, covering, as it does, all that apper¬ 
tains to the mind of man. 



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192 2.] THE USE OF ANALYSIS IN DIAGNOSIS. 


229 


The Use of Analysis in Diagnosis .(*) By T. S. Good, O.B.B., 
M.R.C.S.Eng., L.R.C.P.Lond., Medical Superintendent, Ashhurst 
Hospital, Littlemore, Oxford. 

The subject of my paper to-day is “ The Use of Analysis in Diag¬ 
nosis.” As analysis is ipso facto the reduction of a composite body 
to its component parts, it stands to reason that analysis must 
be used by every medical man in investigating any case. The surgeon 
looks at and feels the growth, and questions the patient; then from 
what he has seen, felt and heard he constructs a mental picture 
as to the nature and site of that growth, and as a result of his analysis 
decides to operate or not, as he may think fit. The physician and 
neurologist act in the same way. They are all influenced by what 
they see, feel, and hear ; they are guided by their own and the patient’s 
conscious thoughts and feelings. From this it will be seen that up 
to quite a recent date the material upon which the physician or 
surgeon have had to draw has been in the “ conscious ” only. But 
nowadays, thanks to the genius and patient work of Freud, a new 
source of knowledge has been opened to the medical profession by 
his discovery that the solution of many of the problems which have 
confronted us in ascertaining the cause of neuroses and psychoses lie 
deeply buried in the unconscious minds of the patients. By special 
methods of inquiry these buried factors can be disclosed by being 
brought into consciousness, and energy which was dammed back in 
the unconscious released, thus effecting relief and even cure. 

Whether we accept the views of Freud completely does not alter 
the fact that the method of inquiry employed by him, or as modified 
or added to by others, has been the means whereby many neurotic 
and psychotic patients have been made whole. Never has this fact 
been better demonstrated than during and after the war in cases of 
shell-shock, so-called, and neurasthenia. The fact remains, that 
however much we quibble as to what constitutes analysis and whether 
hypo-analysis should be included under this term, patients have 
been relieved and cured by psycho-therapy. Psycho-analysis is one 
of the mental instruments used in this therapy. 

It is not my intention to enter into a discussion of the various 
schools of psycho-analysis nor of their differences of opinion, the 
only point that has any immediate bearing upon the subject of my 
paper being, that by the method of psycho-analysis, i.e., by following 
the technique of free association, we are able to diagnose physical 
conditions which would otherwise escape our notice altogether or 

(*) A paper read at the Quarterly Meeting held in London on February 23rd, 
1922. 


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230 THE USE 0F\ANALYSIS IN DIAGNOSIS. [July, 

remain only partially understood, for the reason that the key to the 
solution of the physical mischief lay repressed in the unconscious, 
and in consequence could not be furnished by the patient in response 
to the usual methods of examination. I hope to be able to elucidate 
this point by referring to the notes of two cases originally diagnosed 
and treated as cases of neurasthenia and hysteria respectively. 

The first case is that of a man, H. D—, $t. 50, who joined the Army 
in 1914 and was invalided out in 1918, with the diagnosis of neuras¬ 
thenia. He had been under various forms of treatment for about 
four years for varying periods, and whilst not actually in hospital 
he had, with indifferent success, attempted to follow his pre-war 
occupation of motor-body making and had worked for his old firm. 
Previous to the war he had had no severe illness. There was nothing 
abnormal in the family history. 

On his first attending the clinic his facial expression showed worry 
and anxiety, with down-turned angles of mouth, and slightly dilated 
pupils and detached stare. There was little interest shown; the 
patient moved sluggishly and dropped rather than sat in the chair 
that was offered him. Questions were answered at first without 
emotion and in a rather slow and indifferent way, the patient obviously 
paying little attention and being almost monosyllabic in his replies. 
All he complained of was a vague headache, great depression, inability 
to work, loss of memory, lack of interest in anything, and that he 
could not think what was the matter with him. On being pressed 
to say if there was anything else he could tell, he gave the further 
information that he had been giddy when riding his bicycle to work 
and had once fallen off; also, as he put it, “ felt lost and giddy at 
times.” The headache was described as dull and heavy over the 
eyes and at the back of head. At the first visit nothing further 
could be elicited from the patient himself. Physical examination 
revealed that the right side of face was not so mobile as the left, 
but the paralysis was very slight, and could only be noticed when 
carefully looked for; the tongue was protruded straight. Pupils 
were equal and normal in reactions, no ocular palsies to be detected, 
fundi normal, as also was vision ; reflexes brisk and equal, abdominals 
present; control of bladder and rectum normal. Lower reflexes 
were equal and brisk; the only abnormality to be detected was an 
indefinite plantar reaction on the right, sometimes being extensor, 
but never definitely flexor. There was no Oppenheimer, left plantar 
reflex definitely flexor. Sensation was generally normal, as also 
were co-ordination, muscular sense and tone. All organs appeared 
to be normal. Pulse 80. 

Up to this point, therefore, nothing abnormal was to be detected 
physically that could account in any way for the man’s condition 


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except tl}e very slight facial paresis and the indefinite plantar on 
the right side. These two signs alone, though indicative of organic 
trouble, were not of themselves sufficient for definite diagnosis, but 
it was clear that the case was not entirely functional in origin. 

The man could give no further information except that he could 
not remember a certain period of his war experiences, and at the 
first interview the sum total of information at our disposal for diag¬ 
nostic purposes was (a) from the patient’s statement—depression, 
giddiness, dull indefinite headache and some amnesia ; (b) as a result 
of examination—slight right facial paresis, tongue not involved, and 
an indefinite plantar reflex on the same side. At this first interview 
also the blood was subjected to a Wassermann test, the result being 
negative. 

The second and third interviews with the man only elicited the 
information that he did not believe doctors could do him any good. 
He was sick of hospitals. He showed disinclination to talk of the 
war, except that the war was the cause of his illness, and what he 
wanted was to get away by himself and be quiet. During this period, 
a space of three weeks, he was working spasmodically at his trade. 

After the third interview his demeanour changed and the patient 
began to co-operate in his treatment and associate, with the result 
that his own thoughts and feelings on his illness became clearer. 
He talked more freely, both of his life previous to the war and also 
of his war experiences, which appeared to have been much the same 
as those of others up to a certain point. The only part of his life 
that he could not account for, however, was a period during a voyage 
by sea. The associations always led to this point, and gradually his 
memory was clear up to a certain point and beyond a certain point. 
He had been in a ship that was torpedoed, but could remember 
nothing from the time of the torpedo hitting the ship till when he 
was in hospital. Details became clearer as he showed more interest 
and co-operation, and eventually he remembered and was able to 
describe what happened after the torpedo struck the ship. Shortly, 
the story was this: He was lying in his bunk at the moment of 
impact. The force of the explosion threw him across the cabin on to 
the chest of another man in a bunk on the opposite side, and he struck 
his head a violent blow over the left parietal region against a bulk¬ 
head and heard his head crack, feeling at the same time an acute 
pain. The cabin was full of men at the time and all rushed on deck, 
the patient among them, he feeling very dizzy, sick, and ill, and, 
as he said, as if his head would burst. The ship sank rapidly, and. 
he, with others, jumped overboard with his life-belt on and was picked 
up by a boat and taken to hospital. The whole of this amnesia was 
removed at one sitting, and at the conclusion the patient showed 


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great surprise and made this remark, “ I don't know why.it is, but 
I feel all right and am glad I can now remember everything.” The 
patient returned again in about a fortnight to the clinic. He stated 
he was much better in himself and could remember clearly, was more 
cheerful, had lost the dull headache, but he had a new pain of an 
aciite nature which he had never had before except when he hit the 
bulkhead of the ship when it was torpedoed. He stated it was the 
same type of pain in the exact spot and was constant, and had come 
on soon after he had recovered his memory. It had been present 
ever since and was very severe. He had tried to work, but after 
ten days had been obliged to give up. I wish to emphasise this point, 
that, though the man was now obviously in pain, he still maintained 
he was better, and that the old depression, vague headache and 
defective memory did not trouble him. At first sight it did not 
appear that the recovery of the memory was of much service to the 
man as he had only exchanged one set of symptoms for another, 
but the new symptom was a definite localised pain which the man 
himself could point out; it was located to the exact spot in the skull 
where it struck the bulkhead. Now, this fresh point gives a new 
clue, and we have a possible reason to account for the slight right 
facial paralysis and indefinite plantar: (a) we have discovered that 
the man struck his skull so violent a blow over the left parietal region 
that he felt it crack, and that he has pain over this exact spot; (b) 
on the opposite side there is slight paresis and an indefinite plantar. 

The problem now becomes soluble and the diagnosis clearer. There 
had been injury to left parietal region, probably fracture, and some 
irritation of the brain. The case was at this point handed over to 
the surgeons. An operation was performed, a two-inch fracture being 
discovered at the exact site of the pain, with a bruising of the brain 
substance. 

Three points appear to me of interest: 

(1) That, as far as I could ascertain from the papers and history, 
there had been no suspicion of organic trouble in the past illness. 
The diagnosis had always been neurasthenia and the symptoms 
appear to have been those grouped under this very wide term. 

(2) The patient himself had to supply the clue, which he was pre¬ 
viously unable to do owing to the amnesia. 

(3) The symptoms were such that the attention of the observer 
was directed mainly to the mental side, and they masked the organic 
symptoms until the mental problem was solved by the recovery of 
the amnesia, and I might venture to put forward the hypothesis that 
the attention of the patient was so focussed on his mental feelings 
(emotions) that the physical sensations were unnoticed till the mental 
conflict was solved. 


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It might be argued that the facial paresis and the indefinite plantar 
should have been enough to have suggested an X-ray, but though 
apparently from what the patient told us later one medical man 
had suggested cerebral tumour, no idea had ever been entertained 
of fracture, even though he had been examined many times. 

The man now has recovered his mental poise, though unfortunately 
the cerebral pain is still present and he has a definite slight hemiplegia 
since the operation. 

The second case is one of a young man, H. W—, set. 25, the only 
son ; said to be bright and intelligent and quite normal before the 
war. There was nothing abnormal in the family history, and no 
history of any severe illness previous to the war. The patient joined 
up in 1914; he was discharged with the diagnosis “ hysterical fits ” 
in 1916. 

He was brought to the clinic by his mother, who informed us 
that he had fits; that he had completely altered in disposition, 
and was at times violent, aggressive, and very irritable. She stated 
that the fits were of two kinds, both commencing with twitching of 
the right side of the face, but that sometimes he became rigid, and 
afterwards was lost and dull with headache; in other fits he threw 
himself about and afterwards became violent and irritable. The 
mother was most emphatic in her statements that the fits were of 
two kinds. She said she brought him to the clinic because they 
were afraid he might become worse and they would not be able to 
control him. The patient conversed freely and said he wanted to 
get well, and that he always knew when the fits were coming on, 
because the right side of his face twitched. He said he could not 
remember anything of the fits, showed a certain amount of emotion, 
and said he could not help having them. Both mother and son 
seemed to attach much more importance to the irritable fits than 
to the rigid kind followed by somnolence and headache. He did 
not want to talk about the war, and also became irritable when 
pressed to do so. This was practically all the information that could 
be obtained from the history. 

Physical examination revealed very slight difference in the reflexes 
on the two sides, the right being plus as compared with the left, 
and the plantar reflex on the right was indefinite. There was also 
slight muscular weakness on the right side. The differences, however, 
at this time were so slight that they were simply recorded. The 
blood examination was negative. This was the extent of the informa¬ 
tion obtained at the first interview. 

At the next attendance he was accompanied by his father, who 
informed us that the patient had had two fits that week of the second 
or irritable type, otherwise there was no change. The patient was 


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induced to talk about the war, and it was then that his memory was 
found to be very defective for quite long periods. He had apparently 
no recollection as to why he was sent home or when the fits began. 
On inquiring where and under what circumstances the last two fits 
had occurred, the following information was given by the father 
and corroborated by the son : 

The first fit occurred when he was standing on a bridge looking 
at the river. After the attack, in which he became excited but did 
not fall, the patient was very irritable and the right side of his face 
twitched. The second fit occurred when he was near a farm and 
saw a girl in a blue dress ; this fit occurred two days after the first 
and was similar in type. 

When next I saw the patient he would talk, and was anxious to 
assist. Associations were tried for on the bridge, the river, the boats, 
the people, with very little apparent light till he volunteered the 
statement that the lock was being filled at the time and the man 
had just let down the sluice gate. The patient here showed a dis¬ 
inclination to continue, and the question was asked whether he heard 
the noise of the sluice being closed and if the noise reminded him of 
anything. Upon this he showed agitation and had to be pressed for 
an answer, and then said it reminded him of the noise of a trench 
mortar stick flying through the air. He was associated on this 
and the following memory was regained. He had hated trench 
mortars more than any other kind of explosive weapon. He had 
been on a particular part of the front where they were exposed to a 
great deal of straffing by trench mortars, and on one occasion he 
had been hit on the head by the stick of one (whether it was really 
the stick is, I think, not quite certain). At first he insisted that he 
could remember no more, but later on gradually gave a description 
of his fear that he was killed, and of how he got back into a more 
safe position, with his head aching and feeling very sick, ill, and 
dazed. He gave the site of the blow as a little to the left of the 
middle line of the skull. The patient then said he could remember 
no more. He was associated on the second fit. The farm reminded 
him of a farm in France; the blue dress, which was described by 
the patient as blueish grey, reminded him of the colour of the German 
uniform. The amnesia recovered was that almost immediately after 
the blow on the head. He had advanced with his platoon on a 
farm, where a hand-to-hand fight had occurred, in which the patient 
had nearly been killed by a German corporal. The patient now 
talked freely about these episodes and gave various small details 
which cleared up gaps in the two events, i.e., the blow on the head 
and the attack following on the farm. His parent, who was present 
at this treatment, remarked that she was glad to know this, as her 


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son would never tell them at home anything about the war and 
always became irritable and twitchy if the subject was mentioned. 
From the date of the recovery of this amnesia the irritability became 
much less, and the mother informed us that the emotional fits had 
ceased, but the other kind (the rigid fits) had increased somewhat 
in frequency. At this time the man had only been seen as an out¬ 
patient, therefore the statements of the mother were the only evidence 
we had as regards the attacks. 

At this stage, therefore, we had the following data : 

(1) Mother’s statements and description of the two kinds of attacks 
and the further statement that the recovery of the amnesia had 
been followed by a great improvement in the emotional attacks, but 
a rather increased frequency in the rigid attacks. 

(2) By recovering the amnesia we had acquired the knowledge that 
the man knew he had been hit on the head and was able to point to 
the exact spot. 

(3) The typical examination had already indicated slight disturbance 
in the reflexes, and muscular power of the side opposite to the blow. 
It is interesting that after the recovery of the amnesia the physical 
signs were more marked. 

The weakness on the right side was now explainable, and pointed 
to some increased intracranial pressure probably due to the blow on 
the head. 

He was admitted as an in-patient onjanuary 8th, 1921, and was kept 
under observation till April 5th, 1921, when an operation was per¬ 
formed for decompression. 

Before the operation and while this man was an in-patient he had 
numerous epileptiform attacks, always preceded by twitching of the 
right side of the face. There was, however, no recurrence of the 
attacks of excitement and irritability. After the operation he only 
had two epileptiform attacks, and was discharged about three months 
later. He was brought up in about four Weeks’ time by the mother, 
who stated that there had been no attacks since his discharge and 
that he was now working as a jobbing gardener. 

These two cases have points in common : 

(1) Both had previously been diagnosed as functional, the slight 
organic signs either being ignored or perhaps more likely not being 
considered to have any sufficient bearing on the illnesses. 

(2) It was only on recovery of the amnesia in both cases that the 
clues to the slight organic signs were found. Both men had blows 
on the head, causing definite intracranial injury, of which neither of 
them were cognisant, and therefore could not tell others what was 
the matter as there were amnesias, the result of repressive forces 
acting through fear. 


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236 NATURE OF THE PSYCHOPATHIC INHERITANCE, [July, 


(3) In both cases the later diagnosis of organic mischief was verified 
by the operation, and in each case the operation was performed on 
the area indicated by the patient’s own recovered memory. 

(4) In both cases the purely psychic manifestations, the depression 
in the one and the irritability in the other, had greatly improved 
before the operation. 

(5) It is also a noteworthy point how the two patients with injuries 
of a similar nature react each in a different psychological manner: 
one becomes depressed (introverted), the other becomes excited 
(extroverted). 

In conclusion, I submit that psycho-analysis was the means whereby 
the unconscious clue was discovered which enabled a diagnosis of 
these cases to be made, and if this can be admitted, then psycho¬ 
analysis may be of use in diagnosing organic conditions, thus justify¬ 
ing my choice of title for this paper. 


The Nature of the Psychopathic Inheritance .(’) By H. R. C. 

Rutherford, F.R.C.S.Irel., D.P.H., Senior Assistant Medical 
Officer, St. Patrick’s Hospital, Dublin. 

For nearly all time it has been recognised that heredity plays a 
prominent part in the production of mental disease. There would 
appear, however, to be a present-day tendency to minimise its im¬ 
portance as a causative factor; indeed, there are some who go so 
far as to consider heredity in mental and other diseases to be of 
negligible value. No doubt the advent of the psychogenic school 
of thought is responsible to some extent for directing attention away 
from it into the channels of the subconscious. 

In the last available statistics of the public asylums in Ireland, 
an insane heredity was stated to have been the chief causative factor 
in about 20 per cent, of the cases admitted during the year, although 
in another 10 per cent, it was claimed as being a contributory factor. 
These figures seem somewhat low in number, and this is not a matter 
for surprise when one considers the extraordinary skill with which 
an insane inheritance is liable to be withheld from the history supplied 
upon admission forms. Long since I have been driven to other sources 
of information, with the result that for some years past I have been 
able to elicit a family history of mental disease in about 50 per cent. 
of the patients admitted to St. Patrick’s Hospital, and among the 
remainder there were often another 10 to 20 per cent, about whom 
much doubt existed. 

(‘) A paper read at the Spring Meeting of the Irish Division, held in Dublin on 
April 6th, 1922. 


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The effect of a psychopathic inheritance upon the prognosis of a 
mental attack is not necessarily grave so far as immediate recover¬ 
ability is concerned, but if one considers its influence upon the life- 
history of the individual a very different tale must be told. Take 
any patient with such an inheritance and go through the story of 
his life. There we can usually find the presence of either one prolonged 
mental illness, or the repetition of many attacks which have left 
their mark upon the worldly success of the sufferer, and too often 
have they been the cause of his complete incapacitation from profitable 
employment. The amount of damage done to the country by such 
means is inestimable, and for this reason alone the originating cause 
of mental disease must command more attention from the State 
than it receives at present, and at no distant date. From the already 
mentioned combination of recoverability and recurrence of attacks 
it is obvious that the true inheritance in mental disease is one of 
instability. What is it that constitutes the unstable mind so that 
whenever adverse circumstances come along it is liable to fail ? 

The object of this paper is to submit that the instability is physical 
in origin and hypo-thyroidal in nature. 

For many years thyroidal medication has been a recognised form 
of treatment in mental disease. Up to quite a recent time, however, 
the results of it have been somewhat disappointing. This may have 
been caused by a varying potency of the preparations that were 
utilised, but it is probable that the true explanation lies in the mode 
of treatment employed or the type of patient chosen to receive it. 

It was generally advised that a rapidly increasing dosage of the 
glandular extract should be administered until about sixty grains 
or more were being given in the day. By this method a physical 
disturbance, sometimes of an alarming nature, was liable to develop, 
and the mental symptoms were prone to disappear. Frequently, 
however, the patients were liable to relapse into their former condition, 
and, on the whole, one could not consider the method as being quite 
satisfactory. The production of the physical reaction was not without 
danger to the patient, and to me it appeared comparable to the 
production of a reaction in the administration of tuberculin, and, 
therefore, unscientific according to modern thought. 

With regard to the type of case, apart from patients showing 
definite evidence of myxcedema, and who were, of course, classified 
as being sufferers from myxcedematous insanity—which was considered 
rare—it was said that stupor presented one of the more favourable 
states for success from the treatment. This was somewhat unfortunate, 
as in this condition one is liable to encounter the entity of dementia 
praecox—a disease that has a peculiar liability to a progressive degene¬ 
ration, and one that requires the most persistent treatment, which 


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could not be carried out by the method of dosage that was advised. 
On the other hand, some brilliant results of the treatment occurred 
here and there in several other types of mental illness. The writer’s 
interest in the subject flagged a good deal until the publication of 
McCarrison’s (1) work, when it became apparent that several of the 
symptoms he described as being hypo-thyroidal were intensely 
common among the insane. The proper course to pursue seemed to 
be the treatment of patients presenting these symptoms as being 
sufferers from a deficiency disease, and, therefore, smaller doses of 
the gland were administered than had previously been customary 
with him. 

In the course of treating many cases, some of which were most 
hopeless material to work upon, it became evident that the type of 
patient in which thyroid extract did good was not confined to any 
particular entity of mental disease, and that the boundaries in this 
respect were widely apart. During the treatment of these apparently 
hypo-thyroidal people, the balance of success seemed to lie with those 
who had a bad family history—a feature that was in direct contradic¬ 
tion to all other forms of treatment in mental disease. Especially 
was this point to be noticed in those cases with relatives affected 
mentally of the same generation as the patient who had been treated. 
A type of family would appear to exist, some members of which 
become mentally ill, while others remain well, but each individual 
member thereof is liable to transmit hypothyroidal characteristics to 
his descendants. 

I have selected a few families to illustrate the effect of treatment. 
In using the word “ family,” it is employed in the wider sense of 
.embracing relations, not necessarily confined to one set of parents 
and their offspring. At first I propose to deal with patients who 
have been certified. 

Class A.— Families which have had two or more members under treatment. 

Family i. 

M—, female, set. 23. Stupor following a maniacal attack. At one time very 
suicidal. Had been ill for 4i months. Thyroid for two months—recovered. 
Family history : Was stated to be good, but the patient had one previous attack, 
and at a later period the following two relatives were admitted to the hospital. 

N—, female, set. 17. Stupor following influenza. She had been mentally ill for 
two weeks, when thyroid was given for another two weeks, resulting in recovery. 
Family history : She is a sister to M—. 

A—, female, aet. 30. Auditory hallucinations following an acute puerperal attack. 
Mild excitement, stereotyped actions and occasional periods of stupor continued 
for twelve months, and she appeared to be degenerating into dementia. She 
received thyroid extract for a further twelve months and recovered. Within a 
short time of beginning the treatment a noticeable improvement took place in her 
condition. This patient seemed to be an example of dementia praecox. Family 
history : She is a sister to M— and N—. 

It will be admitted that this was a family with a marked tendency 


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to mental breakdown. Three of them have recovered under treatment 
by thyroid extract. With regard to A—, who was ill for one year 
prior to receiving the treatment, it should be mentioned that the 
true significance of the recovery of her two sisters had not, at the 
time, been appreciated. Further, her mental state was one of 
excitement rather than stupor, so she only received the drug after 
considerable doubts had arisen concerning the outcome of her illness. 

Not one of these three sisters presented any gross myxcedematous 
symptoms. They were very good looking, and, when in their normal 
state, vivacity of manner was characteristic of them. A brother was 
also a patient in the hospital for a short period, but, as there was an 
alcoholic element in his case, and he rapidly got well, no thyroid was 
given to him. The father seemed to be of a particularly healthy type ; 
the mother was quick-brained but obese. 

Family 2. 

A—, male, aet. 30. Depression. Had been ill for one month. Thyroid for two 
months—recovered. Family history : His father died in depression. 

F—, male, aet. 26. Depression. Had been ill for fourteen days. Thyroid for 
two months—recovered. Family history : Patient is a first cousin to A—. 

Family 3. 

R—, female, aet. 39. Hallucinations and delusions following acute excitement. 
Had been ill for one year. She then received thyroid for three months and 
recovered. Family history : Three female first cousins, belonging to two families, 
have at one time or another been insane. 

M—, female, aet. 45. Stupor. Had been ill for one and a half years before 
getting treatment. She is now almost well after three and a half months’ treat¬ 
ment. Family history : She is a first cousin to R—. 


Class B.— Where only one member of the psychopathic family has been 

treated . 

1. G. F. M—, male, aet. 38. Depression. Had attempted suicide. Ill for two 
years prior to treatment. Thyroid for six months—recovered. Family history : 
A sister had a mental attack. 

2. K. A—, female, aet. 24. Depression, markedly agitated. Twelve months ill 
prior to receiving treatment. She received thyroid for one month and recovered. 
Family history : A first cousin was insane. 

3. D. C—, male, aet. 43. Depression. Ill for two months before treatment. 
Thyroid for one month—recovered. Family history : His father committed suicide; 
a brother was insane. 

4. N. S—, female, act. 30. Acute maniacal excitement. Ill for one week before 
treatment. Thyroid for ten days—recovered. Family history : A brother is insane. 

5. M. C—, female, aet. 53. Acute maniacal excitement. Ill for one week before 
treatment. Thyroid for one week—recovered. Family history : A brother was 
insane. 

6. J. F—, male, aet. 19. Delusional state. Hallucinations of hearing. Had 
been ill for eighteen months. Thyroid for three months—recovered. Family 
history : A first cousin was insane. 

7. W. M—, male, aet. 18. Stupor. Had been ill for five months. Thyroid for 
six weeks—recovered. Family history : A first cousin was insane. 

8. E. G—, female, aet. 53. Depression. Had been ill for two years. Thyroid 
for one month—recovered. Family history : A sister is depressed. This was a 
somewhat striking result, in so much as the patient was making very slow progress 


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when she received the drug. Within one week, however, a marked improvement 
set in, and the recovery was complete in one month. 

9. K. W—, female, aet. 34. Depression. Had attempted to throw herself out 
of a window. Ill for seven weeks. After a fortnight’s treatment with thyroid she 
lost her delusions and became more cheerful, upon which she was removed from 
the hospital. Family history : A maternal aunt was neurotic. A first cousin was 
insane. 

10. V. A. B—, female, aet. 72. Maniacal excitement. Had been ill one week 
when thyroid was administered. She became comparatively quiet almost imme¬ 
diately, and has remained so for six weeks. There is, however, some volubility 
and irrelevance of speech. She is able to read the paper every day, and her state 
is one that could have been treated in a general hospital. She sleeps the whole 
night through as a rule. On previous occasions during these attacks, of which 
there have been many, she has been very confused, noisy, restless and destructive 
for seven or eight months at a time, notwithstanding treatment with sedatives. 
There seems reason for belief that, were it not for her advanced age, the present 
illness would have terminated by now. Family history : A sister was insane and a 
niece was defective. 

11. M. M—, female, aet. 30. In a restless emotional state. Had a delusion that 
she was pregnant, and that she would be hanged. Had outbursts of violence. 
Made an attempt to drown herself, and also jumped out through a window. Refused 
all food. Ill for two months. She received thyroid for six weeks, when recovery 
set in. Family history : Her father and sister died insane. 

I can give more examples of Class B, but enough has been written 
to show how responsive many patients with a psychopathic inheritance 
are to the thyroidal treatment. 

The above examples are mainly of the manic-depressive type, 
which, so far as the individual attack goes, is a recoverable one, 
but, unfortunately, if untreated, is liable to entail months of acute 
suffering, which, apparently, can be curtailed greatly in time and 
nature by the action of thyroid extract. 

Class C.— Cases in which the attack has been stopped and certification 

avoided . 

1. K. M—, female, aet. 38. In a tremulous restless state following shock. She 
had experienced several attacks of maniacal excitement, and was always aware 
when an attack was to be expected. On this occasion she had been ill for one 
week. She received thyroid for three weeks, but after the first week it became 
obvious that she was safe from a genuine attack. Family history : Two first 
cousins were insane. 

This case is of peculiar value to my contention insomuch as, on a previous 
occasion, 1 had attempted to stop an oncoming attack with sedatives. The attempt 
on that occasion was unsuccessful, and the patient had to be certified. 

2. L. W—, female, aet. 33. Depression with marked loss of weight. The attack 
had been present for some months without the development of delusions, but 
certain obsessions were a feature of the illness. She received thyroid for one month, 
after which she declared that she felt perfectly well. Family history : Both her 
mother and her sister had mental attacks. 

3. M. R. C—, female, aet. 26. Depression following shock. She was self- 
accusatory and showed a keen desire for death. She received thyroid treatment 
for five weeks and then became cheerful. Family history: A brother committed 
suicide. A sister was insane. 

Classes B and C agree with A in the almost complete absence of 
gross physical symptoms of myxcedema. D. C— in Class B showed 
some thickening of the skin all over the body and his cerebration was 
slow. N. S— in the same class had some enlargement of her thyroid, 


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192 2.] BY H. R. C. RUTHERFORD, F.R.C.S. 241 

but not to a marked extent. In the case of D. C— his heredity was 
exceptionally bad and his response to treatment very rapid. 

In the matter of proving that a subthyroidal state is the initial 
cause of dementia praecox, which, of course, constitutes a large propor¬ 
tion of those who remain insane permanently, there is the difficulty 
of satisfying critics without producing a long list of recoveries. I 
cannot report such a success, but, at the same time, I am satisfied 
that treatment with thyroid does good in a number of these cases, 
and that, in some of them, a remarkable improvement follows. 

I have already referred to one case (A—, Class A) which I believe 
was an example of this entity. The following were diagnosed as 
further examples : 

A. C—, male, at. 22. Following a brilliant collegiate career he became dull 
and confused. He was silent for prolonged periods and he refused food. Delu¬ 
sions concerning various portions of his body were present. He also had 
hallucinations of hearing which gave evidence of exaltation. Stereotyped 
attitudes and movements were marked and there were several periods of stupor. 
He had been ill for seven months without showing any improvement. He then 
received treatment with thyroid for 3J months and he lost his delusions and 
hallucinations. He became voluble in speech and unduly cheerful when he was 
removed home by his relations. I understand that both of these conditions passed 
away some months later. Family history ; A sister had a mental attack. 

A. B—, female, set. 25. She had always been of an introspective, reserved 
disposition, and, in this respect, quite unlike her sisters. She had a period of 
excitement followed by stupor. She then showed herself in a delusional and 
hallucinated state. The delusions were of a quaint character and had reference 
chiefly to her body. She thought that her arms and legs had been removed from 
her and that she had been buried alive. Indifference, stereotyped attitudes and 
movements were also a feature of the case. The illness had been present in a 
marked state for four months when she received thyroid. After a further two 
months she was remarkably improved, but there was still some evidence of auditory 
hallucinations. She was, however, removed home as her parents considered her 
sufficiently recovered to allow this. The hallucinations persisted for some months 
longer and then disappeared. Family history: Her maternal grandmother and a 
maternal aunt became insane and did not recover. 

E. R—, male, aet. 23. The illness started acutely with hallucinations of sight, 
violent conduct, and wandering habits. Later confusion, silence, slowness of 
movement and cerebration became evident. He had the habit of blinking his 
eyelids when he was addressed. If he answered, the reply often came in the form 
of a repetition of the remark addressed to him. He assumed stereotyped attitudes 
Sometimes he gave very absurd answers to even simple questions. He has been 
ill for thirteen months and on treatment with thyroid for four months. Nearly all 
his symptoms have disappeared. Family history: A sister had a mental attack. 

J. M—, male, aet. 25. At first he exhibited negativism. He became silent and 
resented all attempts at conversation. At intervals he had mildly excited periods 
of short duration. He evinced little interest in anything and his energy was 
markedly diminished. Physically he appeared to be in bad health, though no 
organic changes could be found. His facies was suggestive of tuberculosis. He 
had been ill for nine months and appeared to be failing both mentally and 
physically when thyroid was administered. An almost immediate improvement 
took place in his physical appearance. Later he became talkative and mildly 
energetic. He has now been taking the drug for five months, and were it not fora 
want of interest in his work and the absence of desire to go home one could find 
little wrong with him. The family history in this case is very meagre. 

The outlines of these few cases, which had been diagnosed as 
belonging to the entity of dementia praecox, may help to show that 

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242 NATURE OF THE PSYCHOPATHIC INHERITANCE, [July, 

■except where there is distinct evidence of dementia, a reasonable 
hope of success lies in this form of treatment. In order to obtain 
good results, the treatment must be given at an early stage of the 
disease, before marked degenerative changes have taken place in the 
cortical cells, and the drug must be administered with persistence. 
To account for the difficulty of success one must dwell a moment on 
the family history of these people. 

If we look over the list of cases which I have described, one cannot 
but be struck by the fact that in those patients suffering from the 
manic-depressive psychosis, the insane inheritance is more apt to 
show itself in an individual of the same generation as the patient 
who has been treated. 

Now, although the cases I record do not demonstrate this point, 
the family history in dementia praecox is more liable to give evidence 
of mental attacks in relatives belonging to the preceding generation. 
Sir Frederick Mott (2) has shown that mental disease tends to terminate 
within three generations, and that the nature of the illness is liable 
to assume a more gross form with each succeeding generation. This 
limitation to the life of the inheritance is in striking agreement with 
the words, “ Unto the third and fourth generation,” as declared in 
the Commandment. After this number of generations the stock dies 
out or there is a change to the normal type—thus fulfilling the law of 
filial regression. So, when one considers the curability of dementia 
praecox, one is up against an insane inheritance that has probably 
existed for at least two generations, and if one accepts the hypo- 
thyroidal hypothesis, it is probable that there has been a deficiency 
of thyroid secretion in the generation preceding the first insane one, 
and, therefore, a hypo-thyroidal effect in at least three generations. 
This is a very important point in the causation of dementia praecox. 

The pathological findings in the disease have been responsible for 
certain theories concerning its causation. Sir Frederick Mott (3) holds 
that it is due to a regressive atrophy of the sex glands, parallel with 
which certain changes take place in the central nervous system. In 
his examination of the thyroid gland of patients who had suffered 
from dementia praecox he noted that the weight of the gland was 
below normal as a rule, but he was not prepared to associate the 
change in the reproductive organs with any constant microscopic 
changes in the thyroid. Laura Forster (4), in an examination of the 
ovaries, has shown that similar degenerative changes exist therein. 
Matsumoto (5), however, points out that removal, disease or destructive 
injury of the sex organs in puberty or adolescence are not followed 
by dementia praecox, and he concludes that this disease is a mani¬ 
festation of a germinal deficiency, and that the neurones undergo a 
premature decay. 


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243 


Having regard to the function of thyroid in the matter of the 
organism’s growth, it will not be difficult to appreciate the potential 
evil effects of several generations of hypo-thyroidism upon the 
durability of either the sex glands or the neurones when sufficient 
strain is placed upon them. Kojima (6), while not coming to any definite 
conclusion concerning causation, has noted, after investigating the 
weights of the ductless glands in no cases, that in certain females 
in whom the thyroid gland was small the ovaries also were remarkably 
small. Recently Ford-Robertson (7) has described a number of cases 
which have responded to immunisation with vaccines, but at the 
same time he recognises the presence of “ an inherent defective 
resistance to the action of bacterial toxins.” He cites the intestine 
as the habitat of the infecting organisms. In this connection it is my 
experience that the administration of thyroid has a marked effect 
upon the nature of the faeces. It is one of the most potent deodorants 
of the motions that I know of, which I account for by its action in 
stimulating the various digestive glands to increaise their production, 
and also to the virtue possessed by it of raising the immunity of the 
tissues. 

No matter which of these views one may accept, it will leave the 
nature of the inborn defect unsolved. It is my belief that these 
various degenerations and infections occur in an individual who has 
suffered from a deficient secretion of thyroid. 

As additional evidence towards proving the association of mental 
•disease as a whole and hypothyroidism the following points may be 
noted: 

It is known that patients who suffer from goitre are much more 
liable to mental disease than normal people. On the contrary, 
Graves’s disease would appear to be somewhat rare in the insane, 
•for among some 800 admissions to St. Patrick’s Hospital I have 
never seen a pronounced case of it. There have been many cases 
that one might be suspicious of in this respect, but there has not 
been a single one that could be accepted as an example without 
having some doubt attached to it. 

Again, hypothyroidism means not only a small amount of thyroid 
secretion. Under certain circumstances, which frequently occur, 
great irregularity of secretion follows. One can conceive the influence 
of this in the production of stigmata of degeneration which are so 
intensely common among insane people. The same irregularity 
may be accountable for the remarkable feature best expressed in 
JDryden’s words: 

“ Great wits are sure to madness near allied, 

And thin partitions do their bounds divide.” 


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244 nature of the psychopathic INHERITANCE, [July,. 

Hertoghe (8) has shown that nerve-cells are not destroyed in myx- 
oedematous infiltration, but that they become infiltrated and depressed. 
May this not be the reason why febrile attacks are liable to produce 
improvement or recovery in the insane ? Fever is known to stimulate 
both the thyroid and supra-renal glands. These patients would, 
therefore, be receiving the equivalent of endocrine treatment. Myxoe* 
dema is recognised as being of a hereditary nature, which liability 
is more frequently transmitted through the mother.(9) So far there 
is not any pathological evidence to show the presence of a hereditary 
cerebral cause of neuronic degeneration. Further, retardation of 
metabolism is very often a marked accompaniment of mental disease, 
especially in its chronic stages ; the thyroid is a most potent activator 
of this process. 

There has still to be accounted for a very considerable proportion 
of people who develop mental disease and yet whose inheritance, 
under the most strict investigation, will fail to show mental disease- 
within a couple of generations. Sometimes an example of dementia 
praecox occurs in this manner, and its presence has been explained 
as being evidence of a “ throw-back.” 

Now, on going through family histories, there are certain diseases 
that seem unusually common among the insane. They also have 
the further association of running in families. I have little doubt 
that these diseases can replace or equalise a psychopathic inheritance, 
and that, therefore, this psychopathic inheritance is not confined to 
mental disease alone. It may cover tuberculosis, asthma, alco¬ 
holism, gout, some gastro-intestinal affections and malignant 
disease. 

If this supposition should be correct, it would easily account for 
dementia praecox occurring without any apparent psychopathic 
inheritance—in other words, the inheritance would appear in the 
guise of am associated disease. A common time for dementia praecox 
to make its appearance in a woman is in the period following her 
first confinement. The same liability has been experienced in the 
development of tuberculosis. 

One of the functions of the thyroid concerns the control of iodine- 
in the body. I need not dwell upon the benefit to be derived from 
various preparations of this drug in several of the diseases mentioned 
above, but with regard to one preparation containing iodine, namely, 
potassium iodide, it has been stated (io) that this drug produces some 
of its actions by increasing the secretion of thyroid. 

It cannot be denied that chronic inflammatory conditions of the 
gastro-intestinal tract are very liable to be followed by malignant 
disease of the area affected. Recently (i i) it has been declared that in 
the course of investigation upon the cause of cancer, a certain sero- 


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1922.] THE THEORY OF “HERD INSTINCT.” 245 

logical procedure produced a similar reaction in tuberculosis, some 
bacterial diseases, and malignant disease. 

There would seem to be sufficient evidence to warrant the supposi¬ 
tion that hypothyroidism may act in these diseases in the same manner 
as I believe it to act in the case of mental disease—that is as a predis¬ 
posing cause which is capable of being transmitted from one generation 
to another, and which permits the more immediate cause of the 
particular disease to flourish. 

Further, there is some evidence that in acute mental attacks this 
■sub-thyroidal state is followed by a hyper-thyroidal condition, which 
would point towards an attempt of Nature to throw off a possible 
infection, and, therefore, to the importance of the thyroid in main¬ 
taining immunity to disease. 


References. 

(1) McCarrison.— The Thyroid Gland. 

(2) Sir Frederick Mott.— Journ. Ment. Sci., July, 1921. 

(3) Idem. — Ibid., July, 1921. 

^4) Laura Forster.— Arch. Neur. and Psych., vol. vii, 1918. 

(5) Matsumoto.— Journ. Ment. Sci., Oct., 1920. 

{6) Kojima.— Proc. Roy. Soc. Med., vol. x, Section of Psychiatry. 

(7) Ford-Robertson.— Journ. Ment. Sci., Jan., 1922. 

(8) Hertoghe.— Practitioner, Jan., 1915. 

(9) Osier.— Practice of Medicine. 

(10) Rendle Short.— The Newer Physiology in Surgical and General 
Practice. 

(11) Simpson.— Brit. Med. Journ., Feb. 25th, 1922. 


Critique of the Theory of “ Herd Instinct (*) By Ian D. Suttie , 
M.B., Ch.B., F.R.F.P.&S.Glasg. 

When we speak of a “ herd instinct ” we mean an innate motive 
^conscious) or impulse (unconscious) determining social conduct, or 
at any rate regulating individualistic tendencies in such a way as 
to make social life possible or necessary. Such a conception is of 
•considerable significance for medicine in its psycho-social applications, 
and has already attained considerable currency with sponsors of such 
authority as Sir Clifford Albutt and Sir Frederick Mott, to say nothing 
•of Macdougall and other psychologists who accept this theory. Its 
relation to the Freudian doctrine of the “ censorship ” has been 
pointed out by Trotter himself, and, if established, it would prove 

(') A paper read at the Spring Meeting of the Scottish Division at Glasgow, 
March 17th, 1922. 


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246 THE THEORY OF “HERD INSTINCT.’’ Duly, 

no less significant for the theory of hypnotism and suggestion. Indeed, 
for the future development of any criminology or psycho-pathology 
that takes account of conative affective endowment and of the influence 
of social environment, the acceptance of this theory must be crucial. 

The criticism and verification of so important a conception is then 
a matter of the greatest interest. Unfortunately it has proved to 
be of no less difficulty, on account of the indefiniteness of the theory 
and of its lack of all positive content. If we attempt to pin it down 
to any position, to discover its implications, we shall be accused of 
misrepresentation. In fact, the assumption of a gregarious (herd) 
instinct is not formulated in any way, so that its logical coherence 
or consistency with established fact and accepted theory cannot be 
tested. In these circumstances the liability of the notion to abuse 
is obvious. The very descriptive aptitude of the term enables it to 
serve as a cloak for ignorance and slovenly thinking, so that it may 
actually obstruct research and obscure the issues by giving a false 
impression that the analysis of motive is complete. 

To avoid this the concept must be given a clear and definite meaning,, 
and, since the term “instinct" has been applied to it, we are justified 
in assuming that all the recognised characteristics of instinct are 
attributed to it by those responsible for its currency. It is not of 
course denied that in some form the conception of “ associative 
tendency ” may be valid. All that this paper aims to show is that 
its conception as an instinct is unphilosophical, unscientific and un¬ 
necessary. To show, then, that the concept of “ herd instinct ” is. 
invalid, it is merely necessary to demonstrate a difference in kind 
between the associative tendency and the instincts generally recog¬ 
nised as such. I hope further, by tracing the genesis of this fallacy, 
to satisfy you that there is no justification for the retention of the 
notion. 

Before proceeding to criticise “ herd instinct,” it would be as well 
to emphasise two essential characters of instinct in general, upon 
which there is general agreement and without which the conception 
would be empty and worthless : 

(1) Instinct is germinally determined and transmitted, is exercised 
prior to experience, and generally early in life (Shand). Though 
modifiable, it cannot be acquired, and it differs from “ learned ,h 
reactions in many important particulars. 

(2) When we distinguish specific instincts, we imply that each 
particular one so named has a relative independence. If regarded 
as a psycho-physical disposition, it has its special, if subordinate,, 
integration; if regarded as a class of reaction (behaviour), it must 
be supposed to have some degree of homogeneity, at least of common 
function. Instincts generally accepted as such mostly have a definite 


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1922.] 

organic basis. Subjectively they are associated with specific interests 
or motives. As behaviour, they have an equally specific adaptive 
function (indeed, I maintain that instincts, appetites, etc., often 
represent no more than the descriptive concepts resulting from an 
abstract analysis of functional adaptation). Whether we look at instinct 
from the point of view of biology (as a type of active functional 
adaptation to environment), or from that of physiology (as a class of 
reaction, a reflex integration or an organic system), or from that of 
psychology (as a group of motives or feelings), we find always the 
implication of ultimacy, of unity. Even where not explicitly stated, 
the conception plays the part of a prime factor, and entity, causal 
or functional, a conative element (in the sense in which chemistry 
still utilises the conception of its elements as relatively ultimate). 

Now, there is no d priori reason why a descriptive abstraction 
arrived at in one field should be the exact correlative of another 
attained (perhaps by different methods, etc.) in some other field. We 
see now that there was no justification for Gall’s expectation of finding 
a cerebral centre for “hope,” “destructiveness,” etc. (application 
of psychological abstractions in the physiological sphere), yet errors 
of this sort are rife. Macdougall contemplates leaving the classifica¬ 
tion of instincts and emotions to the biologists; but if they choose 
to abstract adaptive behaviour into two (self-preservation and repro¬ 
duction), or two hundred instincts, will he be equally ready to dis¬ 
criminate discrete psycho-physical dispositions correlative thereto t 
The physiologists will certainly not allow that the biological unity 
of the function of self-preservation finds a counterpart in a special 
organic integration. Appetite has indeed more in common with the 
sex instinct than with pain, with which it is actually incompatible. 
The smuggling of conceptions between these three sciences is a 
dangerous and unscientific game. Though we must assume a corre¬ 
lation possible, and work towards it, we must not assume one ready 
made for our convenience. Instinct is a term in use in all three 
with implications in all three, and in my opinion should be used as 
a sort of vital “ x." This would, of course, restrict its use to the 
correlation of these three sciences, since, deprived of any definite fixed 
connotation in any one of the spheres, the sciences must be indepen¬ 
dent of this conception and must exclude it from their terminology. 
A classification of instincts would be a sort of intermediary, subject 
to continual tentative re-definition, and would not admit of the inclu¬ 
sion of an instinct not represented in all three fields of thought. 

I have already mentioned a possible abuse of the conception of 
a specific instinct, as permitting the “ rounding off " of inquiry at 
any convenient point and conveying an illusory impression of com¬ 
plete .knowledge. Obviously the only heuristic justification for 


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248 THE THEORY OF "HERD INSTINCT.” [July, 

conceiving instinct as ultimate is its use to correlate function, motive 
and reactive mechanism, and its progressive definition and relation 
to the more precise conceptions proper to each field of investigation. 
Unless we limit its (the term “ instinct ”) usage to this fluid tentative 
meaning we shall wall up the path to knowledge with our own ideas. 

As currently employed, “ herd ” or “ gregarious ” instinct is little 
more than a verbal proposition. Social conduct is due to “ gregarious 
instinct.” Does this tell us anything about social conduct or help 
Us to discover the motives and mechanisms that determine it ? Surely 
the value of the conception we are criticising is purely descriptive, 
not suggestive or explanatory. We shall now see that it cannot be 
imagined, defined, or verified in any of the phenomenal fields to 
which it is ostensibly applicable. 

Physiology, regarding instinct as a chain reflex of an arbitrarily 
distinguished degree of complexity, has no definite place for this 
conception in its (physiological) formulae. Organ-systems, mechanisms 
more or less integrated, centres for the co-ordination of reflexes, 
it recognises as forming the structural correlative for many of the 
propensities, but not for every aspect of behaviour that an analysis 
of adaptation and conditions of life can discriminate. This structural 
basis is demonstrable in the case of instincts of sex, parentage, nutrition 
and locomotion; a bio-chemical integration is made out for fear, 
rage, etc. Though it will be claimed that the physical basis of herd 
instinct consists in a complex connection of cerebral paths, it is not 
unfair to point out that this is conjectural, difficult to imagine, and 
that, even if we accept its possibility, this circumstance constitutes 
an important difference between the gregarious impulse and the 
instincts. We are asked to imagine an instinct without any special 
Organ to originate and transmit stimuli or to discharge its function, 
or to be the intermediary between the germinal “ Anlage ” and a 
psychic function. 

' In the field of psychology we are invited to recognise the subjective 
aspect of herd instinct in the form of a craving for companionship. 
The social sentiments, we are told, develop from this impulse. Varia¬ 
tion in sociability without corresponding variation in ethical character 
presents a difficulty by no means satisfactorily explained. We can 
hardly imagine the innate basic impulse to vary without causing its 
derivatives to vary. The theory here presents other difficulties also 
in the nature, mode and time of acquisition of the social sentiments. 
They do not appear in children, who are not even sociable. Their 
development coincides in a noteworthy way with the establishment 
of the sexual function, and their nature, like that of the conduct 
they motivate, is complex and highly evolved—the very antithesis 
of the type of reaction, etc., we are accustomed to call instinctive. 


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They are acquired, and with difficulty, are variable and easily lost 
in disease, and they are open to a number of interpretations. Intro¬ 
spective analysis is notoriously inadequate to analyse emotion, and 
the gregarious instinct has admittedly a peculiarly weak, elusive and 
indefinite emotional accompaniment. On a psychological basis alone 
no one could justify this conception. 

If “herd instinct” has no definite and accepted meaning in physio¬ 
logy or psychology, it can have no use beyond that of describing 
behaviour and assisting the interpretation of evolution in terms of 
survival value. I think it can be shown that it lacks even descriptive 
validity, inasmuch as it is based on an arbitrary classification, imperfect 
-observation, and several traditional assumptions that are quite 
fallacious. 

I have pointed out elsewhere ( Lancet , November 19th, 1921, 

Significance of Sex for Anthropology,” etc.) the majority of animal 
societies—ant, bee, ruminant, etc., upon whose social behaviour the 
conception is based—are in reality families —sexual units—and that 
the fact of their cohesion does not imply any bond of union other 
than that of sex. In the same way symbioses and certain other 
^associations indicate that alimentary instincts and fortuitous environ¬ 
mental circumstances may determine the gregarious habit. What, 
then, constitutes a society ? How can we recognise the presence and 
operation of the gregarious instinct ? Upon the possibility of such a 
definition and criterion depends the justification of the hypothesis 
of a special gregarious instinct. 

Besides this artificial distinction between social and asocial animals, 
other fallacies are implicit in our traditional point of view, which 
lead us to regard minds as individual and autonomous, and as com¬ 
posing society and culture by their association and interaction. 
It is more in conformity with the facts to treat mind as a social 
product, as the embodiment of cultural contacts, and from this point 
of view the postulate of an instinctive harmonising control is super¬ 
fluous. 

The introspective method in psychology, theological speculation 
t (e.g., free will) and philosophical idealism culminating in solipsism 
indicate how, and to what extent, mind has been regarded as individual 
and autonomous. The first attempt at a comparative psychology 
Revolutionary) was not the interpretation of higher in terms of simpler 
behaviour, but the attribution to lower forms of life of qualities of 
reason, morality, etc., which are merely human ideals. This anthropo¬ 
morphism may have been due in some measure to the current 
conception of instinct as the antithesis of reason, and as a mechanism 
implanted for the fulfilment of Divine purpose. Such an anti-scientific 
•conception, far from aiding in the interpretation of behaviour, had 


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250 THE THEORY OF “HERD INSTINCT.” [July, 

itself to be combated or given another meaning. As we know, many 
biologists and psychologists, including Darwin and Romanes, actually 
came to explain instinct in terms of reason as “ lapsed intelligence,’* 
though the former, of course, sought here, as always, to reduce teleo¬ 
logical to mechanistic explanations by the principle of chance variationa 
(in impulsive endowment). The earlier evolutionary psychologists, 
however, did not dare, or were unable, to initiate the attempt to 
explain human in terms of animal behaviour. Interpreting the latter 
in terms of a psychology false even in regard to civilised man, it is 
no wonder that these earlier thinkers found that the social integration 
of minds % and especially of insect minds, was a phenomenon so remark¬ 
able as to justify any hypothesis. 

The tendency in favour of simpler, more positive and mechanistic 
explanation {e.g., Lloyd Morgan’s special rendering of the “ canon of 
parsimony ” and the contentions of the Behaviourist School) no 
longer permit us to regard such theories as explanations at all. Innate 
impulse as a function of structure, and hence germinally determined, 
is now the ultimate principle—the vera causa —in terms of which it is 
our business to formulate behaviour. 

We have now, however, fallen into the error of accepting a super¬ 
ficial classification as a true induction. Any activities sufficiently 
homogeneous and striking are constituted a group and referred to 
the operation of a unitary motive (as above). Social behaviour is- 
supposed to be determined by “ herd instinct.” Notwithstanding 
this radical change in method and terms of interpretation, the under¬ 
lying fallacy remains the same. We still regard insect co-operation 
and communal organisation with astonished admiration because we- 
still unconsciously attribute to them our own lazy, selfish, playful, 
variable, experimentally destructive, etc., etc., etc., nature. It is- 
this attitude to the problem (a relic of our prescientific phase of 
education and thought), and this preconception of the independence- 
of mind, that causes us to feel that some special explanation is re¬ 
quired, that some “ agency ” must be discovered to account for the- 
fact that ant, bee, and other insect communities do not fall into 
disorder and dissolve in anarchy. 

Imperfect observation and dramatic exaggeration of the harmony 
of insect societies, the attribution to these creatures of human com¬ 
plexity and variability, ( J ) and of a degree of mental independence 
and individuality wholly untrue of man himself, invest the phenomena 
of animal communal life with an atmosphere of wonder and romance. 
We do not inherit the problem, of course, but we are certainly brought 
up to it. 

The fact is that mind is social in origin and content, and individu¬ 
ality is largely an illusion due to the complex interplay of cultural. 


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251 


influences. It is selected, moulded and developed to cultural or 
traditional pattern, not constrained or subordinated thereto by a 
regulating motive. Every step in every possible line of development 
is a step in social development, and we must not separate in our 
minds the process of development from the process of socialisation. 
They are identical, and if we make this arbitrary and abstract distinc¬ 
tion, we will have to reunite them, to bridge our artificial chasm 
by some hypothesis such as that under discussion. Minds do not 
co-operate to form culture; they are not the units whose combination 
forms society, but are formed by society. 

Impulse, however, is not acquired, though affective-conative 
disposition may to some extent be socially harmonised by habit and 
organic sympathy. On the other hand, this endowment is relatively 
simple even in men, and in insects is highly stereotyped. To this 
extent the possibilities of disharmony are minimised, and when we 
take into consideration the practical absence of sex-rivalry among 
insects (where it can appear, it is expressed as frankly and aggressively 
among social as among asocial animals), we still further reduce the 
justification for the postulate of an instinctive regulating “ agency ’* 
with the function of stabilising society. 

In man, on the contrary, there is abundant need for an active 
gregarious instinct. Unlike insect communities his societies do not 
form mere reproductive units, while the plasticity of his instincts, 
the complexity of his culture, and innate organisation, give rise to 
a variability and individuality of disposition which subjects his social 
organisation to considerable strain. Here, surely, we should be 
able to find evidence of a gregarious instinct in the form of a “ cate¬ 
gorical imperative.” Subjectively this is nebulous, and we have no 
certainty of its congenital nature. Objectively we find everywhere 
formidable organisations based on force: authority and obedience, 
whose functions are to do what the “ gregarious instinct ” and its 
derivatives fail to do, namely, to maintain order, uniformity and 
social cohesion. Though the interpretation of the customs of govern¬ 
ment, etc., is debatable, its general bearing is against the hypothesis 
of a special social instinct. Unless we reduce our conception of herd 
instinct to so general and a-specific a form that there will be no justifi¬ 
cation or use in regarding it as an instinct, we cannot explain why 
training and compulsion should be so conspicuous a feature of human 
social life. 

We have already mentioned the absence of a specific somatic 
mechanism proper to the gregarious instinct. Structural characters 
and their functions are, we know, inherited; the generally recognised 
instincts (nutrition, reproduction, defence, locomotion, etc.) have 
their own demonstrable organic integration and usually special 


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252 THE THEORY OF “HERD INSTINCT.” [July, 

receptor-effector mechanisms. It is certainly difficult to imagine 
the germinal determination of a psychic disposition without any 
organic correlative. Other difficulties also present themselves when 
we attempt to think out the implications of the hereditary trans¬ 
mission of “ herd instinct.” Its manifestation is adult, while the 
rule (Shand would make it a criterion of instinct) is for instinct to 
appear early in life—at least in rudimentary and playful forms. Again* 
we must note that both subjectively and objectively gregariousness 
appears to be a sentiment. As such, we must hold it to be acquired 
and even highly evolved within the limits of ontogeny. Finally, if 
we do not classify animals as social and asocial, we have seen that 
we cannot radically differentiate social from sexual associations. If, 
on the other hand, we do make this arbitrary distinction, we must 
imagine the germinal variations which determine the social habit 
as occurring convergently in different phyla yet limited to certain 
species of a genus. 

Convergent adaptation has certainly occurred, but the identity 
is limited to the end-result—the fact of communal life, not its mode 
or causes. The social habits of ants and men are merely analogous 
and only in respect to adaptation and survival value. There does 
not appear to be any real homology, sociological, psychological or 
physiological. Yet we are asked to believe that this type of behaviour 
is determined by -a specific instinct—a psycho-physical disposition 
identifiable in different phyla (as subsumed under one conception 
having a psycho-physical implication). It is difficult enough to 
conceive a specific (integrated) disposition capable of determining 
the complex and subtle modifications of behaviour we call social. 
It is harder still to imagine its germinal determination. I find it 
incredible that convergent variation should have produced a specific 
disposition psycho-physiologically identifiable in organisations so 
diverse as those of man and insect. But if we adopt the current view 
of the distribution of the gregarious instinct, we must suppose that 
these variations have occurred frequently, and so late in ontogeny 
that certain species only out of a genus—(are any genera or larger 
groups wholly social?)—have been affected, and, of course,indepen¬ 
dently. 

Conclusions.—One of three alternative views of gregarious instinct 
may be adopted: 

(i) That it is really, universal, but may lie latent. 

This brings it into line with other instincts, gets rid of the difficulty 
of distinguishing social from asocial animals and of the impossible 
problem of its origin and distribution. On the other hand, it leaves 
the theory more speculative than ever, still without arty definite 
psycho-physiological meaning, and aggravates the difficulty of dis- 


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253 


tinguishing the effects of the social from those of the sexual 
instinct. 

(ii) That it denotes merely a type of behaviour without implying 
any identity in the psycho-physical mechanisms determining this. 

Such a definition is logically unobjectionable, but is not in accord¬ 
ance with current usage of the term “ instinct.” It further definitely 
denies the conception of herd instinct any validity for psychology 
or physiology, sociology or psycho-pathology. Since the causal 
mechanisms and motives which determine the behaviour may vary 
indefinitely), all that is common to the instinct as manifested by 
different species is its adaptive significance (survival value as affecting 
evolution). 

(iii) The conception of “ herd instinct ” as analogous biologically, 
physiologically and psychologically to sex, nutrition, etc., with the 
exception that it is a specific character of limited distribution, is the 
view here criticised and rejected on the following grounds (it is the 
current conception, and indeed the only one that could have any real 
heuristic value, and has been exclusively considered on that account): 

(a) The theory of “ gregarious instinct ” is formulated to solve a 
problem that is factitious and illusory. It rests upon a false concept- 
tion of mind as individual and autonomous and the anthropomorphic 
interpretation of animal behaviour in terms of that misconception. 
It has other disreputable metaphysical antecedents and relationships. 
It necessitates an arbitrary classification of animals as social and 
asocial without regard to the fact that most infra-human associations 
are reproductive units, and hence not essentially different from the 
families classed as asocial. It ignores the facts of the conative 
simplicity and stereotypy of insects, that their solidarity and specialisa¬ 
tion is organic, therefore mechanically determined by the nature 
of the other instincts, not by a special regulative instinct; that their 
harmony, so far as it extends, is really a unison. Human beings 
betray their lack of innate adaptation to social life by the universal 
and conspicuous phenomena of coercion and authority—a social 
and not an internal, individual control. 

(1 b ) There is no structural integration of the “ gregarious instinct,” 
unlike instincts proper. (The increase of the social sentiments at 
puberty suggests an association with sex.) On this account both its 
germinal determination and subjective representation are much more 
difficult to understand. 

(r) Subjectively the mere impulse to associate is not constant or 
definite enough to be indisputably distinguished from a possible 
sexual derivative or component. The social sentiments, which are 
all that can be verified on introspection, are, like all their class, the 
very antithesis of instincts, the most elaborate acquired reactions 


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MEDICAL EXAMINATION OF DELINQUENTS, {J ul y> 


(orientations of emotional reaction) we know of. This is supported 
by the facts of child psychology. 

(d) We cannot account biologically for the distribution of the 
instinct (sic !) determining the social habit. 

Philosophically, the presuppositions and methods upon which this 
postulate was erected will not bear examination. Psychologically, 
biologically, and physiologically, it has the slightest foundations, and 
raises difficulties vastly more formidable than those it solves. In every 
respect it is so indefinite, so lacking in positive content, that it serves 
more readily the purpose of disguising ignorance and evading diffi¬ 
culties than of increasing our grasp of the complexities of reality. 
I suggest that its use has that tendency and no substantial justification. 

(*) Their organic specialisation is overlooked or even attributed to their social 
habits. 


The Medical Examination of Delinquents.^) By M. Hamblin 
Smith, M.A.Camb., M.D.Durh., Medical Officer, H.M. Prison, 
Birmingham. 

At the Annual Meeting in July, 1921, it was my intention to have 
amplified in a modest way our President’s address, in which he 
dealt with the desirability of greater union between the various 
services which touch upon the “ mental ” side of medicine. I pro¬ 
pose now to offer some remarks on this question as it affects the 
prison service, and it seems a necessary preliminary to say something 
about the position of the prison medical officer. 

It is curious to-day to read John Howard’s book on prisons as he 
found them in the eighteenth century. The medical side was then, 
practically, non-existent. Many of the prisons had a surgeon attached 
to them. But he seems only to have come in when his services were 
specially required. In some cases he is noted as receiving a salary 
which looks to us almost ludicrously small, often being £5 or £10 
annually. In other cases the quaint remark occurs, “ No salary ; he 
makes a bill.” It is not quite clear to whom this bill was “ made.” 
Probably, in many cases, it was to the prisoner. It may be taken for 
granted that the arrangements for our particular specialty were 
-even worse, if that be possible, in prisons than in the outside world. 

I need not say that all this is now quite a thing of the past. And 
for many years every prison has had a regular medical officer as part 
of its establishment. His duties and functions have, however, under¬ 
gone remarkable developments. In the first instance, it would seem 

(*) A paper read at the Quarterly Meeting held in London, November 22nd, 
1921. 


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255 


likely that his duties consisted mainly or entirely in the treatment 
of prisoners who were physically ill. This most necessary work still, 
of course, continues. Our prison hospitals are, so far as my experience 
in the larger prisons goes, well built and well equipped. Many improve¬ 
ments in these buildings have been made during the past twenty 
years. The nursing staff also has altered—much for the better. And, 
on this side of his work the medical officer should find plenty of 
interest. A constant stream of diseased conditions of every kind 
passes through his hands. And, especially in a convict station, he 
will find most interesting opportunities of observing the effect of 
diet and work on persons who are for long periods under his direct 
view, and whose conditions are fixed. He has also the chance of 
watching the gradual development, in either direction, of various 
forms of disease. But this work has even a greater interest than that 
of the physical side. For we are beginning to see how various physical 
ailments conduce to delinquency. They can, of course, only do this 
in so far as they affect the mental life. And there are several ways 
in which this may come about. 

(1) A man who suffers from a severe physical defect—hernia, tuber¬ 
culosis, defective vision, etc.—is, to some extent, predisposed to 
delinquency, inasmuch as he is handicapped in earning his living in 
the ordinary labour market. We may hope that the future will see a 
great development in the direction of the cure of herniae by a radical 
operation, and the correction of defects of vision by glasses, to take 
only two obvious instances. Much is being done, also, in the way of 
the treatment of venereal diseases by the latest methods. 

(2) All who have studied the question must see that early formation 
of good habits of industry, etc., is of the first importance as a preven¬ 
tive of delinquency. Now the physically defective man or woman 
is handicapped in this direction. The phthisical or cardiac case is 
unable to work regularly. The physically weak child is often kept 
away from school. Bad habits are thus formed early. Further, these 
cases naturally receive an extra amount of sympathy from their 
relatives, and they come to expect this. There is thus produced a 
decided predisposition to neurotic troubles, and to delinquency also. 

(3) Again, take the case of a boy with very defective vision. The 
defect may not be known to anyone. But the boy will not be able to 
do his work at school. Consequently he may be in constant trouble 
with his teachers, and he may be rebuked and punished for careless¬ 
ness, inattention, and stupidity. Ignorant of the real cause of his 
trouble, and conscious that he has been doing his best, a mental 
conflict may be the result, and this may ultimately issue in the form 
of delinquency. With the system of school medical inspection in our 
large cities such cases are now discovered and treated. But it is likely 


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256 MEDICAL EXAMINATION OF DELINQUENTS, [July, 


that a delinquent career in many older offenders has been started in 
just this way. 

(4) Once more, certain physical disabilities act in another way. 
They tend to make their possessor anti-social because they induce 
the feeling that he is not as other men are. Epilepsy and severe impedi¬ 
ments in speech may be specially mentioned in this connection. And 
instances of a number of other similar cases have come under my 
notice. The result of the anti-social feeling thus engendered may be 
delinquency. 

But the medical officer’s duties soon grew far beyond the limits 
of the treatment of physical illness. It soon became obvious that it 
was impossible to exercise a rigid uniformity for all offenders in the 
way of work, of diet, and of punishment for offences against discipline. 
Wide discretion had to be placed in the medical officer’s hands as 
regards these matters. And, in these respects, it is not easy to see 
how the powers now vested in him could be usefully increased. The 
sanitary arrangements also came, naturally, within his scope. And, 
having regard to certain difficulties under which we have to work, 
and which are perhaps inherent in the nature of the case, I do not 
think that our present conditions, in this respect, leave much to be 
desired. But I have said enough to indicate the importance of physical 
conditions, and we take more interest here in the “ mental ” side of 
the work. Here, again, there has been a great development. I suppose 
that at one time the medical officer’s duties in this respect were 
confined to the certification of cases of legal “ insanity." A prisoner 
was taken to be either insane, within a somewhat rigid legal definition, 
or to be regarded as quite normal. In this way, however, the ideas 
held in prisons did not differ materially from those held outside. 
But, gradually, the conception arose that a man might not be certi- 
fiably “ insane," and yet that his mental state was such that his 
treatment as an entirely normal person was evidently absurd and 
required modification. It also began to be clear that many persons 
of this type found their way into our prisons, and that their delin¬ 
quency was largely due to their mental condition. Modifications of 
disciplinary conditions were made to suit these cases, and they were 
placed largely under the medical officer’s direct charge. The passing 
of the Mental Deficiency Act of 1913 was, at least partly, caused by 
the influence of the prison authorities. And much evidence was given 
from prison sources before the preceding Royal Commission. We are 
now able to deal with mental defectives, who find their way into 
prison as convicted persons, by certifying them under the Act. I 
shall touch later on the question of dealing with such cases of defect 
before they are sentenced. 

But more is being done. The teachings of psychology have, at least, 


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1922.] 

made one thing clear. We see that conduct is the direct result of 
mental life. And most important consequences follow from this 
position. We see now that we cannot divide our delinquents into two 
classes, one of which contains persons who present mental problems 
for our solution, while the other consists of persons who are entirely 
“ normal.” Every offender presents a problem, and this problem is 
an individual one. As a result, every offender is worthy of investiga¬ 
tion. And to this as our ultimate goal we must look forward. It is 
really as unreasonable to deal with a delinquent without this full 
examination as to prescribe for a patient without examination. And 
to deal with all cases, say of larceny, on the same lines, is as irrational 
as the old plan by which all patients with a cough were given mist, 
pro tuss. But for this universal investigation of offenders the time 
has not yet come. Possibly public opinion is not yet ready for such 
a scheme. And we have not got the staff to do the work. Nor could 
we get the workers, even if the community were willing to pay for 
them; they do not exist in sufficient numbers. So we have three 
objects to keep in view: We have to educate the public and the 
Courts to see the absolute necessity of the work; we have to do as 
much work on these lines as we have time for ourselves; and we 
have to train our examiners of the future. 

For many years every hour which remained to me after the perform¬ 
ance of my routine medical duties has been given to the theoretical 
consideration and the practical elucidation of the problems connected 
with the mental aspect of delinquency. It is clear that in so vast a 
subject—for we are dealing with nothing less than the science of 
human conduct—no one can do more than follow up one or two lines 
of work. My chosen lines have been— 

(1) The selection and application of a scheme of mental tests. My 
earlier work, as is the case with most workers in this subject, was 
done with the Binet scale. But for a number of reasons, to set out 
which in detail would take me far too long for your patience, I became 
dissatisfied with this scheme. I feel sure that many of these tests are 
quite unsuited for our particular purpose. And I am by no means 
certain as to the propriety of much of the present-day talk about 
“ mental age.” After prolonged experimentation with a great number 
of tests, I have at last evolved a scheme which I believe to be well 
suited to the purpose, and which I now use for every case which I 
consider suitable for formal “ testing.” I propose to deal with this 
scheme, and with some of the results obtained by its use, in a book 
on the subject which I hope will be published early next year. But 
I will say here, that no one who has not tried it can have any idea 
how much valuable information concerning the mental characteristics 
which are of importance in the production of delinquency is to be 
LXVIII. 19 


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258 MEDICAL EXAMINATION OF DELINQUENTS, [July, 

obtained by the observant use of a good scheme of “ tests.” I refer 
to such characteristics as observation, memory, attention, persever¬ 
ance, control of mental processes, ability to comprehend a situation 
and to plan a piece of work, ability to profit from errors, susceptibility 
to the influence of suggestion, and the like. 

(2) More recently I have been led to the consideration of the 
wonderful light which is shed upon the problems of delinquency by 
the theories of the so-called “ new psychology." Whether we are, like 
myself, humble disciples of Freud, or whether we adopt one of the 
other hypotheses of the unconscious mind, we shall find that it gives 
us, not additional information, but an entirely new conception of the 
problem. The future, in this respect, is very hopeful. For it is certain 
that our views of delinquency will have to be entirely changed. I do 
not wish to say that there is always a mental conflict at the root of 
delinquency. I will not here enter upon that highly controversial 
topic whether such a conflict is always of a sex character. But this 
much is certain. There often is a mental conflict, and the discovery 
of this may alter the whole way in which we regard our offender, 
and our ideas of his proper treatment. Instance after instance of 
such conflicts have been found by me in my work. And but for the 
very limited time which I can give to psycho-analysis (I need not 
remind you, the large amount of time required is one of the great 
drawbacks to the extension of this branch of practice) very much 
more would have been found. We shall yet see a great develop¬ 
ment in this mode of investigation and treatment of delinquency. 
And a scheme will have to be carefully devised, by which suitable 
cases will be placed under the care of official psycho-analysts. Many 
other conditions—epilepsy, neuroses and psycho-neuroses, various 
psychopathic conditions, alcoholism in various forms (to mention 
only a few)—have to be considered in different cases. 

Much excellent work is being done at many prisons in England 
at which one or more whole-time medical officers are employed. And 
I would not have it thought that I wish for one moment to suggest 
that Birmingham has the only prison at which such work is attempted. 
But Birmingham is in one respect, or so I believe, unique in this 
country. The justices of that great city, being dissatisfied with the 
former arrangements, applied to the Prison Commissioners to have 
a medical officer appointed who would take a special interest in this 
work. As a result I am, in my office, an integral part of the city’s 
scheme for dealing with its delinquents. Constantly consulted by the 
justices, and, I hope I may say, trusted by them, my position is one 
of which I am highly proud, and which I would not lightly change. 
The justices have also appointed Dr. W. A. Potts to act as examiner 
in cases which it is not desired to send to the remand part of the prison. 


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Any case in which, either from the nature of the offence, or for any 
other reason, there appears to the court to be any element of doubt, 
is referred to Dr. Potts or myself, by far the larger number coming 
to me. At the prison we have a male and a female remand department, 
■specially fitted up. These departments are quite distinct from the 
prison proper, and they are arranged and worked as far as possible 
on what I may term “ hospital lines,” the idea of prison being kept 
quite out of sight. My plan is to allow the first few days to pass by 
with only general conversation with the patient, unless an attempt is 
to be made to see if analysis is likely to prove useful. Then, towards 
the end of the remand period, a suitable time can be arranged for a 
formal examination, with “ mental tests ” if thought desirable. The 
patient thus has time to become accustomed to his surroundings and 
to myself. Any nervousness on his part is overcome. And we try to 
make him realise that he is regarded, not as an offender, but as a 
problem which is presented for our solution, and that my only desire 
is to understand and to help him as far as possible. There is also the 
advantage that the examination can be fixed when I have proper 
time to devote to it, for it is supremely necessary that this examination 
should not be hurried. Much can also be learned from the observations 
made on the patient by the attendants. All these advantages are 
only to be had in some form of institution. 

Owing to the operation of this scheme it is now very rare to get 
a mental defective or a psychosis case from the City of Birmingham 
■on conviction. I wish I could say the same for all the courts in my 
district. Some of the smaller courts do their work in this respect most 
casually. It is not uncommon for us to receive a convicted case with a 
note stating that mental examination appears to be desirable ! 
Actually imbeciles have been sent in this way. And when I add that 
the sentence is sometimes too short to allow of the case being dealt 
with under the Mental Deficiency Act, the futility of the whole pro¬ 
cedure will be apparent. There is no excuse for action of this kind in 
such a district as Birmingham, and there should be no excuse any¬ 
where. There are many reasons why mental examination before 
conviction is preferable to such examination after conviction; indeed, 
in many cases the latter procedure may be quite misleading. 

In this connection I would mention that I feel very strongly that 
the country should be divided into convenient districts, each with a 
properly equipped prison with a special medical officer in charge, to 
which all cases requiring mental examination should be sent, irre¬ 
spective of the particular prison to which the general body of prisoners 
from any county or district is committed. There are no doubt adminis¬ 
trative difficulties, but these can surely be overcome. It is unreason¬ 
able, it is not fair to either party, to expect this work, which is highly 


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260 medical examination of DELINQUENTS, [July, 

specialised and takes much time, to be done by a part-time medical 
officer, who is usually a busy local practitioner with no special know¬ 
ledge of mental diseases. 

The only alternative plan, so far as I see, is to have travelling 
mental examiners in each district who can attend where their services 
may be required. This plan is now being tried in the State of Illinois. 
It has the advantage of not committing the case to prison. But there 
is a loss of those other advantages which I have enumerated as arising 
from having the case under close observation in an institution. Further, 
it would often imply the examination being conducted in unsuitable 
surroundings, and at a time when the examiner or the patient was 
not in the best mood for the purpose. 

I should mention that, at the end of the remand period, which is 
extended if I so desire, I report on the case. I detail my findings, 
mental and physical, and make suggestions for treatment. The justices 
then decide, having my report in view, what the disposal of the case 
shall be. As a result, during the two years I have worked in Birming¬ 
ham, less than 25 per cent, of these specially remanded cases have 
been sentenced to imprisonment. I do not for one moment claim 
that the remaining 75 per cent, would have been sentenced to 
imprisonment but for my report. But I do claim, with some con¬ 
fidence, that a large proportion would have been so dealt with. And 
this fact represents a large financial saving to the community, to take 
the question on its lowest grounds, and quite apart from all the other 
obvious benefits. In fact, it is becoming clear that “ uninvestigated ’* 
offenders are about the most expensive luxury in which any com¬ 
munity can possibly indulge. 

Our plans are not yet perfect. I am not wholly satisfied with the 
way in which cases are selected for this special examination. I hope 
to see the day when every court will sit with a medical assessor. 
This plan was suggested in a Bill which was to have been introduced 
for the improvement of the Probation Act. This, like other useful 
legislation, has probably been shelved from lack of time. 

Now I shall be asked why the local asylum officers cannot do the 
work in their several districts. I trust that the asylum officers, who, 
of course, form the great majority of our members, will not be offended 
when I say that, in my opinion, they are not, at the present time, 
the ideal people to do this work. Some of my reasons are as follows : 

(1) Merely having worked in an asylum, for however long a period, 
does not, per se, qualify a man for work with delinquents. There are 
special problems connected with this work which many asylum officers 
have not studied. I have, for instance, found asylum officers who 
were quite unacquainted with the legal problems involved in cases 
of insanity for trial at Assizes. 


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(2) At the present time most asylum officers see only developed 
cases of insanity. No doubt this will be remedied in the future. 

(3) If a patient once gets the idea that an attempt is being made 
to prove him to be insane or mentally defective, he will resent it, 
and this may cause the results of the examination to be misleading. 
It seems to me possible that the presence of an examiner who may be 
known to be connected with the local asylum is very likely to produce 
this undesirable result. In this connection I may mention that the 
title to be given to the examiner is not of unimportance. Such terms 
as “ psychiatrist ” or “ psychological expert ” are somewhat alarming 
to, and are not fully understood by, the laity. This has been felt so 
much in America that the title of “ mental health officers ” has been 
suggested. 

If, however, a closer union between the prison, the asylum service 
and the service which deals with mental defectives were to be arranged, 
the situation would be entirely altered. And we might hope to have 
a unified service, working in each district under a local head (perhaps 
the superintendent of the asylum), who would be the director, the 
organiser, and, above all, the inspirer of all the mental work in his 
•district. His fellow-workers would all have been required, as juniors, 
to have done their turn in each of the three great divisions of our 
subject. When a man had proved his special competency for one 
particular branch of the work, he could, of course, be kept at that line. 

It seems to me that he who would deal with delinquents requires 
■certain definite qualifications. He requires, of course, an adequate 
knowledge of general medicine, and to have made a special study of 
insanity and of mental defect. But, further, it seems that he should 
have some appreciation of “ philosophy.” It is not necessary that he 
should adopt any particular theory of the relations between physical 
-and psychical processes, or of the other great questions of this char¬ 
acter. But he cannot comprehend our special problems, which go right 
to the foundations of human life, without having some knowledge of the 
various theories which have been held, and without having decided upon 
that particular theory which most commends itself to his own mind. 

We may hope, also, to see the day when special instruction in the 
various subjects of our study, and of a diploma.therein, will be an 
integral part of our system. If is a matter for congratulation that 
so many teaching bodies are now taking up this question. The Univer¬ 
sity of Birmingham is holding, next summer, a short post-graduate 
medical course on the “ Medical Aspects of Crime and Punishment.” 
The Prison Commissioners have expressed their full sympathy with 
this scheme. And I am glad to be able to say that we can make 
arrangements for members of the class to see the practical work as it 
is done in Birmingham Prison. And it is hoped that, if this course is 


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MEDICAL EXAMINATION OF DELINQUENTS. [July 


a success, it will lead on to a diploma in the subject. Anything^ 
which tends to promote interest in and study of our problems is 
to be welcomed. There are many controversial questions involved. 
These will have to be fought, not without dust and heat. But the 
end will be peace. 

And we must not, in this connection, overlook the importance of 
the school medical officer. His functions also have developed. And 
he is no longer concerned only with tonsils, adenoids and the like. 
The psychological aspect of education is of vast importance. The 
beginnings of delinquency go back to early life—far further back than 
was, at one time, deemed possible. The real, basic problem of delin¬ 
quency is not its cure, but its prevention. And surely the places 
where delinquency can be prevented is in our homes and our schools. 
The second of these are more under our control than the first. And 
a really good system of education, in the true sense of the word, 
would prevent much delinquency in after life. It has often been said 
that the true function of a teacher is not to attempt to form the 
pupil’s mind upon some predetermined ideal, but rather in accordance 
with those possibilities and dispositions which he may find to be 
inherent in the pupil’s mind. It is the task of education to ensure 
that, as far as may be possible, no future harm to society, or to the 
child itself, shall ensue from the dispositions of the child ; that the 
child’s natural tendencies are guided in useful directions; and that 
there shall be no future need for a process of re-education, which is, in 
a sense, what psycho-analysis means. In the furtherance of this great 
ideal the school medical officer is called upon to play an essential part.. 

I must apologise for having trespassed so long upon your patience, 
and for having dealt so largely with w"hat may be regarded as matters 
of administration. Whatever may be the other objects of such a 
society as ours, its scientific work transcends them all. I should have 
liked to have dwelt at further length on the scientific aspects of my 
work. But it seems to me that the time has not yet, perhaps, come 
for any definite pronouncements. Still, administrative matters are 
useful, and, indeed, are necessary. And I trust that I may have 
at least done something towards showing how important is the proper 
examination of delinquents. I hope that the asylum medical officers 
or physicians may be disposed to look upon the service which deals 
directly with delinquency as a sister service, and not so much, as has 
been the case in the past, as a “ sister-in-law.” And may a closer 
union between the asylum, the prison, the mental deficiency and the 
school services be a step in the direction of what is but the dream of 
the present, but is the hope of the future—one great, universal, unified 
medical service. 

(For the discussion which followed see pp. 101-4.) 


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“ FORGETTING.” 


263 


“Forgetting.”?) By C. Davies-Jones, M.B., Ch.B.Edin., Ashhurst 
Hospital, Littlemore, Oxford. 

I have taken as my title for this short paper the word “ Forgetting/' 
But I think it would be well to explain that I do not think it would 
be satisfactory to attempt to touch upon all forms of forgetting in 
the time allotted to me. I shall, therefore, not enter at all into the 
question of the more serious and complete amnesias such as are met 
with in the practice of psycho-analysis. Such amnesias are brought 
about by mental traumata, which then result in a dissociation of the 
painful memory from consciousness. They are more grave in their 
nature and formation than the cases of “ forgetting" to which I 
wish to confine myself. 

Prof. Freud, of Vienna, claims that forgetting, whether it be in 
relation to words or deeds, is not a mere fortuitous occurrence incapable 
of rational explanation. However trivial it may be, a reason for its 
production can generally be found by psycho-analytic methods. 
Sometimes it may be so insignificant as to call for no attention; on 
the other hand, an apparently trivial amnesia may prove to have in 
its origin material of great importance. One means of gauging the 
importance or value of an amnesia is the emotional affect accompany¬ 
ing it. If, in other words, the subject experiences mental pain or 
distress in connection with the forgetting or the attempt to remember, 
then we can generally take it that the condition merits investigation. 

Numerous instances are forthcoming, I venture to submit, of 
things forgotten in the every-day lives of all of us. By this I do not 
refer to those instances where the subject forgotten has failed to 
make a sufficient impression upon the memory to achieve its retention. 
Such cases are met with normally in states of preoccupation, and 
only differ in degree from those found in cases of confusion and states 
of anxiety. It is rather with the type of forgetting in which the 
impression has been made but where a bar to its revival has been 
introduced that I am going to deal. 

Sometimes we find ourselves forgetting things we feel that we 
should not forget, or perhaps we experience that tantalising 
sensation of having a word on the tip of the tongue. All of these 
conditions are capable of examination, and to those who wish to 
take anything of the nature of an active interest in psycho-analysis 
useful opportunities for exercise in the method are thereby afforded. 
It is with regard to the forgetting in the psycho-pathology of every-day 

(*) A paper read at the Quarterly Meeting held in London, November *2nd, 
1921. For discussion vide pp. 104 ^. 


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264 “FORGETTING.” [July, 

life that I wish to bring to your notice Wo instances which I hope 
may prove interesting. Before doing so, I feel that it would be well 
to outline as briefly as possible one or two details. 

This form of forgetting is an active process ; we forget because we 
do not wish to remember. It would therefore be expected that we 
should wish to forget what is unpleasant or what clashes with our 
innate tendencies. This is a broad statement, but it is borne out in 
practice, though at times the “ wish ” is somewhat difficult to discover. 

In forgetting, an active force is brought to bear— i.e., the unpleasant 
element is repressed or pushed away into oblivion. Every time that 
a resuscitation of the painful memory occurs, or is likely to occur, an 
attempt is made to thwart its expression. Eventually the repression 
will become a part of the unconscious itself. It will cease to find its 
outlet by being remembered. Nevertheless it has a latent energy 
which can never be destroyed. Expression in consciousness will be 
found in some way or other—most frequently by routes so devious 
that the patient is unable to discern for himself whence the trouble 
arises, and yet feels a sense of dissatisfaction frequently amounting 
to great distress in relation thereto. If we trace back step by step 
by the psycho-analytic method, one will arrive at this source once 
more—it can be brought to consciousness, and a new and better 
adjustment made for the condition causing trouble. 

Freud employs the method of free association to achieve this. 
The person under examination is instructed to say freely whatever 
comes into his mind without let or hindrance. The analyst will collect 
this information and prevent the patient from leaving the main 
channel, etc. In the two instances I now quote I hope you will be 
able to see more clearly what I have in mind. 

In the first instance the name of one’s servant is forgotten on 
every occasion when one has need to use it. The name is discovered 
to be Dean, and the fact that it has been habitually forgotten is 
excluded. Free association leads on as follows : 

Dean—the Dien in Ich Dien—I serve—to serve the mass at Church 
—the words the “ Sacrifice of the Mass ”—something given up or 
taken away—a loss—the attach^ case lost off the Maltese cart at 
Menin—Dean was responsible for packing the cart, through his 
negligence the case was lost. Dean did not serve well by losing it— 
its contents were of great sentimental value to the owner. He must 
not be reminded of the loss; he must forget all that reminds him, 
incidentally Dean. 

The second instance is somewhat more intricate. 

A friend of mine forgot for two hours how to tie his necktie one 
morning. At this time he was the transport officer in the battalion 
and wore a stock. I allowed him to go on talking, and it was as 


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265 


well that I did, for a curious lapsus lingua helped to connect up his 
associations later. He said the following : 

" After trying I went and had my dinner—I mean breakfast.” 
It was evident that the word “ dinner” was what one calls a complex 
indicator. I inquired whether he slept well or had any dreams. His 
reply was, “ I never dream ; when I go to bed I die till the morning.” 
Then, as an afterthought, “ Of course I sleep; I don’t die.” This 
last utterance led me to ask him to associate upon death. He said 
that death reminded him of his brother’s death which had just recently 
occurred. The news created a very profound impression upon him. 
He thought of the Christmas and New Year’s dinners his family kept 
during his brother’s lifetime; then of the fact that his family were 
congratulating themselves by a toast at dinner over the fact that all 
the boys were safe when the news of the brother’s death arrived, 
changing their joy to sorrow. His brother’s kit arrives home in driblets, 
keeping the wound open. Then in a flash he remembers that on the 
previous morning he had had half a mind to wear an ordinary stiff 
khaki collar. He was fitting a tie into it when he noticed his brother’s 
name marked on the collar. 

Memories flooded to his mind of the day some time ago when his 
brother, home on leave with him, was getting rid of collars and gave 
him these. My friend spoke as follows, showing another lapsus: 

“ He was hunting through his ties and gave me fifteen or more ties, 
all different shapes and sizes, saying, ‘ Here, old chap, you can have 
these ties.’ ” I then remarked to him, “ Blit wasn’t it collars ? ” 
He replied, “ Of course—I’ve got ties on the brain this morning.” 
We then proceeded a little further, and he remembered that he finally 
decided not to put on the collar because it reminded him of his brother’s 
death. 

We are now in a position to sum up. 

To wear his brother’s collar needs an unusual tie. This means that 
be must exercise care in tying it. Moreover, to wear the collar recalls 
his brother’s death, which is a painful memory. Next morning he 
forgets how to tie a tie at all, so that the collar used may not remind 
him of his sorrow. The effect at repression was unsuccessful, however, 
as he suffered great distress. 

Before I end I ought to say that the analysis brought much more 
to light out of this apparently trivial matter. The dead brother, for 
instance, was the youngest—the baby of tfce family. “ He even 
couldn't tie his tie,” said my friend, and, in following this train, we 
discovered that the wish was not only to forget the death, but to 
replace the dead brother; to do so it became necessary to be unable 
to tie one’s tie. 

(For the discussion which followed see pp. 104-6.) 


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CLINICAL NOTES AND CASES. 


[July. 


Clinical Notes and Cases. 


Lilliputian Hallucinations.( l ) By Dr. Leroy, of the Maison Blanche, 
Asile du D6partement de la Seine. Communicated by G. W. B. 
James, M.C., M.D.Lond., D.P.M.Lond. 

Last November, while on a visit to Paris, I was kindly received at 
the Maison Blanche, one of the hospitals of the Ddpartement de la 
Seine, by Dr. Leroy, who showed to me a considerable number of his 
patients. Some of them raised the subject of hallucinations, and 
Dr. Leroy demonstrated one case in which the hallucinations were 
of a somewhat unusual type, and before I left gave me a short article, 
the substance of which he begged me to communicate to the Medico* 
Psychological Association. Dr. Leroy is particularly anxious to 
hear if similar observations have been made by his English colleagues, 
and I hope to be able to forward to him some remarks from those- 
present at this meeting. 

Leroy first called attention to what he terms Lilliputian hallu¬ 
cinations in 1909. Since that date he has made several communica¬ 
tions to French medico-psychological societies describing cases in 
which this type of hallucination has occurred. 

The patient sees small figures, men and women, about 20 cpi. 
in height. The figures are almost always dressed in bright 
colours: for example the breeches of the men are yellow and the- 
coats are red or blue ; the women wear brightly coloured shawls. 
The figures are in some cases accompanied by animals, generally 
horses, whose size corresponds to that of the other figures. They 
may occur singly or in small groups, but more commonly in consider¬ 
able numbers, some patients describing actual orderly processions, 
marching two by two. The figures appear to talk together, grimace, 
and even play hide and seek among the articles of furniture in the- 
room. Their reality is a striking feature of the hallucinations; the- 
patient seems to be actually viewing the country of Lilliput, whence 
Leroy’s descriptive title. The duration of the hallucinations varies. 
Commonly they last half an hour or thereabouts. Leroy cited a case 
in which the figures appeared daily for over two years. Aural hallu¬ 
cinations do not appear to accompany the visual disturbance. 

Leroy has observed that the condition occurs most commonly in 
patients suffering from alcoholism, drug toxaemias, senile dementia, 
and, less commonly, general paresis. 

In contrast to the alarming nature of most toxic visual hallucina¬ 
tions, with their accompanying psychic state of fear, or at least anxiety, 

( l ) A paper read at the Spring Meeting of the South-Eastern Division, May 2nd„ 
1922. 


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1922.] 

these Lilliputians arouse interest and amusement in the patient, 
only rarely producing apprehension. The patient is obviously 
absorbed, laughs from time to time, and will describe the hallucina¬ 
tions to others without hesitation. 

Two typical cases follow: 

The first, a young alcoholic woman, escaped one evening from the house of her 
friends in order to visit the cur6 of the village. On her way she found herself 
surrounded by a crowd of small persons, gaily dressed, and frolicking along the 
road and the walls of the houses bordering the road. When she reached the 
presbytery the figures even attempted to prevent her ringing the bell. This 
patient was not afraid, and exhibited these hallucinations repeatedly during her 
illness. The appearance of the Lilliputians followed a period of acute alcoholic 
delirium in which the typical fearful visual hallucinations had occurred. 

The second case described is that of an elderly man, who had an old rheumatic 
cardiac lesion, and suffered also from albuminuria. This man described a 
procession of little figures, from 15 to 20 cm. in height, who, dressed in their 
best clothes, marched in procession through his room, entering by the window and 
leaving by the wall paper. They generally appeared in the evening, and sometimes 
at night. The patient was amused by them, laughed at them, and occasionally 
pursued them with his stick. In the closing months of his life this case developed 
ideas of reference and exhibited some anxiety about the hallucinations. 

Leroy states that similar hallucinations are recorded in The Life 
of the Saints, as occurring to St. Macaire, who lived in the fourth 
century. This man appears to have mortified himself to excess, so 
that he was probably suffering from the toxins of starvation. 

To summarise, then, Leroy reports the characters of the so-called 
Lilliputian hallucinations as small, very vivid visual hallucinations, 
usually of living figures about 20 cm. in height. The figures 
are gaily coloured, active, may occur singly but more often in large 
numbers. They are to be observed in toxic states accompanied by 
mental confusion, and are agreeable to the patient, in striking contrast 
to the usual terrifying visual hallucinations seen, for example, in 
alcoholism. 

Note .—Members of the Association who have made observations 
of similar hallucinations are requested to forward them to Dr. James, 
Moorcroft House, Hillingdon, Middlesex, who undertakes to translate 
them and forward them to Dr. Leroy. 


The Arneth Count in Insanity. By Eric Ponder, M.B., Ch.B.Edin. 

(From the Department of Physiology, University of Edinburgh.) 

Cooke (i) has made a study of the changes in the Arneth count 
met with in tuberculosis, and records the fact that in many diseases 
of an infective nature there is a “ left-hand dislocation ” of the count 
such as is found in tuberculosis. He further records that such a 
“ dislocation ” occurs in cases of insanity, and he gives counts derived 
from cases of locomotor ataxy, general paralysis, epilepsy, imbecility; 
and senile dementia. The cases considered are only twelve in number. 


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268 CLINICAL NOTES AND CASES. [July, 

Cooke remarks that this change in the count in insanity requires 
further explanation. It appears that the first thing necessary is not 
explanation, but amplification. 

In this paper will be considered the results of Arneth counts made 
in 417 cases of insanity. These results will be treated statistically. 
No explanation of the deviations from the normal will be offered. 

The method of making the count was that recommended by Cooke ; 
this method has been found satisfactory, consistent results being 
obtained after some experience. The blood was drawn from the ear ; 
the stain used was Giemsa. The count was based on the observation 
of 100 polymorphs. 

Instead of giving, for any case, the Arneth count in full— i.e., the 
numbers of cells with 1, 2, 3,4 and 5 lobes to the nucleus respectively— 
it is convenient, when dealing with large numbers of cases, to express 
the count as a single number. There are two ways of doing this : 
•one by calculating the “ index ” of Bushnell and Trucholtz, and the 
other by using the “phagocytic index” of Hamilton Black(2). The 
latter index is based on his observation that the phagocytic powers 
of cells with I, 2, 3, 4 and more lobes to the nucleus are in the ratios 
10:18 : 22 : 25 : 25. The “ index ” is obtained by multiplying the 
number of cells with a one-lobed nucleus by 10, the number with a 
two-lobed nucleus by 18, the number with a three-lobed nucleus by 
22, and the number with nuclei more complex by 25, the number of 
xells observed being 100. The normal index may be taken as about 
2,000. This index is a function of the count, and its variations may 
be studied instead of variations in the count itself, thus obviating the 
difficulty of dealing with the five sets of figures of which the count is 
composed. Indices obtained in this way will therefore be used in this 
paper throughout. 

The cases studied were 417 cases of insanity, patients in the Mon¬ 
mouthshire County Asylum, Abergavenny. All were males. They 
are divided as follows : 

(l) Into groups depending on the presence or absence of tubercular 
infection ; and (2) into groups according to the nature of the mental 
condition. 

(1) Since it is very difficult to decide which cases were infected with 
tuberculosis and which were not, the method adopted was to classify 
as tubercular all patients suffering from the disease in an active condi¬ 
tion, and all who, during their residence in the institution, had been 
known to show signs or symptoms of the disease. Some of the tuber¬ 
cular group are thus cases of quiescent tuberculosis. 

(2) The classification according to mental condition was made 
according to the system laid down by the Board of Control of England. 

The mean of the indices (M) for each group is given, and also the 


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highest (c*) and the lowest (e 1 ) extreme met with in the group. The 
standard deviation (<r) and the co-efficient of the variation (C) for 

each group is given. The probable error of the mean ( E„) is — 

when n is the number of cases in the group. The value of 3 E„ is also 
expressed for each group, since differences between means, greater 
than this value, are of significance. It has been thought unnecessary 
to give the value of E„. 

The result obtained from the study of the 417 cases is given in 
Table I. 

In Table I the result in normal cases is inserted for comparative 
purposes, and is based upon Cook’s normal cases. 

Table II is obtained from Table I, and expresses the means and 
probable errors in order of magnitude, in tubercular and non-tuber- 
cular cases respectively. Table III gives the means, etc., for tuber¬ 
cular and non-tubercular cases, irrespective of mental condition, and 
shows the effect of the tubercular factor. Table IV gives a comparison 
between the mean of the non-tubercular melancholic and maniacal 
cases (i.e., the recent cases), and the mean of the other non-tuber¬ 
cular cases of insanity (the chronic cases). 

The tables are largely self-explanatory. 


Table I. 



n. 

*h. 

e i. 

M. 

0. 

c. 

En. 

3 E„. 

Normal cases = 60. 

60 

2163 

1820 

2007 

71-25 

35 

&2 

18*6 

Congenital cases = 34. 

Not tubercular . 

• 2 3 

1769 

>395 

1550 

no* 1 

75 

16*3 

489 

Tubercular 

. II 

1476 

127 6 

1406 

6096 

43 

12*4 

37‘2 

Dementia praecox = 33. 

Not tubercular . 

. 24 

1679 

1390 

> 53 » 

92-51 

60 

12-74 

38*22. 

Tubercular 

• 9 

1546 

J320 

1418 

72-47 

5 > 

>63 

489 

Mania = 10. 

Not tubercular . 

8 

1685 

XS>6 

1615 

6685 

4 * 

* 5*9 

47-7 

Tubercular 

2 

1657 

1372 

1464 

> 5 >-> 

10-3 

72* 17 

2165 

Melancholia = 24. 

Not tubercular . 

. 12 

1749 

>520 

1015 

7 >" 3 * 

4-4 

13*9 

4>7 

Tubercular 

. 12 

I 59 i 

> 33 > 

1452 

8 S -43 

58 

168 

50*4 

Epilepsy — 32. 

Not tubercular . 

. 24 

1818 

>399 

> 55 » 

949 

6-o 

13*08 

3924 

Tubercular 

. 8 

1404 

> 3>9 

>354 

303 

2*23 

7*2 

21*6 

General paralysis = 23. 

Not tubercular . 

. 18 

1723 

1375 

1500 

83-43 

5-4 

13*24 

39*72 

Tubercular 

• 5 

1407 

1385 

*394 

7-68 

0-55 

2*29 

687 

Paranoia *» 62. 

Not tubercular . 

. 46 

1770 

1352 

1563 

9 ^* 5 * 

OO9 

957 

28*7 

Tubercular 

. 16 

1552 

1144 

1380 

9276 

67 

15-6 

46*8 

Dementia * 100. 

Not tubercular . 

• 155 

*794 

1250 

1513 

120*5 

79 

6*53 

>9-59 

Tubercular 

. 44 

1492 

i *39 

>358 

94-95 

69 

9*64 

28*92 



*h. 

e t. 

M. 

0 , 

c. 

En. 

3E„. 


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Table II. 


According to mental 

Not tubercular. 

Tubercular. 


condition. 

M. 



M. 

E n. 

3 *». 

Mania 

. 1615 

»59 

477 

1464 

72*17 

216-5 

Melancholia 

• 1615 

» 3’89 

41-67 

1452 

16*8 

50-4 

Paranoia 

• «563 

957 

2871 

1380 

15*6 

46-8 

Epilepsy . 

• 1558 

1308 

3924 

1354 

7*2 

21‘6 

Congenital 

• 1550 

16-3 

489 

1406 

12*4 

372 

Dementia praecox 

• 1530 

1274 

3822 

1418 

1 6*3 

48-9 

Dementia 

• » 5 i 3 

653 

1959 

»358 

9*64 

2892 

General paralysis 

. 1506 

13-24 

3972 

*394 

2*29 

6*87 


Table 

III. 





Normal. 

Not tubercular. 

Tubercular 


« 

60 

. 

310 

• 

107 


M . 

2007 

• 

1556 

. 

*403 


<r 

* 7*2 5 

. 

38 85 . 

. 

39 *oi 


E n • 

6*2 

• 

9 27 . 

• 

9*30 


3 £n 

18*6 

• 

2781 . 

• 

279 


Table IV.— 

-N on-tubercular cases, 310. 





n. M 

a. 

E n . 

3 E„. 

All cases except mania and melancholia 

200 IS 30 01.8 TC 

io*5 

Manias and melancholias . 

. 

. 20 1615 68 

XJ V 

* 4*3 

429 


Difference of 

means 

= 85 - 3 *« 

= 53-4* 




To these tables may be added two short tables, conveniently con¬ 
sidered separately—a table of the indices of patients who died and 
who were examined for tubercle post-mortem, and a table of indices 
of patients who were discharged recovered. 


Table V.— Cases of Death (not included 






Index. 

Post-mortem notes. 

Mental condition. 

1788 

No tubercle found. Aortic disease 

Paranoia. 

1500 

Tubercular pneumonia . 

. Paranoia. 

1400 

No tuberculosis .... 

. General paralysis. 

1346 

Tubercular pneumonia . 

. Dementia. 

133J 

Miliary tuberculosis 

Dementia. 

1276 

No tubercle. 

General paralysis. 

1252 

Tubercular pneumonia . 

. Dementia. 

Il 68 

Miliary tubercle .... 

. Dementia. 


Table VI.—“ Recovery ” Cases (not included in 417 


Mental state. 

Index on 
admission. 

Index on 
discharge. 

Tubercle. 

Mania 

1440 

1899 

No 

General paralysis 

. 1480 

1507 

No 

Epilepsy 

1818 

1962 

No 

Epilepsy 

1523 

1716 

No 

Dementia praecox 

1 33 2 

1526 

T.B. hip 

Melancholia 

1444 

1742 

N 


cases). 

Notes. 

Recovered. 

Improved. 

Improved. 

Improved. 

Improved. 

Recovered. 


Discussion. 


It is obvious that in insanity there is a marked “ dislocation of the 
-Arneth count to the left,” the tendency being for the polymorphs to 


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be possessed of a simple nucleus rather than of one divided into several 
lobes. The figures given above confirm Cooke’s observation. The 
“ dislocation ” met with in insanity is not caused by tuberculosis; 
in cases of mental derangement where no tuberculosis exists, the dis¬ 
location is well marked (Table III); if tuberculosis be present the 
amount of this left-handed dislocation of the count is increased. 

When cases of insanity are grouped according to mental condition, 
the values of the means of the indices of the various groups do not 
•differ greatly except in the case of melancholia and mania— i.e., the 
“ recent ” cases—as opposed to those of long standing (Tables II, IV). 
That the difference between the mean of the non-tubercular maniacal 
and melancholic cases differs from the mean of the other non-tuber¬ 
cular cases by more than three times the probable error justifies the 
consideration of maniacal and melancholic cases as a group apart, in 
•which the Arneth count is less dislocated than in other types of insanity. 

Table II, column 2, bears this out. 

Table V confirms the statement that a dislocation of the Arneth 
count can exist in insanity in absence of tubercle. 

Table VI shows that an improvement of mental condition may be 
accompanied by a return of the Arneth count towards normal. 

Conclusions. 

(1) In various forms of insanity the Arneth count shows a left- 
handed dislocation. This dislocation is not due to tuberculosis. 

(2) The dislocation is greater in amount if tuberculosis is co-existent 
with the insanity. 

(3) Cases of recent mania and recent melancholia show a less marked 
dislocation of the count than do cases of other forms of insanity. 

(4) Improvement in the mental condition may be accompanied by 
a change of the Arneth count in the direction of normality. 

References. 

(1) Cooke, W. E .—The Arneth Count, 1914. 

(2) Hamilton Black.— Brit. Med. Journ., January 18th, 1913. 


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.] 

Rex v. Ronald True. 

Reported by Dr. M. Hamblin Smith. 

The case of Rex v. Ronald True, tried at the Central Criminal 
Court in May, before Mr. Justice McCardie, raised in an acute form 


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272 RECENT MEDICO-LEGAL CASES. [July, 

the old dispute as to “criminal responsibility.” And the storm of 
public excitement which it created has directed attention to the 
position of the medical witnesses in such cases. 

True was indicted for the murder of a prostitute, in a flat at Bromp- 
ton. The woman’s death was due to strangulation ; and, in addition, 
five severe wounds had been inflicted upon her head. The motive 
suggested by the prosecution was robbery, inasmuch as money and 
jewelry had been taken from the fiat. That the woman was murdered 
by the prisoner was not seriously disputed. And the sole point 
which arose in the case was the question of the prisoner’s state of 
mind. 

True, who is thirty years of age, appears to be the son of a wealthy 
mother. She had always provided him with funds, and there was 
no evidence that she had ceased to do so. He had been educated 
at a well-known public school. It was stated that he had always 
been considered an abnormal boy. After leaving school he farmed 
in New Zealand. Later he got into the Royal Air Force, and had 
two bad “crashes.” He had become addicted to the use of morphia, 
and was at one time taking 30 gr. daily. He had been in two nursing 
homes for the treatment of this habit. And he was convicted and 
fined in October, 1921, for obtaining morphia by means of forged 
prescriptions. There was much evidence of the existence of those 
mental characteristics which are common in morphinism—the boastful¬ 
ness, the disregard for truth, the invention of sensational stories 
without any apparent motive, the lack of foresight, etc. And there 
was also evidence that he had a definite delusion, to the effect that 
he was impersonated by another man named Ronald True, and that 
this man was trying to murder him. The prosecution attempted to 
break down this last piece of evidence by suggesting that it was not 
to be considered as a genuine delusion, inasmuch as there appears 
actually to be another man of that name, who is known in some 
forms of London society. The defence urged that this actual Ronald 
True was not the man referred to by the prisoner, and that the 
prisoner’s idea on this matter was a genuine delusion. And this 
latter view was the one taken by the medical witnesses. 

The medical evidence called for the defence was exceedingly strong 
and entirely unanimous. Dr. Norwood East, medical officer of 
Brixton Prison, had True under observation for about two months 
from March 8th, which date was only two days after the murder. 
He formed the opinion that True’s idea as to impersonation was a 
genuine delusion and he was prepared to certify him as insane. 
Dr. Young, also of Brixton Prison, gave evidence to the same effect. 
Dr. R. Percy Smith had examined the prisoner, regarded him as 
insane, and was quite prepared to certify him as such. Dr. W. H. B. 


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Stoddart had also examined the prisoner, and had formed the same 
opinion. It may be remarked that no medical evidence to rebut 
that brought by the defence was called by the prosecution, presum¬ 
ably because they were unable to find any. Some interesting evidence 
as to True’s conversation and conduct while under observation in 
the prison was given by a hospital attendant. 

Something was made by the prosecution of the fact that True had 
attempted to cover the traces of his crime. To some extent he 
appears to have done so, although that would not disprove insanity. 
But there was also evidence that he went to the shop of a tradesman 
to whom he was known, on the day of the murder, and had bought 
a suit of clothes, exhibiting fresh blood-stains on his trousers, which 
stains he accounted for by a most improbable tale. At the same 
time he showed some of the jewelry which had been taken from the 
dead woman’s flat. 

The usual discussion as to the meaning of the McNaughten criteria 
took place, especially as to the precise connotation of the words 
“ nature and quality of the act ” and the word “ wrong.” It appears 
to be agreed that this latter word connotes “ morally wrong”—that is 
to say, an act which would be generally reprobated by society. 
And this seems to be the only tenable view of “ morality,” unless 
we are prepared to postulate the existence of a special “ moral sense.” 
There was, however, nothing in the published reports which threw 
any new light on the other questions involved, or as to how an accused 
person’s “ knowledge ” of the “ nature and quality,” etc., is to be 
determined. 

During the legal arguments at the trial the case of Bellingham was 
mentioned, and it seems as if this case has still to be considered. 
Bellingham was tried in 1812 for the murder of Mr. Percival. And 
Chief Justice Mansfield, who tried the case, laid down that what had 
to be proved, to establish a defence of insanity, was that, at the 
time of doing the act, the accused man did not know that the act was 
‘‘a crime against the laws of God and Nature.” He does not appear to 
have enlightened us as to what these laws of Nature are, or how murder 
could be a crime against them. And the other part of his ruling would 
seem to exonerate a man who was able to satisfy the court that he did 
not believe in God. If we are to go back to this case, there seems no 
reason why we should stop there. And we could return to the rule 
laid down by Mr. Justice Tracey (Rex v. Arnold, 1723). And to 
judge from certain letters in the public press, this is what some 
persons think we should do. For it has been suggested that the 
proper test of “ responsibility ” is whether the accused man would 
have committed the crime had a policeman been standing at his 
elbow. 

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All the four medical witnesses stated that, at the time when they 
saw him, they were prepared to certify True as insane. And this 
test of certifiability seems to be the really reasonable one. The idea 
which underlies the process of certification is that, for the safety 
and well-being of society, a certain man should be placed under care, 
control, and treatment. If a man’s mental state is such that he 
needs the adoption of these measures, then it would seem clear that 
he cannot be held “ responsible,” in the sense of being liable to 
punishment for his antisocial acts. Conversely, if a man is not a 
fit subject for certification, then he may be held socially responsible. 
The test is a practical one, and avoids all discussion of the really 
insoluble problems as to what the man “ knew.” And it is the test 
which is adopted not only in non-criminal cases, but in the case of 
criminal offences of a lesser kind. It is unfortunate, though, perhaps, 
unavoidable, that these legal discussions nearly always take place in 
cases of murder. In the smaller offences, even those tried at assizes 
or quarter sessions, all this trouble never arises. And in police court 
work many cases never get further than the first remand: the man 
is found to be insane, is removed to an asylum, and the case goes 
no further. The test of certifiability might, of course, fail in the 
exceptional case of a man who committed a crime, and was not 
arrested and brought under observation until some time later, when he 
might have completely or partially recovered from his insanity. 

Something was made at the trial, and much has been made since, 
of the fact that no steps had been taken to have True placed under 
restraint until the commission of the murder. There is nothing 
unprecedented in this. And it is difficult to see how it can ever be 
entirely obviated under any conceivable system. Many a man has 
gone about with his insanity unsuspected or ignored until he has 
committed some crime. But, in this particular case, it is only fair 
to say that True’s wife appeared to have been contemplating the 
step of having him placed under restraint. And it is quite likely 
that, had a full examination been made into True’s mental state at 
the time when he was convicted for obtaining morphia by forged 
prescriptions, his insanity would have been discovered and dealt 
with. This is simply another argument, were any such argument 
really needed, for the closer investigation of persons coming before 
any of our courts. Deliberation and cunning are not necessarily 
disproofs of insanity. And it is interesting to observe that these 
points were just those which were raised in the public discussion at 
the time of McNaughten (see Queen Victoria's Letters , vol. i). That 
many of the patients appear to be quite sane is a remark often made 
by lay visitors to our mental hospitals. 

The judge, in his summing up, stated that he intended to go some- 


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what further than the criteria in the McNaughten case. He left 
to the jury the classical questions given in the judges’ answers. He 
further told them that if they found that the prisoner while in an 
epileptic seizure murdered the woman, they should find him “ guilty 
but insane.” Whether this really goes further than the McNaughten 
case will depend upon whether we read the questions put to the 
judges by the House of Lords, together with the answers thereto. 
If the questions are read into the answers, then a crime committed 
during an epileptic state would, probably, not come within the 
McNaughten criteria. For the questions referred to crimes committed 
by persons suffering from insane delusions. But if the judges’ 
answers are read alone, there is no doubt at all that crimes committed 
in an epileptic equivalent or a post-epileptic state would fall within 
the McNaughten ruling. Probably epilepsy was suggested by the 
defence as an attempt to bring the case definitely within the 
McNaughten ruling. There was very little in the published evidence 
which indicated epilepsy, and the results of Dr. East’s observations 
were quite against this supposition. 

The judge further instructed the jury that even if the prisoner 
knew the physical nature of the act, and knew that it was morally 
wrong and punishable by law, and yet was, from mental disease, 
deprived of the power to control his actions, then the verdict should 
be “ guilty but insane.” Whether this is an extension of the 
McNaughten ruling is a question for legal authorities to decide. Mr. 
Justice Stephen would appear to be uncertain on this point. See 
his statement as to what the law is (not what the law should be) 
in his History of the Criminal Law, quoted and discussed at length 
in Mercier’s Criminal Responsibility. But even if it is an extension, 
the proposed criterion is, from a scientific point of view, quite as 
objectionable as the old tests, and its application would give rise to 
quite as many acrimonious disputes. 

Ultimately the jury found True guilty. That they were legally 
entitled to reject, as they did, all the medical evidence seems certain. 
The ultimate decision as to the bearing of the evidence lies with the 
jury. Whether they would have as readily rejected similar weighty 
and uncontradicted evidence in a case of “ physical ” illness is a 
matter about which we may have our doubts. But it has been 
said that every layman considers himself a competent judge in matters 
of insanity. 

The case, of course, went to the Court of Criminal Appeal, and 
Sir Curtis Bennett strongly urged that the jury were not entitled to 
reject the medical evidence. But the court refused to accept this 
view, and the appeal was dismissed. The court did not give any 
decision on the question of the power of controlling actions, on the 


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276 RECENT MEDICO-LEGAL CASES. [July, 

ground that, the jury having rejected that alternative, the question 
did not arise in this case. 

The next step was the appointment, by the Secretary of State, 
of a special commission, consisting of Dr. S. R. Dyer, Sir John Baker 
and Sir Maurice Craig to examine True. There is nothing at all 
unusual in this procedure, which is definitely laid down in the Criminal 
Lunatics Act, 1884, Sect. 2 (4). And such action on the part of the 
Secretary of State was foreshadowed, both by Mr. Justice McCardie, 
and by the Lord Chief Justice, who presided at the appeal. The 
members of the commission unanimously reported that they con¬ 
sidered True to be insane. True was reprieved by the Secretary of 
State and removed to Broadmoor. It has been urged that the 
Secretary of State was not legally obliged to act upon the findings 
of the commission which he had appointed. It may be that he is 
not absolutely obliged so to do. But this would leave us, practically, 
in the peculiar position that a man convicted (say) of larceny, and 
sentenced (say) to three months’ imprisonment, and who is, in prison, 
found to be insane, is not to serve out his sentence, but is at once 
to be removed to an asylum, while a similarly insane man, who 
happens to be convicted of murder, is to be hanged. 

It has been suggested that the finding of the special commission 
indicates that True was sane at the time of the trial, and had become 
insane while under sentence. Such an occurrence is, of course, 
conceivable, although very unlikely. But such a state of affairs is 
not necessarily to be assumed. The verdict at the trial is concerned 
with certain legal views as to “ knowledge,” etc. The members of a 
special commission are not hampered by any considerations of this 
kind. Their position is precisely similar to that of physicians called 
in to inquire into the sanity of a man not under sentence, or of a 
man convicted of some crime other than murder. 

Again, it has been urged by a high legal authority that True, 
having been allowed to plead to the indictment, is necessarily to be 
considered as having been sane at the time of his trial. This reveals 
a complete misconception. The questions as to fitness to plead to 
the indictment will be found fully described in a paper in the volume 
of this journal for 1916. These questions are concerned with certain 
special points. A man, a paranoiac for example, might be quite 
insane, and yet might quite properly be found fit to plead to thfr 
indictment. 

There was an outbreak of most unedifying excitement after the 
final decision in this case was announced. The newspapers, with a 
few honourable exceptions, joined in a chorus of denunciation of the 
Secretary of State, and of the value of professional evidence in cases 
of this kind. Such manifestations are of interest to us, for the 


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1922.] 

psychology of the mass is as important as that of the individual. 
But we have an even greater reason for interest. The conservative 
legal mind realises that an attack is being made upon one of its 
strongholds. When the dust of this particular conflict has settled 
down, it will be seen that the whole trend of educated opinion at 
the present day is towards having, not less, but far more stress laid 
upon the psychological examination of offenders. The legal mind 
is always anxious to frame and apply a strict “ tariff for crime." 
But thoughtful people are beginning to see that merely to name the 
offence does not in any way characterize the offender or suggest 
the appropriate treatment. The ultimate decision must, of course, 
always lie with the administrative authorities. And it has never 
been seriously proposed that the fate of offenders should be placed 
in the hands of “ specialists from Harley Street," as one judge has 
seen fit to phrase it. 

Attempts were made to divert attention from the real issues by 
writing about “novel theories of the unconscious mind." It would 
not appear that considerations of this kind entered into this particular 
•case. But at the same time we must not forget that, whether we 
adopt the theories of Freud, or some other position, this question 
of the influence of the unconscious mind will, ultimately, have to 
be reckoned with. Another point raised was that modern theories 
reject what is known as “ free will,” and that they are, consequently, 
destructive of morality, and subversive of our system of punishment. 
This is a most unjustifiable attempt to confuse the issue. It is very 
likely that many modern scientists hold deterministic views. But 
the strictest determinism is quite compatible with the retention of 
deterrent punishment. Indeed, it may well be argued that deter¬ 
minism is the only logical basis upon which to found a system of 
punishment. 

One newspaper argued that even if True were insane, it was wrong 
to keep so “ degenerate ” a person alive; not apparently reflecting 
upon what the results would be were this principle to be carried to 
the limit. There was a reminder of the Geddes “ axe ” in the com¬ 
plaints made of the expense of keeping inmates in Broadmoor, which 
establishment was referred to as an “ asylum de luxe." Objection 
was even taken to the cost of the special commission. It would be 
interesting to compare the fees paid to the medical witnesses with 
those received by counsel in this and similar cases. 

In all these discussions it must never be forgotten that prison 
medical officers have, quite often, quashed, by their evidence in 
court, pleas of insanity of a quite unjustified nature. And also that 
juries have, before now, persisted in finding a prisoner insane, in the 
face of medical evidence to the contrary. 


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OCCASIONAL NOTES. 


[July, 


The present excitement will fade away, and saner counsels will 
again prevail. But the existing position as to the question of 
“ responsibility " is about as unsatisfactory as it well could be. It is 
likely that the courts may see fit to reconsider their rulings and their 
procedure. But the time has come for our Association to take up 
the question once more. Much has happened since the last com¬ 
mittee sat on this subject. Even if we find that the whole legal 
position is so unscientific that we cannot properly take part in it, 
that finding alone would be worth placing on record. But we need 
not take so extreme a view as yet. There should be no difficulty in 
appointing a small committee of men of experience, of knowledge, 
and yet of what the newspapers call “ ordinary common sense.” 
And the report of such a committee, when accepted by the Association, 
would command great respect. The whole question is admittedly 
abstruse and complicated. But this furnishes all the greater reason 
for giving it full and careful consideration. 


Occasional Notes. 

National Council of Mental Hygiene. 

Sir Courtauld Thomson, K.B.E., C.B., presided over a very 
representative gathering of physicians, alienists, neurologists, lawyers, 
the clergy, lunacy officials, members of various societies interested in 
the welfare of the mentally afflicted and deficient, and many others 
in sympathy with any movement which aims at greater efficiency in 
the care and treatment of the insane, which was held at the house of 
the Royal Society of Medicine on May 4th to inaugurate the proposed 
National Council of Mental Hygiene. 

It was a successful, almost enthusiastic meeting in spite of the 
jarring note of the now familiar bilious kind struck by one speaker, 
which sounded incongruous in such a serious and well-informed 
assembly, and contrasted strangely with the weighty utterances of 
other speakers. 

Sir Courtauld Thomson proved an able and courteous chairman, 
who, after announcing that a most sympathetic message had been 
received from the National Council of Mental Hygiene of America, 
stated the objects of the proposed National Council in the following 
words: 

“ The objects of the National Council were for the benefit of the 
whole country; all the skill, devotion and energy of the medical 
profession would be of little avail without the whole-hearted support 
of the general body of the public. Laymen on the Council might 
relieve their medical and scientific colleagues of much of the work in 


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connection with organisation and propaganda. He made an earnest 
appeal for the support of laymen, to whom the institution of this 
Council offered an opportunity for co-operating with the medical 
profession in helping forward the health and mental soundness of the 
nation.” 

Sir Humphry Rolleston, the President of the Royal College of 
Physicians of London, followed, and emphasised the importance of 
preventive medicine, and the special need for the detection of the 
early symptoms of functional disorder which preceded any organic 
change in the body. Mental disorders were not rare, but on the 
contrary exceedingly common. It was often said that we were all 
more or less on the way to being mad. There was an important 
difference to the community between the occurrence of bodily and 
nervous derangement, for whereas the subject of the former might 
still be able to take his part in the world’s affairs, in the latter case 
there was much greater incapacity. Hence the importance of preven¬ 
tive measures in the wide domain of nervous and mental disorders. 
Reference was then made to similar movements in America, Canada 
and France, and the aims of the National Council of Mental Hygiene 
given in more detail: 

(1) The encouragement, and the correlation and organisation of 
means of communication between the various societies and associa¬ 
tions concerned with mental hygiene. 

(2) To join with the other national councils to form an international 
league, for combined action and the interchange of knowledge. 

(3) To study the causation and prevention of mental disturbances, 
which were extremely common in this and other countries and had 
been increasing since the beginning of the war ; including the study 
of environment, heredity, and various poisons, such as alcohol and 
lead, the dangerous trades, and the important subject of syphilis. 

(4) To include the subject of mental hygiene permanently in 
medical education. 

(5) To further the establishment in general hospitals of special 
clinics for the early treatment of mental disorders in such conditions 
as would remove the public prejudice against the word “ mental,” 
which implied that the person was not stable. 

(6) To improve the conditions of the treatment of mental disorders 
particularly in the early stages, when a great deal of good could be 
done at home by the Institution of social service; and 

(7) Judicious propaganda. 

Sir Humphry Rolleston’s reference to the frequency of functional 
nervous and mental disorders was very important. We should not 
be far wrong in stating that in reality general practice consists largely 
of the treatment of the patient’s mind under the cloak of physical 


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treatment. It is sad to think how ill-equipped therefore young 
practitioners are on leaving the schools to carry out one of the many 
tasks which confronts them, i.e., the treatment of the disordered nerves 
and minds of their patients. How much more efficient the medical 
service generally would be if medical students were more adequately 
trained in the theory and practice of psychiatry! The importance 
of mental hygiene requires bringing home not only to the public but 
also to the medical profession, and if the National Council of Mental 
Hygiene is successful in the latter direction only it will confer untold 
benefit on humanity. 

Thus the National Council for Mental Hygiene came into existence 
with Sir Courtauld Thomson as Chairman, and a Provisional Committee 
to draw up a constitution and elect an Executive Committee was 
appointed, to report in six months’ timej 1 ) 


Professor Sir John Macpherson, C.B., M.D., F.R.C.P.Edin. 

We desire to offer Sir John Macpherson our hearty congratulations 
on his Knighthood. The King’s Birthday Honours, 1922, included 
no name more worthy of public recognition. His services to Scottish 
Lunacy have extended over a period of approaching forty years, and 
he has taken an active part in the great advancement the care and 
treatment of the insane has made during this time. His contribu¬ 
tions to psychiatric literature have been important and he is widely 
quoted. His ripe experience and learning have also been esteemed 
in the larger field of sociology. Readers of the Journal will no 
doubt remember his last brilliant paper in 1920 on “The Identity 
of the Psychoses and Neuroses.” 

Sir John Macpherson, after ten years’ service as Medical Super¬ 
intendent of the Stirling District Asylum, Larbert, was appointed in 
1899 Medical Commissioner of the General Board of Control for 
Scotland, from which post he recently retired. On June 6th he was 
the recipient of a testimonial by his many friends, professional and 
others, the ceremony taking place in the Hall of the Royal College of 
Physicians, Edinburgh. As Lord Polworth remarked in making the 
presentation, Sir John Macpherson “ was not retiring into oblivion 
or idleness on a pension well earned, he was going out to a new 
country to give that country the benefit of his great experience 
acquired in the old country." 

This was a reference to an announcement recently made in the 
press that Sir John Macpherson had been offered through the Agent- 
General for New South Wales, and had accepted for a period of three 

(’) Vide Lancet, British Medical Journal, May 13th, 1922 ; The Times, May 5th, 
1922. .> 


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years, the Chair of Professor of Psychiatry in the University of 
Sydney. 

We feel we voice the unanimous wish of our Association that all 
success will meet his latest endeavour to further the interest of 
psychiatry as a branch of general medicine of prime importance to 
the welfare of the community, and their admiration that his zeal and 
enthusiasm continue at so high a level that he can postpone his 
retirement and rest from active work which his valuable public 
services have rendered him so justly entitled to. 


Part II.—Reviews. 


The Basis of Psychiatry ( Psycho-biological Medicine ): A Guide to the 
Study of Mental Disorders for Students and Practitioners. By 
Albert C. Buckley, M.D. Philadelphia and London: J. B. 
Lippincott Co., 1921. Med. 8vo. Pp. xii -f 477. 79 Illustra¬ 

tions. Price 30$. net. 

The author dedicates his book to the memory of his father, Dr. 
William C. Buckley. 

We have delayed the writing of this review—in fact, the delay has 
been unavoidable. A precursory glance at once showed that we were 
to deal with no mere text-book on mental diseases of the kind we have 
in recent years become accustomed to, which convey the same informa¬ 
tion but clothed in different language—sound enough no doubt but 
wherewithal in essentials the same. Here, however, was an author 
who would essay a new departure and unfold his subject psycho- 
biologically, commencing from the basis that acquired mental diseases 
are reflections of some bodily disorder affecting “ the organ of adjust¬ 
ment—the nervous mechanism and its lower and higher (psychic) 
reflexes”—and preventing appropriate adaptations to environmental 
conditions. Regard was to be paid the view now being increasingly 
held that “ Psychology is the science of behaviour,” and psychiatry was 
not to be presented as a strange and novel subject, but approached 
through paths familiar to the student when studying general medicine. 

The book has therefore called for careful reading and study, and we 
are bound to admit that it has been a refreshing and profitable experience 
and one we can wholeheartedly recommend to our readers. 

Pursuant of his plan, Dr. Buckley deals in the first place with the origin 
and subsequent evolution of the nervous mechanism. Under “ Bio¬ 
logical Phenomena,” after explaining how living are distinguished from 
non-living things by having the attribute of being able to “ react ” to 
external influences (reaction), he shows that the simplest organisms are 
devoid of nerve-elements. He then traces the development and elabora¬ 
tion of the nervous system from its first appearance in Coelenterates 
through the successive higher planes of the animal kingdom. He 
describes the various types of nerve mechanisms as they evolve: first 
diffuse, then linear, then ganglionic and finally tubular with its cerebral 


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masses. Following this he shows how the development of new function 
is correlated with the development of new structure, how the nervous 
apparatus brings about the adaptation of the organism to environment; 
he explains the formation of the functional divisions of the nervous 
apparatus and the appearance of receptors, conductors, effectors, and 
the conditioned reflexes, etc. 

The second half of this chapter is devoted to heredity. The 
various laws and conditions governing cell differentiation as taught by 
Weissman, Mendel, Galton, Pearson, Bateson and others are expounded, 
with the assistance of many excellent diagrams and photographs, and 
the subject brought thoroughly up-to-date. 

Continuing, the author demonstrates how the highest degree of 
development and complexity of the nervous mechanism is attained in 
man and adapted for the purposes of carrying out the many-sided 
activities of the life of the individual. This involves a consideration of 
the anatomy and physiology of the brain, of the development of mental 
functions, and of the psychological processes. This ground is covered 
in three chapters of absorbing interest. Every subject is evolved from 
the simple basic facts until the comprehensive whole can be grasped by 
the student. We are not asked to accept bald statements but given the 
reasons for their advancement, and all the known evidence is laid bare. 
The author carries the reader along with him, and the most difficult 
and obtuse matters thus become intelligible. The reader soon becomes 
convinced that, though the subject is manifestly difficult, involved, and 
in some aspects obscure, it is not beyond him and he is encouraged to 
continue. Throughout Dr. Buckley keeps to his text that mental 
phenomena are representatives of the biological reaction of the indi¬ 
vidual as a whole, and that the development of mental activities 
parallels with that of the physical, and is dependent upon pre-existing 
fundamental activities in the germ. 

The student is now fully equipped for the consideration of morbid 
mental phenomena—disturbances of the organ of adjustment, causing 
faulty behaviouristic reactions, etc. Elemental living tissue has become 
the sentient individual; the body with its nervous mechanism has been 
clothed in its psychic personality. 

The study of mental disorders is opened in the traditional way ; 
aetiological factors, exciting causes, classification, general symptomatology 
and methods of examinations are successively encountered and bring 
Fart I to a termination. 

Our author agrees with Tanzi that the best classification is one which 
has the best working basis—one founded on pathological anatomy as 
far as possible, with due regard to symptomatology, and grouped to 
include the greatest number of aetiological factors. However, this is 
impossible at present, so he adopts, and we think wisely, three main 
groups: (i) mental disorders with an organic substratum leading to 
dementia ; (2) one which represents a quantitative disturbance of the 
normal mental functions; (3) one characterised by a primary distur¬ 
bance of the sensory sphere, with mental confusion, and results in 
qualitative disturbance. These groups and their subdivisions represent 
“ reaction types ” of the individual rather than morbid categories. 

General symptomatology is treated of under disturbances of (1) 


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sensation and the process of perception, (2) association processes, (3) 
the emotions, (4) volition and action. 

The methods of examination are stated clearly and concisely, and 
include laboratory diagnostic methods such as the Wassermann reaction, 
colloidal gold reaction, determination of blood alkalinity, and urinary 
acidity. 

Part II of the book comprises the clinical psychiatry usually found in 
the manual or text-book on mental disorders, with the exception that 
purely agenetic types or defective groups are omitted. Indeed they are 
now best treated separately as involving many considerations which 
would encumber a book written like most manuals primarily on acquired 
mental diseases. 

The clinical side of psychiatry is dealt with on well-accepted lines, 
frequent reference being made to the biological and constructive 
chapters in Part I, and can be safely recommended to both student, and 
practitioner. From Dr. Buckley’s attitude generally to his subject, one 
would be led to suspect that he had at one time sat at the feet of 
Clouston and absorbed some of his philosophy. 

The glossary of biological, psychological and psychiatric terms which is 
appended adds greatly to the reader’s convenience; the 79 illustrations 
are well selected, and the author is to be congratulated on a most useful 
work, which commands respect and should be widely read. 

J. R. Lord. 


Nerve Exhaustion. By Maurice Craig, C.B.E., M.D.Cantab., 
F.R.C.P.Lond. London : J. & A. Churchill, 1922. Demy 8vo. 
Pp. 148. Price 65. net. 

The first question which occurs to one on reading a book is—“ What 
motive had the author in his mind in writing it ? ” It is not always 
obvious, especially when the subject has already been well written 
about. The apologia of the writer himself in his preface is not 
always a reliable guide, and may not be borne out by the contents 
of the book, but in the case of the work before us there can be no 
doubt. Sir Maurice Craig’s speech at the inauguration of the National 
Council of Mental Hygiene, his recent Maudsley lecture, and the 
authorship of this book, are all conclusive evidence that the matter 
nearest his heart is the prophylaxis of mental disorders. Thus in 
this book stress is everywhere laid upon those earliest departures 
from normal health and conduct, both in childhood and adult life, 
which indicate the beginning of nervous exhaustion, and which, if 
taken in hand at once, prevent the occurrence of functional nervous 
disease—commonly the precursor of the psychoses. 

Marked attention is drawn to what Sir Maurice Craig calls hyper¬ 
sensitivity. This is either physical or psychical, or more frequently 
both, and may be inherent or acquired. “ Hypersensitivity means that 
the threshold of minimal sensitivity is reached earlier than the normal, 
and slighter stimuli produce response on both the physical and the 
mental side.” 

Causation is dealt with under the headings of inheritance, mental 


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and physical causes in early life, emotions, work, recreation, worry, 
sleeplessness, defective circulation, menorrhagia, puerperal period and 
lactation, alimentary canal, diet, alcohol, body-weight and height, 
eye strain, endocrine glands, intoxicants, sexual excess, climate, 
concussion, general accidents, surgical operations—all important 
considerations. This is the most valuable chapter in the book, and 
has a direct and practical bearing on prevention. Sir Maurice Craig’s 
conception of nerve exhaustion is something more than mere neuras¬ 
thenia or functional nervous disease. Thus his symptomatology is 
widely drawn, and includes, in addition to the latter, the milder forms 
of the exhaustion psychoses, and, though he does not state it, perhaps 
the prodromal and early stages of the schizophrenias, paraphrenias 
and manic-depressive insanity, and even general paralysis. We 
think there is wisdom in this. The prodromal stages of the psychoses 
generally have much in common, and if the latter are to be recovered 
from, it is imperative that they should be given the chance of treat¬ 
ment at the earliest possible moment. Thus the practitioner should 
be reminded that in recognising the symptoms of nerve exhaustion, 
especially the early ones, he may be dealing with the incipient stages 
of grave mental disorder. At the same time, Sir Maurice Craig 
would have him understand that in many cases the symptoms of 
the graver forms of the psychoses may be evidence of nerve exhaustion 
only, and end at that if properly treated. Further, the practitioner 
cannot be too seriously warned that patients suffering from nerve 
exhaustion do sometimes become suicidal, homicidal, hallucinated 
and deluded. Under symptomatology the author deals with disordered 
function regarding sensation, perception, attention, emotion, associa¬ 
tion of ideas, movement and will power in relationship to action, 
impulse, suggestibility, conflict and repression, various physical 
conditions, etc., as evidence of nervous exhaustion. He not only 
describes the various symptoms, but is at pains to show how and why. 

This latter attitude to his subject he maintains throughout his 
book. It is a reasoned effort, original, attractive, simple but forcible, 
and not written above the heads of those whose knowledge of psycho¬ 
physiology and psycho-pathology is negligible. Indeed, it could be 
read with advantage by the general public, especially the sections 
dealing with Freudism and psycho-analysis, and would act as a 
wholesome corrective to those whose minds are clouded, even deluded, 
by the indigestion of recent psychological literature. 

Sleeplessness and its treatment is considered in a separate chapter, 
and the concluding chapters are on diagnosis and prognosis and 
treatment. Throughout the book frequent reference is made to 
treatment, especially preventative treatment, but in the last chapter 
it is dealt with comprehensively. 

In a work of this kind many points suggest themselves for criticism, 
but if regard be paid to the diversity of views held on such matters, 
the book is well within the compass of soundness, and as such can 
be confidently recommended to our readers. Some useful additions 
might be carefully made in future editions, such as an amplification 
of the chapter on diagnosis, especially as regards differential diagnosis, 
but it would be a pity to overload a work, which is a revelation of 


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the personal teaching and views held by the author, with techni¬ 
calities readily found elsewhere, and thus reduce it to a mere text¬ 
book or manual, of which there is at present no scarcity. 

We had read no book of recent time which has given us greater 
profit and pleasure, and its appearance could not have been timed 
at a more opportune moment. J. R. Lord. 


The Psycho-Analytic Study of the Family. By J. C. Flugel, B.A. 

The International Psycho-Analytic Press, 1921. Pp. x + 259 - 

Price 105. 6 d. net. 

With the ever-increasing flood of literature dealing with psycho¬ 
analytic doctrines, it becomes the more important to differentiate 
the writings of well-meaning but poorly equipped authors from 
authoritative productions, of which this volume is an excellent 
example. Whether or no the (Edipus complex is accepted as the 
central nucleus of all psychoneuroses, no one who has any clinical 
experience in psychopathology would deny the enormous importance 
of the various influences, conscious and unconscious, which the family 
affective relationships have upon the moulding of character and the 
future mental well-being of the child. William White, of Washington, 
has happily termed such experiences as “ the family romance.’' 
Though the various schools of thought differ to some extent in detailed 
deductions made, all of them are united in viewing the maternal 
and paternal forces and their surrogates as factors requiring intimate 
study. How wide-spread these family influences extend will be 
surprising to those unversed in such matters, and within these pages 
we can plainly understand how in the past the emotions relating to 
parents have played such an extensive rdle in all religions and many 
vital questions involving society and the State. Seeing herein vast 
moulding forces for good or ill, both individually and socially, it is 
evident that these become an important study for all those whu 
have to deal with the mental factor either in health or disease. An 
increased knowledge of the early affective agencies which condition 
later mental conflict will, we hope and believe, not only give us a 
greater understanding into the intricacies of the psychoneuroses and 
psychoses, but will slowly and surely enable us to prevent such 
states through a more enlightened education in the formative years. 

Very modestly Mr. Flugel warns the reader that he gives him little 
that is original, and, though it is certainly true that the main concepts 
have already been elsewhere put forward by Freud and his followers, 
we are much indebted to him for individual extensions of such ideas, 
and more especially to his biological formulations. 

At the commencement we are shown how the primitive emotions 
centre around the family, and how love, hate and jealousy arise. 
It is interesting to note that in the child’s relations towards its parents, 
love would seem to be the emotion which is usually first evoked, 
but that with brothers and sisters hate through envy and jealousy 
is in most cases the primary reaction. Those primitive tendencies, 
however, soon become controlled in their unrestricted expression. 


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and become modified through mental conflict as the moulding forces 
of education and herd suggestion come into play. Thus by means 
of repression, displacement and sublimation of the early love and 
hate, changes are wrought in the emotional attitudes and objects. 
The Freudian School regard these early conflicts as founded upon 
incestuous fancies and wishes, and, though the author gives due 
credit to Jung’s view that sexuality does not enter into the family 
complexes, he cannot but reject the view that parental dependence 
is only a symbol of the desire to return to the state of protection 
enjoyed in early years. 

In discussing “ the family and the growth of individual personality,” 
it is seen that normal psychic development involves a gradually 
increasing loss of dependence on parental authority. Without this 
we may trace in later life an undue subservience to the will and opinion 
of others. Sound moral progress is characterised by an ever-added 
degree of autonomy, though a too rapid emancipation is apt to lead 
to a dangerous revolt. A definite distinction is made between the 
sexual and the dependence aspects, though in real life they are stated 
to be inextricably interwoven. The various abnormalities and 
varieties of development which may occur through the exaggerated 
love, hate, and dependence aspects of the CEdipus complex are interest¬ 
ingly reviewed. Thus home-sickness, inability to love freely, psychic 
impotence or frigidity, homosexuality, Don Juanism, exaggerated 
love concealing hate, and open hatred, are successively dealt with 
in relation to the incestuous side. On the dependence side the 
manifestations are more positive than negative, as there is a lesser 
liability to repression. 

Two somewhat digressional chapters are given on “ Ideas of Birth 
and Pre-natal Life ” and “ Initiation and Initiation Rites,” but the 
contents plainly show that the aspects of family life which are forcing 
themselves upon us now are the same as those which have influenced 
mankind at all times and in all places, and have manifested themselves 
everywhere in human beliefs and institutions. 

Under the heading of “ The Development of Parent Substitutes,” 
the various displacements of the original parental love are spoken of, 
and of particular interest is the displacement towards relatives 
in law. In psychological terms we see the reasons for the notorious 
and oft-joked-about special affective relationship existing between 
son-in-law and mother-in-law. 

The development of the love life through family influences is highly 
instructive, and Mr. Fliigel adopts Freud’s classification of loves into 
the narcissistic and dependence types. The first is a result of a 
projection of the lover’s self on to some other person, and in the 
second—more genuinely object-love—the lover finds something that 
is essential to the fulfilment of his own bodily or mental needs. 
Light is here thrown upon such problems as love at first sight, only 
falling in love with betrothed or married persons, the desire to keep 
the love secret, the rescue phantasy, a sexual leaning towards prosti¬ 
tutes, masturbation, and the desire for chastity in the loved one. 

Questions of great sociological import are dealt with in the chapter 
on " Family Influences in Social Development.” Thus displacement 


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from the parents may involve a special intolerance of authority, and 
a very considerable proportion of criminal actions may be traced to 
such an unconscious source. A displacement to groups, places, 
societies and institutions may take place, and so home, ancestors, 
school, college, towns and country can have a peculiar affective value. 
England is looked upon as a mother country, while Germany is habitu¬ 
ally spoken of as the Fatherland. It is seen, too, that there is some 
distinct correlation between the family and the State organisation. 
From what has gone before it is an easier step to the subject of dis¬ 
placement to the supernatural, and the family influence in religion is 
discussed at some length. Totemism, exogamy, ancestor worship, the 
Devil conception, baptism, sacrifice, and many religious rites are all 
given their psycho-analytic significance. An exceedingly valuable 
chapter is that on “ The Attitude of Parents to Children.” It clearly 
shows how unwittingly the child’s future may be warped by harmful 
attitudes towards them, which, however, are mainly unconscious in 
their motivation. 

In the latter portion of the book, having completed the descriptive 
part, Mr. Flugel attempts to correlate the psychological mechanisms 
he has dilated upon with the relevant facts of anthropology and biology. 
Since the hate attitude in relation to the family is mainly consequent 
on love, this latter is the more complex and important. Since an 
incestuous affection is regarded as the basic factor, the author inter¬ 
estingly discusses what the influences can be which bring this about 
and what further influences have induced its repression. It is plain 
that a special attachment should ensue from the long period of infancy 
and childhood, but to give this an erotic colouring it has to be assumed 
that (as according to Freud) sexuality shows itself early in partial 
components, and that the large source of energy which is disposable 
for development is in a wide sense sexual in nature. Exogamy is 
looked upon as an institution adopted as a precaution against incest, 
and, in dealing with the influence of heredity and tradition, it is 
asserted that “ there is in man an hereditary tendency to direct his 
love and sexual inclination to those who are of his own blood, or at 
any rate to those with whom he has been brought up and has been 
familiar since his infancy. . . . The tendency to incest may 

thus be due ultimately to the action of natural selection.” Just as 
the reasons for the existence of a general sexual repression is a theme 
which is highly debatable, so the factors relating to incestuous 
inhibition are considered incomplete and unsatisfactory. The opinions 
of many authorities are reviewed and criticised. Westermarck’s 
theory that incest barriers arise because of an innate idea that in- 
breeding is injurious can by no means be supported. Nor do the 
ideas of Durkheim, Wundt or Herbert Spencer give adequate explana¬ 
tion. Mr. Flugel, therefore, endeavours to throw fresh light on the 
point. He speaks of the “ biological absurdity ” of parent-child 
incest, and sees important counter-influences existing in the fact that 
strong family ties conflict with social and individual development. 

In conclusion, two chapters are given on the ethical and practical 
applications of the information gleaned from a psycho-analytic study 
of the family. It is seen that it is the tendency which draws the 


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individual towards the family which is most often in excess and 
therefore requires restraining, while the tendency away from the 
family is most often deficient in strength and hence needs stimulation. 
Efforts must be made to aid the process of weaning from family 
attachments both in its sexual and dependence aspects. In an ideal 
early upbringing lies our great hopes for the betterment of the indi¬ 
vidual and society. 

The book is extremely readable and lucid. Mr. Flugel accepts 
more or less whole-heartedly Freud’s views, but his attitude is never 
narrow-minded, and he logically gives us his reasons for any conclusions 
to which he may come. It can hardly be too highly recommended to 
any reader of the Journal who wishes to orientate himself better on 
such a vastly important subject as the psychology of family life. 

C. Stanford Read. 


Functional Nervous Disorders: Their Classification and Treatment. 

By Donald E. Core, M.D.Manch., M.R.C.P. Bristol: John 

Wright & Sons, Ltd., 1922. Medium 8vo. Pp. xvii + 361. 

Price 25s. net. 

Since it is stated in the preface that there is more confusion existing 
in the problems presented by the functional disorders than in any 
other branch of medicine, and that one source of this confusion appears 
to be associated with the current vagueness in the definition and 
classification of these conditions, we naturally expect to find that the 
contents of this book will in some way help towards a clarifying of 
our conceptions. In this hope we are not only disappointed, but Dr. 
Core seems to have brought confusion where little or none previously 
existed. To find early such a statement as—“ Clinically hysteria is 
to be considered as primary, secondary and tertiary, according as to 
whether the manifestations are associated directly with an uncontrolled 
emotional tone, with discomfort of any description, or with the expec¬ 
tation of discomfort respectively,” does not augur well, and when in 
the endeavour to gain some grasp of the author’s meaning we read 
subsequent chapters, a condition akin to vertigo seizes upon us. That 
there is originality in the work is undoubted, but we are unable to 
understand how such seemingly bizarre conclusions are arrived at. 
The arguments throughout the book are so highly involved that we 
are precluded from any detailed criticism. One or two points, however, 
may be mentioned because of their startling novelty. The term 
“ schizophrenia,” used by Bleuler as a synonym for dementia praecox 
and implying a splitting of the personality, is used in these pages as 
signifying negativism; a use of the word which seems quite un¬ 
warranted. In the chapter on the drug treatment of hysteria the 
astounding statement is made that if any drug could be obtained 
which from its taste or smell earns the wholesale detestation of the 
patient, it might quite conceivably be as efficient a means of treatment 
as could be found ! Dr. Core’s ideas concerning psycho-analysis 
are stale and fallacious. In his preface he says that psycho-analysis 
is a somewhat pompous name to apply to a simple procedure which 
amounts to little more than detailed case-taking. Such a statement 


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was excusable many years ago when knowledge of the subject was 
scant among the medical profession, but at the present day it must 
be severely condemned. He advocates this form of treatment in 
certain functional disorders such as the “obsessive form of the mnemo- 
neurosis,” but shows an absence of knowledge of such therapy by 
stating in a footnote—“ Anyone who has performed psycho-analysis 
realises how surely, as the proceeding goes on, the patient, sooner 
or later, becomes angry; the very remorselessness of the questions, 
quite apart from their implication, induces in many a feeling of bitter 
hostility.” Anyone who really psycho-analyses knows nothing of 
the sort. A psycho-analyst who knows his business rarely speaks 
at all. 

It is difficult to find anything in this volume to recommend it. 
The writer has evidently worked hard at his subject, but his style is 
very diffuse and clouded, and we cannot help but think that the 
functional disorders are dealt with much more scientifically and 
accurately by more than one modern authority. 

C. Stanford Read. 


Part III.—Epitome of Current Literature. 


1. Psycho-Pathology. 

A Method of Personality Diagnosis and Evaluation with Provision for 
Social Service Propaganda. ( Journ. Nerv. and Ment. Dis., 

October , 1921.) Fernald, G. C. 

Recent advances in the study of defective delinquents are largely 
dependent on the findings in the field of character, that component of 
mentality which connotes its quality in contrast to its degree, viz., 
intelligence. 

Action or behaviour eventuates from mental organisations fully as 
significant as indexes of personality-efficiency as are those which 
eventuate in thought and its expression. Thinking is the product 
of intelligence, behaviour the product of character, and on the latter 
each personality is accountable in daily usage and in juridical procedure. 

Character deviations or rectitude cannot as yet be technically tested 
and numerically scored, but can nevertheless be presented in scientific 
description. Fernald details a classification of behaviour disorders in 
use at the Psychopathic Laboratory, Massachusetts Reformatory, the 
inquiry being in three fields—mental disease, intelligence and character. 

Unless strength of will exists in the character of the individual the 
tendency to sloth will defeat the success of a high as readily as of a 
low intelligence. Mediocre ability to persevere in the pursuit of well- 
chosen purpose causes economic and sociological failure as often as 
does incompleteness of knowledge of the course to follow. The imbecile 
without self-determination will respond to his maximum capacity if on 
a farm as a chore-boy, content, trusted so far, but always supervised; 
not so another who as a tramp begs and pilfers but will not work. The 
essential difference lies in the field of character. 

LXVIII. 21 


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The investigation of the psychiatric personality determines (i) the 
presence or absence of mental disease, (2) the mental intelligence level, 
and (3) deviations or rectitude of character, as egocentricity, sex-conflict, 
anti-social trend, lack of self-respect, of ambition, of amenability to 
reason and authority, emotional faculty, unbridled acquisitiveness, etc. 

Character then determines the life-activities of the individual. 
Defective intelligence is stationary and cannot be advanced, but 
character-growth can both be stimulated and improved. Healy believes 
in emphasis of the study of character as a thing by itself. Mental tests, 
so strongly advocated to-day, do not cover all the elements of intelligence. 
They are insufficient for the determination of conduct-prognosis, of the 
outcome of character traits, or of vocational possibilities. Psychologists 
are beginning to awake to this fact. Aristotle’s dictum cannot be 
maintained—that good intelligence will prevent a man from doing 
wrong; that if he was not a fool he would not do wrong. 

Investigations in a large factory showed that mental tests gave little 
useful information except regarding clerical workers. There is otherwise 
little correlation between the tests and the behaviour prognosis, i.e., 
success at work. Some of the most reliable workers may have poor 
mental capacity, e.g., label-pasters and laboratory cleaners. In fact 
intelligence may be a handicap in very necessary phases of industrial 
life; there is instanced a delinquent defective whom his master stated 
to have been the only one who had ever carried out his particular work 
satisfactorily. 

Healy holds that responsibility is hardly a feasible category in such % 
scheme of classification. Responsibility is a metaphysical conception 
not open to clear definition, and in practice has little to do with the 
successful management of many cases. In this regard the law seeks 
finite answers to questions that are unanswerable. It is high time that 
in the practical issues hereon dependent psychologists should make a 
plain declaration to the legal profession. John Gifford. 


2. Neurology. 

The Vascularity of the Cerebral Cortex of the Albino Rat. ( fourn . 

Comp. Neurol ., August , 1921.) Craigie, E. Horne. 

By vascularity is here meant the sum, per unit volume of tissue, of 
the lengths of the capillaries measured with the micrometer in successive 
serial sections. Craigie reports observations on the relative vascularity 
of the various cell laminae of the cerebral cortex of the albino rat. He 
finds that in every cortical area examined the lamina granularis interna 
(Brodmann’s lamina IV) is much the most richly vascular, the lamina 
pyramidalis (III) coming next, with the lamina ganglipnaris (V) very 
little behind it; the poorest layer is the lamina multiformis (VI) in every 
area except the insular, where the lamina zonalis (I) is very slightly 
poorer. These observations are interesting in reference to what is at 
present known of the development and functions of the laminae. From 
the work of J. S. Bolton, G. A. Watson, Ariens Kappers, van Valkenburg, 
Nissl, van’t Hoog and others, it appears that the granular layer (IV) is 
a primary layer having functions originally receptive, that the functions 
of the infragranular layers (V, VI) are mainly those of projection and 


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intra-regional association, and that the supragranular layers (II, III), 
which are the last to appear phylogenetically, are concerned chiefly with 
associations of a higher order (interregional), including intellectual 
processes. It is interesting now to learn that these newer and more 
highly specialised portions of the cortex are less richly vascular than the 
granular layer (IV), from which, according to Kappers and van’t Hoog, 
they have phylogenetically been developed (cf. Journ. Ment. Sci., April, 
1921, p. 229). Further, the observation that the infragranular layers, 
which give rise to corticifugal fibres, are less richly vascular than the 
granular and supragranular layers, which are receptive and associative 
in function, has suggested to Craigie a comparison with lower centres 
in the brain stem, where likewise the motor nuclei are less richly 
vascular than the sensory and correlation nuclei. Whereas in projection 
cells the nervous current is directly realised and led away, in the granule 
cells with short axons forming an intricate network the stimulation is 
kept within a circumscribed region, so it is perhaps only reasonable to 
expect that such a region of concentrated local activity should have the 
relatively rich blood supply that Craigie finds. 

Comparing different cortical areas with one another, he observes that 
the average vascularity of all the layers is the same in the occipital as in 
the temporal region, and is only slightly less in the praecentral region. 
The parietal region is distinctly richer than the others, while the insular 
region is much the poorest. 

Differences of vascularity in the two sexes, and in different strains of 
rats, appear to be more marked in the cerebral cortex than in other 
parts of the central nervous system. The vascularisation of the more 
recently evolved centres appears more susceptible than that of more 
ancient regions to sexual, hereditary or environmental influences. 

Sydney J . Cole. 


3. /Etiology. 

The Relation of Oral Infection to Mental Diseases. (State Hosp. 

Quart., November, 1920.) Root, IV. R. 

Cotton cites cases where extraction of unhealthy teeth in early 
mental cases resulted in marked improvement or recovery, and states 
that insanity can be prevented or cured by principles discussed in his 
paper. The organism principally concerned in dental infection is a 
non-haemolytic streptococcus known as Streptococcus viridans. The 
non-haemolytic group of streptococci are non-pus-producing, slow- 
growing organisms which do not cause pain, swelling, or even a rise in 
temperature, hence easily overlooked, producing a chronic infection. 
They may suddenly become active and cause the death of the patient. 
The extraction of teeth alone may not correct the results from a 
secondary focus in the kidney, liver, or gastro-intestinal tract. The 
streptococcus may damage the intestinal mucosa and allow the colon 
bacillus to pass through into the lymphatic circulation. Thus toxi- 
infectious psychoses may be caused. The physical disabilities of the 
mental patient must be more seriously considered and treated. 

Manic-depressive insanity, dementia praecox and the paranoid states 
are stated to have a common aetiology, namely, chronic infections and 


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resulting toxaemias. They are stated to recover after treatment of the 
oral infection. Hence we must either change our diagnosis in the cases 
which recover from dementia prsecox to manic-depressive insanity, or 
admit that dementia prsecox is not the incurable malady we have 
believed it to be. 

The existence of chronic infection is determined by methods as 
follows: (i) Complement-fixation test of the blood for Streptococcus 
viridans. (2) Examination of the teeth: The X ray must be used. 
All capped and pivot teeth are extracted and all fixed bridge work 
removed. (3) Infected tonsils: These should be enucleated. (4) 
Gastro-intestinal tract: Involvement of stomach, duodenum, or lower 
intestinal tract occurred in 50 per cent, of cases. A routine examina¬ 
tion is made and autogenous vaccines are used. Streptococcus viridans 
is the principal infecting organism but a virulent colon bacillus may be 
present. 

At the Trenton State Hospital, as the result of treatment the average 
monthly discharges to admissions increased from 43 per cent, to 80 per 
cent. Mills does not hold these optimistic views, and states that teeth 
were freely sacrificed without a single convincing result. Anders also 
believes that the latest fad, as he terms it, has far-reaching baneful 
effects, although he admits that many morbid medical conditions may 
be oral in origin. He thinks that the medical and dental profession 
should protest against the all too common custom of extracting teeth on 
the mere assumption that when tooth root disease exists it is the cause 
of disseminated infection. All other foci of infection should be 
eliminated before consulting a dentist. 

Fine also believes that too many teeth are extracted and thinks that 
the systemic disease may account for the dental disturbance. Fones 
thinks that dentistry should concentrate on the soft tissues (gums, 
pericementum and pulp), for these permit the ingress of bacteria into 
the lymphatics, thus producing many systemic infections. He agrees 
with Cotton. 

Cahn states that there are faddists in every profession, and as 
hundreds of ovaries and appendices have been needlessly sacrificed, so 
have thousands of teeth, although a great number of seemingly hopeless 
cases have been cured by the eradication of oral sepsis. Any infected 
area should be removed, be it in the mouth, throat or prostate. The 
removal of vital and healthy teeth for the supposedly clearing up of an 
oral infection is gross ignorance and malpractice, but the removal 
of dead infected teeth or the clearing up of a pyorrhoea alveolaris 
should be strongly advised. W. J. A. Erskine. 

The Nature of So-called Idiopathic Epilepsy according to Recent Studies. 

(Archiv Neurol, and Psych., February , 1922.) Pagniez, P. 

The formulated conceptions of idiopathic epilepsy still maintained 
are that it is a resultant of (1) a predisposition due to a congenital or 
acquired lesion of the nervous system, and (2) a precipitating cause, viz., 
an intoxication, usually alimentary. The antecedent brain lesion is due 
to local mischief, possibly traumatic, but frequently toxic. 

In a series of cranial war injuries French workers demonstrated 10 to 
20 per cent, of subsequent epileptic seizures, partial or complete, and 


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the longer the observation the greater the incidence. The attacks 
supervened after a variable latency, commonly three to five months, but 
in one-fifth of the series five to ten months. General epilepsy was less 
prevalent than the Jacksonian type. The latent period coincides with 
cicatrisation of the lesion, the form and particularly the extent of the 
scar-tissue being the determinant, and not the lesion itself. 

The crisis of grand or petit mal is produced by a cortical vaso-motor 
derangement, whether anaemia or stasis. Anaemia must be an adequate 
cause, for suppression of systole in certain cardiac cases results in 
vertigo 3 secs., fainting 8, and epileptiform convulsions 12 to 15 secs. 
Leriche is stated to have observed manifest anaemia in exposed brains 
in two subjects. Also the retinal arteries have been seen in spasm 
20 secs, before convulsion and persistent throughout status epilepticus. 

Alimentary intoxications are admitted the most important cause of 
onset, sometimes the accumulation of normal waste products, sometimes 
polyglandular inefficiency. The stereotyped manifestations of epilepsy 
cannot be identified with the variable phenomena of anaphylactic 
■crises. 

Edgeworth claimed complete cure in 40 per cent, of a short series by 
protein therapy—small doses of peptone intravenously. No success 
attended auto-serotherapy. John Gifford. 


4 . Clinical Psychiatry. 

General Paralysis and Heredity \Ueber die Rolle der Erblichkeit bei der 
Paralyse\. (. Arb.fur Psychiat ., Miinchen, Bd. ii, February , 1921.) 
Meggendorfer , F. 

From the time of Bayle the influence of heredity in the causation of 
general paralysis has received much attention, and at the present day 
there are many leading authorities who hold that, next to syphilis, 
heredity is the most potent setiological factor. It has been shown that 
in the families to which paralytics belong there is an hereditary mental 
taint, less than in the families to which persons affected with other 
mental diseases belong, but greater than in the families to which normal 
persons belong. Further, in the descendants of paralytics a mental 
taint has often been observed, so that some authors have held that 
general paralysis not only arises from degeneracy but produces degene¬ 
racy. Most studies, however, of the offspring of paralytics have dealt 
chiefly with young persons, and do not show their fate in adult life; on 
the other hand, investigation of the family histories of mentally affected 
congenital syphilitics yields results that are misleading, because account 
is taken only of the diseased and not of the healthy. An inquiry into 
the mental constitution of the descendants of paralytics, if it is to yield 
results that shall be comparable with those yielded by a survey of the 
•descendants of persons of other categories, must start from the paralytics 
themselves. 

From the entire paralytic case-material of Upper Bavaria since the 
year 1859, Meggendorfer has selected such cases of general paralysis as 
satisfy certain requirements : The diagnosis must be beyond doubt, the 
date at which the paralytic became infected with syphilis must be 


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approximately known, and his youngest living child must now be at least 
thirty years old. In 43 of these cases he has been able to make search¬ 
ing inquiry of relatives. He gives statistical information respecting 
the offspring of these 43 paralytics, and he gives a number of genealogical 
trees. Dividing the offspring into those begotten before and those 
begotten after the parent’s infection with syphilis, he finds: Miscarriages 
or stillbirths, 2 and 29 respectively; died of syphilis, o and 49; died of 
non-syphilitic accidents, 5 and 19; healthy sane persons, 14 and 50 " T 
psychotic, o and 6; psychopathic or neurotic, 4 and 32. He has col¬ 
lected information also respecting 120 grandchildren. 

Among the children begotten after the infection there are many quite 
sound persons. Consider, for example, a family in which the father 
acquired syphilis before marriage and then infected his wife. She soon 
became tabetic; he, later, paralytic. There were five children of the 
marriage, of whom the fourth died in childhood; there were no mis¬ 
carriages ; the three last children were born when the mother already 
had tabes. The eldest son, a fine, big, handsome man, is a high officer 
of state, with an exceedingly responsible position in the Empire ; the- 
second son is a colonel; the third, a high official ; the daughter, too, is 
in every way a person of first-rate qualities. The two married sons have 
large families of healthy children and grandchildren. Meggendorfer’s 
material affords several other instances in which the families of paralytics 
have won social advancement. Moreover, the three persons included 
who were begotten after the father became paralytic are all quite sane 
and healthy. 

The psychotic and psychopathic groups of offspring exhibit a great 
variety of disorders, which are found in about the same proportions in 
those begotten before as in those begotten after the infection. There 
is a comparatively large number of excitable and hot-tempered psycho¬ 
paths. Such a character, as Plaut has shown, is not rare in young 
people who have been congenitally syphilitic, but it is not to be regarded 
as a result of syphilis, or of germinal injury arising from syphilis. The 
material includes several schizoid psychopaths. We know that the 
causation of dementia praecox has often been ascribed, particularly by 
the Viennese school, to syphilitic damage of the germ; but all the 
schizoid cases here have dementia praecox in their family history; the 
psychosis is transmitted irrespective of the general paralysis, and the cases 
arising can be simply explained on Mendelian principles without assump¬ 
tion of any germinal injury of syphilitic origin. So, too, wherever in 
this material a manic-depressive disorder is noted, similar disorders 
have occurred in the ancestry. 

Psychotic or psychopathic taint does to some extent make a person 
more liable to general paralysis, but only by inclining him to reckless 
indulgence of sexual appetite and so increasing his risks of syphilitic 
infection; the taint has no greater importance for the production of 
general paralysis than for the acquisition of syphilis. There are various 
indications that the exceptional proneness to general paralysis in certain 
families is due to some familial peculiarity of the physical defences 
against the spirochsete; there is no indication that this peculiarity is in 
any way related to hereditary mental taint. 

Sydney J. Cole. 


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The Forms in which Insanity Expresses Itself [Die Erscheinungsformen 
des Irreseins]. ( Arb . fur Fsychiat., Miinchen , Bd. ii, 1921.) 

Kraepelin , Emil. 

Many have been saying of late, and with some amount of truth, that 
the methods we have hitherto used to distinguish forms of mental disease 
are to a considerable extent exhausted, and that we must find new ones. 
Our desire is to get beyond mere differentiation and classification ; we 
wish to understand the essential nature and inner relationships of the 
morbid processes, to learn the laws that govern the occurrence of mental 
disorders, and to comprehend these disorders as results of pre-existing 
conditions. The diversity of the clinical pictures occurring in the same 
fundamental disorder shows us that such conditions must be very 
complex. The results even of so simple a cause as head injury are 
very varied, for it affects an organ that has behind it an extremely 
elaborate racial and personal evolution. The external cause determines 
little more than the general outline of the clinical picture; the details 
are filled in by the personality of the patient. Thus, for example, 
particular poisons can produce particular emotional states, but the 
effects of these states depend on conditions already laid down in the 
personality. 

What clinical means have we of learning the inner history of produc¬ 
tion of a mental disorder, and how are we to know that the conception 
thus obtained of it is true? We may give rein to an imaginative 
sympathy as of the poet, or we may take the sufferer’s own explanation; 
but the fancies of the psycho-analyst can nohow be verified, and many 
a melancholic in asylum will have it that all her woe is home-sickness, 
yet when she recovers we see it was not. By collating great quantities 
of observations we may investigate the influence of sex, of age, and of 
race; but the indispensable pre-requisite for all such comparative 
psychiatry is the recognition of definite morbid processes produced by 
definite causes; comparative studies of pathologically heterogeneous 
material are bound to suffer shipwreck through the ambiguity of the 
phenomena observed and the confusion of causal with modal influences. 
By studies of family histories we may investigate the influence of heredity, 
but we are never able to probe such histories far enough back; we see 
some results of the mixture of dispositions derived from different families, 
but we see also traces from ancestors immeasurably remote. We may 
search into the previous personal history of the patient himself, and we 
know, for instance, that impressive experiences occurring in the course 
of sexual development sometimes leave a conspicuous mark in fetichism, 
but the complexity of his total past experience is bewildering. 

We have to reckon not only with fundamental disorders determined by 
particular causes of disease, but with forms of expression determined by 
innate or acquired characters of the personality. Disturbances that occur 
without exception in the same morbid process may roughly be regarded 
as the direct effects of the underlying cause, the variable phenomena as 
referable to personal peculiarities. The fundamental disorder, however, 
will show gradations according to the strength, time relations and 
locality of the morbific influence; and what is more, the common 
human characters of the patient will so outweigh his personal peculiari¬ 
ties that the greater part of the form in which the disorder expresses 


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itself will have a constant recurrence as the natural response not 
only to this morbific influence but to other morbific influences as 
well. 

Thus, as by a process of exclusion, Kraepelin finds that our best plan 
now is to try for an understanding of those forms of expression which, 
being dependent on pre-established constitution of the human organism, 
are met with again and again in a variety of diseases. In the morbid 
disturbances, phenomena that are observed at lower stages of develop¬ 
ment, in children, in uncivilised man, and in animals, are often repro¬ 
duced. The mental equipment of the adult is a stratified deposit from 
innumerable stages of phylogeny and ontogeny, and buried in its strata 
are relics of extinct dispositions, which can be revivified by the stimulus 
of disease or resurrected by removal of the superincumbent layers. 
They are mere broken fragments, and most of the extinct dispositions 
must have vanished without leaving any such trace. A particular form 
of expression cannot be correlated with a particular stage of development 
of personality, but from such relics as are brought to light we may be 
able to tell more or less what strata are affected by the disease, and to 
get some inkling of the laws that determine its spread from one stratum 
to another. 

Kraepelin distinguishes three main groups of expression forms: a 
higher group comprising delirious, paranoid, emotional, hysterical and 
impulsive forms; a lower group comprising encephalopathic, oligophrenic 
and convulsive forms; and a middle group comprising schizophrenic 
and speech-hallucinatory forms. Every one of these forms can occur 
in a great variety of morbid processes. Those of the first group, 
comparatively superficial, can combine with one another, and perhaps 
with those of the middle group, but not with those of the lower. Those 
of the middle and lower groups are frequently accompanied by those of 
the higher. In those of the middle group we occasionally find mixtures 
from both higher and lower. 

Endless attempts have been made to distinguish hysterical from 
epileptic disorders by particular clinical signs—for example, by the 
character of the fits. But the character of the fits shows only the 
sphere in which the disturbance is taking place, not what the disease is. 
In either disease we may have the phenomena of both. To distinguish 
the morbid process we must employ other criteria—the mental condition 
as a whole, the aetiology, and perhaps the metabolism. Similarly it is 
often impossible to distinguish manic-depressive insanity from dementia 
praecox; yet we know they cannot be the same, for on the one hand we 
have patients recovering over and over again, and on the other hand 
patients who pass into hopeless dementia with grave destructions of 
cortex. The emotional and the schizophrenic expression forms do not 
indicate the nature of the morbid process; they show only what sphere 
of personality is affected. While, however, in dementia praecox we 
often see manic and depressive phases, it is much rarer to find marked 
schizophrenic signs in manic-depressive insanity. A destructive process 
can have wide-spread inhibitory or excitatory effects, but a disorder that 
can right itself will seldom penetrate deeply. 

Sydney J. Cole. 


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Suicide among Soldiers at the Psychiatric Hospital at Mombello. (Archiv 
Neur. and Psychiat., September, 1920.) Sacchini, G. 

Suicidal attempts are more frequent among mentally diseased soldiers 
than civilians. The idea of death is rendered less repugnant and even 
familiar by the violent reactions of war. In one type of personality 
suicide is the preferred alternative to suffering. 

Fifty cases are analysed : there was only one fatal result. Fourteen 
had made previous attempts in civil life. Hereditary taint was pro¬ 
nounced—of alcoholism 32 per cent., suicide 30 per cent., psychopathy 
16, neuropathy 16. Ten cases were syphilitic, 3 tuberculous and 3 
fearful of disease. Six were convalescent from trauma or acute disease ; 
20 had been neurasthenic following grave illness. Immediate causation 
was stated thus—“tired of living ” 8, hypochondriasis 9, love disappoint¬ 
ment 4, and not assignable 6. Definite pathologic causes were— 
attacks of unconsciousness, complete or partial, 12, gross mental disease 
3, and military reasons were fear of censure and fear of return to the 
front. 

The means chosen were—poison 22, precipitation to ground 9, under 
heavy vehicles 2, hanging 7, “cutting” 5, drowning 5, firearms 4. Two 
made multiple attempts. 

Mental disorders classed mainly as neurasthenia, epilepsy, dementia 
praecox, and feeble-mindedness. Most had degenerative stigmas, 8 had 
criminal records, and 7 had previously been rejected for service. The 
analysis emphasises the frequency of an abnormal basis and the conse¬ 
quences of war on abnormals, whether or not congenitals, and particu¬ 
larly on defectives. John Gifford. 


Voluntary Sequestrations and Liberty Psychoses [Les Sequestrations 
volontaires et les psychoses de la liberte ]. (Ann. Mid.-Psych., 

December, 1921.) Courbon, Paul. 

According to Dr. Courbon forcible and illegal incarceration in 
asylums is a thing of the past in France. The sceptical visitor, expect¬ 
ing to encounter persons unjustly detained, is not only surprised at 
finding none, but is still further surprised by the discovery of patients 
pleading, in the most reasonable manner imaginable, to be allowed to 
remain and not to be given their freedom against their will. 

The present article is concerned with those individuals who volun¬ 
tarily seek admission to, or beg to be allowed to remain in, an asylum, 
though not presenting any mental trouble actually. The cases are 
divided into two main groups: 

(1) The first or utilitarian group comprises those individuals who 
seek shelter in an asylum as the most convenient way of escaping 
justice, or of avoiding work. In order to obtain admission they simu¬ 
late insanity or claim to have had previous psychopathic attacks. Their 
willingness to remain is but short-lived, for their object is not to escape 
from their evil impulses, but on the contrary, to be able to indulge them 
to better advantage. They soon begin to demand their discharge on the 
pretext that their mental state is normal. The cases belonging to this 
group are malingerers, and as such are abnormal; but they are not insane, 
nor does it follow that they become insane when given their liberty. 

(2) The individuals belonging to the second group have a sincere 


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wish to be detained on a permanent basis. Internment is for them final: 
it is in fact their only means of defence against themselves. The asylum 
is, as it were, a shelter from insanity, which attacks them as soon as 
they are given their discharge. Let loose on society they become on 
the one hand the inoffensive dupes , or, on the other, the irresponsible 
scourges of humanity. In these cases insanity is the direct result 
of freedom, hence the author describes them as liberty psychoses. 
According to whether the faculties of initiative or of inhibition are at 
fault there are two types of liberty psychoses: 

(a) To the first type belong those timid, retiring persons who dread 
any responsibility in life; who are deficient in initiative, but above all 
in judgment. As long as they are supported by someone possessing 
that energy which they themselves lack they can conduct themselves 
normally; but when this support disappears it becomes necessary for 
them to seek protection in an institution, otherwise they rapidly lose 
their reason. Dr. Courbon says these cases are psychopaths of the poly¬ 
morphous type, whose mental disturbance is perfectly obvious to alL 
Socially they are a danger to themselves and become easy victims of 
the machinations of others. 

(1 b ) The second type of liberty psychosis includes those persons who 
are subject to impulsive obsessions of a special kind—the morbid 
impulses only being awakened by contact with external influences. 
Their gratification brings no satisfaction to the subject, but on the 
contrary, these obsessions are a constant source of anxiety to him. 
In consequence, from the moment that there is no temptation from 
without the impulses become latent and the anxiety ceases. Whence 
the desire on the part of the subject to avoid all provocation in future. 
Judgment is not affected in this type. It is essentially the power of 
inhibition which is insufficient. The result is that all the intellectual 
faculties become subservient to the impulses; and the evil conduct is 
so well co-ordinated that the incompetent observer has some difficulty- 
in recognising its morbid origin. 

A description of two extreme cases illustrating the two types of 
liberty psychoses is given by the author, who states that, though it is 
rare to meet with types so complete as those he mentions, one very 
frequently sees cases which resemble them in many particulars. 

Norman R. Phillips. 


5. Treatment of Insanity. 

Treatment of Melancholic Depression by Large Doses of Strychnine 
[Traitement de la dlpression mllancholique par la strychnine a tres 
hautes doses], (Le Prog. Med., March 19 th, 1921.) Hartenberg , 

Hartenberg treated a series of six cases of melancholia with large 
doses of strychnine with the result that he obtained five complete 
successes and one partial success. The principle of the method he 
employs consists in causing the patient to absorb the largest quantity 
possible of the drug until the nervous system and the organism generally 
become saturated. According to the author’s observation it is not until 
the patient has begun to take about 5 cgrm. in the 24 hours that 
the alkaloid begins to act. Anything short of this quantity remains- 


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without effect, and this fact explains why the therapeutic value of 
strychnine in these cases has so far remained unknown. But this 
minimal dose of 5 .cgrm. is not sufficient to ensure success. It 
is necessary to go far beyond it, to push the drug to the extreme limits 
of tolerance—up to between 7 and 8 cgrm., i.e., until satura¬ 
tion of the nervous system occurs. At this point a state of 
subacute strychnism is established, with muscular hypertonia, as 
evidenced by contracture and exaggerated reflexes, the influence of 
which on the evolution of the malady is decisive. By the powerful 
super-excitation which it involves, this drug reaction creates a kind of 
organic crisis which acts as a shock to the patient, stimulates his 
nutrition, awakens his sensibility, revives his physical and intellectual 
activity, rids him of his inertia and torpor so that he again becomes 
fitted for a normal life. 

This intensive treatment is realised by progressive and repeated doses. 
Tolerance for the drug is such that the author found it possible to 
increase daily each dose by \ mgrm. Moreover he found that 
elimination took place in about five hours. 

The actual method of procedure is as follows: using a 100 per cent. 
solution of sulphate of strychnine, the treatment on the first day consists 
in administering either by mouth, or, if the patient refuses, by injection, 
7 drops, or 3! mgrm., repeated three times at intervals of at least five hours, 
i.e., about 1 cgrm., or 2 x drops in twenty four hours. On each succeeding 
day each dose is increased by a drop or 4 - mgrm. If, after a few days, 
symptoms of strychnism—vertigo, giddiness, stiffness of the legs or of the 
jaws—should supervene, the patient is kept on the same dose until that 
reaction disappears. Then again it is increased by a drop daily, and so 
on. The time arrives, however, when tolerance is no longer exhibited 
—the same dose invariably producing a reaction. This indicates that 
the point of saturation is reached beyond which one cannot proceed. 

The cure progresses in proportion as the drug is increased. Until 
5 cgrm. is reached, i.e., for about the first month, amelioration is nil or 
insignificant; on the contrary, once beyond that dose, progress becomes 
rapid. It is found that the patient wakes up, revives, speaks, begins to 
interest himself, occupies himself, smiles. At the stage of saturation 
the normal state is generally regained. It only remains to decrease the 
drug more or less rapidly by three times three drops each day until the 
initial dose is regained, when it may be discontinued without risk of a 
relapse. 

A brief resuml is given of the six cases treated by this method. 

Norman R. Phillips. 

Is the Treatment of Patients with General Paralysis Worth While ? 

( Journ. Nerv. and Ment. Dis., October, 1921.) Solomon, H. C. 

Pathologically general paralysis is a degeneration of the parenchyma 
of the central nervous system. As to the efficacy of treatment there is 
a great diversity of opinion. Diagnosis is very difficult as between 
dementia paralytica and cerebrospinal syphilis—cases put in either 
category may prove to be the other. Essential to the diagnosis is more 
or less insidious deterioration of the personality of the individual with 
the neurological symptoms, especially facial tremor and speech defect; 


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[July, 

and also positive laboratory findings, vis., Wassermann plus with o*2 c.c. 
of spinal fluid, paretic gold curve, globulin, excess albumen and cell 
count near ioo. 

Solomon believes that thorough treatment of general paralysis results 
in prolonged remissions of two to six years with restoration to good 
economic ability and efficiency. In 1916, of the cases treated 25 per 
cent, were discharged on remissions. Age does not seem a criterion— 
cases set. 65 have done well, but one cannot be dogmatic in prognosis. 
A young man with good heart and kidneys may do badly, probably from 
loss of immunity from a virulent infection. 

The methods used were injections of arsphenamin o*6 grm. intra¬ 
venously twice a week for three to four months, but intensive continuance 
is essential. The author feels that he has been over-conservative in 
limiting the doses to *6, 8 and i‘o grm.; larger doses do not appear to 
approach the tolerance of the patient, and at the worst excessive dosage 
would but shorten a life which per se would extend a few months at 
most. 

In combination with this method is used the intraspinal route, and 
the intraventricular (cistern puncture) route of Ayer. In inflammatory 
conditions of brain or cord the latter method revolutionises treatment; 
and when used in conjunction with the other routes, it necessitates a 
revision of our ideas of prognosis. Spinal drainage is also advisable in 
some cases. 

Ruggles confirms this view of Ayer’s intra-cistern method, and in his 
hands a series of fifty cases have revealed a lessened reaction, ready 
co-operation on the part of thfe' patients, and absence of bad results. 
Where intravenous treatment plus spinal drainage, or intravenous plus 
intraspinal injections fail, the intracistern route should be adopted. 

In the absence of these treatments the patients concerned would, it 
is believed, either be dead, or be still in institutions. 

John Gifford. 


6 . Mental Hygiene. 

Childhood; The Golden Period for Mental Hygiene. (Merit. Hygiene, 
April, 1920.) White, W. A. 

Mental illness is a type of reaction of the individual to his problems 
of adjustment which is conditioned by (1) the nature of those problems, 
and (2) the character equipment with which they are met. 

As regards the first of these factors, the general statement may be 
made that if the stress of adjustment be sufficiently great any individual 
may break down. The second factor, the character equipment, is the 
important one for consideration. It may be enforced by mental hygiene. 
Mental illnesses depend upon defects in the personality make-up, and 
this latter is what it is as a result of its development from infancy 
onward. Mental illnesses are the outward and evident signs of intra¬ 
psychic difficulties (conflicts). Conflicts depend upon traits of character 
originating in childhood. The peculiar trait of character with which 
the individual has been struggling all his life—suspicion, cruelty, 
jealousy, timidity, curiosity, over-consciousness, etc.—is conditioned 
early in life as a result of the influences exerted by the members of the 


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family or their surrogates. The child is peculiarly plastic. Childhood 
is therefore the period par excellence for prophylaxis. The germ-plasm 
theory of heredity and certain derivatives of this theory are too fatalistic. 
Even if fundamental traits are inherited, they may be turned into a 
useful direction; for instance, intense curiosity may be turned into 
scientific investigation. 

The points of attack are as follows : First, a real understanding and 
development of child psychology. Study what the child is trying to 
do in terms of the child psyche, not as if it were a small adult. 

Second, an understanding of the nature of the child’s relations to its 
environment, particularly its personal environment, and specifically to 
the members of the family. The family situation contains within itself 
certain elements of a disruptive nature. It is as essential that the child 
should ultimately escape from its bondage to the family as it is that, for 
a time, it should be a part of that family and more or less subject to its 
direction. 

Thirdly, a full understanding of these matters must reach their 
application in education. Education needs to be developed as a 
scheme for assisting and guiding the developing personality. And, 
finally, as the child cannot acquire all this information and then apply 
it to itself, it is essential to develop some means whereby such informa¬ 
tion can be translated into effectiveness. As the family is less accessible, 
such approaches must come largely through the schools, although there 
are many problems that cannot be approached in this way. Much 
knowledge must also be acquired about the child before it is of school 
age. In Washington this work is done in connection with a private 
charity, which helps the mother during pregnancy and the child for the 
first six years. 

Serious breaks in adjustment do not ordinarily occur without the co¬ 
operation of some lack of balance in the personality make-up; they are 
rarely accounted for by the influence of extraneous circumstances alone. 
We should correlate the sick adult with the knowledge we have that his 
illness is traceable in its beginnings to his early life. 

Much work now being done has mental hygiene implications—the 
determination of the minimum requirements of food, clothing, wages, 
etc. Here also come in the care of the pregnant woman, child labour, 
sex education, school sanitation, and more specifically the problems of 
the atypical child and juvenile delinquency, all of which can be better 
dealt with in proportion to our increased knowledge of child psychology, 
while such social problems as marriage, divorce and birth control have 
direct bearings. 

The child is the unfinished product of the past through heredity of 
the innumerable elements, largely personal, of its environment, of its 
instincts as they work out in that environment, of social and family 
traditions, and of the social standards of its time and place, and all of 
the various approaches indicated can be made more effective in the 
light of such knowledge. 

As many of the breaks occur in the adolescent period or the period 
of early adulthood, the author recommends that in school or college 
there should be an adviser skilled in matters psychological, and 
sympathetic and understanding of the problems of the young. 

W. J. A. Erskine. 


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The Certification of Children of School Age. {Stud. Ment. lneffic '., 
April, 1920.) Shrubsall, F. C. 

The writer cites the various Acts dealing with defective and epileptic 
children, comments on the mechanisms involved, and gives practical 
elucidations toward diagnosis. Between the ages of 7 and 16 years 
provision for education and to a certain extent residential school 
accommodation must be made by the local education authority. 
Parents’ interests are safeguarded, but consent must not be un¬ 
reasonably withheld. Should a child be discharged from a special 
school as no longer defective the certificate is returned to the parent, 
and cannot be received in evidence in legal proceedings without the 
consent of the child or its parent. 

In certification it is important to determine deficiency as against 
mere backwardness, and further, where defective (but not imbecile or 
idiot), whether the child is educable in a special school. Diagnosis is 
essentially composite, and the examination is conducted abroad by a 
commission of three—an inspector, the rector of the school and a 
medical officer. In this country the usual practice under Act 1899 was 
for the statutory examination to be held by the medical officer in the 
presence of a special school teacher and the class (or head) teacher 
from the ordinary school, thus permitting consultation, which is 
eminently advisable. The Act 1914 contemplates similar procedure but 
by way of written reports. The medical officer is solely responsible for 
the final decision; it is, however, only right that a member of the 
profession primarily concerned should certify the failure to profit in the 
usual channels. 

The scholastic retardation being decided, the cause is sought and 
the question of permanency considered. Mental deficiency forms but a 
small proportion of the total cases, of which one-fourth are due to 
physical defects and sick-absence; rather more than a fourth to truancy, 
change of school and bad home conditions. It is common to find 
hereditary limitation of educability. Such information is essential to 
the medical officer, who obtains it (1) from the form of nomination, (2) 
from the attendance officer, and (3) the care committee. Large 
allowances are necessary for illness and malnutrition. The capacity is 
'estimated in grades and standards, and average progress demands 
advance of a standard a year, from Standard I at 6} years to Standard 
VII between 13 and 14. Backwardness is noted, as a rule, about 6£, 
when a child leaves the infant for the senior school. There is no 
precise definitiohof backwardness, but from the regulations this appears 
to mean a lack of two to three years behind the normal. The backward 
child will make steady progress, but not at the normal rate, and will 
attain Standard IV in the ordinary school classes ; the deficient will need 
individual attention and a special school. Defects of vision or hearing, 
or ill-health, should be treated prior to the statutory examination, and 
where such are detected the child should be referred back to ordinary 
training. 

Educability depends not only on general intelligence but on special 
aptitudes. Normals vary in accordance with the laws of probability, 
but defectives of all grades are characterised by great irregularity of 
mental development. Even highest grade normals may fail in special 


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MENTAL HYGIENE. 


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aptitudes, as music, drawing, and unless of social importance this 
passes unobserved. But even a genuine defective may maintain a 
position in the world if possessed of special aptitude of social value. 
Normal education methods postulate facility in linguistic and numerical 
symbols; manual dexterities are only of late being introduced. Children 
failing in these postulates are defective, for the definition of feeble¬ 
mindedness in the child is incapacity for education by ordinary 
methods—yet such children will be acceptable in the world if they 
possess the power to reason out problems of daily life and social life. 
It is to be noted that the German Common Law Code defines imbecility 
(which includes our feeble-minded) as the inability to consider the 
consequences of acts. The examination is essentially the assessment of 
this ability by tests appropriate to the age of the child. 

The imbecile or idiot is one who cannot care for himself in due 
proportion to his age; the deficient one who can fend for himself, but 
cannot compete with his normal fellows in the earlier school classes and 
needs special instruction. 

The Board of Education requires a special record under motor and 
sensory reactions, emotions, intelligence, mental age (by Binet-Simon 
tests), will-power, other moral characteristics. The tests are simply 
performances to order on the basis of which a quantitative estimate can 
be made of the shortcomings from normal standard. Good relations 
between observer and child are essential. 

Ordinary school is indicated by a deficiency of 2 years Binet to 
age eight, 3 years to age twelve, and 4 years above this. Deficiency in 
excess of this predicates a special school, with the proviso that informa¬ 
tion as to attainments, general behaviour and street knowledge is used 
as a check. It is not the results of the tests, pass or fail, which are im¬ 
portant, but the behaviour of the child to each test. The total result 
gives mental age, the behaviour may show lack of attention, co-ordina¬ 
tion and memory. Emotional conditions may mean reference back to 
school and a subsequent re-examination. 

Children aged seven years testing near 3 years go to special school; 
testing below 3 years with restlessness and no attention cannot so 
benefit, but are re-tested later. Children seen at seven to eight years 
not previously tried in the infants’ department have a mentality of 3 
years or less; they should be seen on two occasions with some months’ 
interval before they are labelled imbecile. A child in an infant school 
without interest, vegetative and placid, or restless and wandering, may 
be diagnosed at once. 

In general, a child up to eight years who can do some 4-year tests 
and up to ten who can do some 5-year tests would be given a trial at 
school. 

Children from a special school are termed imbecile after long trial 
without appreciable progress—usually 5 years’ retardation and basal 
Binet age (/.«., all tests passed) appears unchanged or advanced only 1 
year after several years’ trial. No child should be excluded if there is 
progress, however slow. If good advance is obtained in a special school 
he may be returned to ordinary school if likely to maintain the advance; 
but it is to be considered that this will mean association with younger 
children in a low standard, and, perhaps, loss of the manual training 


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which has engineered his recovery. A consultation should obtain 
between the head teachers of the special and ordinary schools, as special 
oversight must be continued. Dispute is referred to the Board of 
Education. 

On approaching the age of sixteen—the school-leaving period—each 
case requires review as to suitability for employment and social effi¬ 
ciency. General adaptability is the criterion, capacity for fulfilling tasks 
and following instructions, also the possibility of opening for employ¬ 
ment. If diagnosed feeble-minded, guardianship or institutional care is 
requisite. The evidence from all sources need not be sufficient to 
enable the local authority to prove that withholding of consent is 
unreasonable, but if this factor is present it should be recorded. 

John Gifford. 


Part IV.—Notes and News. 


MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN 

AND IRELAND. 

The Quarterly Meeting of the Association was held in the Rooms of the 
Medical Society of London, 11, Chandos Street, W., on Thursday, May 25th, 1922, 
Dr. C. Hubert Bond, C.B.E., the President, occupying the Chair. The Council 
and various committees met on the previous day. 

The minutes of the last meeting, having already appeared in the Journal, were 
accepted as read and duly signed. 

Obituary References. 

The President said that since the Association last met it had lost by death 
three valued members. They were Dr. F. C. Blakiston, who had not long been 
Superintendent of the Isle of Man Mental Hospital, Dr. H. K. Abbott, who for many 
years had occupied a similar position at Fareham, and, lastly, Dr. J. Middlemass- 
With regard to Dr. Middlemass, he made the announcement with a deep sense of 
personal regret, a feeling which he knew was shared by every member of the 
Association, particularly by those who had been associated with him on the 
Council, and notably, lately, in connection with the revision of the Nurses* Hand¬ 
book, as well as on the various committees of the Association. For the past 
twenty-three years Dr. Middlemass had been Medical Superintendent of the 
Sunderland Borough Mental Hospital, and his membership of the Association 
commenced in 1893. There were but few who had the foresight or the opportunity 
to lay so sure a foundation for their medical studies as did Dr. Middlemass, for 
before commencing them he attended all the courses for the full curriculum, first in 
Arts, then in Science, in both of which Faculties at the University of Edinburgh 
he was a graduate before he proceeded to the degrees of Bachelor and Doctor of 
Medicine. During the brief period of the speaker’s residency at Morningside he 
came into close touch with Dr. Middlemass, who was then Pathologist there under 
Sir Thomas Clouston. He was possessed of very high scientific attainments, was 
most painstaking in his work, and his counsel, teaching and friendship would long 
be treasured by those who were privileged to obtain them, among whom the President 
had always been glad to count himself. 

For the past three years Dr. Middlemass had been Lecturer in Psychologicaf 
Medicine at the University of Durham, and the last letter the speaker received from 
him expressed the desire to see developed, at Newcastle and at the neighbouring 
public mental hospitals, arrangements for teaching and research in mental dis¬ 
orders, which would be worthy of the name of a school of psychiatry. Those irv 
a position to do so owed it to his memory to do all they could to secure the fulfil¬ 
ment of that wish. In this room and at other places where the Association had r 


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from time to time, met, they all remembered Dr. Middlemass as an indefatigable 
confrere , and it must be no small grief to the senior members of the Association 
that he had not been spared, as was their hope, to occupy—probably in 1924— 
the President’s chair. 

He was sure it would be the wish of the Association that the Honorary General 
Secretary should convey to Mrs. Middlemass and the relatives of the other 
deceased members the Association’s sympathy in their bereavement. 

This was agreed to by members rising in their places. 


Matters Arising out of the Council Meeting. 

The President said that at the meeting of the Parliamentary Committee a 
matter was discussed which was reported to the Council, and which ought to come 
before this general meeting, namely the projected legislation for the early treat¬ 
ment of mental disorders without certification. He was himself at that meeting 
only for a few minutes, but he understood there was a full and long discussion, 
and that a resolution was passed that had a bearing on the question which, in the 
past at least, had been a vexed one, namely the supervision of such treatment in 
any newly-created places. The resolution passed, he understood, expressed the 
opinion that there should be no division in the supervision of the care and treat¬ 
ment of the mentally affected, but that it should be entrusted to the Board of 
Control, which at present supervised the institutions under the Lunacy and Menta 
Deficiency Acts. He took it that this might come before the Association in a 
more formal way on another occasion, but the General Secretary had reminded 
him that it would be of interest to the general body now. The wish was expressed 
that in communicating the resolution to the proper quarter it would be better for 
it to emanate from the Association as a whole, rather than from any of its com¬ 
mittees. He had not the exact terms of the resolution, in the absence of the Chair¬ 
man of the Parliamentary Committee, but its purport was as follows: u That in any 
projected legislation for the temporary treatment of mental disorders without 
certification, the supervision of such treatment should be carried out by the Board 
of Control.” 

The resolution was agreed to on the proposition of Prof. G. Robertson, seconded 
by Dr. J. F. Dixon. 


Election of Candidates for Membership. 

The following were duly elected members of the Association : 

Price, Alfred Edward, M.D., M.S.Lond., M.R.C.S.Eng., Medical Super¬ 
intendent, “The Flower House,” Thanet Lodge, High Street, Bromley, 
Kent. 

Proposed by Drs. T. B. Hyslop, F. H. Edwards, and H. J. Norman. 

Williamson, David Hardie, M.B., Ch.B.Edin., Assistant Medical Officer, 
Woodilee Asylum, Lenzie. 

Proposed by Drs. H. Carre, A. M. Dryden, and A. Dick. 

Rollins, Ernest Edward, M.B., B.Ch.DubL, Second Assistant Medical 
Officer, Graylingwell Mental Hospital, Chichester. Lieut. R.A.F. Medical 
Service. 

Proposed by Drs. H. A. Kidd, S. Nix, and R. Worth. 

Logan, Frederick Colquhoun, M.B., Ch.B.Glasg., Assistant Medical Officer, 
County Asylum, Prestwich. Address : County Mental Hospital, Prestwich, 
near Manchester. 

Proposed by Drs. D. Orr, Bedford Pierce, and R. Percy Smith. 

Gasparine, John Jones, M.R.C.S., L.R.C.P.Lond., D.P.H., Assistant Medical 
Officer, Horton Mental Hospital, Epsom, Surrey. 

Proposed by Drs. J. R. Lord, N. Roberts, and E. S. Litteljohn. 

Riches, Reginald George, M.R.C.S., L.R.C.P.Lond., Assistant Medical 
Officer, Horton Mental Hospital, Epsom, Surrey. 

Proposed by Drs. J. R. Lord, N. Roberts, and E. S. Litteljohn. 

Rodger, Kenneth Mann, M.B., Ch.B.Glasg., Assistant Medical Officer, 
Horton Mental Hospital, Epsom, Surrey. 

Proposed by Drs. J. R. Lord, N. Roberts, and E. S. Litteljohn. 

LXVIII. 2 2 


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Paper. 

"The Genetic Origin of Dementia Praecox,” by Sir Frederick Mott, K.B.K., 
M.D.Lond., F.R.S. 

It was illustrated by micro-photographs and drawings. 

The President said it was to be regretted that the audience that morning was 
not larger. All present had enjoyed this most interesting thesis, which was full of 
importance, and when they had leisure to read and ponder it, they would see in it 
matters of grave import in their treatment of mental disorders. In fact—especially 
in regard to Sir Frederick's earlier remarks—one would be compelled to revise 
some misconceptions very materially, i.e ., the way in which such disorders were 
grouped, and the way in which the subjects were taught to students. He asked 
whether Sir Frederick considered that the dictum of Hughlings Jackson as to the 
latest faculties developed being the first to go was a progressive fact. In other 
words, as era succeeded era—if era expressed a sufficiently long time—would those 
more recently developed structures assume a greater degree of stability P 

Dr. J. F. Dixon said Sir Frederick Mott laid much stress on the fact that strain, 
without being associated with a poor heredity, did not cause a breakdown in the 
individual; then he proceeded to mention the large number of Serbian prisoners 
who had undergone all kinds of stress and strain, and only 5 of 10,000 developed 
insanity. He also mentioned the women in the North of France. The speaker 
therefore asked whether there was a history of absence of insanity in those 
populations, and, if so, whether that would account for the freedom from mental 
disease among them. 

Dr. Menzies asked whether the Betz cells were affected. If not, that was a 
serious source of objection, as those cells were analogous to new cortex. They 
were a late philogenetic and ontogenetic development, therefore they ought, on 
Sir Frederick Mott’s theory, to be affected in primary dements. The primary 
dement did not get ordinary paralysis, though he might have absence of movement 
from the afferent side. If sufficiently stimulated he was able to walk. The Betx 
cells were not myelinated until long after birth. 

Dr. J. Carswell, after expressing in well-chosen words his sense of gratification 
regarding the paper they had just heard, referred to the occurrence rate of insanity 
among 10,000 Serbian soldiers who had had a long course of hardship and priva¬ 
tion. For a number of years the speaker had worked out the proportion of persons 
between 15 and 45 in a great engineering district in Glasgow who had become 
insane for the first time, and the rate was exactly the same as among the Serbians 
referred to—5 in 10,000 per annum. The proportion was worked out before the 
war. There was therefore ample proof that the population was not a degenerate 
one, but, notwithstanding the stress and strain incidental to a working-class 
population, including alcohol, was very strong and virile. In districts, however, 
where dwelt a "sediment” population, with a high death-rate and much depravity, 
the proportion of first cases of certified insanity rose to 10 or 12 per 10,000 per 
annum. The impressions gained in long years of practice were valuable, though 
they could not always be put into figures; and, having seen in their homes for 
a number of years these cases of occurring insanity, he gave it as his conviction, 
forced upon him by experience, that this genetic element always confronted one. 
Stresses and strains had seemed so inadequate to explain some of the forms of 
insanity, particularly the great group which alienists had got into the habit of 
calling dementia praecox. Therefore his contribution was one of thanks to Sir 
Frederick Mott, and, from practical experience, a confirmation as to the com¬ 
paratively slight incidence of insanity in a fairly healthy industrial population, 
and a rate about thrice as high among a population which, economically, had 
shown its unfitness to live before it became insane. 

Dr. Harvey Baird said that in view of the association of disease of the repro¬ 
ductive organs with mental disease he would like to hear whether Sir Frederick 
Mott thought various gland extracts, such as ovarian, were of any use. In the few 
cases of dementia praecox in which the speaker had used them practically no 
benefit had resulted. Was it because they were used too late P 

Dr. J. Mills also expressed his indebtedness for the fascinating lecture. He 
gathered that Sir Frederick attributed much of the condition dementia praecox to 
the defective development of the supra-marginal layers of the cortex and failure of 


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1922.] 

the endocrine glands. Were those combined failures necessary for the production 
of the disease, or if not, which had the greater influence ? 

Prof. George Robertson said he desired to associate himself with the words 
of praise used by Dr. Carswell in regard to Sir Frederick Mott’s lecture. It 
was a lecture which brought feelings of both admiration and despair—admiration 
at the extent of Sir Frederick’s knowledge, and despair as to how those who gave 
instruction in psychiatry were to teach the subject in the future. Sir Frederick 
began his lecture by wiping off the slate all the varieties of insanity which members 
had been accustomed to teach to students, and which in the past were treated with 
respect by such men as Clouston, Savage and others. If this review was to be 
made, it was possible it would mean having to wipe off the slate every form of 
insanity which they had been regarding as an entity. But it had been recognised 
by them all—and he referred to it in his prefatory note in speaking of manic- 
depressive insanity—that all forms of insanity at their margins appeared to run 
into one another; that they struck one as akin to the colours in the rainbow: each 
colour was distinct in its own zone, but each tended to blend into the next. 
Another point which upset him, yet interested him greatly, was the following: 
According to Sir Frederick, it was not the brain one looked to as being the cause 
of insanity; there were other parts of the body, perhaps more important, which 
caused the mental condition; and in this respect he had always been interested in 
the observation of Pinel, who stated in his book on insanity that its cause was in 
the intestinal tract; he did not lay stress on the changes in the brain. Pinel 
believed insanity arose through some changes in the abdominal organs. Probably 
the first person who drew attention to changes in the brain was he whose 
centenary had been celebrated in Paris—Bayle—who, at his mental hospital, 
performed a post-mortem examination on every case which died of insanity, and 
observed the changes in the meninges and the character of the brain in general 
paralysis. He was the first pathologist who drew attention to the pathological 
changes in the nervous system as being the cause of the mental systems. He said he 
was not in a position to criticise the observations Sir Frederick had just made, and 
he did not presume to do so. There were one or two observations he made 
with regard to the changes which took place in the higher areas of the brain, and, 
associated with them, changes in the testes. He, the speaker, did not think those 
two regions were strictly comparable. Sir Frederick said that the realms of the 
nervous system most apt to become diseased were those which were most com¬ 
plicated and most voluntary, and therefore, on that account, disorder took place in 
the higher realms of consciousness. But he would point out to Sir Frederick that 
the organs of sex were certainly not the most complicated, nor the last to be 
formed, nor the least firmly established. Philogenetically they were the very 
earliest. Secondly, Sir Frederick indicated on the diagram the limited area of the 
nervous system, from which, ultimately, the principal portions of the brain 
■developed. There were millions of nerve cells in the brain, and the lecturer 
pointed out the enormous proliferation in these regions had probably exhausted 
the original energy of these cells and predisposed to disease, on account of this 
proliferation of nerve cell. He would ask Sir Frederick to consider this fact—that 
once these cells were produced, no further proliferation took place in them. On 
the other hand, the cells of the other tissues of the body went on proliferating for 
a hundred years. Therefore the amount of proliferation which took place in some 
of the meaner tissues of the body might very much more exhaust the vital energy 
than did the changes which took place in the brain, because there, when once, 
shortly after birth, the cells were formed, they never proliferated again. He 
could speak for a long time on the points the lecture had raised, but he would be 
content with making those few observations, and again thank Sir Frederick for 
his most interesting address. 

Sir Frederick Mott, in reply, said the Serbians were a peasant population, 
and nationally they had had a very rough time for a long time past. And he 
thought the Serbians did not take so much care of their lunatic imbeciles as we 
did ours in this country. He doubted whether they had asylums, therefore 
natural selection and the survival of the fittest had proceeded there in a proper 
manner. With regard to the women in northern France, what he said was that 
there was no increase of lunacy among them. In the Serbian Army those who 
were left must have been very hardy; they had stood the stress of many years of 
fighting, and it was likely that the imbeciles and epileptics must have been wiped 


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out long ago. But the important point was, that those 10,000 were like the people 
he spoke of whom one could hit on the head and give them a good deal of alcohol 
without making them insane. Even the 5 out of the io f ooo who were insane 
probably had some mental defect which they had inherited. He believed that 
was also the opinion of Dr. Lewis Bruce, Dr. Stanford Read and others who gave 
evidence before the Shell-shock Enquiry. In answer to Dr. Menzies as to the 
affection of the Betz cells, they very often escaped—at any rate they did not show 
the same change which was found in the other cells. The myelination showed 
that those cells were, ontogenetically, of earlier development than the rest of the 
cortex. There was myelination in all the projection centres. The sensory-motor 
cells must be myelinated before the association cells, because it was only at birth 
that an individual could have a simple sensation; afterwards they got linked up with 
perceptions. The Betz axons took time to develop into the final common path. 
The optic radiations showed myelination ; it was the whole principle of Flexner’s 
theory. He, the speaker, could have shown the members a picture of a dog’s 
brain in which the myelination was much more developed in ten days than took 
place in the human brain in three months. It had to be remembered that the ceil 
nourished itself; it was not nourished. It was like the case of an individual who 
might have food put before him but might be unable to digest it. He did not 
anticipate any improvement in the kind of cases under discussion from the 
administration of any the gland extracts. The Harmers had sent over from America 
much testicular extract, and Sir Frederick wrote that clearly the interstitial cell con¬ 
stituents must be included in the powder, for unless the testes of developed animals 
were used there could be no good. Harmers then sent some material which had been 
prepared in that way, but from its use he had not been able to trace any real benefit, 
though some of the cases had been a little stimulated. He regarded the disease 
as a cell inadequacy, for the same reason that the subjects of it could not resist. 
If one took a large industrial population, such as Dr. Carswell had spoken of and 
worked amongst, i.e. t under 45 years of age, it was a very good type for generalising 
upon. The persons under discussion had a low vital energy, and many developed 
tuberculosis, or some chronic disease, because they were very deficient in resist¬ 
ance, and he doubted whether anything would make that better. This was not a 
disease which was limited to civilised or to poor people ; it existed in all parts of 
the globe where homo sapiens lived. One could not tell the difference between 
the brain of a cannibal and that of a civilised person. It had been thought that the 
brain of the former would be found to be of low convolutional pattern and of lesser 
weight, but Aohlbrudde came back from his researches with the humiliating confes¬ 
sion that their brains weighed more than that of the average European. It was not 
sufficiently remembered that these processes had been going on for millions of 
years. The Piltdown skull was probably a type between homo sapiens and the 
higher anthropoid apes. It had been shown that this was an enormous develop¬ 
ment from relatively few cells, and that this was why there was a tendency to 
degeneration of this highest level. With regard to the endocrine glands, there 
was no doubt that the endocrine system played a most important part in con¬ 
nection with the vital activities of the whole body. The medullary substance was 
sympathetico-tonic. He had examined 100 specimens of suprarenal gland, and 
changes were found there, and though it might play an important part, he did not 
think it was a primary condition in the disease. Certainly in the case of the thyroid 
there was that evidence, because it was essential for the development of the brain, 
and also for its proper functioning. In cases of hypothyroidism he had found the 
cells of the brain deficient, and even complete absence of the basophil substance, 
which he regarded as kinetoplasmic substance, and the slowness of thought and 
action was characteristic of this disease. He asked members to remember the three 
levels. There was a release of higher functions, and an over-action of the lower, 
which Hughlings Jackson said was the most important cause of the symptoms. 
The thyroid gland was the most helpful of all the glands in the treatment of 
disease, because the thyroid secretion originally went into the alimentary canal, 
therefore it could be absorbed ; whereas with the other glands, when given by the 
mouth, one did not know what happened to them. It might be well to give them 
by the rectum or the vagina. He wished to thank Dr. Carswell and Prof. 
Robertson for their appreciative remarks. The latter stated that the reproductive 
organs were the oldest; that was true, whereas the structures he, Sir Frederick, 
had been referring to were comparatively recently developed. He had been sug- 


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gesting reasons why that recent structure should break down early, because if 
there was failure of nuclear proliferation of the neuroblasts one did not get the 
patient unable to walk and living a vegetative existence; he was an imbecile. 
The part arrested was the latest developed phylogenetically. There were people 
who became old sooner than others without apparent reason; in others the mind 
became affected. Apart from this disease there was evidence of defective meta¬ 
bolism, and there were present lipoid granules instead of Nissl granules in the 
cells. On this question of durability he thought stress came most upon the latent 
structures and they were unable to bear it, and the weakness was accordingly 
brought out in the highest level first, therefore symptoms arose in consequence of 
this loss of control. In primitive races it was there, but it depended on the 
recovery of social experience and religions. All that, however, was secondary to 
the dementia. The typical form of the disease was dementia simplex—loss of 
mind—and that he associated with degeneration of the nerve cell, which could not 
be repaired. Many of the symptoms met with might depend on the hypo-function, 
and they might get better. He was very glad to have had the matter discussed 
fully; he quite appreciated Prof. Robertson’s criticisms; but when people said 
there was no material basis for the disease he thought the time had come to protest. 

The Third Maudsley Lecture, by Sir Maurice Craig, C.B.E., 

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

After the luncheon interval the meeting re-assembled at the old County Hall, 
Spring Gardens, London, S.W., to hear Sir Maurice Craig deliver the Third 
Maudsley Lecture, the subject being—“Some Aspects of Education and Training 
in Relation to Mental Disorder.” 

In introducing the Lecturer, the President said he did not propose to intervene 
for more than a brief moment between those assembled and the lecture they were 
all so much looking forward to hear. It was, however, his privilege to remind them 
that the man, after whose name—though not at his request—this Lectureship had 
been most appropriately called, was one of the foremost, perhaps the foremost 
neuro-psychiatrist of his day, and, as Medical Superintendent of Cheadle Royal, 
Dr. Maudsley greatly added to the fame of that mental hospital. His professional 
knowledge and skill were great, to which was added a philosophical bent which 
stamped his many writings, and raised the important books of which he was the 
author from that plain in which, as the result of subsequent research, so many 
scientific works find oblivion, into classics and masterpieces which will endure. 
His interest in the study and treatment of mental disorders was so profound that 
many years before his death he stripped himself of most of his fortune, which he 
handed to the London County Council—whose County Hall has been kindly lent 
for this occasion—in order to enable them to found the hospital now known 
as the Maudsley Hospital, which is in course of being opened for the purposes 
Maudsley intended, and where Sir Frederick Mott did so much work during the 
war on behalf of the soldiers. This gift of money received a substantial addition 
under Dr. Maudsley’s will, in which was also a bequest to the Medico-Psycho¬ 
logical Association which enabled it to establish this Annual Lectureship. They 
were very fortunate this year to have secured the services of Sir Maurice Craig, 
and he now called upon him to deliver the third Maudsley Lectureship. 

At the completion of the Maudsley Lecture, the President congratulated 
Sir Maurice Craig on his most excellent address, and Sir Maurice Craig suitably 
replied. 


SOUTH-EASTERN DIVISION. 

The Spring Meeting of the South-Eastern Division was held by the courtesy 
of Dr. F. R. P. Taylor and the Visiting Committee at the East Sussex County 
Mental Hospital, Hellingly, Sussex, on Tuesday, May 2nd, 1922. 

Among visitors present were Miss C. G. K. Scovell (a member of the Committee), 
and Sir C. O’Brien Harding (a past member of the Committee), Dr. Graham 
{Specialist, Neurological Clinic at Brighton), Mr. R. C. McQueen, Dr. T. Turner, 
Dr. Hamilton (D.C.M.S., Brighton), and Rev. H. R. White (Chaplain). 

At the close of the luncheon a vote of thanks to Dr. Taylor and the Committee 
was proposed by Dr. C. Hubert Bond and carried with acclamation. Dr. Taylor 
replied on behalf of himself and the Committee. 


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The Genera] Meeting was held at 2.30 p.m., Dr. C. Hubert Bond in the Chair. 

The Minutes of the last meeting were taken as read and confirmed. 

Dr. Noel Sergeant and Drs. John Brander, F. H. Edwards, J. G. Porter Phillips 
and F. R. P. Taylor were unanimously elected Hon. Divisional Secretary and 
Representative Members of the Council respectively for the year 1922-23. 

Drs. Cedric W. Bower, A. Helen Boyle and J. N. G. Nolan were elected members 
of the Divisional Committee of Management. 

The following gentlemen were elected as Ordinary Members: 

Back, Frederick, M.R.C.S., L.R.C.P.Lond., Junior Assistant Medical Officer,. 
East Sussex County Mental Hospital Hellingly, Sussex. 

Proposed by Drs. F. R. P. Taylor, J. N. G. Nolan, and Noel Sergeant. 

Duncan, Williams Arthur, M.B., Ch.B.Edin., Second Assistant Medical 
Officer, East Sussex County Mental Hospital, Hellingly, Sussex. 

Proposed by Drs. F. R. P. Taylor, J. N. G. Nolan, and Noel Sergeant. 

Dunlea, John G., M.B., B.Ch.,N.U.I., Assistant Medical Officer, Kent County 
Mental Hospital, Maidstone. 

Proposed by Drs. H. Wolseley-Lewis, W. E. Collier, and Noel Sergeant. 

Graham, Malcolm Frank Dougless, B.A., M.D.Toronto, M.C.P.&S. 
Ontario, Specialist at Neurological Clinic, Ministry of Pensions, Brighton, 
3, Whitehall Place, London, S.W. 1. 

Proposed by Drs. F. R. P. Taylor, J. N. G. Nolan, and Noel Sergeant. 

McCord, Robert N. B., M.B., B.Ch.Belf., Assistant Medical Officer, Brook- 
wood Mental Hospital, Surrey. 

Proposed by Drs. J. A. Lowry, W. Brooks Keith, and Noel Sergeant. 

Martyn, Pierce Patrick, M.B., B.Ch.,R.U.I., Assistant Medical Officer, 
Kent County Mental Hospital, Maidstone. 

Proposed by Drs. H. Wolseley-Lewis, W. E. Collier, and Noel Sergeant. 

Stewart, Francis Hugh, M.A., D.Sc.St.And., M.D.Edin., Major I.M.S. 
(retired), Assistant Medical Officer, County Mental Hospital, Cambridge. 

Proposed by Drs. M. A. Archdale, A. F. Reardon, and Noel Sergeant. 

The invitation of Dr. A. Helen Boyle to hold the Autumn Meeting, 1922, at 
Hove was accepted with many thanks. (Note, —This acceptance has been post¬ 
poned until Spring, 1923.) 

Papers. 

“ Present Treatment of Incipient Insanity in East Sussex," by Dr. J. N. G. 
Nolan. This paper was supplemented by a few remarks from Dr. Harper and Dr. 
Graham concerning the work at the Clinic at Brighton, and by Dr. Taylor, who 
spoke of the efforts that were being made to inaugurate a central clinical laboratory 
that would serve the needs of the three Sussex and two Kent County Mental 
Hospitals. Dr. C. Hubert Bond expressed his appreciation of these communica¬ 
tions and opened the discussion, in which the following members and visitors 
participated: Sir William J. Collins, Sir C. O'Brien Harding, Drs. Collins, 
Baird, Bower, and McDowall. 

“ Lilliputian Hallucinations," by M. Leroy. This paper was read by Dr. 
G. W. B. James, who mentioned one case which he had met with in his own 
practice. Sir William J. Collins also mentioned an extremely interesting case, 
in which he attributed these “lilliputian hallucinations" to the effect of an early 
cataract on an abnormally imaginative temperament. 

Owing to the lateness of the hour it was impossible to continue the discussion, but 
the communication is to be printed in the Journal of Mental Science , with a 
suggestion that readers shall send to the Journal a short account of any similar 
case, or cases, coming under their observation. 

The members were then entertained to tea, which brought to its conclusion 
another pleasant and instructive meeting. 


SOUTH-WESTERN DIVISION. 

The Spring Meeting of the Division was held, by the kind invitation of Dr. 
Peachell, at the Dorset County Mental Hospital, Herrison, Dorchester, on Friday, 
April 28th, 1922. 

General Gordon Steward, Major Gundry, Rev. Slemeck, and Drs. Ash, Gowringf, 
Rodd and Smerdon were present as visitors. 


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Dr. W. F. Nelis was voted to the chair, and the minutes of the last meeting were 
read and signed. 

Dr. G. N. Bartlett was elected Hon. Divisional Secretary. 

Drs. T. S. Good and J. G. Soutar were elected Representative Members of 
Council. 

Drs. G. E. Peachell and E. Barton White were elected members of the Com* 
mittee of Management, and Dr. J. E. P. Shera was elected to that Committee in 
place of Dr. Stanford Read, who has left the Division. 

The date of the Autumn Meeting was fixed for October 27th, 1922, that of the 
Spring Meeting April 26th, 1923. The place of the Autumn Meeting was left to 
the Secretary to arrange. 

Dr. G. E. Peachell then read his paper, “A Case of Insanity associated with 
Pregnancy and previous Exophthalmic Goitre.” This paper provided much 
interesting matter, both clinical and pathological, and was emphasised by the wet 
specimens and sections shown. Sections of thyroid, ovary, kidney, pituitary body 
and suprarenal glands were exhibited on the screen, and the interdependence of the 
various internal secretions was debated. 

Drs. Ash, R. Eager and Gowring took part in the ensuing discussion. 

Dr. E. Barton White read his paper on Bacillus coli infection in mental 
hospitals, and illustrated the life-history and relationships of the Bacillus coli , 
and possible sources of infection with this organism by means of the common fly, 
cockroach, etc., as proved by experiment. 

Dr. W. F. Nelis moved a vote of thanks to General Gordon Steward, the 
Chairman of the Mental Hospital Committee, for his welcome to and entertain¬ 
ment of the members, and Dr. G. E. Peachell was also accorded a hearty vote of 
thanks for his kind hospitality and the provision of a most interesting programme. 


NORTHERN AND MIDLAND DIVISION. 

The Spring Meeting of the Division was held at the Derby Borough Mental 
Hospital, through the courtesy of Dr. J. Bain, on Thursday, April 27th, at 2 p.m. 

The members were shown over the Hospital in the forenoon and were entertained 
to lunch by Dr. Bain, who was cordially thanked for his hospitality. 

The minutes of the last meeting were read and confirmed. 

The following candidates were balloted for and duly elected: 

Jane Elizabeth Hay, M.B., Ch.B., D.P.H.Edin., Assistant Medical Officer, 
Storthes Hall Asylum, Huddersfield. 

Proposed by Drs. T. S. Adair, J. E. Kitchen and J. R. Gilmour. 

Gilbert Malise Graham, M.B., Ch.B.Edin., Assistant Medical Officer, 
Derby Borough Mental Hospital, Rowditch, Derby. 

Proposed by Drs. J. Bain, J. R. Gilmour and G. Mackie. 

Dr. J. R. Gilmour was elected Hon. Secretary to the Division, and Drs. T. 
Stewart Adair and J. V. G. B. Tighe Representative Members of Council for the 
ensuing year. 

Papers. 

“ On the Behaviour Changes Supervening on Encephalitis in Children,” by 
Dr. G. A. Auden. 

“ Notes from a Psycho-therapeutic Clinic,” by Dr. J. E. Middlemiss. 

“ Colloidal Gamboge Reaction.” Drs. Riddel and Stewart gave a descrip¬ 
tion, with clinical results, of the technique of this reaction in the cerebro-spinal 
fluid, which they had recently introduced at Whittingham. 

Interesting discussions followed the reading of these papers. 

Demonstration. 

Drs. Orr and Sturrock showed lantern-slides illustrating the effects of dis¬ 
turbances of the sympathetic mechanism on the localisation of toxi-infective 
lesions in the brain. After the cervical sympathetic is divided in the rabbit’s neck 
and a general infection subsequently produced, both hemispheres are affected, but 
the lesions are more intense on the divided side. Nerve-cell degeneration is found 
on the cornu ammonis, the caudate nucleus, the amygdaloid nucleus, the pyriform 
lobe, and in the cerebral cortex. All those areas derive their blood supply from 


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[July, 

the pial vessels, which are under sympathetic control. In addition to the nerve 
cell changes, there were found lipoid secretion from the choroid plexus and epen¬ 
dymal ventricular lining, periarteritis in the head of the caudate nucleus, and a 
generalised hyaline change in the contents of the vessels with perivascular oedema. 

Dr. Sturrock followed with a short note, pointing out how these findings could 
account for certain mental symptoms in cases with infections of various organs. 

An interesting debate followed. 

Dr. E. S. Simpson read a paper 44 On the Nursing Question, 1 ’ with a view to 
introducing a discussion on this topic, but, owing to the lateness of the hour, the 
discussion was postponed until the Autumn Meeting of the Division. 


SCOTTISH DIVISION. 

The Spring Meeting of the Scottish Division was held in the Hall of the 
Royal Faculty of Physicians and Surgeons, Glasgow, on Friday, March 17th, 1922. 

Prof. Geo. M. Robertson was called to the chair. 

The minutes of last Divisional Meeting were read and approved. 

Drs. D. Ross and N. T. Kerr were unanimously elected Representative Members 
of Council for the ensuing year, and Dr. W. M. Buchanan was elected Divisional 
Secretary. 

The following candidates after ballot were admitted to membership of the 
Association. 

(1) Marion Cameron Alexander, M.B., B.Ch.Belf., Assistant Physician, Royal 
Asylum, Edinburgh. (Proposed by Drs. Ross, Robertson, and Macleod.) 

(2) Percy Banbury, M.R.C.S., L.R.C.P.Lond., Assistant Physician, Crichton 
Royal Institution, Dumfries. (Proposed by Drs. Easterbrook, Hotchkis, and 
Buchanan.) 

(3) James Dickson, M.C., M.B., Ch.B.Edin., Assistant Physician, Crichton 
Royal Institution, Dumfries. (Proposed by Drs. Easterbrook, Hotchkis, and 
Buchanan.) 

(4) James Watson Kernohan, B.Sc., M.B., B.th., D.P.H.Belf., Clinical Patho¬ 
logist, Crichton Royal Institution, Dumfries. (Proposed by Drs. Easterbrook, 
Hotchkis, and Buchanan.) 

( 5 ) J°hn Campbell Smith, M.A.St. And., M.B., Ch.B.Edin., Assistant Physician, 
Crichton Royal Institution, Dumfries. (Proposed by Drs. Easterbrook, Hotchkis, 
and Buchanan.) 

The Secretary reported that, in terms of remit from last meeting, the Busi¬ 
ness Committee had met and considered the question of further action with regard 
to the Division’s amendments to the Asylum Officers’ Superannuation Act. The 
Committee, while realising that there was little likelihood of obtaining legislation 
in the near future, resolved that the matter should not be allowed to drop. They 
recommended that a reasoned memorial embodying the amendments should be 
prepared and presented to Royal Asylum Boards, District Boards of Control, and 
Scottish Members of Parliament. The meeting endorsed the action of the Busi¬ 
ness Committee, and instructed the Secretary to circulate draft copies of the 
memorial amongst the members of the Division for review and suggestions, so that 
the document may be finally prepared and presented with as little delav as possible. 

During a discussion on the Nurses’ Registration Act it was pointea out that the 
Regulations for the Nursing Certificate of the Association had been criticised by 
members of the Scottish Nursing Council in respect that no provision was made 
for representatives of the nurses taking part in the examination of candidates. 
After a very full discussion the meeting unanimously agreed to recommend to the 
Council 44 that it should be made possible for matrons to take part, not only in the 
training in practical nursing, but also in the examination in practical nursing, of 
candidates for the Nursing Certificate of the Association.” The Secretary was 
instructed accordingly. 

Dr. Ian D. Suttie’s paper, 44 Critique of the Theory of Herd Instinct,” copies 
of which had been circulated, gave rise to an interesting and instructive discussion, 
taken part in by Drs. T. C. Mackenzie, G. D. McRae, J. H. Macdonald, D. Ross, 
David Yellowltes, and the Chairman. 

A vote of thanks to the Chairman for presiding terminated the business of the 
meeting. 


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IRISH DIVISION. 

The Spring Meeting of the Irish Division was held on April 6th, 1922, at 
Hampstead and Highfield Private Mental Hospitals, by the kind invitation of 
Drs. H. and W. Eustace. 

Dr. H. Eustace presided. 

The minutes of the last meeting were read and approved. 

A letter of thanks was received from Dr. Colies, K.C., acknowledging the 
resolution passed at last meeting and sent to him. 

The resignation of Dr. Hetherington, of Londonderry, was accepted with regret. 

The meeting next proceeded to elect an Hon. Secretary and two Represen¬ 
tative Members of Council. Dr. L. Gavin and Dr. W. N. Eustace were named 
scrutineers, and the Chairman declared that Dr. R. R. Leeper was re-elected Hon. 
Secretary and Drs. H. R. C. Rutherford and P. O’Doherty were elected Repre¬ 
sentative Members of Council for the ensuing year. 

The meeting next proceeded to elect an ordinary member of the Association, 
and, on a ballot being taken, Patrick Daniel Sullivan, F.R.C.S., L.R.C.P.Irel., 
Medical Superintendent, Verville, Clontarf, Dublin, was elected an ordinary 
member. 

The following dates were fixed for the meetings of the Division for the ensuing 
year: 

Summer Meeting to take place at Mullingar Asylum on July 6th, 1922 (*/ 
circumstances permit ). 

Autumn Meeting, November 30th, 1922. 

Spring Meeting, April 26th, 1923. 

Dr. H. R. C. Rutherford proceeded to read his communication on “The 
Nature of the Psychopathic Inheritance.” 

The paper was discussed by all the members present. Dr. H. M. Eustace gave 
his experiences of the treatment of the insane by thyroid extract as originally 
carried out at Morningside Asylum by the late Sir Thomas Clouston^ 1 ) All of 
the speakers congratulated Dr. Rutherford upon the good results he had achieved 
and for the very interesting communication he had brought before the meeting. 
Dr. Rutherford having replied to the various points raised by the speakers, a 
cordial vote of thanks to Drs. H. and W. Eustace for their kindness and hospitality 
in entertaining the Division was passed unanimously. 


PARLIAMENTARY NEWS: 

April 11 th y 1922; Ex-service patients in West Ham Asylum .—Mr. Leonard 
Lyle asked the Minister of Pensions to state the actual maladies from which the 
61 ex-service men now in West Ham Asylum were suffering; whether there was 
any hope that they might eventually regain their normal condition ; whether they 
were periodically examined to that end; whether any of them were disabled; if so, 
how many; whether they were local men; if so, how often were their relatives 
allowed to see them ; if not, would he have them transferred to a place nearer their 
own home; and whether any of them were untraced.—Sir A. Mond replied : There 
are at present 55 service patients in the West Ham Mental Hospital whose cases 
may be classified as follows: dementia praecox 23, melancholia 11, mania 4, 
delusional insanity 6, general paralysis 5, epilepsy 3, secondary dementia 3. About 
20 per cent, of these men may be expected to recover, and all cases are periodically 
examined. Two of the patients are disabled and both are local men. Relatives 
are allowed to visit on any day, and there is only one case in which no relatives 
can be traced. 

April 1 2 th t 1922: Discharges from asylums. —Mr. Robert Richardson asked 
the Minister of Health whether, in the matter of dealings with applications for the 
discharge of patients from asylums, the question was decided by the local visiting 
committees sitting fortnightly at the asylum and in touch with its inmates, or 
whether any influence was exercised in this respect by the central London County 
Council Committee sitting at Arundel Street; and what were the functions per¬ 
taining to the latter body.—Sir A. Mond replied: Under the L.C.C. (General 
Powers) Act, 1915, all the duties of a visiting committee under the Lunacy Acts, 

(*) The method was devised by Dr. L. C. Bruce.— Eds. 


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1890 to 1911, in respect of the County of London, are transferred to the L.C.C., 
but stand referred to the Asylums and Mental Deficiency Committee, which meets 
not at Arundel Street, but at Spring Gardens. All applications for the discharge 
of patients from the London County Mental Hospitals are considered and dealt 
with at each hospital by the members of visiting sub-committees appointed by the 
Asylums and Mental Deficiency Committee for the management of the hospital 
and by them alone. 

May 9th, 1922; The Lunacy Bill .—The Lunacy Bill to amend the law relating 
to Chancery lunatics, which has already passed through all its stages in the House 
of Lords, was read a second time. This measure substitutes a single Master in 
Lunacy and an assistant for two Masters in Lunacy as at present. Under Clause 2 
the provisions of Sections 133 to 143 of the Lunacy Act, 1890, relating to vesting 
and other orders as amended by subsequent enactments, are declared to apply to 
criminal lunatics. The remainder of the Bill deals with legal matters affecting 
the property administration of lunatics. 

June 13/A, 1922: The case of Ronald True .—Mr. Stanley Holmes asked the 
Home Secretary whether he had any statement to make regarding his action in 
this case. Mr. Shortt (Home Secretary) said he understood that his action was 
criticised on two grounds: (1) that he need not have instituted any inquiry into 
the mental condition of True; and (2) that having received the report certifying 
him insane he need not have acted upon it. The section under which he acted— 
Section 2 Sub-section 4 of the Criminal Lunatics Act, 1884—stated:— 

“ In the case of a prisoner under sentence of death, if it appears to a Secretary 
of State, either by means of a certificate by two members of the visiting committee 
of the prison or by any other means, that there is reason to believe such person to 
be insane, the Secretary of State shall appoint two or more legally qualified medical 
practitioners, and such medical practitioners shall forthwith examine the prisoner 
and inquire as to his sanity, and after such examination and inquiry such prac¬ 
titioners shall make a report in writing to the Secretary of State as to the sanity of 
the prisoner, and they or the majority of them may certify in writing that he is 
insane.” 

These doctors gave evidence at the trial, as did two other medical men, to the 
effect that in their judgment the prisoner was certifiably insane. What were the 
grounds for an inquiry in this case? He (Mr. Shortt) had the reports of two 
prison doctors who had had the prisoner under close observation for two months. 
There were, in fact, two issues which were quite distinct. The first was—Was the 
prisoner at the time he committed the offence insane within the limit of the doctrine 
of criminal responsibility as laid down by the courts ? That was a question on 
which the jury gave an answer. The further question which arose under the Act 
was whether the prisoner at the time of the statutory inquiry, being then under 
sentence of death, was insane within the meaning of the ordinary law so that he 
could be certified and removed to an asylum. That question was left by the 
Statute to the unfettered judgment of two or more medical men, and in instituting 
such an inquiry he (the Home Secretary) was in no way running counter to the 
views of the judges. On the contrary, the judge who tried the case in the first 
instance, in reporting that he had passed sentence of death, drew his special atten¬ 
tion to the medical evidence as affording matter for his (Mr. Shortt's) further 
consideration; while at the conclusion of the appeal, which was dismissed, the 
Lord Chief Justice said there were certain powers vested in the Home Secretary 
which, in a proper case, were always exercised. If under these circumstances he 
had neglected to put the provisions of the Statute into operation by neglecting a 
medical inquiry he would have been guilty of a flagrant breach of public duty, and 
when challenged he would have had no defence. On the question whether he was 
bound to act on the medical report, Mr. Shortt said that the principle that an 
insane man should not go to execution had been enshrined in the law of this country 
for at least 300 years. Mr. Shortt concluded his statement by quoting a number 
of legal authorities, including Sir Edward Coke, for the legality of the action he 
had taken. 

Mr. Stanley Holmes failed to obtain leave to move the adjournment of the 
House on the matter, only 28 Members rising in support. 

June 24th , 1922 : The case of Ronald True .—Mr. Kennedy asked, on June 15th,. 
whether the attention of the Home Secretary had been drawn to the reported 
statement of Mr. Justice Avory, when charging the Grand Jury at Devon Assizes,. 


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that he very much doubted if the recrudescence of crime experienced after the 
war would continue to abate if the infliction of penalties of the law was to be left 
to the discretion of experts in Harley Street; and whether, seeing that such a 
statement indicated the need of a clear definition of the law relating to criminal 
lunacy, it was proposed to introduce legislation to remove any ground of judicial 
misunderstanding or divergence of judicial opinion.—Mr. Shortt replied that he 
had seen a newspaper report of the learned judge's remark. As regards the latter 
part of the question the matter was one for careful consideration, but he was not 
prepared at present to say that legislation was either necessary or desirable. 

Sir Donald Maclean inquired whether the Home Secretary would consult the 
Leader of the House as to what opportunity would be given to the House to discuss 
this matter, not merely in relation to the particular case, but on the general 
question of principle involved.—Mr. Shortt said he would consult Mr. Chamber- 
lain.—At a later date Sir Donald Maclean pointed out that the subject could not 
be taken on the estimates, as legislation might be required, and that could not be 
raised on the estimates.—Mr. Chamberlain replied that in the present state of 
public business he did not see how it would be possible to find a day for supple¬ 
mentary subjects, especially if the House was to rise in anything like good time, 
having regard to the probability that it would have to meet in the autumn in 
respect of Irish matters. On a further question, Mr. Chamberlain said he thought 
it might be possible for the subject to be discussed on a vote in Committee of 
Supply, provided that no mention were made of legislation. 

In reply to another question Mr. Shortt said that since the Court of Criminal 
Appeal was established in 190S the sentence of death had been respited and the 
prisoner removed to Broadmoor after statutory inquiry in eleven cases. He knew 
of only one case similar to that of True—namely, the case of Townley in 1864— 
when the prisoner was afterwards certified sane. In that case the sentence of death 
which had been respited was commuted to one of penal servitude for life, and the 
man was removed from the asylum to prison. In no recent case had the prisoner 
been certified sane under Section 3 of the Criminal Lunatics Act, 1884. There was 
nothing in the law to prevent a man being executed after he had recovered his 
sanity, but whether it was done was another matter. Mr. Shortt said that in 
eight of the eleven cases that had occurred since 1908, either the judge or the 
Court of Criminal Appeal, or both, while satisfied that the verdict of the jury was 
correct and that the prisoner had been properly found guilty of murder and not 
insane, in the legal sense, when he committed the crime, nevertheless suggested 
that it was desirable that further inquiry under the powers vested in the Home 
Secretary should be made as to the mental condition of the prisoner. 


RETIREMENT OF SIR JOHN MACPHERSON, C.B. 

Sir John Macpherson, C.B., M.D., F.R.C.P., who recently retired from the 
position of His Majesty’s Commissioner of the General Board of Control, and is 
shortly going to Sydney as Professor of Psychiatry, was on June 6th presented with 
a testimonial by professional and other friends in recognition of his long and useful 
services devoted to the interests of the insane. The ceremony, which took place in 
the Hall of the Royal College of Physicians, Queen Street, Edinburgh, was largely 
attended. Professor Sir Robert Philip, President of the Royal College of 
Physicians, presided, and among others present were Lord Polwarth, Lord Salvesen, 
Sir David Wallace, President of the Royal College of Surgeons, and Lady Wallace ; 
Sir James Hodsdon, Sir George McCraej Sir David Paulin, Sir John Rankine, Dr. 
John Fraser, Dr. J. Crawford Dunlop, Registrar-General; Mr. K. Addison Smith, 
C.V.O., Mr. H. M. Cadell, of Grange, Dr. H. C. Marr, Commissioner, and Mr. 
A.D. Wood, secretary, General Board of Control. 

The Chairman said that Sir John Macphersbn was one of their most beloved 
Fellows of that College, a man to whom Fellows in time of difficulty went for 
advice, feeling sure that they would have shrewd, tactful, wise counsel. 

Lord Polwarth, in making the presentation of a piece of plate and a cheque to 
Sir John Macpherson and a diamond brooch to Lady Macpherson, said it was with 
a sense of real pleasure that, after reading a somewhat long list of names, he found 


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the name of one who really and most sincerely deserved the honour which had 
been accorded to him the other day. (Applause.) They congratulated Sir John 
and Lady Macpherson on the honour which had so rightly been awarded by His 
Majesty. He first knew Sir John Macpherson when he became Commissioner in 
Lunacy in 1899. Prior to that he had acted as Medical Superintendent of the 
Stirling District Asylum, Larbert, his services to Scottish lunacy extending to a 
period of nearly forty years. During his long public service Sir John Macpherson 
was actively associated with the many reforms which had taken place to improve the 
care of the insane and advance the treatment of mental disease. He was not 
retiring into oblivion or idleness on a pension well earned ; he was going out to a 
new country to give that country the benefit of his great experience acquired in the 
old country. They wished him a very happy time in Sydney, and a safe return. 
Sir John Macpherson had played a very important part in lunacy administration in 
Scotland, which he ventured to think for long and still was probably the best in any 
part of the world. They had seen of late much about alleged abuses of lunacy 
administration south of the Border. From many of these, he thought, they had been 
entirely free in Scotland, but certainly no one could have conducted his duties with 
a truer spirit of humanity and kindness and consideration than had been shown by 
Sir John Macpherson. (Applause.) 

Sir John Macpherson said it was impossible for him to express in adequate and 
suitable language the gratitude of his wife and himself for their great kindness. 
After referring to the services rendered by Lord Polwarth on the Board of Lunacy, 
he said his own connection with Scottish lunacy dated back to 1883, when as a youth 
of 23 he became an assistant medical officer in Stirling District Asylum. Shortly 
afterwards he went to Morningside under the then greatest living authority, Sir 
Thomas Clouston, whose memory as a master and teacher he revered. He drilled 
into his pupils that psychiatry was one of the most important branches of medicine, 
that mental disease was a physical disease, and that physical disease had its mental 
side. These facts were only now beginning to be realised. In the course of a 
professional experience of nearly forty years, he had, of course, witnessed many 
changes in the methods of care of the insane. He thought he might say that in 
that time their methods had been completely revolutionised. In his experience the 
greater number and the most important reforms in administration originated with 
and were carried out by the medical superintendents of Scottish mental hospitals. 
It was necessary, however, to qualify that statement lest some of his friends should 
become conceited, or lest he should expose himself to a charge of fulsome flattery. 
The reason why Scottish medical officers were able to originate and carry out 
reforms which not only transformed Scottish administration, but had spread from 
here over the civilised world, was that it happened, in the providence of God, that 
the original members of the General Board of Lunacy were so intellectually eminent 
as to be incapable of believing that wisdom in these matters was their own sole 
prerogative. They set the policy which had been faithfully adhered to down to the 
present day. They said, in effect, "Whatever project is advantageous we will 
encourage; on that which is doubtful we will reserve judgment; what is obviously 
wrong we will condemn.” Under such conditions, with a practically unrestricted 
field for individual effort, Scottish genius so asserted itself that in this small and 
remote kingdom in Northern Europe the torch of reform has burnt brightly from 
time to time, and cast its rays over the whole world. (Applause.) 

An indirect result of the wise policy of their predecessors was the invariably, 
friendly relations which had existed for more than 60 years between the Central 
Board on the one hand and the various local authorities and the medical officers 
of mental hospitals on the other. Of course, in this, as in all human affairs, there 
must be differences of opinion, often sharp; but he was not aware that there had 
been as a result any personal animosity. Within that hall and in the precise 
circumstances in which he now stood he had listened at separate times to three of 
his predecessors returning thanks for presentations made to them. They all three 
testified to the cordial relations in which they stood with the medical and lay 
authorities in Scotland concerned with the care of the insane. With diffidence, 
and in all humility, he thought, in his turn, he might say the same. Co-operation 
in a real sense and for a common purpose explained this good feeling, which, 
unfortunately, did not always exist between Government Departments and the 
public. 

With regard to the changes and reforms to which he had alluded, he could 


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imagine someone quite properly asking what results of a tangible nature had been 
achieved by them. It might be asked, for instance, “Has insanity decreased? 
Are we any nearer a knowledge of its nature, its causes, or a method of curing it ? ” 
He feared none of these questions could be answered in the affirmative. But he 
would ask them to consider three of the great advances and reforms in medicine 
and surgery—vaccination by Jenner, chloroform by Simpson, antiseptics by Lister. 
These discoveries did not abolish disease, but they diminished some of its most 
loathsome and most horrible features to the irreducible minimum. It was exactly 
the same thing that had been achieved by reforms in the care of the insane. By 
the hospitalisation of asylums, skilled nursing, open-air treatment, open-air work, 
and as great an extension of liberty as was consistent with actual safety, features 
that formerly were loathsome enough had become not unpleasant to look upon, 
suffering had been relieved, and life under abnormal conditions had been rendered 
more endurable. (Applause.) 

Of the nature and causes of certain forms of insanity, those who had devoted 
their lives to investigation would be found most ready to admit how little was really 
known. Although insanity was not decreasing, although the recovery-rate in mental 
hospitals was very slightly but perceptibly decreasing, and although no preventive 
or curative measures had as yet been devised to combat it, the prospects were 
never more hopeful than at the present time. Throughout the whole field of 
scientific medicine constant advances were being made, many of them having a 
bearing on their subject. Some day—it might not be in their time—a light would 
be thrown upon problems which were now obscure. Even when that day came 
problems would remain presenting themselves, as now, under two aspects—a 
constant and a variable one. The constant was the insoluble problem of life; the 
variable was the view they chose to take of it. From their views of life all their 
civilisation had proceeded. It was the same with insanity. The constant was the 
problem of its nature and causes. From the variable had proceeded all the 
advances and reforms in its treatment, which had resulted in Scotland in such a 
uniformly high standard of excellence. (Applause.) 

On the motion of Dr. Marr, a vote of thanks was accorded to the chairman ; and 
on the call of Mr. A. D. Wood acknowledgment was made of the services of Dr. R. B. 
Campbell, medical superintendent, Stirling District Asylum, Larbert, who had 
acted as hon. secretary and treasurer.— Scotsman , June 9th, 1922. 


PSYCHIATRY IN AUSTRALIA. 

Sir John Macpherson, C.B., Edinburgh, who lately retired from the post of 
Commissioner of the Board of Control for Scotland, has been offered, through 
the Agent-General for New South Wales, and has accepted for a period of three 
years, the post of Professor of Psychiatry in the University of Sydney. This Chair 
is the first of its kind in any university in Australia. 


AMERICAN PSYCHIATRIC ASSOCIATION. 

At the last meeting held at Boston, 1921, the American Medico-Psychological 
Association changed its name to the American Psychiatric Association. At the 
same meeting the Journal of Insanity became the American Journal of 
Psychiatry. 


LONG GROVE MENTAL HOSPITAL, EPSOM. 

The charges made by a witness against the staff of one of the most up-to-date 
mental hospitals in the United Kingdom, before the Departmental Committee 
appointed by the Ministry of Health to consider the allegations made against 
asylum administration contained in Dr. Lomax’s Experiences of an Asylum 
Doctor , were sown broadcast by the Press, but, carrying out its usual inconsiderate 
attitude to mental hospital employees, the same publicity has not been given to 
rebutting evidence. 


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We are glad, therefore, to be able to record that at a sworn inquiry held by the 
Board of Control on April 24th and 25th, 1922, into these allegations, Long Grove 
Mental Hospital and its medical and nursing staff emerged triumphantly. The 
Commissioners, after a very searching investigation, came to the conclusion that 
the charges made as to cruelty against the attendants in the wards were untrue and 
had no foundation in fact. Referring generally to the allegations they conclude 
their report by stating—" Our task has been to decide whether his allegations are 
true, and as to their falsitude we have no shadow of doubt.* 1 We regret that the 
exigencies of space do not permit of us reproducing in its entirety this most 
interesting and instructive report. 


OBITUARY. 

John Turner, M.B., C.M.Aberd. 

John Turner was born at Portsmouth on March nth, i860. He was the eighth 
child in a family of nine. One of his brothers, Sir George Turner, became famous 
for his work on leprosy and other diseases. He was at one time M.O.H. for 
Portsmouth, and afterwards became M.O.H. for the Transvaal and Medical 
Superintendent of the Leper Asylum at Pretoria. Turner graduated in Medicine 
at Aberdeen in 1883, and soon afterwards became a medical officer at Brentwood 
Asylum, in which institution he spent the whole of his professional career. During 
the greater portion of his service he occupied the position of Assistant Medical 
Officer, and succeeded the late Dr. George Amsden as Medical Superintendent in 
1910. He became a member of the Medico-Psychological Association in 1890. 

Turner had the spirit of the true scientist. He was extremely modest, had no 
desire for publicity, sought no honours, and was quite free from the modern 
disease of self-advertisement. He loved knowledge for its own sake, and was a 
patient, accurate and zealous scientific investigator. His passion for research soon 
became evident, and in 1888 we find what appears to be his first contribution to our 
Journal—a record of a case of post-febrile mental stupor. His investigation of this 
case reveals his unswerving adherence to the biological methods of research; he 
had but little sympathy with the modern psychological trend in psychiatry. The 
bibliography appended to this notice will indicate in some slight measure Turner’s 
unflagging industry. These papers only include his contributions to the Journal 
4 >f Mental Science . He wrote many others, and was a valued contributor to Aldren 
Turner’s well known work on Epilepsy. 

Dr. J. C. Shaw, of Goodmayes Asylum, an intimate friend of Turner, has 
supplied the following personal details of his character and interests : “ With Dr. 

Turner others always came first; he was kindness itself to all classes and was much 
beloved by his patients and staff. There was hardly a subject on which he could 
not converse; he was a great reader of the classics and of fiction—especially 
detective stories. He never wasted a minute ; he spent hours in the post-mortem 
room and the laboratory, but nevertheless knew all about his patients. He had 
numerous hobbies; he was an enthusiastic but not very competent golfer, a keen 
motorist, a skilled photographer and an antiquarian. During his later years he 
.devoted much attention to antiquarian pursuits; he used his motor very largely to 
survey Essex for the purposes of his hobby, and this was his chief interest after he 
retired from Brentwood. He was especially keen on the “windmills” of Essex 
and had some intention of publishing a book on the subject. He left all his books, 
MSS. and other materials to the Southend-on-Sea and District Antiquarian Society, 
of which he was one of the founders.” 

Dr. Turner was not a strong man, and his extensive scientific contributions are 
all the more remarkable from the fact that he had to battle against ill-health for 
the last twenty years. As long ago as 1904 he was taken seriously ill when 
attending a congress in Canada as a delegate from England. It was hoped that 
after the severe illness which had brought about his retirement had cleared up, he 
* would have had many years of rest and leisure. This was not to be, however, and 
he died on March 6th, 1922. Dr. Turner was married and his widow survives 
him, but he had no children. 


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One cannot help reflecting that psychiatry owes a great deal to Turner and men 
bf his kind. His heart was in his work, and he was content to work for no material 
rewards. Unfortunately, in the past there has been but little inducement for men 
to give their lives to scientific work such as Turner accomplished. Things are 
better now, and there are a number of asylums where thoroughly well-equipped 
laboratories enable the medical officer of scientific bent to undertake research under 
extremely favourable conditions and with skilled guidance, but the pioneers of 
psychiatry who persisted in research with but little assistance, teaching or 
encouragement, should always be gratefully remembered. Amongst these must 
John Turner be numbered, and he did much to contribute to our knowledge of 
mental disorder. 


Bibliography. 

44 A Case of Post-Febrile Mental Stupor or Acute Dementia,” Journ . Merit. Sci. t 
vol. xxxiv. 

44 Remarks on the Urine and Temperature in General Paralysis of the Insane,” 
vol. xxxv. 

44 Asymmetrical Conditions met with in the Faces of the Insane,” vol. xxxix. 

44 Sulphates in the Urine of General Paralytics,” vol. xli. 

44 Statistics dealing with Hereditary Insanity based on upwards of a Thousand 
Cases,” vol. xlii. 

14 Phagocytosis in the Brains of the Insane,” vol. xliii. (Bronze Medal of the 
Association.) 

44 Giant Cells of the Motor Cortex,” vol. xliv. 

44 Pathological Changes in the Great Nerve Cells of Insane,” vol. xlvi. 

44 A Theory of the Physical Conditions Necessary for the Production of 
Melancholia,” vol. xlvi. 

“ Central Chromatolysis with Displacement of Nucleus in Cells of Central 
Nervous System,” vol. xlix. 

44 Twelve Cases of Korsakow’s Disease in Women,” vol. xlix. 

44 The Continuity of Nerve Cells,” vol. li. 

44 Anatomy and Pathology of Epilepsy,” vol. liii. 

44 Thrombotic Origin of Epileptic Fits,” vol. liv. 

44 Blood-Pressure and Vascular Disease in the Female Insane,” vol. lv. 

44 Alcoholic Psychosis (Korshaw’s Polyneurotic Psychosis),” vol. lvi. 

44 Examination of the Cerebro-Spinal Fluid,” vol. lvi. 

44 The Classification of Insanity,” vol. Ivii. 

44 A Biological Conception of Insanity,” vol. lx. 

44 Observations on the Rolandic Area in a Series of Cases of Insanity,” vol. Ixiv. 

H. Devine. 


An extended obituary notice of the late Dr. James Middlemass will appear in 
the October number from the pen of Dr. Bedford Pierce. 


NOTICES OF MEETINGS. 

Annual General Meeting: At the Royal College of Physicians and 
University, Edinburgh. 

Monday, July 17th: Committee meetings at 3 p.m.; Council Dinner in the 
evening. 

Tuesday, July 18th : Council and committee meetings. 

Wednesday, July 19th: General meeting—morning session at 10.30 a.m; at 
1 p.m. the Managers of the Royal Hospital at Morningside invite members to 
lunch ; 3 p.m., afternoon session, Presidential Address; 8 p.m., the Annual Dinner. 


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Thursday, July 20th : Morning session at 10.15 a.m., at the University—addresses; 
1 p.m., Chairman of Board of Control for Scotland invites members to lunch at the 
University Union; afternoon session, 2.30 p.m., addresses ; 8.30 to 10.30 p.m., “ At 
Home ” at Craig House. 

Friday, July 21 st; Morning session, 10.30 a.m., Discussion on the Treatment 
of Insanity. 

[British Medical Association (Section of Neurology and Psychological 
Medicine) at Glasgow. Tuesday, July 25th: Discussion on Psychotherapy will be 
opened by Drs. Mitchell, Brown and Crichton Millar. Wednesday, July 26th: 
Discussion on Neuro-syphilis will be opened by Sir James Purves Stewart and Dr. 
Kinnier Wilson. Thursday, July 27th: Papers. President of the Section, Prof. 
G. M. Robertson.] 

South-Western Division .—October 27th, 1922; April 26th, 1923. 

Irish Division .—July 6th, November 30th, 1922; April 26th, 1923. 


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THE 



JOURNAL OF MENTAL SCIENCE 


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


No. 283 [To.\T‘] OCTOBER, 1922. Vol. LXVIII. 


Part I.—Original Articles. 


The Hospitalisation of the Scottish Asylum SystemSf) The 
Presidential Address at the Annual Meeting of the Medico- 
Psychological Association of Great Britain and Ireland, held in 
Edinburgh, July 19-21, 1922. By George M. Robertson, 
M.D., F.R.C.P.Edin., Professor of Psychiatry in the University 
of Edinburgh ; Physician-Superintendent <.{ the Royal Hospital 
at Momingside. 

I. Introduction. 

The dominating motive which for more than a generation has 
directed the activities of the asylum authorities in Scotland has 
been the desire to make the asylum in that country an institution, 
inspired by the same exalted principles and conducted on the same 
medical and nursing methods as those existing in our great general 
hospitals. That ideal has the supreme merit of being simple and 
tangible as well as high, for the voluntary hospital is the most perfect 
embodiment of practical humanitarianism and science at present 
known to us, and the position it occupies is unique among medical 
institutions. The more nearly this ideal is reached, the more closely 
will the care of those suffering from mental disorder approximate to 
a state of perfection, and the more completely will the asylum be 
transformed into a hospital for the treatment of a special disease. 
This is what is understood by the phrase, “ the hospitalisation of the 
asylum,” which was first used in 1902. 

To give effect to this dominating principle has not been found in 
practice to be an easy task. A special disease like insanity needs 
special methods of treatment, and it is impossible to carry these out 
properly in the ordinary wards of our general hospitals. Further, it 
has been found that much required to be undone before hospital 
ideals could be adopted. Although the older and more repulsive 

(') Delivered in the Hall of the Royal College of Physicians, Edinburgh, July 
19, 1922. 

LXVIII. 


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features had already disappeared, traditional methods of treatment, 
peculiar to asylums, handed down from one generation to another, 
still persisted, and it was exceedingly difficult to alter or abolish them. 

Speaking broadly, the asylum had its origin in the prison, and 
neither in its construction nor in its administration has it yet emanci¬ 
pated itself completely fron this prototype. The policy, for example, 
of building numerous single rooms in asylums, formerly called cells, 
is directly adopted from the prison, and the practice of confining 
patients in these rooms, almost a natural consequence of their con¬ 
struction, is another relic of this origin. Thus a practice, which is 
now condemned as a regular procedure, was encouraged by the 
designs of architects, who, as a rule, knowing little or nothing of 
medical ideals, copied from one another, and perpetuated undesirable 
features and methods. The exclusion and non-employment of 
women to nurse the sick and the infirm in the male wards of asylums 
is still another result of this legacy. It is a perpetual reminder of 
the fact that the original conception of an asylum was less that of 
a hospital for the care and treatment of a special disease than of a 
safe place of detention for the custody of a dangerous class. 

The responsibility resting on those charged with the care of the 
insane is a heavy one. These patients consist of individuals whom 
the public, after careful inquiry, has found unfit to be at large. It 
has officially, through a judge or magistrate, deprived them of their 
liberty, and has ordered their detention in special institutions, prim¬ 
arily for the purpose of safety. It expects them to be cared for 
kindly, but in effecting this it has no idea of the practical difficulties 
of steering a middle course between the safety of the lieges on the 
one hand, upon which it insists, and the happiness of the patient 
on the other. It does not realise that this very deprivation of liberty 
imposed by itself forms the patient’s chief complaint and his greatest 
hardship. The public is also inclined to extreme and hysterical 
views on this subject. When, for instance, a former patient who 
has not completely regained an even balance of mind, who in conse¬ 
quence suffers from warped views, a treacherous memory, and a 
grievance against all who have had anything to do with his detention, 
writes to the papers, there is an outcry that sane persons are being 
illegally detained and harshly treated. On the other hand, when 
some crime has been committed by an insane person, or when an 
escaped patient has alarmed some quiet neighbourhood, equally 
indignant letters appear saying how intolerable it is that lunatics 
should be allowed to be at large, or that more stringent measures 
should not be taken to prevent the escape of such dangerous persons. 

As liberty is the most cherished prerogative of the human being, 
it is not without good reason that persons of unsound mind are 


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3922.] 

deprived of it. The measures required for their care very often involve 
questions of life and death. Every melancholic patient at one stage 
or another of his illness is a case of potential suicide; every patient 
•suffering from hallucinations of hearing and from delusions of persecu¬ 
tion is a possible homicide ; while the weakminded and the impulsive 
are all liable to commit irresponsible acts of a dangerous character. 
"Were such patients treated with a sole regard to their wishes and 
feelings, tragedies would happen which would move the public to 
indignation. It has in a large measure escaped such experiences, 
and in consequence it seems probable that a section of it does not 
realise that any danger exists at all. The medical superintendent of an 
asylum is a man who walks on the edge of a precipice, who lives over 
a powder magazine, and he is wise to err on the side of safety. 

In Scotland the medical superintendent is the sole authority over 
all that relates to the medical care of the patients, and he alone 
admits and discharges them. He is, very properly, controlled by a 
Board consisting of some of the ablest men engaged in public life, 
who exercise a prudent and reasonable economy in all matters con¬ 
nected with administration and expenditure. If the expenditure of 
any asylum exceeds the average, it must be justified whereby a 
•check and a limit are imposed upon extreme medical and philanthropic 
aspirations. Were, for example, the staff of one of the rate-aided 
Asylums to be doubled in number, the benefit to. the patients by 
increased personal attention would be enormous. Even then they 
would not enjoy the same privileges as many private patients do 
who pay the higher rates of board in the Royal asylums, but what 
public authority would submit to this extra expenditure, seeing that 
the present heavy financial burden of caring for the insane is not 
tome by the ratepayers without complaint ? 

In effecting reform many difficulties have to be overcome, and 
among these not the least are those connected with human nature. 
As we grow older we tend to become prejudiced against innovation, 
and in the matter of asylum administration the effects of this human 
failing have been felt as in other spheres. Progress has often been 
•delayed by the older medical superintendents, who were more or 
less immune from criticism for the following reasons: Asylum 
administration is not a form of public service that can be thrown 
open to public inspection and criticism, which in so many other fields 
is as useful a corrective as the admission of sunshine and fresh air 
to dark and stagnant places. The relatives of patients object to 
publicity. So do those patients who, after recovery, have to face 
the world again, lest they be seen and recognised, while ill and under 
treatment. Further, the information given by the majority of 
patients is inaccurate and very misleading, except to those who 


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have a knowledge of the symptoms of mental disorder. Finally, the- 
requirements of the insane can only be known by those who have 
made a study of this difficult medico-social problem. 

The General Board of Control, the Government Department 
controlling the application of the Lunacy Laws, has played a notable- 
part in reform by its encouragement of any good work that had been 
effected. It has always had distinguished medical commissioners on 
its staff and enjoys a reputation which is European, as Mr. Munro,. 
the Secretary for Scotland, informed the House of Commons, when 
resisting a motion for its absorption in the Board of Health. Shortly 
after its establishment, in 1857, the Board took a momentous decision 
which has had far-reaching consequences, the influence of which 
still continues to be felt. It decided not to create a stereotyped 
official system, nor to insist on a rigid conformity to any system of 
care, treatment or building construction, but to leave each asylum 
authority free to initiate its own administrative arrangements and 
methods of care. It is believed that to the scope thus given to-, 
individual initiative, combined with the freedom of action entrusted 1 
by the laws to medical superintendents, much of the success of the- 
Scottish system is due. The medical superintendents, finding them¬ 
selves free to launch reasonable schemes in any direction their personal 
inclinations led them, did so with an enthusiasm they never would 
have shown had. these been measures forced upon them by any 
external authority. While one made a special feature of the occupa¬ 
tions and amusements of his patients, another of their food or clothing, 
a third of the extreme limits to which freedom could be accorded 
them, a fourth of the excellence of their nursing, yet another devoted 
himself to medical treatment, to clinical research or to laboratory 
work, though there was least inducement to follow these last important 
lines of pursuit. The Board of Control, watching each development, 
brought successful experiments of every kind to the notice of other 
superintendents, and these innovations, if approved of, were introduced 
with more or less success into the other asylums. By these means- 
stagnation was avoided, a high general average was attained, and 
there was no asylum that did not pride itself on some feature in 
which it firmly believed it excelled all the others. 

II. Abolition of Prison Features. 

No attempt will be made to describe in systematic or chronological 
order all the innovations introduced into the Scottish asylums. 
Progress, too, though apparently resistless, has been irregular, like 
that of the advancing tide. The elimination of prison-like features-, 
will first be sketched. 


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All the asylums built for some time after the passing of the 1857 
Act had airing-courts attached to their wards. These were open 
spaces surrounded by high walls where the patient got fresh air and 
■exercise, as the name implied. They were a feature obviously in¬ 
herited from the prison. “ The airing-court system ” had grave 
objections, but it was a convenient way of giving considerable numbers 
-of patients fresh air and some exercise without the employment of 
a large staff and with the minimum risk of escapes occurring. During 
the progress of structural alterations in a provincial asylum the 
"walls of one of the airing-courts were taken down, and, to the super¬ 
intendent's relief and amazement, none of his patients attempted to 
•escape. The question then occurred to him, why confine the patients 
in airing-courts ? Why not make walks for them round the extensive 
grounds with which most asylums are provided ? Practical effect 
was given to these ideas, and two generations ago this action led 
to the entire abolition of the airing-court system in all the Scottish 
■asylums. This advance is an excellent example of a great reform 
■started at the periphery by the initiative of one superintendent. 
There were undoubtedly some merits in airing-courts, but the 
■abolition of the system did much to modify the administrative 
atmosphere of the Scottish asylums and to pave the way for further 
•changes. 

At one time it was customary to place the insane in mechanical 
restraint by means of strait-jackets, gloves, muffs and hobbles for 
any or every manifestation of conduct that gave the attendants 
trouble. Then came the era of “ non-restraint,” associated with the 
^honoured names of Gardiner-Hill and Conolly. It is not generally 
known, however, that Conolly, in lieu of mechanical restraint, locked 
np his troublesome patients in single rooms or cells. It was he also 
who invented the padded room, which he quaintly described as 
a room of which the floor is a bed and the four walls are padded.” 
•Conolly realised the danger of “ the abuse of single rooms,” and, 
•although it is not asserted that this noble-minded physician employed 
them to excess, he certainly used them more freely than modern 
standards of opinion would approve, and it was he who 
introduced the euphemistic term ” seclusion ” as descriptive of the 
practice. In criticising seclusion, however, it must be remembered 
that a great change has taken place in the conduct of the insane 
in our day, owing chiefly to the more considerate and humane treat¬ 
ment which they now receive. So dangerous were they in Conolly’s 
time that the Metropolitan Commissioners for several years set 
their faces sternly against the introduction of the “ system of 
non-restraint ” on account of the danger to which they believed it 
•exposed the staffs of asylums. 


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The solitary confinement of patients in single rooms during the 
day, technically described as “ seclusion,” became an abuse just as- 
mechanical restraint had formerly been, and to check this a note of 
its employment had to be registered for the information of the Board 
of Control. In several large asylums, however, it was found that 
its use could be altogether discarded, so about twenty years ago 
the Board decided to publish in their Annual Reports a comparative 
table of its use by the different superintendents of asylums. This 
was quite sufficient for the purpose in view, for it soon led to the 
practical abolition of its use in Scotland except in very special cases 
in which it was justified. 

“ The padded room ” of Conolly was also used freely by a former 
generation of medical superintendent. I have taken scores of 
laymen round asylums in the past, and I always found that the 
padded room had a morbid interest amounting to a fascination for 
them. To experience in jest the emotion of being locked up in 
one was the climax of their interest in their visit. Many persons 
seem to entertain the idea that asylums are plentifully supplied with 
such conveniences, and that they form the characteristic feature of 
the care of the insane. Our largest and best-managed asylums do 
not now possess any padded rooms. A delirious patient who does 
not know what he is doing, like a patient suffering from the analogous 
delirium of typhoid fever, should not be left alone in a room, even 
though the floor be a bed and the walls padded, for he requires constant 
supervision and attention. 

As already mentioned, architects have endowed asylums lavishly 
with single rooms, and some use has to be made of them. They 
were originally employed at night for locking up patients who were 
excited, noisy and violent. No attempt was then made to treat 
their mental symptoms at night, and failure to do so often led to* 
these becoming more firmly established and almost ineradicable.. 
Even recent and recoverable cases of insanity ran a danger of being; 
put out of sight at night in these rooms, to their great detriments 
No single agency has probably done more to provide some justification* 
for the supposed manufacture of “ the asylum-made lunatic ” than* 
the abuse of single rooms. Several of the younger superintendents, 
in Scotland took up the subject of this reform with such enthusiasm 
that in the course of two or three years the single-room system was- 
abolished in many asylums, and no patients were ever locked up* 
by them in single rooms either by day or by night, the rooms being, 
used solely as privilege rooms or private bed-rooms for convalescent 
patients. 

The keynote of this reform is the substitution of continuous personal 
attention for the mechanical safeguard of a locked and shuttered 


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327 


room. Within living memory in one of our largest asylums the 
night staff consisted of one night-watchman, who did duty on both 
the male and the female sides. With this minimal staff the only 
way of preventing serious accidents, such as assault or even homicide, 
was to lock up in separate rooms during the night all dangerous and 
troublesome patients. At the present time the night staffs in all 
our asylums have been so greatly increased in number that they are 
numerically sufficiently strong to give continuous personal attention 
in classified dormitories to all the patients whose symptoms require it. 
The ideal standard of care during the night should be equal to that 
maintained by day, otherwise the progress toward recovery made by 
day is lost at night. Efficient night nutsing is now one of the most 
satisfactory features of the Scottish system. 

The breakaway from the prison type of institution is further mani¬ 
fested by the introduction of “ the open-door system," which was 
an attempt to reduce to a minimum the number of locked doors, 
with the object of removing the undesirable prison-like impression 
produced by locked doors on the minds of many patients. Sir John 
Tuke observed that in an asylum, suitably constructed, this unpleasant 
feature could be almost eliminated. The enthusiasm of a pioneer 
carries him very far, and for this we have reason to be grateful. If 
all the doors of our asylums are not kept unlocked, we have at least 
learned the lesson that many of the wards containing convalescent 
and quiet patients may safely have open doors, and the patients in 
these may be permitted to lead almost an ordinary domestic life. 
This conception has been further realised by the erection for this 
class of patient of detached villas without obvious institutional 
features. We thus logically and irresistibly arrive at the stage of 
granting parole to patients who promise not to attempt to escape, 
who then live in open wards, and enjoy complete freedom of movement 
within and even without the grounds of the asylum. This practice 
is extensively adopted and is comparatively seldom abused. It is 
eagerly sought after by many patients, not only for its manifest 
advantages, but because it gives a status to the patients and adds to 
their self-respect, just as the further selection of a patient for an office 
or post in the asylum, however humble it may be, adds to his pride 
and contentment. Especially in dealing with the insane is a policy 
based on the study of human nature that which gives the best results. 

In this connection a most important feature of the Scottish 
system is the removal from asylums of harmless patients and the 
placing of them in the country under the care of selected guardians. 
This is known as “ the boarding-out system,” under which over 
2,000 unrecovered but harmless patients in Scotland, who no longer 
need the special and expensive treatment supplied by mental 


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328 HOSPITALISATION OF SCOTTISH ASYLUM SYSTEM, [Oct., 


hospitals, are provided for. Its success has attracted the attention of 
the civilised world, and it has been the subject of innumerable reports 
by foreign commissions of inquiry. It costs less than any other 
method of maintaining the insane, and, in addition, the State is 
spared the necessity of building expensive institutions to accommodate 
these patients—a very important consideration in these days. Further, 
the patients are far happier leading natural lives in a congenial environ¬ 
ment as simple members of a rural community, doing such work 
as they can, than as units of a multitude in a large public institution. 
Here our practice has gone as far away as it possibly could from any 
suggestion of prison or of restraint, and the unrecovered patient is 
replaced in a natural home under more familial and domestic super¬ 
vision. 


III. Introduction of Hospital Features. 

Passing now to the hospitalisation of the asylum, honour must 
first be paid to the distinguished pioneer of this movement in Scotland, 
the late Sir Thomas Clouston. During a long life he did much for it, 
at the same time inspiring a scientific spirit and an enthusiasm for 
their work among the medical officers of asylums. No keener observer 
of the symptoms of insanity ever existed, and no one who in such apt 
phrase painted so vivid a picture of its many varieties. From an 
early period of his career he taught that an asylum should be an 
Institution for medical observation and treatment, and to enforce 
this idea his favourite recommendation was that every asylum should 
be provided with a separate hospital block. As the medical super¬ 
intendent and his assistant entered its portals on their daily rounds, 
•he believed they would instinctively feel and breathe a medical 
atmosphere. In its wards all recent cases of recoverable insanity 
and all cases of bodily illness occurring in the asylum < would be 
treated, and the nursing staff in their training should first pass 
through its wards. The majority of the modern Scottish asylums 
have been provided with these separate and distinctive hospitals. 

The next advance to which I shall refer was taken in 1880 by the 
late Dr. Campbell Clark when he began courses of instruction for 
nurses and attendants on the lines of those given in general hospitals. 
He described his methods to the Scottish Division of the Medico- 
Psychological Association, after which similar courses were im¬ 
mediately instituted in other asylums, and in order to standardise 
this instruction the Scottish Division published a Hand-Book for 
Attendants on the Insane. The Medico-Psychological Association 
of Great Britain and Ireland ultimately adopted this as the official 
text-book for the use of nurses and attendants who were candidates 
for the Certificate of Proficiency in Mental Nursing, which it instituted.. 


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329 


This certificate was conferred on nurses after a period of training 
and after passing certain examinations, when they became eligible for 
•enrolment on the Association’s Register of Certificated Mental Nurses. 
Thus, thirty years before the recent Act for the Registration of Nurses 
was passed, mental nurses through the agency of this Association 
enjoyed practically all the advantages now being conferred for the 
first time on hospital and other nurses. The training and instruction 
•of mental nurses in the Scottish asylums has all along been con- 
■ducted with care, success, and zeal, as was only natural in view of 
the history of the movement. 

Another important advance was the appointment of hospital 
nurses as matrons of the female divisions of asylums. Its main 
object was to improve the quality of the sick-nursing, but another 
was to place an educated woman with medical training and instincts 
at the head of the female staff. The most serious defect of this 
•departure at first was the total ignorance of the new matron of even 
the elementary procedures of a special kind needed for the safe and 
proper care of the insane. After many failures had occurred it was 
recognised that some preliminary asylum experience was necessary, 
and this defect was overcome twenty-five years ago by the appoint¬ 
ment of three hospital nurses as assistant matrons with the 
•object of training them in mental nursing and asylum management, 
so as to fit them for the post of matron. When these had gained 
the experience needed, they were all successful in obtaining 
appointments because there were no other candidates with equal 
•qualifications to compete against them. After this object-lesson 
had been given, hospital nurses were anxious to come for training, 
and as this system of appointing hospital nurses as assistant matrons 
is an established feature in Scotland, there is now an excellent supply 
■of qualified candidates for the post of asylum matron. 

It will be at once seen what a powerful instrument for the hospital¬ 
isation of the asylum, at least on its female side, is the constant 
presence of assistant matrons within the wards working under the 
direction of a matron who is also a hospital trained nurse. Provided 
these women have been wisely selected and receive support and 
•encouragement from the medical officers, the approximation of the 
methods of the asylum to those of the hospital proceeds apace, 
ior the practical steps to be taken are very simple and are as follows : 
Every feature which exists that is peculiar to the asylum is suspect. 
If it can be abolished without detriment, it is given up. If it can 
be replaced by some hospital method equally good, then that is 
■adopted in preference. Two or three years of honest administrative 
rspade work on these lines has completely transformed many features 
•alien to hospitals that still existed in Scottish asylums. 


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We have so far dealt mainly with the female side. Can the male 
side of an asylum be considered to be part of a modern hospital 
without the presence there of a single female nurse ? Women show* 
such superior aptitude for the duties of nursing that this vocation 
is universally recognised as theirs, and the reason for this superiority 
is not obscure. It rests on the solid foundation of the mothering- 
instinct, which is sometimes so strong in women that it cannot be- 
suppressed and must manifest itself in some form or other. No- 
scheme for the hospitalisation of asylums can be complete, indeed 
it cannot be said to have been properly initiated unless women are- 
employed, so far as that is practicable, to nurse the male insane, 
who are apparently the last class of the sick and helpless to receive- 
the benefit of their sympathy and skill. 

The above statement explains why so many attempts have been 
made to overcome the difficulties connected with the employment of 
women on the male side of asylums. The first was made by Dr. Hitch, 
of the Gloucester Asylum, the founder of the Medico-Psychologicaf 
Association, who employed the wife of the charge-attendant of the- 
refractory ward in the year 1841. I was informed by his widow 
that Dr. Hitch employed this woman not for her nursing abilities, 
but to counteract the rough behaviour of the male attendants to 
the patients in her husband’s ward. Dr. Hitch’s plan of employing 
married couples, as a form of “ auxiliary female care,” was adopted by 
several superintendents, especially in their sick wards. Further 
progress was made, twenty-five years ago, when a successful experi¬ 
ment was carried out by Dr. Turnbull of employing women in a. 
hospital ward of an asylum, not as auxiliaries to male attendants r 
but in complete nursing charge of thirty male patients during the day.. 
At a still later date a male ward in another asylum was placed by 
night as well as by day in the entire charge of female nurses! The- 
patients in these wards, of course, received auxiliary mkle care 
when it was necessary, as, for instance, for the purpose of bathing. 
This system of female nursing in some measure or other has now 
been adopted for nearly a generation in all but one of the asylums- 
in Scotland. The vast majority of women prefer to nurse male- 
patients, because they are not only less troublesome and less excitable- 
than female, but because they find that they usually receive more- 
courtesy and readier obedience from men than from members oF 
their own sex. 

The hospital wards containing the sick and the infirm were naturally 
the first parts of the male side to be staffed by women, but having 
obtained a footing, the sphere of usefulness of female nurses ancb 
assistant matrons has gradually extended to other departments. 
It is not only in the care of the sick and the helpless that the speciab 


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1922.] BV GEORGE M. ROBERTSON, M.D. 331 

qualities of women are of advantage. It has been found that they 
possess more control than men over many cases that might be thought 
most unsuitable and unfavourable for their care. Excited patients, 
for example, who are ready to fight with any man who ventures to 
exercise authority over them, will often do anything they are asked 
to do by a woman, and will often become calm and tractable if they 
receive a few simple words of sympathy from her. A woman con¬ 
tinues to exert much the same subtle influence over an insane man, 
who is not actually delirious and confused, as she does over one who 
is supposed to be in his right mind. Feelings of chivalry and of 
honour do not necessarily die because a man suffers from some 
derangement of mind. 

Another step has been taken in more than a third of the Scottish 
asylums, namely, the appointment of a matron over the whole 
asylum, both male and female sides, whereby the analogy to the 
general hospital is rendered still more complete. This step was 
inevitable, if the hospital ideal, as set forth above, was to be attained, 
because no facilities are given to men in our general hospitals to 
obtain full training in nursing and a hospital certificate. The appoint¬ 
ment, therefore, of a male attendant to act as head of the nursing 
staff of the male side of an asylum is a practice that is gradually 
falling into disuse in Scotland as vacancies occur. 

An increase in the numbers of the medical staff, and a more thorough 
study of the physical disorders associated with insanity by all the 
scientific methods of investigation employed by hospital physicians, 
are features that are intimately connected with the process of hospital¬ 
isation. So also is a higher education in the science of psychiatry, 
to further which diplomas in psychological medicine have recently 
been instituted by the Universities and licensing bodies at the request 
of the Medico-Psychological Association. The Scottish asylums, 
by the advantageous preparations they have already made, are 
ready for a great development of the medical treatment of the insane 
on these scientific lines. It, however, remains a matter for surprise 
that the State has in the past taken so little interest in research 
or offered so little encouragement to investigations into the nature 
and the prevention of insanity, seeing that the care of the insane is 
so heavy a financial burden. One mental disorder alone, namely, 
dementia praecox, probably costs the country more in maintaining 
its helpless victims for life than any other single disease. It is hoped 
that this defect will be removed by the organisation of systematic 
research work in our laboratories. 

Lastly, the Scottish asylums are administered under an archaic 
code of laws, of which the parent Act was passed a few years after 
Sarah Gamp had been presented to the world, but before Florence 


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332 HOSPITALISATION OF SCOTTISH ASYLUM SYSTEM. [Oct., 


Nightingale had reformed our hospitals or Hard Cash had been 
■written by Charles Reade. The provisions of this Act were designed 
to suit a form of social life that no longer exists, and medical science 
and the art of nursing have long ago left it far behind. As the Board 
of Control has admitted the necessity for a new Act, let us hope that 
it will be framed on medical lines, and particularly that under its 
provisions it will be possible for any unfortunate person, who is 
sick in mind, to obtain the medical treatment and nursing his illness 
requires, without first being legally branded a lunatic as at present, 
and then committed to detention by a judge or magistrate, as if 
he were a species of criminal. After all, such a procedure is not 
very different from the trial of the sick person in Samuel Butler’s 
Erewhon, who, suspected of being consumptive, was apprehended 
and tried, as a common criminal would be with us for burglary. Not 
till the cruel anachronism of these laws is removed, which after 
<64 years’ service have outlived their purpose, will the asylum shed 
its last prison features, be cleansed of the prison taint and be free to 
develop along purely medical and hospital lines. That it can be 
removed without evil consequences following is demonstrated by the 
amazing situation that has come to pass in Scotland, where the 
majority of private patients paying the higher rates of board are 
actually being admitted^ to the Royal asylums, not under medical 
certificates and judicial orders, as was intended by our well-meaning 
legislators of other days, but as voluntary patients. Why should it 
not be possible for the rate-aided poor to enjoy this privilege ? Their 
need is just as great as those endowed with wealth, and, being without 
means, they are less likely to be the victims of designing persons or 
plots. But, as a matter of actual fact, no one, rich or poor, has 
ever been found by our courts of law to have been wrongly detained 
in a Scottish asylum. 

IV. Conclusion. 

On taking now a broad survey of the numerous changes that have 
been introduced into the Asylum system of Scotland during the last 
two generations, we can crystallise the essential features of these 
•developments into two simple yet comprehensive ideas or formulae. 
These are, firstly, the abolition of prison features, which are an 
inheritance from the past, by the substitution of continuous personal 
attention; and, secondly, the hospitalisation of the asylum by the 
introduction, as completely as possible, of the methods employed in 
hospitals for investigating, treating, and nursing disease, which still 
remain the ideal for the future. 

The effects of these changes have been so great that they might 
correctly be described as revolutionary, were it not that the .process, 


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1922.] THE GENETIC ORIGIN OF DEMENTIA PR^COX. 333; 

though still incomplete, has been so gradual. The patients, who in 
former days were often unruly and even dangerous, have become so 
much more calm and orderly that those whose recollections go back 
nearly forty years ask themselves, “ Has the type of insanity changed 
to one with milder symptoms ? ” The public, of course, still imagines 
that every patient in an asylum is a raging maniac, but years pass, 
without such a case being seen, because to a large extent they were 
the product of the treatment they formerly received. The nurses, now 
trained, take a more intelligent interest in their work and give more 
careful attention to their patients. Their status has improved, 
and many of them now complete their training in General Hospitals. 
Lastly, the tone and the whole atmosphere of the institution is 
different. It is at once more human, more sympathetic and more 
medical. This is perhaps the most striking change of all, and although 
it is very difficult to explain in words, its influence is all-pervading and 
dominant. When, then, the medical officers of asylums have been in¬ 
creased in number and have received a special training in psychiatry, 
and when the laws cease to place a prison-stigma on asylums and 
their inmates, and to obstruct by legal technicalities the admission 
and treatment of patients in the early and curable stages of mental 
disorder, then will we attain the exalted ideal we have cherished and 
that has dominated our activities. Then will the Scottish asylums 
become special hospitals in the true sense of the term, and take their 
place honourably by the side of our great general hospitals, which 
have served as faultless and priceless models for their imitation. 


The Genetic Origin of Dementia Prcecox.i}) By Sir Frederick W. 
Mott, K.B.E., M.D., LL.D., F.R.S., F.R.C.P., Director of the 
L.C.C. Pathological Laboratory, Maudsley Hospital. 

Mr. President, Ladies and Gentlemen, —Last year I had the 
honour of delivering the Maudsley Lecture, and I brought forward 
a certain amount of evidence in favour of the genetic causation of 
dementia praecox. I have continued these investigations and 
published the results in papers entitled “ Further Pathological 
Studies in Dementia Praecox, especially in Relation to the Interstitial 
Cells of Leydig,” Proc. Roy. Soc. Med., 1922, vol. xv (Section of 
Psychiatry), pp. 1—30; also “ The Reproductive Organs in Relation 
to Mental Disorders,” Brit. Med. Journ., March 25, 1922. The 
former investigation included 27 cases of dementia praecox, the onset 

0 ) A paper read at the Quarterly Meeting of the Medico-Psychological Associa¬ 
tion held in London, May 25, 1922, with lantern demonstration of photo¬ 
micrographs, etc. 


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occurring in adolescence; also the results obtained in 9 cases of 
psychoses other than dementia praecox occurring in post-adolescence, 
and 4 cases of primary dementia, in which the demential symptoms 
•came on in post-adolescence. From these investigations, and from 
others which I have been pursuing, I have come to the conclusion 
that it is better to speak of primary dementia, which may occur 
•either in the pre-adolescent period, adolescence, or post-adolescence ; 
moreover, I am of opinion that all the psychoses belong to one group 
and are genetic in origin. In those forms of psychoses in which 
recovery takes place—for example, confusional insanity or exhaustion 
psychosis, benign stupor, periodic insanity, or manic-depressive 
insanity—we may assume there is a suspension of neuronic function 
in the highest psychic level; but all these conditions I have found 
may end in a terminal dementia, in which the changes in the reproduc¬ 
tive organs and in the brain do not differ from those met with in the 
primary dementia of adolescence, the dementia indicative of a sup¬ 
pression of function. In the primary dementias, naturally, the 
symptoms may be partially due to a suspension, and partially to a 
suppression of function, and I would explain partial remission of 
symptoms by a partial restoration of function in neurones in which 
the nuclear change was either not present or not advanced. 


Two Schools ok Thought in Relation to Dementia Pr.®cox— 
The Psychogenic and Physiogenic. 


There are two schools of thought, one physiogenic, the other 
psychogenic. The former attributes the mental disorder to a primary 
bodily pathological condition, the latter to a primary non-adaptable 
psychological function. The frequency with which psychoses and 
psycho-neuroses follow emotional shock connected with the sex 
impulse, the character of the dreams and their interpretations, the 
nature of the hallucinations and delusions in a great number of 
•cases, suggest an origin in excitement or repression of the sex instinct. 

It was thought, and is still, by the psycho-analyst school that in 
the primary dementia of adolescence—dementia praecox, as it is 
called—there were no bodily changes sufficient to account for the 
signs and symptoms of mental disease. The physiogenic changes 
that are met with, it is stated by Jung, are the result, not the cause, 
•of the psychogenic disorder. Thus this author in his work, Analytical 
Psychology, states: 

“ The difference between us is as to the question whether, in 
relation to anatomical basis, the psychological disorders should be 
regarded as primary or secondary. The resolution of this weighty 


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BY SIR FREDERICK W. MOTT, M.D. 


335 


■question depends upon the general problem as to whether the prevail¬ 
ing dogma in psychiatry—‘ disorders of the mind are disorders of 
the brain ’—presents a final truth or not. This dogma leads to 
absolute sterility as soon as universal validity is ascribed to it.” 
And—** Such an idea is only incomprehensible to those who smuggle 
materialistic preconceptions into their scientific theories. This 
question does not even rest upon some fundamental and arbitrary 
spiritualism, but upon the following simple reflection. Instead of 
assuming that some hereditary disposition, or a toxaemia, gives rise 
directly to organic processes of disease, I incline to the view that 
upon the basis of predisposition, whose nature is at present unknown 
to us, there arises a non-adaptable psychological function which can 
proceed to develop into manifest mental disorder; this may secon¬ 
darily determine organic degeneration with its own train of symptoms. 
In favour of this conception is the fact that we have no proof of the 
primary nature of the organic disorder, but overwhelming proofs exist of 
a primary psychological fault in function, whose history can be traced 
back to the patient's childhood 

The physiogenic theory presupposes an inherent germinal narrow 
physiological margin of normal functional capacity of the brain, and 
stresses which we will consider under the heads of physiological, 
psychological, and pathological, reveal, excite or accelerate a genetic 
inadequacy causing a disintegration of the psychic unity. I will 
consider seriatim these various forms of stress. 

i. Physiological stress. —The period of adolescence in both males 
and females in connection with the sex impulse may be an exciting 
cause of this primary disintegration. The normal physiological 
processes of gestation, parturition, and lactation in the female 
require a greater production of formative energy than the body is 
capable of producing; consequently we find in this period of life a 
large number of adolescents breaking down and exhibiting signs of 
either suspension of function in the highest psychological level, or 
in the severer cases, suppression, although the stress is merely that 
of a normal physiological process. 

In the current number of the Journal of Mental Hygiene (April, 
1922) some valuable statistics are given, throwing, I think, some light 
upon the influences connected with the sex instinct in relation to 
dementia praecox.( 2 ) 

Marital Conditions of First Admissions with Dementia Prcecox. 

Malss. Females. Males. Females. 

Single ... .. 2,401 1,100 75*0 43-2 

Married ••• • • ••• 649 1,111 20-3 44’4 

The differences in percentages are noteworthy. Particularly 


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336 THE GENETIC ORIGIN OF DEMENTIA PR^ECOX, [Oct.,. 

• 

striking is the large percentage of single men and the large percentage 
of married women. Masturbation may be correlated with the former, 
and the physiological stress of pregnancy, parturition and lactation 
with the latter. 

2. Psychological stress .—Emotional shocks, mental conflicts con¬ 
nected with the primal instincts of self-preservation, propagation,, 
and the social instinct, are sufficient to induce neuronic stress, in¬ 
somnia, and metabolic hypo-function of the highest psychic level, 
in which there is, for reasons to be discussed, a lack of durability. 
Disturbances of the normal balance of the internal secretions of the 
reproductive endocrine glands may be causally connected with 
disturbance of the functions of the vegetative or autonomic nervous 
system by which they are normally brought into harmonious functional 
relationship. The emotions and passions not only have their bodily- 
expression in such external secreting glands as the salivary, sweat, 
and tear-glands, but the endocrine organs, the organs of respiration, 
circulation, digestion, assimilation, and reproduction, which are like¬ 
wise controlled by the vegetative nervous system, are profoundly 
affected when an individual is the subject of violent or continued 
emotions or passions. Moreover, repression of their external visible 
manifestation does not save the individual from their harmful 
influences upon the functions of the internal organs, over which 
the will has no control. A vicious circle is thereby apt to be set up. 
Anxiety neuroses with terrifying dreams in soldiers were not 
infrequently accompanied by symptoms of Graves’s disease, exoph¬ 
thalmos, palpable thyroid, Von Graefe’s and Mobius signs, fine 
tremors, tachycardia, and high blood-pressure. The aspect of the 
man was similar to that of terror, which is contemplative fear. 
There is an interrelation of the suprarenal and the thyroid glands, 
and probably the fear led to an increased discharge of adrenalin 
into the circulation, and this may have excited or increased the 
function of the thyroid gland. 

Pathological conditions .—Disturbances of the normal balance of the 
internal secretions of the reproductive and endocrine glands may 
therefore underlie many mental disorders. 

Thyroid Insufficiency. 

In some cases of women, at the involutional period of life especially, 
there is a subminimal deficiency of thyroid secretion into the blood 
(hypothyroidism), and myxoedema occurs with the characteristic 
symptoms of slowness of thought, of speech, and of action, and not 
infrequently a disintegration of psychic unity with hallucinations and 
delusions, and even dementia occurs. I have now examined 7 
cases, and I find this hypothyroidism is associated with a marked 


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I9 22 -] BY SIR FREDERICK W. MOTT, M.D. 337 

•disappearance of the Nissl basophil substance, which may be regarded 
•in a measure as indicative of the loss of energy substance of the 
neurone. We know that administration of thyroid gland will restore 
the function. Moreover, the idiocy of sporadic cretinism can be 
averted by the administration of thyroid. It has been shown that 
thyro-iodin increases the electrical conductivity of the neurone. We 
thus see that the functions of the suprarenal and thyroid glands are 
interrelated with the functions of the nervous system. 


Inadequacy of Bodily Defences against Microbial Toxins. 

Microbial toxins and insufficiency of the normal bodily defences by 
production of antitoxins is well known. Their influence, however, in 
the production per se of mental disease, in my opinion, is somewhat 
exaggerated. In the case of the mental affections, termed puerperal 
mania and lactational mania, there is a disintegration of the psychic 
unity. This failure is due generally either to a physiological or 
psychic stress, but it may also be due to microbial toxic agencies, 
•causing suspension or suppression of function especially of the highest 
psychic level. The patient may, as a result of one or more of these 
•exciting causes, suffer from an exhaustion psychosis from which she 
may completely recover, or it subsequently may prove to be the 
first attack of a periodic insanity. Since in both these mental dis¬ 
orders there is a return to normal mentality, it may be assumed 
that there was only a suspension of neuronic function. But the 
patient may not recover, and passes into a state of dementia, eventu¬ 
ally to die in an asylum of some intercurrent disease, often after many 
years’ residence. Since similar nuclear and cellular changes are found 
in the neurones of the cortex of cases of adolescent or post-adolescent 
-dementia* where the patient has died of an acute disease lasting only 
a few days, e.g., pneumonia or acute dysentery, or a chronic disease, 
•e.g., pulmonary tuberculosis or chronic dysentery, the neuronic 
changes cannot therefore be ascribed as secondary to the prolonged 
•effect of the toxins. The same argument applies to the regressive 
atrophy of the ovary; consequently the assumption that these 
■biogenetic changes in the brain and reproductive organs are due to 
the toxins of the chronic disease falls to the ground. Moreover, we 
know that in women with active and chronic tuberculosis not only 
do the Graafian follicles undergo maturation, but that they become 
pregnant and give birth to a living child, their mind remaining 
perfectly clear. Moreover, I have shown that chronic pulmonary 
tuberculosis and chronic dysentery does not arrest active spermato¬ 
genesis in the male. 

Since therefore all the before-mentioned forms of stress do not as 
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a rule, produce per se either a disintegration of the psychic unity or 
a genetic failure in the reproductive organs, we may inquire what' 
can be the essential cause unless it be an inborn germinal defect. 

Imbecility and Genetic Inadequacy. 

I have shown that in low-grade imbeciles and idiots there is ans 
absence of spermatogenesis. In many low-grade congenital imbeciles 
of the female sex there is frequently a failure of maturation of the 
primordial follicles, as illustrated jjy the following case, in which 
there was arrest of development of the supragranular layer of pyra¬ 
mids from birth. At puberty an acute degenerative process occurred 
which affected especially the infragranular layer. Now, this case is of 
considerable interest, for it shows that a congenital imbecile, till the 
stress of adolesence occurs, is able in a childish way to make 
simple mental adjustments to satisfy the primal instincts of self T 
preservation and the social instinct. She was only educable to a 
limited degree, and this fact may be correlated with a morphological 
fact, viz., an imperfect development of the supragranular layer of 
pyramids. But if you look at the drawing (Plate I), you will see 
that there is also a gross recent morbid change in the deeper layers of. 
pyramids, and especially of the polymorphic layer which may be 
correlated with the terminal dementia. 

Congenital Imbecility with Terminal Dementia in Adolescence. 

Age on admission : 16. Age at death : 20 . Single. 

Pregnancies and results. — Nil. 

Heredity.—Nil known of history. 

Menstruation. —Irregular, slight; no further information obtainable. 

Nature of mental disease and brief history of the same : Congenital imbecility 
with terminal dementia.— She has been dull from childhood, and has been getting 
worse for the last two years; neglected to do things when told; cheerful at times* 
at other times reserved. Sexual excitement. On admission threatened to commit 
suicide, but later there was no return of these suggestions. A note made a week: 
after admission says that she is a congenital imbecile. She is weak-minded, and 
unable to give a connected account of herself. She thinks she is in the Hackney 
Asylum. She cannot add the simplest numbers. She laughs in an irresponsible 
way. Her speech is that of a child of tender years. She does not know the day 
of the week. Talkative, restless and childish. Dirty in her habits. Her general 
health is good. A note on her condition taken six months before death says that 
she is becoming more and more demented, and is able only to answer the simplest 
question. 

Cause of death and other pathological conditions. —Tubercular broncho-pneu¬ 
monia ; gangrene of lung. 

Brain weight. —1,010 grms. 

Weight of uterus .—Uterus is infantile. 

Weight of ovaries not given. 

Remarks .—Ovary very small, not larger than that of an infant of eighteen 
months. Numbers of primordial follicles in stroma ; very few show any zona granu¬ 
losa; the nuclei show an imperfect network as a rule. There are no signs of 
corpora iutea, but a number of atretic follicles of varying size from a small pin’s, 
head downwards. There are a few follicles commencing to maturate, but the 
nucleus shows no network and is obviously degenerated. The zona granulosa 


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339 


1922.] 

shows hardly any chromatin in the nuclei, and the cells are obviously degeneratedi 
The larger atretic follicles show no epithelial cells. There are a few small corpora 
atretica. 

Examination of the brain .—Frontal region and motor area: various regions of 
cortex, stained by polychrome, show absence or deformity of Meynert’s columns 
and great paucity of pyramidal cells with excess of neuroglia cells. In the deeper 
infragranular layers there is marked swelling of the large pyramidal cells and 
vacuolation due to lipoid degeneration. Most of the medium and small pyramidal 
cells show this change, and many of them are distorted and have their processes 
broken off and show no apical processes. The same appearances are seen in the 
polymorph layer, where there are fewer cells and more degeneration (Plate I). 
These changes, which appear in all layers, are seen also in CajaT-Silver preparations. 
Similar degenerative changes are seen in the stellate cells, many of which are mere 
shadows. There are large numbers of pale nuclei of glia cells, and they can- be 
seen adherent to the dead ganglion cells. Stained by Scharlach the vacuoles are 
seen to be due to lipoid granules. The cells have the same appearance as observed 
in amaurotic idiocy, and I have seen similar appearances in a case of acute 
dementia praecox dying of tuberculosis. 

The medulla oblongata: All the groups of cells with the exception of the olive 
show some degree of fatty change of the cytoplasm and disappearance or diminu¬ 
tion of the NissI substance. A number of the cells, especially the smaller, present 
an appearance similar to amaurotic idiocy. 

Spinal cord; The large anterior horn-cells as a rule show a fair pattern of Niss! 
granules. The cells of Clarke’s column show some perinuclear chromatolysis. 
The intermedio-lateral and the small cells at the base of the anterior horn show 
little basophil substance, and a good many the degenerative change. 

Cerebellum : The cells of Purkinje are well stained and show no vacuoles. The 
cytoplasm in nearly all the cells contains Nissl granules. There is no deformity of 
the cells. The granule layer appears to be normal. 

Cortex: Weigert-stained sections show diminution of tangential fibres, also 
of supragranular fibres and interradial fibres. There is some attenuation of fibres 
of medullary rays. 

Medulla oblongata : There is some degeneration of fibres and sclerosis, diffuse 
in character, in the pyramids and in the antero-lateral tracts. 

Spinal cord: There is diffuse degeneration in the lateral columns corresponding 
to tracts of Gowers and Flechsig and the crossed pyramidal and direct tracts. 
None in the posterior columns. 

Summary. —There is a selective action in this case which does not quite corre¬ 
spond with what is found in amaurotic idiocy ; for although the cortex and medulla 
are affected with the characteristic change the Purkinje cells have escaped. 

Unfortunately the endocrine glands were not kept and therefore not examined. 

Correlation of Clinical Notes with Anatomical Findings . 

The diminution of pyramidal cells in the supragranular layer, the distortion of 
the cells in that layer, indicating arrest and failure of development, may be cor¬ 
related with the statement “ dull from childhood.” 

At puberty the symptoms of dementia praecox came on, terminating in degene¬ 
ration of the deeper layers of the cortex. 

This case supports Bolton’s view thal the infragranular layer is connected with 
the vegetative functions, including reproduction. The infantile condition of the 
ovaries and uterus may be associated with a genetic inadequacy. 


Probable Functions of Supra- and Infragranular Layers of 

the Cortex. 

Shaw Bolton( s ), by very careful micrometric measurements, has 
shown that the supragranular layers are developed at a later 
period of life than the infragranular layer. From an evolutional 
point of view I have shown, and especially Brodmann has shown, 


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that as we rise in the evolutional scale the layer of supragranular 
pyramids, which forms a continuous sheet of cells over the whole 
neo-cortex, increases in depth and extent in proportion as the asso¬ 
ciated perceptions of hearing, sight and touch as directive faculties 
of movement permit of more refined and complex adjustments in 
the life of external relation. In man this layer of cells in depth 
and extent has far exceeded that found in the anthropoid apes, and 
recent anthropological researches indicate that a distinctive feature 
of the brain of homo sapiens over his ape-like ancestors is an increased 
development of the temporal, parietal and frontal lobes. I have 
digressed a little, but I will now return to the infra-granular layer, 
the function of which Shaw Bolton considers is vegetative—that is, 
connected with the life of internal relation, including, of course, the 
important function of reproduction. The integration of the neuronic 
structures ministering respectively to the life of external relation and 
of internal relation is essential for psychic unity, and it may be 
remarked the onset of the demential symptoms in this case may 
be correlated with the changes observed in the deeper layers of the 
cortex, and the active degenerative change it may be assumed as 
due to an inborn germinal defect similar to that which caused the 
arrest of the pyramidal layer. Now in the primary dementia of 
adolescence we find very marked nuclear and cytoplasmic changes with 
a great excess of neuroglia cells in the deeper layers. These patho¬ 
logical changes cannot be explained by vascular or toxic causes, 
otherwise we should see evidence of the former, and if the latter were 
the cause, the toxin in the blood should affect all the cells of the 
central nervous system. Now, nuclear changes, deficiency of the 
basophil substance and replacement by lipoid granules in the cyto¬ 
plasm—evidence of hypofunction—are found in all layers of the cortex, 
and in the basal ganglia and to a less degree in the medulla in dementia 
praecox. These microscopic changes in the neurones indicate incom¬ 
plete oxidation and metabolism, and they may be assumed to be 
sufficient to lower or interfere with the normal functions of neurones so 
affected ; but under favourable conditions such changes are not irre¬ 
parable. Where, however, the nuclear, dendritic, and cellular changes 
are very pronounced, evidence is afforded of a neuronic incapacity, 
indicative of a decay, and in extreme degrees a destruction, which 
renders a return of function impossible. Although the axons may still 
be present, and there may be but little fibre destruction, yet the affected 
neurones cannot transmit impulses because there is synaptic disso¬ 
ciation. It is in the cortical neurones where this decay and permanent 
synaptic dissociation and functional incapacity is most pronounced. 
Where the neurones are most devitalised there the neuroglia cells are 
most abundant—in fact, they can be seen sticking on the degenerated 


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341 


ganglion cells and exercising a phagocytic action. If, then, it be 
admitted that there is a primary neuronic decay of the cortical cells, 
we may inquire—Why do we so often find the large Betz cells of the 
motor area and the large flask-shaped cells of the ascending parietal, 
also the large motor cells of the calcarine striate area, of fairly normal 
appearance as regards nucleus and Nissl granules, while the adjacent 
cells of the infragranular and supragranular layers are profoundly 
affected ? It cannot be because the cells are larger and have a greater 
resistance, for the small association cells of the spinal cord do not 
show degenerative nuclear changes in this disease. May it not be 
that these large motor cells are of a lower evolutional level than the 
other cortical neurones ? They may be, as it were, interpolated into 
the neo-cortex, and in support of this view, as we shall see later, 
their axons are myelinated before the axons of the other cortical 
neurones. 

In contrast with this case of congenital imbecility terminating in 
dementia at puberty I will now direct your attention to a case of 
acute dementia praecox in a highly intellectual youth. 


Summary of Clinico-Anatomical Investigation of Case of 
Acute Dementia Pr.*cox.( 4 ) 

A youth, aet. 19, was admitted to Claybury Mental Hospital 
with the following history : - 

Father died in an asylum; father’s sister (one of 12) insane. On 
the maternal side grandmother died of diabetes ; grandfather insane ; 
mother’s brother (one of 9) insane. The patient is one of a family 
of 5. A brother died of penetrating bullet-wound of the right 
temple (suicide ?). A sister was recently admitted for the fourth 
time to an asylum. The patient’s intelligence was above the average, 
and he was a good athlete. 

Present illness .—He had been working hard for an examination, 
and suffered from excitement and insomnia. He passed the examina¬ 
tion, but became depressed when his sister was sent to the asylum. 
He became worse, and had a delusion of having committed a great 
sin, and asked for poison. The certificate stated that he was acutely 
melancholic, agitated at intervals, speaks reluctantly, and only in a 
whisper. Says he is done in for robbing people. He was sent from 
the Infirmary to a London mental hospital on November 10th, 1921, 
and died November 21st, 1921. The. most noticeable physical change 
was the rapid action of the heart, pulse 140. There was general 
hyperesthesia. 

Fading erysipelas^ of left side of face. 

His mental state varied between a dull semi-conscioss resistance to 


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342 THE GENETIC ORIGIN OF DEMENTIA PRiECOX, [Oct., 


all interference, and to partial consciousness. He had no control 
over his sphincters. The temperature was normal on admission, but 
rose to ioo and later to 102 ; it was subnormal for two days before 
death. Cultures of the blood were negative, and the examination of 
the cerebro-spinal fluid was negative in every way. 

Post-mortem examination and histological investigation of the organs 
of the body revealed nothing to account for death, except very 
marked congestion and redness of brain, with minute haemorrhages, 
especially in the medulla. The testes weighed, when freed from 
tunica albuginea and epididymis, 8 grm. each. Strange to say, the 
testes of the brother that died of bullet-wound of brain showed a 
similar regressive atrophy. The organs of this case had been sent to 
me from a London Hospital, when I was seeking in 1915 normal 
material from cases that died of injury. 

In both of these brothers the testes showed numbers of tubules 
with greatly thickened basement membrane, increase of fibrous 
interstitial tissue, and diminution in size and in number of the Leydig 
cells (Plate III, fig. 1). The epithelium lining the tubules either con¬ 
sisted only of Sertoli cells, or there were obvious signs of a progressive 
genetic inadequacy to form gonads. The nuclei of the spermatocytes 
showed no mitosis, or if spermatids were formed, they were relatively 
few in number, and were frequently seen to give an acidophil reaction. 
In a few of the tubules there were a few heads of spermatozoa, but 
these were often distorted in shape, and many gave an acidophil 
reaction. In fact, the histological changes corresponded with those 
seen in cases of advanced dementia praecox (Plate II, figs. A, B, C). 

Microscopic examination of the brain by Nissl method, Hortega 
method, and Scharlach stained frozen sections counterstained with 
haematoxylin, revealed similar changes to those observed in dementia 
praecox: swelling of nucleus, lipoid granules replacing Nissl granules 
in the cytoplasm, especially marked in the surpragranular layer of 
pyramids, the granule layer, and the polymorph layers accompanied by 
a proliferation of glia cells (Plate III, fig. 2 and Plate IV, figs. I and 2). 
Similar changes, though less marked, were observed in the basal ganglia, 
pons and medulla. These changes were not observed in the cerebellum. 
Kraepeljn,( 6 ) alluding to the researches of Reichardt, states that cases of 
acute dementia praecox occur in which there is cerebral congestion and 
oedema of the brain. What part the erysipelas may have played I 
do.not know, but that the condition was not due to a septicaemia 
or a meningitis was shown by the results of the examination of the 
blood and cerebro-spinal fluid, and the negative results of histological 
examination of the various viscera, including the heart and kidneys. 
Unfortunately the suprarenal glands were not sent for examination. 

, The existence of an hereditary taint on the maternal and paternal 


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.1922.] BY SIR FREDERICK W. MOTT, M.D. 343 

•sides, the condition of the testes in both the patient and his brother, 
point strongly to a primary genetic inadequacy, which under the 
psychical stress of preparing for an examination, insomnia, the 
knowledge of his family’s antecedents, his sister’s being sent for the 
fourth time to an asylum, culminated in an acute disintegration of 
his psychic unity, which could be explained by the microscopic 
•changes found in the brain. 

A full description of this case will be published in Ramon y 
■Cajal’s 70th Birthday Memorial Volume. 

The Last to Come Ontogenetically and Phylogenetically 

the First to Go. 

We must look at the psychoses from the biological point of view of 
Hughlings Jackson: “ The last cerebral structures to come evolution- 
ally and developmentally are the first to go.” It is a fact that 
primitive people suffer with the same psychoses and psychoneuroses 
•as the most cultured people, but the symptoms are coloured by 
•social usages, customs, religion and traditions, upon the experiences 
•of which the furniture of their minds is largely constituted. There is, 
however, no essential discoverable difference in the macroscopic or 
microscopic structure of the brain of “ homo sapiens ,” whether he 
be a cultured European or a primitive man. Indeed, Kohlbriigge 
found the brains of the native Javanese (Analphabeten) to be heavier 
than the average European brain. Seeing that these primitive 
people suffer with the same psychoses as civilised people, culture 
and civilisation cannot be an essential cause, although, by interference 
with natural selection and survival of the fittest, civilisation does 
undoubtedly lead to an increased number of individuals suffering 
with a genetic germinal deficiency, and therefore of all forms of 
insanity. 

But the question may be asked—Is there a morphological reason 
why increased depth and extent of the cerebral cortex, in man consti¬ 
tuting the main difference of structure of the brain from that of all 
the lower animals, including the anthropoid apes, should be the seat 
•of a lack of formative activity and of durability akin to that failure 
of spermatogenesis and of follicle maturation which I have found in 
the reproductive organs in cases of primary dementia ? 

If the development of the central nervous system be studied from 
the .earliest stages of growth of the human embryo, we shall see 
that out of a relatively few of the protomeric cells which form the 
neural tube with .its three primary cerebral vesicles the whole mass of 
•cortical neurones are developed (vide illustration after His). Therefore, 
if there be a defect in the vital energy of the germ-plasm—and we have 
•seen that there is evidence of this in the reproductive organs—such 


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I* 


Brain of human embryos (after His). The dotted region of the pros¬ 
encephalon represents the protomers from which all the countless, 
millions of cells of the highest psychic level are developed. Fig. i.— 
Brain of embryo of about 15 days. Fig. 2.—Brain of an embryo of 
about 3i weeks old. The optic vesicle has been cut away. Fig. 3.—Brain 
of an embryo about 7i weeks old. Fig. 1 gives an idea of the relative- 
proportion of these protomeric cells which are going to form the great 
brain as compared with the rest of the brain. 




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BY SIR FREDERICK W. MOTT, M.D. 


345 


defect would more likely show itself either (i) in arrest of development 
of the cortical cells as we find is the case in idiocy or imbecility, or (2) 
by a lack of durability, which will show itself in early life by precocious 
dementia in adolescence and in later life by presenile dementia. In 
support of my argument I will show a drawing to illustrate the develop¬ 
ment of the cortex from the first secondary vesicle, and it is obvious 
how great must be the formative nuclear activity of a relatively few 
protomeric cells to lead to the formation of the great brain with its 
countless millions and millions of cells carrying engrams of species, of 
race, and of family ancestry. 


The Mnemic Theory and Heredity. 

According to the theory of the mneme of Richard Semon, there is 
an identity between the marvellous properties of hereditary matter 
and the no less marvellous properties of brain. It is characteristic 
of every living organism to build itself up according to a certain 
inherited type, and each fertilised ovum is endowed with the formative 
capacity of building up the bodily and mental characters peculiar to 
species, race and ancestors. Engraved upon the whole body, including 
the brain, are all the later evolutionally developed characters, and 
they are developed ontogenetically in the order of their evolution ; the 
later characters of ancestry are thus less fixed and organised engrams, 
consequently are more readily disorganised. 


The Mneme and Sex Characters. 

Male and female characters are represented in every cell of the 
body ; the male characters, however, are generally dominant. Now, 
unlike the male, in which the interstitial cells disappear soon after 
birth, and do not reappear till puberty approaches, the ovary of the 
female continues after birth onwards to produce Graafian follicles, 
and with them thecal cells, which produce an internal secretion. 
The follicles do not mature sufficiently to undergo dehiscence, but 
become atretic, and form eventually corpora atretica. The object 
of this is biological: the internal secretion which is formed by the 
thecal cells around the Graafian follicles passes into the blood and 
exerts a sensitising influence upon the cells of the body, including 
the brain ecphorising the female characters. Every cell of the body. 
possesses male and female characters, and the former are dominant; 
it may be postulated that the internal secretion of the thecal cells 
of the Graafian follicles inhibits the male dominance. There are 
clinical facts and experiments which tend to prove this. Thus young 
pullets, if their ovaries are removed, develop into birds which look 
like and behave like cockerels. 


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Ontogenesis a Recapitulation of Phylogenesis. 

A study of successive periods of myelination of the central nervous 
system by Flechsig showed that myelination (which may be regarded 
as evidence of preparedness for function) was present at birth in the 
two lower levels, but the highest psychic level which is such a pre¬ 
dominant feature of the brain of man is not myelinated. The cortex 
shows no myelination except in the region of the sensory-motor 
projection areas. The whole cortex is not myelinated till three or 
four months after birth, and comparison of the same with that of 
an adult indicates a continuance of myelination of the cortex from 
birth onwards. That the cortex in the motor area is myelinated in 
part because the axons of the large Betz cells have acquired a myelin 
sheath is indicated by Flechsig( 6 ) in his Atlas, for there is a figure of 
a brain of a newborn child of 9J months that lived only one day which 
shows not only myelination in the sensory-motor projection region of 
the cortex, but the pyramidal tract in the pons is shown to be myelin¬ 
ated. Moreover, myelinated fibres are seen passing into the corpus 
callosum. There is complete absence of myelination in the frontal, 
parietal and temporal lobes. It would thus seem that the sensory- 
motor projection systems are interpolated into the highest psychic 
level; they are in, but not of this level. 

Conclusions. 

(1) By primary dementia is meant a progressive suppression of 
function of the highest phylogenetic and ontogenetic level of the 
central nervous system. This suppression is an irrecoverable con¬ 
dition ; it may be preceded or accompanied by suspension of function, 
which is a recoverable condition. The symptoms due to suspension 
do not necessarily differ from those of suppression of function, but 
whereas the former is due to a functional disorder or inactivity of the 
neurones of the highest level, the latter is associated with and 
dependent upon an organic defect of the nucleus. 

(2) The neurones are complex cells which nourish themselves and 
are not nourished; they are all present at birth and are endowed 
with a specific energy, which in the normal healthy nervous system 
will endure and function for the whole life of the individual. 

(3) The neurones of the neo-cortex form the great bulk of the 
brain. They are developed from a relatively few of the protomeric 
•cells of the neural tube and cerebral vesicles of the human embryo. 
The neo-cortex consists of six layers of cells, the molecular, three 
layers of pyramids, a layer of granules and a subjacent layer of 
polymorph cells. The neo-cortex with slight modifications in certain 
regions has this uniform architecture. 


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[Plate I. 



Nissl stained section of cortex of frontal lobe showing disappearance of many cells of pyra¬ 
midal layer, some with processes broken off, acute fatty degenerative change of deeper 
layer of pyramids and polymorph cells. Great increase of neuroglia cells. Magnifica¬ 
tion 160. To the right are eight cells showing degeneration of cytoplasm and displace¬ 
ment of the nucleus. Magnification 600. 


To illustrate paper by Sir Frederick W. Mott. 


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JOURNAL OF MENTAL SCIENCE, OCTOBER, 1922. 


Plate II. 



A. Portion of spermatic tubule examined with oil immersion and ocular 4. A 
striking feature is the number of spermatogenic cells in which the nucleus 
possesses little or no chromatin. (1) Nuclei of two spermatocytes. (2) 
Heads of spermatozoa which gave the acidophil instead of basophil reaction. 
(3) Formation of spermatids; in one there is obviously a degeneration with 
formation of acidophil granules. B. Interstitial cells smaller than natural 
with nuclei deficient in chromatin collected around a small vessel. C. Re¬ 
gressive atrophic changes of interstitial cells, nuclei small, irregular and 
immature, similar to those found in some cases of advanced dementia praecox. 
A, B, and C, magnification 1000. 

To illustrate paper by Sir Frederick W. Mott. 


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[Plate III. 


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Fig. 1.—Section of testis stained haematoxylin eosin. Regressive 
atrophy of tubules in all stages. Five tubules in the centre are seen 
with thickened basement membrane and containing only Sertoli cells. 
There are no signs of spermatogenic cells and formation of gonads. 
Other tubules are seen in which there is active spermatogenesis. 
The interstitial cells are not visible. This may be partly due to the 
magnification, which is only 110 diameters. 




Fig. 2.—Photomicrograph of section of ascending parietal stained by 
Nissl method. Note the large pyramidal cells are stained deeply, the 
nucleus is not swollen, the Nissl substance is present. Beneath are 
the stellate or granule cells with such swollen nuclei that the cyto¬ 
plasm is hardly visible. There is also marked swelling of the nuclei 
of the polymorph layer of cells and the small and medium-sized 
pyramids. Magnification 160. 

To illustrate paper by Sir Frederick W. Mott. 

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JOURNAL OF MENTAL SCIENCE, OCTOBER, 1922. [Plate IV. 



! 


? r 

V 



■ 




Fig. 1.—Photomicrograph of cells at junction of polymorph and 
granule layer showing great swelling of nucleus. Magnification 450. 



Fig. 2.—Drawing of cells of cortex showing swelling of nucleus. Vacuolation of 
cytoplasm due to the lipoid having been dissolved out in the mounting in Canada 
balsam. Frozen sections stained by Scharlach and haematoxylin showed lipoid 
granules in the cytoplasm. Pale neuroglia nuclei are seen, some sticking on to 
cells. Magnification 1000. 

To illustrate paper by Sir Frederick W. Mott. 


Adlard Of Son & lVest Newman , Ltd. 


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347 


. (4) The psycho-motor cells of earlier ontogenesis may be regarded 
••as belonging to a lower evolutional level. Their axoris are myelinated 
•earlier than those of the other neurones in the cortex. 

(5) The supragranular layer is of later phylogenesis and ontogenesis 
than the infragranular layer; the former is associated with educability, 
the latter with the reproductive and vegetative functions (Bolton). 

(6) This neo-cortex, consisting of a uniform architecture, represents 
the highest evolutional level. It has attained enormous dimensions in 
.homo sapiens as compared with the anthropoid apes and even with that 
of man’s ape-like ancestors. Being of later developement it is not as 
fixed and organised as the lower levels. It has a more refined and 
'delicate poise and is capable of greater variations in its functional 
activities in response to stimuli. 

(7) A genetic inadequacy manifest in the reproductive organs 
which in the adolescent period energise the whole body would more 
likely show itself in this latest developed structure with its complex 
■functions. Again a genetic adequacy would likely show itself by 
-arrest of development of this neo-cortex having regard to its 
• development from relatively a few protomeric cells. 

(8) This genetic inadequacy may be associated with lack of vital 
durability, so that physiological stress, psychological stress, or patho- 
lbgical stress may be sufficient to excite, recal or accelerate its 
.'functional or organic disorder. (For discussion see July No., pp. 306-9.) 

( 2 ) “The Social Significance of Dementia Praecox,” by Edith M. Furbush, 
.Statistician, The National Committee for Mental Hygiene.—( 3 ) Brain in Health 

■ and Disease, 1914 .—(*) I am indebted to Dr. Petrie for the clinical and post-mortem 

■ notes of this case.—(*) Dementia Preecox and Paraphrenia. Translation by 
Mary Barclay, M.A., M.B., from the Eighth German Edition of The Text-Book of 
Psychiatry, vol. iii, Part 11 .— if)Anatomie des Menschlichen Gehirns and Reckun- 
marks auf Myelogenetischer Grundlage, Erster Band, 1920. 


The Influence of the Internal Secretions on the Nervous System!}) 
By Prof. Sir E. Sharpey Schafer, LL.D., D.Sc., F.R.S., 
Department of Physiology, Edinburgh University. 

The influence of the internal secretions is exerted by means of 
•chemical substances—very few of which have been isolated or satis¬ 
factorily examined. Many of these substances closely resemble in 
their action that of medicaments, especially such drugs as the alkal¬ 
oids. So far as their physiological action is concerned drugs can 
•be classed in two divisions, viz., those which increase the excitability 
•of, irritable tissues, and incidentally induce their activity when 
•quiescent; and those which diminish their excitability, and inci- 

0 ) An address given at the Annual Meeting of the Medico-Psychological 
Association, held in Edinburgh, July 20, 1922. 


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[Oct., 


dentally produce quiescence if administered during activity. As. 
instances of the action of those two kinds of drugs on the nervous- 
system strychnine and morphine may be mentioned ; similar 
examples may be found in the action of antagonistic drugs upon the- 
secreting glands, upon skeletal, plain, and cardiac muscle, and upon 
protoplasm in general. The principle is of extensive application, 
some drugs being definitely excitatory, others definitely inhibitory, 
the effect, whichever it may be, being produced by a reaction between 
the chemical substance which forms the active constituent of the- 
drug and a constituent of the living tissue, this being in certain 
cases represented by a special material, termed by Langley “ receptive- 
substance,” which has in all probability been formed under the- 
influence of the nerves which pass to the tissue. The action of the- 
internal secretions is due to specific chemical substances which act 
upon or react with constituents of the cells. Such reaction, as in 
the case of drugs, tends either to increase or to diminish the excita¬ 
bility of particular tissues, either stimulating the living substance- 
to activity or increasing its activity, or decreasing or arresting any 
activity that may be present. The expression “ chemical messenger ’** 
was employed by Bayliss and Starling in their work on the action of 
secretin upon the pancreas to denote any material circulating in 
the blood which tends to excite a tissue to activity. Subsequently 
the word “ hormone ” was invented by Starling as a short equivalent 
—not, as he is careful to insist, to be confined to the chemical principles, 
of the internal secretions, but to be used also for any chemical sub¬ 
stance, of whatever nature or origin, which acts as an excitant; e.g ., 
Starling gives as an example of a hormone the C 0 3 of the blood, 
which, when conveyed to the medulla oblongata, excites the activity- 
of the nerve-cells composing the respiratory centre. Subsequent 
writers, e.g., Biedl, have displayed a tendency to restrict Starling’s, 
term to the active principles of the internal secretions, in place of 
using it, as he himself proposed, for all chemical substances exciting 
activity—a proposition in strict accordance with its derivation, 
which is from the Greek word I excite. This restriction of 

the term is the more unfortunate because it has become customary 
by most authors to include under the term of hormones or excitants- 
substances which have exactly the opposite effect—that, namely, of 
restraining or inhibiting activity, the custom having arisen probably- 
from the fact that at first the existence of such substances was not 
sufficiently recognised. Since it is obviously improper to apply the- 
term “ hormone ” (or “ excitant ”) to inhibitory substances, I have- 
ventured to propose that an analogous term, “ chalone,” derived 
from the Greek word I restrain, should be employed to designate- 

such substances, and that a general expression denoting their drug- 


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1922.] by PROF. SIR E. SHARPEY SCHAFER, LL.D. 

like character should be used to describe all the specific principles 
contained in the internal secretions which promote changes in other 
organs, whether in the way of excitation or inhibition. Such an 
expression is appropriately found in the term “ autacoid,” which is 
derived from the Greek words i<vri, self, and *«<>», a drug or remedy, 
i.e., a drug-like substance produced within the body itself: the 
latter part of the expression being already in general use in the form 
** panacea ” or universal remedy. A striking example of a chalone 
o* restraining principle is furnished by the ovary, which produces 
in its internal secretion a chemical substance—not as yet isolated— 
which restrains the development of the male characteristics in the 
female. When this restraint is lacking, as occurs after removal of the 
ovaries, a tendency to development of male characters makes its 
appearance. A hen, for example, deprived of its ovary develops the 
bodily form, the tail, comb and wattles of a cock, crows like the male 
bird, and even attempts to “ tread ” other hens. And if the 
ovary of another individual is successfully transplanted into such a 
bird, the chalone which is contained in its internal secretion inhibits 
the tendency to develop male characters, and these presently dis¬ 
appear, so that the animal again assumes all the characters of a hen. 
Nor is this occurrence of a chalone in the generative glands confined 
to the hen. There is one variety of Sebright fowls in which the cocks 
are hen-feathered. In this breed, as has been shown by T. H. Morgan, 
the testis contains cells, similar to certain cells in the ovary, which 
apparently yield a chalone, similar to that of the ovaries of ordinary 
breeds of fowl. And when the testes are removed from the hen- 
feathered Sebright cock, the castrated animal assumes the plumage 
characteristic of the ordinary cock-feathered variety of Sebright. 
Since, therefore, there are two principles of opposite character yielded 
by the internal secretions, I shall in speaking of their action upon 
the nervous system employ the expression “ autacoid ” as a general 
term to denote the active chemical agent of any secretion, and the 
special terms “ hormone ” and “ chalone ”—with their adjectives 
“ hormonic ” and “ chalonic ”—to express the mode of action of 
particular autacoids according to whether this is excitatory or inhi¬ 
bitory. These preliminary remarks are introduced to enable those 
members of my present audience who are not familiar with the 
history of the subject, and especially with its nomenclature, to under¬ 
stand exactly what is meant by the expressions I propose to use, 
in order to avoid the confusion which would otherwise result from 
the employment, as is so frequently done, of the same term—hormone 
—in opposite senses. 

Of the internal secretions those which are known to exert a direct 
influence upon the central nervous system are produced by the 


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INFLUENCE OF INTERNAL SECRETIONS, [Oct. v 


generative organs and the thyroid. Other internal secretions, it is; 
true, may influence the nervous system, but they act either on peri¬ 
pheral nerves or by their effects on general metabolism, and are not 
therefore to be regarded in the same light as those which directly 
affect that system. And as the time at our disposal is limited, it 
will be best to confine ourselves mainly to the action of these two, 
with, in addition, a brief reference to the parathyroids. 

• • 

The Internal Secretion of the Generative Organs. 

We may begin by considering the influence of that of the organs 
of generation, since this has been longest known, having been the 
subject of experiment and observation from time immemorial. It 
has not, however, been long recognised that this influence is exerted 
by an internal secretion. For before the subject of the internal 
secretions became a special object of study, it was assumed that 
changes in the nervous system associated with the generative organs 
were entirely due to the excitation, or absence or excitation, of their 
afferent nerves, whereas it is now commonly conceded that such 
changes are brought about by the autacoid substances yielded to 
the blood by the glands in question. These autacoids, however, 
are not formed by the gametes or generative cells themselves, but 
by other cells in the gonads (testis or ovary) which are known as the 
“ interstitial cells,” or collectively as the “ interstitial gland.” The 
evidence on this point is conclusive. For the reproductive cells 
themselves may be destroyed by X rays or otherwise, or may remain 
congenitally undeveloped, yet if the interstitial cells of the testis 
or ovary be left, not only do the bodily secondary characters significant 
of the sex still appear, but the mental characters as well. If these 
interstitial cells are removed in the adult animal along with the 
true gonad—as by complete castration—the effects of the operation 
are not confined to a tendency to retrogression on the part of - the 
accessory organs of generation and of the external or extra-genital 
secondary sexual characters, but extend to the functions of the nervous 
system, the mental attitude and disposition of the individual becoming 
also strikingly altered. If the operation is performed before puberty, 
a condition of infantilism is established ; and, by grafting one or 
other gonad, either male or female characteristics may be produced— 
although the implanted organ may or may not—(most commonly 
does not)—produce sex cells. In man the effects of castration in 
the male sex have been known from the earliest ages: in woman 
they are less familiar as the result of operation, although not un¬ 
known ; but they are evident in cases of ovarian retrogression or 
destruction by disease, and have been described by many authors. 


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1922.] BY PROF. SIR E. SHARPEY SCHAFER, LL.D. 35 I 

To put the matter shortly, the female is female not only because' 
she produces ova, but because she also produces in the ovary along 
with ova certain special cells which secrete a hormone having the 
property of stimulating the development of the secondary characters, 
peculiar to the female, and a clialone which suppresses those peculiar 
to the male sex : while the male is male not only because he produces, 
spermatozoa, but because he also possesses certain special cells, 
in the testicle secreting a hormone which stimulates the development 
of the secondary characters peculiar to the male, and a chalone 
which suppresses those peculiar to the female sex. These autacoids. 
have not yet been isolated, but we are justified by analogy in assuming 
their separate existence. For the same reason we may regard it as. 
probable that—as compared with such substances as proteins— 
they are of a relatively simple chemical composition, so that their 
isolation and chemical analysis and even eventually their synthesis, 
will be only a question of time. If this view is regarded as optimistic, 
we may point to the autacoid to which the secretion of the thyroid 
owes its activity—which produces just as profound changes in the 
organism as do the autacoids of the sexual glands. Yet, as we shall 
see in discussing the thyroid gland, its chief autacoid has already 
been obtained in a crystalline form, and its chemical constitution 
exactly determined, so that its synthesis is merely a matter of detail, 
and indeed has perhaps already been effected. I need hardly add 
that the isolation, analysis and synthesis of the autacoid of the 
suprarenal medulla is now almost a matter of ancient history. 

The influence of the autacoids of the generative glands upon the 
nervous system is strikingly exemplified by the psychic changes, 
which take place, along with the rapid development of the gonads, 
with the advent of puberty in both sexes, and by those which occur 
at the time of the climacteric in the female sex. It is true we have 
not the same accumulation of experimental evidence of the dependence 
of these psychic changes on the internal secretions of the gonads, 
which exists for the development (or retrogression) of the somatic 
secondary sexual characters, and the belief that such psychic effects 
may be produced through afferent nervous impulses from the testis 
or ovary is not so readily capable of being controverted as in the case 
of the somatic effects. But reasoning from analogy and judging 
from the altered behaviour of animals in which experiments upon 
the subject have been frequently carried out, there seems no reason 
to doubt that the increase or suppression of the internal secretions. 
of the gonads is accountable as well for the psychic changes observed 
as for those of a somatic character. It is possible to suppose that 
the psychic changes may not be brought about by a direct action 
of the gonadal autacoids on the nervous system, but that they may 


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influence that system indirectly through other organs, such as the 
thyroid—which, especially in the female, is known to undergo marked 
-alterations with the changes in the sexual cycle. But this supposition 
is hardly probable in view of the fact that the psychic changes ac¬ 
companying alterations in sexual life are not identical with those 
which accompany excess or diminution of thyroid secretion, nor 
can they be prevented by thyroid treatment. 

Apart from the general effects of the gonadal autacoids, a direct effect of a 
special autacoid upon the central nervous system is evidenced by the experiments 
•of Nussbaum on the frog, which also furnish one of the most striking proofs that 
the development of a secondary sexual characteristic is dependent on an internal 
secretion of the testis. Nussbaum found that male frogs from which both testicles 
have been removed before the copulation period not only have no tendency to seek 
Jthe female, but do not develop the swelling of the thumb or the concomitant 
hypertrophy of the forearm muscles which are essential for the prolonged reflex 
of the sexual embrace. But if a piece of testicle from another frog is implanted in 
4 he dorsal lymph-sac. of the castrated animal, the hypertrophy of thumb and arm 
muscles soon begins to appear, disappearing, however, again as the implanted 
piece of testicle undergoes degeneration and absorption. Nussbaum further found 
’that if, in a normal frog, the nerves of one arm are severed, those of the other 
remaining intact, the hypertrophy of thumb and arm does not occur on the side of 
section, although appearing as usual upon the side the nerves of which are intact. 
This shows that for this particular sexual development, the influence of the 
•central nervous system is required. Since it concerns a pure reflex phenomenon, 
the lesson of this experiment is not entirely applicable to secondary sexual 
characters which do not involve the nervous system. But it is none the less an 
indication of the fact that changes which are brought about by autacoids are not 
necessarily due to the direct action of this upon the tissues concerned, but may be ' 
-effected, or at least regulated, by the nervous system. In this respect also we 
recognise a resemblance between autacoids and drugs, since many of the latter 
produce their effects upon the tissues through that system. 

It has further been found that injection of testicular substance from mature frogs 
-causes the embrace-reflex to become possible in castrated frogs, or in frogs which 
are naturally impotent from imperfect development of the testicles. All these 
changes are due to a special autacoid which is formed in the testicle only during 
the spawning period; it is not contained in the testicles at any other time, and 
-disappears after spawning is finished. Its nature is chalonic. For it has been 
shown (Steinach) that the embrace-reflex is at any other than the spawning period 
prevented by inhibitory impulses passing to the cord from the optic lobes; since 
*the reflex becomes operative at all periods if the optic lobes are removed. This 
particular autacoid has therefore the effect of stopping these inhibitory impulses 
and thus permitting the reflex to come into activity. 

But these observations and experiments of Nussbaum, although 
“highly instructive, constitute a special case. With regard to the 
-general effect of the gonads, the opinion which formerly prevailed 
that the phenomena of ovulation, menstruation, pregnancy and 
parturition are brought about through the nervous system has long 
■been given up. It is now nearly fifty years since Goltz showed 
that a bitch with the lumbar cord completely removed can come 
.into heat, become pregnant, and bring forth and suckle a litter of 
pups in an apparently normal manner. There is here no question 
-of the nervous system being concerned: all the successive changes 
must have been brought about by internal secretions, mainly no 


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353 


doubt of the ovary. Further, the dependence of menstruation upon 
secretion of the ovaries has been shown in monkeys (Halban) by 
removing those glands from their normal position and successfully 
implanting them in an entirely different situation. As long as they 
were left undisturbed menstruation occurred as usual, but on re¬ 
moving the grafts it entirely ceased. It has also been shown (Marshall 
and Jolly) that implantation of the ovary of a bitch in heat, or even 
injection of extract of such an ovary, will cause certain of the pheno¬ 
mena accompanying heat to appear in another bitch which had 
previously had its ovaries removed. Moreover, the successful trans¬ 
plantation even of a piece of ovary into an animal from which both 
ovaries have been removed will prevent the retrogressive changes of 
the uterus which otherwise result from castration. Transplantations 
of ovary have frequently been successfully effected in the human 
subject, with like results. In none of these cases can there be any 
question of the complicity of the nervous system in the reaction. 

Brown-S^quard, who was the first to investigate the effects of the 
injection of organ extracts, and especially of extract of testicle, 
administered hypodermically, was of opinion that such medication 
could produce a kind of rejuvenescence, both bodily and mental. 
This he ascribed to an internal secretion of the organ acting upon 
the nervous system. But other observers failed to obtain like results, 
and Brown-S 4 quard’s experiments, which were conducted upon 
himself, have been generally discredited or set down to auto-sugges¬ 
tion. There has, however, of late years been a revival of the notion 
that the secretion of the interstitial cells of the testis can to some 
extent combat the changes which occur as the result of advancing 
age in the body generally and in the nervous system in particular. 
The experiments on this subject differ from those of Brown-S^quard 
in that in place of the injection of testicle extract, the vas deferens 
is occluded by ligature. This operation causes degeneration and 
disappearance of the spermatozoa and of the spermatocytes from 
which these are produced, so that the seminiferous tubules become 
almost empty; but the interstitial tissue of the organ undergoes 
hypertrophy, and presumably furnishes an increased amount of its 
special secretion to the circulating fluid. It is stated that this has 
the same effects as those claimed by Brown-S 4 quard for the injections 
he employed, viz., a tendency to defer or relieve senescence and the 
causation of a feeling of rejuvenescence. But these results are hardly 
sufficiently established to command acceptance: whether they will 
survive the test of further experiment remains to be seen. 

It is not possible to perform similar experiments with the ovaries, 
and it is generally conceded that extracts of these administered 
hypodermically produce no noticeable effect on the general system, 
LXVIII. ?5 


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although it was claimed by Brown-S^quard that they produce effects 
similar to, but more ephemeral than, those which he described as 
yielded by testicular extract. Nevertheless extracts, either of the 
whole ovary or of the corpora lutea are in frequent therapeutic use 
in ailments of the genital system, which may, it is believed, be in¬ 
fluenced by them. Their effect in bringing on the changes which 
characterise menstruation has already been alluded to. Moreover, 
the internal secretion of the ovaries, and especially of the corpora 
lutea, appears to be concerned with the preparation of the uterus 
for the fixation of the embryo, and with the functional evolution of 
the mammary glands. These are, however, direct effects, and, so 
far as we know, they have no bearing on the relation of the internal 
secretions to the nervous system. 

Although, therefore, it would seem that the effects produced upon 
the nervous system by the gonads are due, at least in great part, 
to the action upon it of their internal secretions, this statement 
does not exclude the possibility of the nervous system being also 
influenced by afferent nervous impulses arising in the gonads. Indeed, 
it is probable that, as with most other organs in the body, both the 
nervous system and the internal secretions take a share in the produc¬ 
tion of the results obtained, the effects being in each case due to 
alterations in the balance between activation and inhibition, both of 
which can be brought about either through nerves or through autacoid 
substances carried by the blood and acting as chemical agents upon 
the cells. 

The Internal Secretion of the Thyroid. 

As Sir Frederick Mott is to follow me on the special subject of 
the reproductive organs, it would be superfluous on my part to 
attempt to deal with the subject at greater length, although in 
dealing with the physiological action of internal secretions on the 
nervous system, it is impossible to omit all mention of organs which 
exert so profound an influence upon that system as these are known 
to do. I will therefore proceed to the consideration of the secretion 
of the thyroid gland, which of all the internal secretions is the one 
the influence of which upon the central nervous system is most easily 
demonstrated. For if the thyroid is removed surgically, or becomes 
atrophied, all the functions of the nervous system are depressed. 
Those which are latest in development are most in abeyance ; the 
brain ceases to be active : the athyroid individual becomes a cretinous 
idiot. There are evident changes in many nerve-cells which probably 
account for the functional disturbances of the nervous system. But 
alterations are not confined to that system, for metabolic and other 


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1 9 22 -] by PROF. SIR E. SHARPEY SCHAFER, LL.D. 

changes occur in all parts of the organism: growth is retarded ; 
fat is laid on ; the skeleton is profoundly modified; the connective 
tissues and skin become swollen ; the face puffy ; the epidermis dry 
and liable to excessive desquamation ; basal metabolism is diminished ; 
the body temperature lowered ; the movements sluggish ; the pulse 
and respiration slowed. The picture is a familiar one. Something 
has been removed which promotes the activity of all the functions 
of the body, and especially the functions of the nervous system. 
This something is the principal autacoid of the secretion. It has 
been isolated in a crystalline form and examined by Kendall, and 
has been termed by him “ thyroxin.” It has the formula C u H 10 O 3 NI 3 , 
and contains, therefore, as will be seen, at least 65 per cent of iodine.( 2 ) 
The structural formula of thyroxin, at least of one of the forms in 
which it has been examined, is :— 



This is similar to that of tryptophane: 



from which it may be considered to be derived. It occurs in thyroid 
juice in combination with protein as a substance termed “iodo-thyro- 
globulin.” The evidence that thyroxin is the chief active agent of 
the secretion is obtained by comparing its physiological effects with 
those of thyroid juice or thyroid extract: they are found to be in 
most matters identical. At the same time it does not follow that 
thyroxin is the only autacoid present in thyroid secretion. There are 
certainly others, but very little is kriown about them, and there is 
no evidence that they directly influence the nervous system. 


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356 INFLUENCE OF INTERNAL SECRETIONS, [Oct., 

The symptoms which have been described as resulting from thyroid 
removal or thyroid atrophy can all be combated—as Murray first 
showed( 8 )—by administration of thyroid juice, which, if given in such 
an amount as just to balance the deficient secretion, will restore 
the patient completely and render him a healthy, intelligent, and 
useful member of society, always provided that the affection has 
not lasted long enough for permanent changes to have been produced 
from lack of the secretion—although even then the amelioration of 
both bodily and mental conditions is pronounced. Nor does it matter 
from what species of animal the thyroid extract is prepared. 

Every physician is familiar with the alteration in the picture— 
especially in a young subject—the transformation of the apathetic, 
slobbering idiot into the alert, bright, healthy-looking child ! This 
is the nearest approach to a miracle which is met with in medicine, 
and may well be viewed with astonishment by those to whom it is 
revealed for the first time. It is, indeed, a real subject for wonderment 
that the activities of the nervous system, and especially its highest 
functions, should be dependent upon the addition to the blood of a 
chemical substance of relatively simple constitution formed in an 
organ which has no morphological connexion with the system which 
its secretion so profoundly affects 1 For there is no substitute for 
the secretion of the thyroid. Iodine in any other form than that 
in which it occurs in this organ is without effect on thyroidless animals, 
although if administered to animals which are still in possession of 
a thyroid it markedly increases the activity of the gland. 

It is further remarkable that the thyroid is constant in the Verte¬ 
brate series. (Whether it has any sort of representative in Inverte¬ 
brates is unknown.) In Amphioxus and Petromyzon it is an exter¬ 
nally secreting gland pouring its secretion into the mouth, and the 
study of its development in all Vertebrates shows* that it is morpho¬ 
logically to be regarded as a buccal secreting gland. Possibly this 
accounts for the fact that its juice is the only internal secretion 
which can be administered per os just as effectively as if passed 
directly into the blood or lymph. 

Physiological Action of Thyroid. 

The principal autacoid of the thyroid is the most powerful excitant 
of metabolic processes known. In a condition of hypothyroidism, 
such as occurs when the gland is atrophied or surgically removed, 
the metabolism of the body during a period of rest and fasting (basal 
metabolism) may be reduced by 40 per cent., and can readily be 
brought back to normal by thyroid administration. If given to 
normal subjects the basal metabolism mounts rapidly, more or less 


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357 


parallel to the dosage, and the increase of metabolism causes loss of 
body-weight from the increased oxidation of the tissues—the fat 
being the first to go; hence the practice of thyroid administration 
in obesity. The rise in metabolism is produced, not by acceleration 
and augmentation of the chemical processes of any one tissue in 
particular, but by the action of the autacoid on almost every cell 
in the body. In many organs it tends to promote rapid cell-division, 
and even cells which usually never show any sign of division—such 
as the secreting cells of the alveoli of the pancreas—exhibit numerous 
mitoses after a short course of thyroid feeding (Kojima). 

But what concerns us here is the effect produced by the thyroid 
autacoid on the central nervous system. The question how that 
effect is brought about—whether directly by exciting the protoplasm 
of the nerve-cells, or indirectly by affecting their metabolic processes, 
is undetermined—and an attempt at its solution, although of great 
physiological interest, need not now detain us. If thyroid extract is 
administered to a normal individual—the dose varies with the activity 
of the extract and with the idiosyncrasy of the subject—signs of 
nervous excitation soon show themselves. There is a feeling of 
restlessness: the heart beats rapidly and often irregularly; the 
respirations are fast and shallow; the blood-vessels are dilated ; 
the skin is flushed and feels hot; the activity of the sweat-glands 
is increased ; there may be diarrhoea. With large doses the psychical 
excitement is accompanied by hallucinations, and may even simulate 
mania; there is sleeplessness; tremors of the limbs are common, 
and the reflexes tend to be exaggerated. In extreme cases there 
may be exophthalmos and dilated pupils. The increased action of 
the heart is accompanied by hypertrophy and dilatation, sometimes to 
an alarming extent. On ceasing the administration, the symptoms 
which it has produced soon subside. Some of the effects—those on 
the heart and eye and sweat-glands—are similar to the results obtained 
by exciting sympathetic nerve-fibres and resemble those produced 
by adrenalin; but others—such as the dilatation of the blood-vessels— 
are directly contrary; and the tremors of the muscles and the 
psychical excitement are also obviously not referable to sympathetic 
excitation, but are probably the result of the action of the autacoid 
or autacoids on cells of the central nervous system. This may 
therefore be the case with the “ sympathetico-mimetic ” effects as 
well; for, as we now know, the sympathetic is not an independent 
system, but originates in cells of the central nervous system. 

Numerous experiments have been made to determine whether the 
amount of adrenalin formed in the suprarenal medulla is influenced 
by thyroid secretion. Herring, in one series of experiments, took 
three cats of about the same size—A, B and C. A was thyroidecto- 


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mised (but the parathyroids were included in the removal), B was 
used as a control, C was fed with addition of thyroid to its ordinary 
diet during 21 days. All were otherwise kept under the same condi¬ 
tions as regards food, and were killed at the same time. The adrenalin 
in their suprarenals was extracted completely with 30 c.c. of Ringer’s 
fluid and 2 c.c. of each extract was injected into the jugular vein 
of a pithed cat, the relative effects being recorded at the same place 
on the smoked paper of the kymograph. The tracings show that A 
has the least adrenalin, C the most, whilst B occupies an inter¬ 
mediate position. There is therefore an absolute increase of adrenalin 
in the thyroid-fed animal as compared with the normal. The decrease 
in the thyroid-deprived animal may, however, be in part due to the 
concomitant removal of the parathyroids in this experiment. 

Later experiments on rats by the same investigator confirmed this 
conclusion of an absolute increase in amount of adrenalin produced 
by thyroid feeding, but show that the whole suprarenal capsule, 
both cortex and medulla (but the cortex more than the medulla) 
is enlarged under this treatment, so that the percentage amount of 
adrenalin in the capsules may be somewhat decreased. In female 
animals, which are more susceptible of the effects of thyroid feeding 
than males, not only the relative but even the absolute, amount 
may be diminished. It cannot therefore be affirmed for all animals 
that thyroid feeding increases the adrenalin content of the suprarenals 
—still less that more adrenalin is poured into the blood. There is 
nevertheless a considerable bulk of evidence that adrenalin is poured 
out into the blood of the suprarenal veins in greater quantity as the 
result of the injection into the blood-stream of thyroid extract, 
although this evidence is, as we shall see, not beyond question.( 4 ) 

Admitting that adrenalin normally under influences passing down 
the splanchnic nerves is secreted by the cells of the suprarenal medulla 
into the blood of the suprarenal vein—where its presence may be 
detected both by chemical and physiological methods—it is obvious 
that it must pass from the suprarenal vein into the inferior vena 
cava ; nevertheless no means has been found to be sure of its presence 
in the general circulation. To this point I shall have to return in 
connexion with the subject of exophthalmic goitre, which must 
now claim our attention. 

In exophthalmic goitre there is strong evidence that the thyroid 
is in a condition of superactivity. It is true that there is less colloid 
and probably less thyroxin in its vesicles, but this is what one might 
expect in an over-active gland, which would be pouring out its secre¬ 
tion into the blood as fast as it is formed—instead of storing it up 
in the alveoli, as one finds to be the case in endemic goitre. The 
gland itself—normally one of the most vascular organs in the body, 


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1922.] BY PROF. SIR E. SHARPEY SCHAFER, LL.D. 359 

receiving in proportion to its size five times as much blood as the 
kidneys—is enlarged and hyperaemic: its arteries are dilated so 
that the tumour which it forms may pulsate with the beats of the 
heart; its vesicles are not rendered spherical by distension with 
colloid, nor is their epithelium flattened as in a normal gland, and 
to an exaggerated degree in endemic goitre; but they are irregular, 
and the epithelium tends to be columnar. The symptoms of the 
disease resemble those of hyperthyroidism such as is caused ’by 
excessive thyroid administration. The general and basal metabolism 
is increased; there is loss of flesh ; diminished ability to assimilate 
carbohydrates, so that alimentary glycosuria is easily produced ; 
the blood-vessels are dilated and the face flushed ; the heart palpitates 
and its beats are rapid and often irregular; the respirations are 
shallow ; there is often profuse sweating ; the expression is anxious 
and restless ; there is nervous and psychical excitement and often 
muscular tremors ; the palpebral aperture is wide ; the pupils often 
dilated and the eyes prominent ; diarrhoea is common. These are 
all effects such as can be produced by thyroid feeding—although it is 
only rarely that the special symptom of eye-prominence which is 
characteristic of advanced stages of the disease and has given it its 
name is seen as the result of thyroid administration. Evidently 
many of the symptoms are the result of the action of a toxic agent 
upon the nervous system, and there can be little doubt that this 
toxic agent is an excess of a hormone contained in the internal 
secretion of the gland. 

Even more distinctly than in the case of thyroid administration 
certain of the symptoms above enumerated * closely resemble those 
produced by adrenalin. This is particularly the case with the accelera¬ 
tion of the heart, the dilatation of the pupils, and the prominence 
of the eyeball with its concomitant increase of the palpebral aperture, 
and it has by some been supposed that these symptoms are produced, 
not by the thyroid hormone itself, but by its action in liberating 
an unusual amount of adrenalin from the suprarenals. Alternatively 
they might be explained by supposing that the thyroid autacoid 
renders the endings of the sympathetic nerves—which are stimulated 
by adrenalin—more sensitive to the action of that hormone. Asher, 
of Berne, and his fellow-workers have published a large amount of 
evidence in support of this supposed property of thyroid secretion. 
Their experiments mainly consist in determining the least possible 
electrical stimulus which will produce a given result on exciting 
the nerve under investigation (a) before and ( b) after administration 
of thyroid extract by intravenous injection or otherwise. Similar 
experiments have been made by employing an intravenous injection 
of adrenalin as the exciting agent, and determining the extent of its 


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360 

effect before and after thyroid administration. Dr. Dryerre, in my 
own laboratory, has lately made a large number of experiments of 
this nature with the object of confirming or otherwise the Berne 
results. There are two main sources of difficulty in such experiments, 
viz., (1) the exact control of the intensity of the artificial stimulation— 
electrical or other—which is employed; and (2) the spontaneous 
variations which show themselves, and which are due to physiological 
causes the nature of which it is impossible to determine. So far as 
they have gone Dryerre’s experiments have not tended to support 
Asher’s theory. But the investigation must be carried further and 
all sources of error as much as possible eliminated before any definite 
statement can be made regarding it. 

With reference to the question of hyperthyroidism in exophthalmic 
goitre—as we have already seen in that produced by thyroid feeding 
—the fact that only some of the symptoms caused by adrenalin are 
present, whilst others are conspicuous by their absence, points to 
the fact that it is not only by exciting an increased secretion from 
the suprarenal medulla that the thyroid autacoid in the blood exercises 
its activity. It probably has a direct action on cells of the central 
nervous system—some being affected more than others. To explain 
its adrenalin-like effect we might assume that certain cells in the 
cord from which sympathetic fibres arise are amongst those stimulated 
by the thyroid hormone ; or, alternatively, that the thyroid hormone 
excites cells in higher centres which influence those giving origin 
to the sympathetic fibres. 

In connection with this subject we have to bear in mind that the 
thyroid secretion itself is under the influence of the nervous system. 
Its principal nerve supply is from the cervical sympathetic, although, 
according to Asher and Ossokin, it also receives fibres from both 
superior and inferior laryngeals and from pharyngeal branches of 
the vagus. But Cannon and Cattell obtained a current of action 
from the gland when the cervical sympathetic was stimulated, whereas 
no such effect was obtained on stimulating the vagus. The same 
result was got when adrenalin was injected. And in animals in which 
a phrenic nerve had been cut and its central end joined up with the 
peripheral end of the cervical sympathetic by such means that its 
fibres might be conducted to the gland and find their way to its cells, 
Cannon and Fitz were able to obtain symptoms of hyperthyroidism 
which disappeared on removal of the thyroid of the same side.( 5 ) 
So that not only does the secretion of the thyroid stimulate the central 
nervous system, but, through its secreting nerves, the central nervous 
system excites the thyroid to increased secretion—a vicious circle 
being thus set up, which may perhaps account for the obstinacy 
with which Graves’s disease resists treatment. Nor can, as might 


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1922.] BY PROF. SIR E. SHARPEY SCHAFER, LL.D, 36 1 

perhaps be supposed, one cut the circle by severing the cervical 
sympathetics, for these nerves contain the vaso-constrictors to the 
gland and their severance will increase the blood-flow within it, 
and in all probability more of its hormone will be tfcken up by the 
circulating fluid. We must also remember that there will be a liability 
for the cells to which the sympathetic fibres are distributed—whether 
secreting cells or peripheral nerve-cells—to be rendered hypersensitive 
to the action of adrenalin, which is apparently poured out in increased 
amount under the influence of a hormone produced by the thyroid, 
and this may be responsible for some of the phenomena of hyper¬ 
thyroidism. 

To this question of the possible increase in the adrenalin of the 
blood I shall have to come back immediately. But before discussing 
it I should like to open up another question, a positive reply to which 
is generally assumed, viz., Are we justified in believing that the 
thyroid hormones are normally present in blood and increased in 
amount in exophthalmic goitre ? 

Before this can be answered we must see what tests can be applied 
to detect the presence of small amounts of the thyroid secretion in 
the circulating fluid. Chemical tests fail us here, partly by reason 
of the complex nature of blood, partly by reason of the infinitesimally 
small amount of the secretion in the blood at any one time. Traces 
of iodine have been described in blood, but, even if present, it is in 
much too small an amount to be estimated quantitatively, nor do we 
know that it is present in the form of thyroxin or of iodo-thyro- 
globulin. We are therefore confined to physiological tests, three of 
which are applicable, viz., the action of thyroid on intestinal muscle, 
the aceto-nitrile test of Reid Hunt, and the remarkable property 
which thyroid possesses of hastening the metamorphosis of tadpoles 
(Gudernatsch). 

(a) The intestinal muscle test .—This test consists in suspending in 
Ringer’s fluid a strip of longitudinal muscle from the small intestine 
of any animal—ileum of the cat by preference—and passing into 
the vessel containing it some of the same solution to which a known 
small amount of the fluid to be tested is added. Precautions are 
taken to keep the fluid oxygenated and warmed to about the body 
temperature, and tracings are taken of the spontaneous contractions 
of the strip, magnified by the recording lever. Such a strip if fed 
continually with fresh Ringer will continue for hours to beat with 
regularity. If a minute amount of thyroid juice be passed into the 
fluid surrounding the intestinal muscle, its contractions are both 
accelerated and increased in extent. If normal human serum is 
passed in—even in very small quantity—there is also a marked 
acceleration and augmentation of the contractions. But if serum 


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from a case of exophthalmic goitre is used in place.of normal serum, 
the effect is much more marked, the piece of intestine often passing 
into a condition of extreme contraction, which may last for several 
minutes, even after the serum which produced the effect has been 
washed away. 

This would be both a definite and a delicate test for the presence 
of a thyroid hormone in the blood if such an effect were confined to 
thyroid extract. This, however, is not the case, for, as Dr. Alexander 
Young—working some years ago in my laboratory—showed, there 
are other substances which might be present in blood and which are 
capable of increasing the extent if not the rate of the intestinal beats. 
One of these is extract of posterior lobe of pituitary, the other choline. 
But to get any effect with the former, the strength of the solution 
has to be at least 2 per cent, of the dried gland—an impossible amount 
to be present in blood. On the other hand, Young found that cholin 
would produce some effect at a dilution of only I in 50,000, although 
the action was not very strong even with 1 in 5,000, whereas thyroid 
extract, even dilute, produces a marked effect. There is reason to 
believe that a trace of choline is present in blood, and it has also been 
found in thyroid tissue. Moreover, the action of choline is abolished 
by atropin, which is also the case with that of thyroid extract, although 
large doses are needed for this. As the action of exophthalmic 
blood serum on intestinal muscle is more marked than that of normal 
serum, it is probable that there is present in it an excessive amount 
of the particular thyroid hormone, which is responsible for increasing 
the activity of the contraction of intestinal muscle. This hormone 
is certainly not thyroxin, for a solution of thyroxin has no more 
effect on intestinal muscle than the dilute alkali which must be 
added to bring it into solution. It may be choline, although there 
is no strong evidence for this. 

(b) Reid Hunt's aceto-nitrile test .—Reid Hunt found that a minimal 
lethal dose of aceto-nitrile administered to a white mouse was no 
longer fatal if the animal had been previously fed with thyroid. He 
used this test to determine if such extract was present in exophthalmic 
blood, and obtained a positive result. He accordingly came to the 
conclusion that the blood in Graves’s disease contains an unusual 
amount of thyroid secretion. 

(c) It is not certain that the tests we have considered are specific— 
indeed, the first one is certainly not, since it is not produced by the 
specific autacoid, thyroxin, and its effect may be simulated by 
other substances than those yielded by the thyroid. And although 
Reid Hunt claims specificity for the aceto-nitrile test, it is not certain 
that other animal extracts may not to some degree share with thyroid 
extract the property of antagonising the poison of aceto-nitrile. 


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192 2.] BY PROF. SIR E. SHARPEY SCHAFER, LL.D. 363 


The third test, that namely of inducing precocious metamorphosis 
in tadpoles, is, however, so far as we know, quite specific, and is mani. 
fested with small amounts of thyroid, which may be administered 
for a very short time. It has seemed to me therefore of importance 
to apply this test to blood, and especially to the blood of exophthalmic 
patients ; and during the spring of the last two or three years I have 
taken the opportunity of examining the behaviour of tadpoles which 
have been placed or kept in water to which blood-clot or serum 
from normal and exophthalmic individuals has been added, compared 
with that of other tadpoles kept under otherwise similar conditions 
as controls. I have varied the experiments in many ways—sometimes 
leaving the blood after it had been coagulated under alcohol in the 
vessel with the tadpoles, without other food, so that they actually 
ate portions of the clot; sometimes adding serum—normal and 
exophthalmic—to the water in which they were kept, with the weed 
which formed their food; sometimes making an extract in water 
of the dried blood and placing the tadpoles in this at various dilutions 
for a few hours. But I have never seen any sign of accelerated 
metamorphosis in animals treated in these ways either with normal 
or with exophthalmic blood. So that this—the only really specific 
test—has given a negative reply to the question whether the specific 
thyroid hormone, thyroxin, is present in appreciable quantity. 

One unexpected result showed itself. Of the tadpoles which were immersed for 
some hours in a dilute extract of the dried blood—normal and exophthalmic— 
those in the extract of dried exophthalmic blood, although not lively on being 
stirred up, became quite active after being washed and transferred to water, in 
which they continued to live indefinitely, without, however, showing any signs of 
acceleration of metamorphosis; whereas those which had been in the extract 
of dried normal blood were found dead the next morning. I was able to make a 
similar experiment with two samples of human milk which were kindly furnished 
me by Dr. A. Ritchie—one normal, the other from an exophthalmic patient—with 
the same result. The tadpoles in diluted normal milk died ; those in exophthalmic 
milk, equally diluted, remained well and lively, and continued to live indefinitely 
on being transferred to water, but without developing any signs of precocious 
metamorphosis. 

The negative result of the tadpole test, which is specific for thyroid, 
does unquestionably tend to cast some doubt on the validity of the 
positive results of the other two tests—at any rate so far as thyroxin 
is concerned. Nevertheless it is difficult not to believe that there 
is constantly a very small amount of thyroid secretion circulating 
in the blood, and that this amount is increased in exophthalmic 
goitre. If this is so, the negative result with tadpoles must be due 
to the very minute percentage amount of thyroxin in the blood, 
for it has not been determined what amount is necessary to produce 
the metamorphotic change. This is a question which can, however, 
be decided, and I hope that we shall be able to answer it. by the next 
tadpole season.( 6 ) 


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364 INFLUENCE OF INTERNAL SECRETIONS. [Oct., 

There is one point which is brought out very clearly in the intestinal 
muscle test, viz., that neither in normal human blood nor in blood 
from exophthalmic patients is there any appreciable amount of free 
adrenalin. For adrenalin, as is well known—even in the proportion 
of one to a million—arrests or inhibits the contractions of intestinal 
muscle, whereas so far from getting inhibition the contractions are 
increased by both kinds of serum, and notably so by the serum of 
exophthalmic blood. ( 7 ) This raises the question as to what becomes 
of the adrenalin which is normally being automatically poured into 
the circulation from the suprarenal veins (in which its presence can 
be detected by both chemical and physiological methods), and in 
greater amount under certain abnormal circumstances—such as 
fright, asphyxia, stimulation of splanchnics and injection of thyroid 
and perhaps of other extracts. The question is of great interest, 
although it would carry us top far from our present subject to follow 
it up. I venture, however, to suggest that there are two possible 
explanations, viz., the adrenalin may enter into some form of combina¬ 
tion or absorption with some constituent of the blood which neutralises 
its activity within that fluid, although the tissues as they require it 
may have the power of liberating and utilising the autacoid, which, 
after exercising its particular action, is destroyed, perhaps, as suggested 
by Cramer, as the effect of formaldehyde, which is formed in the 
tissues in the course of metabolism. The other explanation is that 
the dilution of adrenalin in the general circulation is always too great 
to enable it to produce any effect, except on tissues which have been 
rendered hyper-sensitive to its action either by previous denervation 
or by the presence of a sensitising agent such as has been alleged 
to be furnished by the thyroid secretion. 

There is, however, one reason for regarding it as improbable that 
adrenalin takes an important part in producing the symptoms seen 
in exophthalmic goitre. For some cases of this affection are success¬ 
fully treated by the administration of adrenalin, which, if the above 
were true, would produce exacerbation of some of the most distressing 
symptoms of this affection. On the other hand, thyroid administra¬ 
tion in Graves’s disease does produce exacerbation of the symptoms, 
whilst surgical removal of the enlarged gland or of the greater part 
of it is in severe cases the only efficient remedy for the disease. Both 
of these facts point to the pouring of an excess of thyroid secretion 
into the blood as the cause of the symptoms, and since thyroid secre¬ 
tion does not itself directly affect the heart nor produce protrusio 
bulbi, nor affect the pupil, whilst on the other hand it unquestionably 
acts upon the central nervous system, it seems reasonable to suppose 
that all the pronounced symptoms of the disease are primarily caused 
by its action on nerve-cells. 


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1922.] BY PROF. SIR E. SHARPEY SCHAFER, LL.D. 365 

The Parathyroids. 

There is one other group of endocrine organs which cannot be left 
out of consideration in dealing with the effect of internal secretions 
upon the nervous system. In all the earlier experiments in which 
the thyroid was extirpated—including these performed by surgeons 
in removing the gland for goitrous tumours—the parathyroids were 
usually included. This accounts for the fact that, in many of these, 
acute nervous symptoms were manifested which are never seen when 
the operation is confined to the thyroid. It was not until 1880 that 
the parathyroids were recognised as distinct structures by Sandstrom, 
nor until 1891 that their functional independence was shown by 
Gley. Long after this some physiologists clung to the idea that they 
might be undeveloped portions of thyroid tissue. But even these 
“ die-hards ” have at length been compelled to yield to the evidence 
that developmentally, structurally and physiologically the para, 
thyroids are organs quite distinct from the thyroid and play an 
entirely different role in the organism. 

The parathyroids do not furnish a secretion which acts in any way 
upon the central nervous system, yet their complete removal is the 
cause of the production of remarkable and characteristic effects 
upon that system. It was early noticed amongst the results of 
removal of the thyroid both in animals and man that in many cases, 
in place of or in addition to the chronic effects upon growth and 
metabolism and on the nervous system which are caused by such 
removal, peculiar symptoms of nervous excitation show themselves. 
These take the form of muscular tremors and convulsions of a clonic 
character, passing eventually into fits (but without consciousness 
being affected), and often terminating fatally—sometimes within a 
few days. Besides these symptoms the heart-beats are quickened 
and augmented ; there is profuse salivation; sometimes vomiting 
and diarrhoea. The body temperature rises during the fits, and the 
respirations become rapid and gasping. If the affection lasts some 
time changes occur in the skin and hair, which tends to be shed. 
There is deficient calcification of the teeth in young animals, as well 
as of the bones. All the above symptoms are produced by removal 
of the parathyroids alone. It is further found that after such opera¬ 
tion the excitability of the peripheral nerves to galvanic stimulation 
becomes extraordinarily increased. ( 8 ) The symptoms resemble those 
characterising an affection common in infancy—but not confined 
to the earliest years of life—known as “ tetany ” ; the corresponding 
syndrome caused by parathyroid removal was accordingly termed 
tetania parathyreopriva or parathyroid tetany. It is not a little 
remarkable that the removal of these four minute glands—the smallest 


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[Oct.. 


independent organs in the body, collectively not weighing more than 
about 2 grin.—should produce results so serious ; and it is little 
wonder that many surgeons refused to believe in the teachings of 
physiology regarding them, and continued for a time to include the 
parathyroids in operations for removal of thyroid tumours—often 
with disastrous consequences to their patients. 

The parathyroids differ from the thyroid, suprarenal and pituitary 
glands in yielding no active extract which directly affects either the 
nervous system or peripheral nerves and muscles. It is only on 
their removal or destruction that nervous symptoms show themselves. 
Several possible explanations of this have been put forward. One is 
that these organs yield a chalonic or inhibitory autacoid which 
restrains the activity of nerve-cells, especially of the motor neurones, 
so that on the removal of the parathyroids these run, as it were, 
amuck and produce the symptoms of tetany. Another, that their 
secretion is necessary for maintaining the calcium balance of 
the blood, and that in their absence there results a deficiency of 
calcium salts—a condition known to increase the excitability 
of nerve and muscle. A third supposition was that the internal 
secretion of these glands contains an autacoid which antagonises 
some toxic substance in the blood which affects nerve and muscle, 
so that after their removal this substance has free play to act, 
and produces the symptoms of tetany. It was conjectured that 
such a toxic substance might be found in guanidin. Recent investiga¬ 
tions—particularly those carried on by Prof. Noel Paton and his 
colleagues in the Physiology Department of the University of Glasgow 
—have shown that this third hypothesis is correct. They have found 
that guanidin and methyl-guanidin produce, when administered to 
animals, precisely the same symptoms as those of tetany, and that 
in cases of tetany—whether spontaneous in the human subject or 
experimental tetania thyreopriva in animals—there is an excess of 
guanidin in the blood sufficient to produce the characteristic symptoms 
of tetany. 

The question as to the source of this guanidin is easy to answer, 
for guanidin is closely related to creatin which is methyl-guanidin 
acetic acid and is a product of the metabolism of proteins. Probably 
in minute amounts it fulfils some physiological function, but being 
highly toxic it cannot be allowed to accumulate, but must be further 
metabolised. It is this further metabolism for which the parathyroid 
autacoid appears necessary. How exactly it acts we do not know, 
but we may conjecture that it may play the part of complement or 
amboceptor in the sense of Ehrlich, and serve to link the molecule 
of guanidin with the element in the cells of the body which effects 
its further transformation. Thus we see that without having any 


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192 2.] ENDOCRINE GLANDS AND NERVOUS SYSTEM. 367 


direct action on the nervous system the parathyroids indirectly 
play an important part in influencing some of its functions, so that 
if they are destroyed or affected by disease serious nervous disturbances 
may ensue. Many more affections of the nervous system than tetany 
have been ascribed to alterations in the parathyroids, and it has been 
recommended to employ extracts of these glands in various conditions 
characterised by increase of response to reflex or cortical excitation. 
It has also been suggested that chronic increase of their secretion 
may be the cause of the symptoms in nervous affections in which 
there is a relative inertness of response to such excitatiop. But 
most of these suggestions have little justification, and, as is so often 
the case, speculation has gone further than the experimental facts 
warrant. 

In conclusion I trust I have been able to show that there is already 
a great deal known regarding the influence of the internal secretions 
upon the nervous system, although it is evident that the extent of 
the unknown is much greater than the known. For in this, as in all 
branches of science, our knowledge is bounded by an ever-widening 
circle, and the more this circle is enlarged, the greater the number 
of points of contact with the vast expanse of the unknown beyond it. 

( s ) The thyroid is the only organ in the body which normally contains an 
appreciable amount of iodine.—( s ) Murray has lately given the complete life- 
history of his first case, a woman, set. 46, treated' continuously and successfully with 
thyroid until her death at 74 (Brit. Med. Journ., 1920 ).—(*) Gley and Quinquaud 
state that the effect is not peculiar to extract of thyroid, but is produced by several 
other glandular extracts, and is less than that of liver extract.—( 6 ) It must be 
stated, however, that Langley and others have failed to obtain this result with the 
phrenic.—(®) Rogoff states that blood from the thyroid veins of dogs collected 
during massage of the organ and during stimulation of the cervical sympathetic 
does accelerate the metamorphosis of tadpoles. But the figures he gives of these 
hardly bear out this statement (Journ. Pharm. and Exper. Ther., 1918, xii).— 
(') Cannon and de Paz ( Amer. Journ. Physiol., I9ii,xxviii) have also got an 
increased extent and rate of contraction from the addition of serum. Such 
increase is generally followed by a period of rest, which they ascribe to inhibition 
caused by adrenalin in the blood. But a similar period of rest follows the 
increased contraction caused by thyroid extract alone, and the period of rest is 
evidently the physiological rebound from the previous period of over-activity— 
( 8 ) The nervous symptoms of tetany are quite different from those of hyper¬ 
thyroidism; in the latter there is no increase of galvanic excitability of the 
peripheral nerves and muscles such as is characteristic of tetany. 


Some Chemical Influences in regard to the Endocrine Glands 
and the Central Nervous System.Q') By Jonathan C. 
Meakins, M.D., F.R.C.P.Edin., Christison Professor of Thera¬ 
peutics, University of Edinburgh. 

Mr. President, Ladies and Gentlemen, —In view of what has 
already been said to-day I am afraid that anything which I may 
(*) An address given at the Annual Meeting held in Edinburgh, July 20, 1922. 


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368 ENDOCRINE GLANDS AND NERVOUS SYSTEM, [Oct., 

be able to contribute to this discussion will be superfluous, but 
perhaps, by approaching the subject from the point of view of the 
influence of certain chemical substances on the general function of 
the animal organism, an additional side-light may be obtained on 
this subject. It is difficult to separate many of these chemical 
actions, as the functional activity of the endocrine glands and the 
nervous system are so intimately connected. In addition the active 
principles of some of the endocrine secretions are now identified as 
definite chemical compounds closely allied to other substances which 
may possibly be produced in the organism under pathological 
conditions. 

The general control of the activities of thp animal organism, whether 
those of function or of structure, is of an extremely complex nature ; 
in fact, the more one delves into the subject and more facts are 
obtained, the more difficult is it to see our way ahead. But there 
is one point which now seems very clear—that the function of no one 
organ can be considered as an isolated phenomenon unto itself, but 
all the intimate and intricate co-ordinations which are so beautifully 
balanced in health must be considered in this light when we are 
dealing with disease. 

This correlation of function is chiefly brought about either through 
the nervous system or through substances produced in different part s 
of the body, which, carried by the blood-stream, make their influence 
felt in definite specific actions elsewhere. This does not imply that 
the nervous system acts independently of the chemical substances j 
which the various functionating structures produce. The two are 
practically always co-ordinated. It is well known that not only 
does the secretion of the thyroid gland affect the nervous system, 
but also that stimulation of certain portions of the nervous system 
may affect the function of the thyroid gland. Further, it was com 
sidered probable that emotional disturbances such as fright might 
produce an increased secretion of epinephrine. This belief arose from 
the similarity of the symptoms exhibited under strong emotional 
circumstances and those which were produced when epinephrine was 
injected into the blood-stream. Cannon (i) investigated the subject, 
and his results would appear to confirm this hypothesis, but subsequent 
work by Stewart and Rogoff leaves the question still in doubt. 

The influence of the endocrine glands on the chemistry of the 
body may be observed not only in normal function and structure, 
but also in the biological evolution of the individual. Probably in 
no sphere of the regulation of the organic function of the body is 
the influence of the endocrine glands so apparent as in regulating 
the general metabolism of the body. Through all the vicissitudes 
of rest and work, breaking down and building up of the various 


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structures of the body, these metabolic processes proceed with great 
exactitude. It is now quite apparent that the control of these 
chemical reactions depends in great part upon the influence of the 
thyroid gland, although the actions of the other ductless glands 
play an important but probably subsidiary part. When the thyroid 
function is either increased or decreased, definite disturbances of 
basal metabolism are apparent. It is interesting to us, from a chemical 
point of view, to inquire as to what substance or substances in the 
thyroid internal secretion control and influence this regulation of 
metabolism. It was at first found that thyroid extract, when ad¬ 
ministered by mouth in sufficient doses, could bring about all the 
signs and symptoms of increased physiological function of the thyroid 
gland, but it was not known whether this was due to one or many 
chemical or biological substances. Kendall (2), however, isolated in 
a pure form a chemical substance which he found to be trihydrotriiodo- 
alphaoxyindolepropionic acid. This substance when administered to 
animals produces all the phenomena which are usually found by 
administering thyroid extract, even to the action of bringing about 
a metamorphosis of tadpoles in extremely small amounts.(3) He 
found that the physiological activity of this substance was due to 
the imino group (CONH). So it will be clearly seen that the physio¬ 
logical action of the thyroid is apparently due to a definite chemical 
substance. It has been called by Kendall “ thyroxin.” 

It has been considered that the thyroid function alone influences 
basal metabolism, but experiments performed by Murray Lyon 
(not yet published) have demonstrated quite clearly that epinephrine 
may also bring about a very definite change. He found that by 
injecting 5—10 m. of epinephrine subcutaneously there was a 
pronounced increase in the basal metabolic rate. Furthermore, it 
was indicated that this increase was possibly due to the metabolism 
of substances which on combustion would give a respiratory quotient 
approaching unity. In view of the well-known effect of epinephrine 
in increasing the blood-sugar, it would be suggested that this increased 
metabolism was. in great part due to the increased combustion of 
carbohydrates. The curve of the increased basal metabolism ran 
closely parallel to an increase in the respiratory quotient of the 
expired air. • 

It has been found that the active principle of the supra-renal 
gland is also a definite chemical substance, which has been isolated 
in crystalline form and has been identified as orthodioxyphenyl- 
ethylolmethylamine. Thus it will be seen that the active principles of 
two at least of the endocrine glands are isolatible chemical compounds. 

These chemical substances are apparently produced by the thyroid 
and adrenals, and affect the nervous system and the general chemical 

LXVIII. 


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economy of the body after a definite manner. But on the other 
hand, experiments have shown that disturbances of the chemistry 
of the body in so far as the essential supply of oxygen and removal 
of carbon dioxide are concerned also profoundly influence the action 
of certain of the endocrine glands and the central nervous system. 
The diminution in the supply of oxygen below a certain point has a 
very definite effect upon the central nervous system, as is very 
strikingly shown by the effect of the rarefied atmosphere on ascent 
to high altitudes, either by railway or by other mechanical means 
such as balloons and aeroplanes. Under such circumstances, the 
principal symptoms clearly point to a disturbance of the central 
nervous system, both in so far as the control of the body is concerned, 
and also in so far as the mental processes are operative. The chief 
symptoms are headache, vomiting, mental confusion, restlessness, 
insomnia, and, if carried to an extreme degree, coma and death. 
It has been found that of all the organs of the body so far investigated 
the suprarenal gland consumes the most oxygen per gramme of its 
weight. It will be quite readily appreciated therefore how important 
it is in the chemistry of the human body, and particularly in regard 
to the co-ordination of the nervous system and the endocrine glands, 
that a sufficient supply of oxygen be provided. It has been shown 
by Kellaway (4) that asphyxia brings about an accelerated secretion 
of epinephrine, and that this is chiefly due to the lack of oxygen, 
the excess of carbon dioxide playing at the most a subsidiary part. 
Numerous other examples might be cited as to how the want of 
oxygen disturbs the function of the central nervous system and the 
normal operation of the ductless glands. It matters not whether 
the deficiency of oxygen be brought about by oxygen unsaturation 
of the arterial blood, diminished carrying power for oxygen, as in 
anaemia, or a deficient blood supply, as in endarteritis. On the other 
hand, the importance of the proper balance of carbon dioxide in the 
body cannot be ignored. It has been shown by Dale and Evans (5) 
that the excessive removal of carbon dioxide from the blood brings 
about a very prompt and dangerous fall in blood-pressure, which 
may be equally readily restored by the inhalation of air rich in carbon 
dioxide. They have shown that the effect of forced removal of 
carbon dioxide from the body is not consequential upon changing 
the H-ion concentration of the blood, but is due to depression of the 
vasomotor centres of the bulb and the spinal cord. The physical 
and chemical characteristics of carbon dioxide make it an ideal 
regulator of the intra-cellular reaction, and, as it is the condition 
present within the cell which is of supreme importance, it will be 
readily realised how important this substance is in the regulation 
of the respiratory and vasomotor centres. 


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Furthermore, in man, forced over-ventilation, if kept up for a 
sufficiently long time, may produce typical attacks of tetany (6) 
which are indistinguishable from those resulting from deficiency of 
the parathyroid secretions. The ordinary spasmodic features of this 
condition are readily produced, and also the evidence of irritability 
of the peripheral nerves may be demonstrated (7). This may not 
only be produced artificially in man, but in cases of very severe 
hyperpncea resulting from pathological causes typical attacks of 
tetany may develop (8). 

It will be seen, therefore, that the withdrawal of either oxygen or 
carbon dioxide from the tissues may lead to very serious effects upon 
both the central nervous system and certain of the ductless glands. 

It is well known that the introduction of certain chemical substances 
may stimulate or depress the functional activity of the endocrine 
glands, as, for instance, the injection of nicotine has definitely been 
proven to bring about a great increase in the secretion of epinephrine 
by the adrenals, and other similar instances might be cited. 

But apart from these artificially-introduced chemical bodies, one 
would naturally inquire as to whether there is any evidence that 
there are formed in the body under normal or pathological conditions 
substances which may bring about a disturbance of the control of 
the central nervous system and of the endocrine glands. During the 
past two years it has been our endeavour to determine whether there 
be formed in the human gut during the process of digestion any 
chemical compounds which might be considered as toxic on the 
general organism. Such influence might result from either the direct 
action of bacteria or their endogenous or exogenous toxins per se, 
or else from toxic substances resulting from the action of the bacteria 
on the contents of the bowel. If these toxic substances are formed 
by such action on the contents of the bowel, they are most probably 
derived from the end-products of normal digestion. 

Under varying conditions the intestinal bacteria may exert different 
actions. If the habitat be anaerobic, these bacteria have a more or 
less common property of splitting off the amino-group from the protein 
molecule, but if the surroundings be aerobic, the carboxyl group is 
first separated. It is of great practical importance whether this 
separation of the carboxyl group takes place after or before deamidiza¬ 
tion. If after, substances such as indol and phenol are formed, which 
have little or no toxic proparties. On the other hand, if the separation 
of the carboxyl group takes place before the amino group is split off, 
very toxic substances such as histamine, tyramine, etc., are formed. 
When we commenced our study there was no direct proof that such 
substances were formed in the human gut, or if they were, that they 
were absorbed by the intestinal tract; but it had been conclusively 


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372 ENDOCRINE GLANDS AND NERVOUS SYSTEM, [Oct., 

proven that they exerted a violently poisonous action if inoculated 
subcutaneously or intravenously into animals. In considering the 
various end-products of putrefactive digestion which might under 
abnormal circumstances exert a toxic action on the organism in 
general, we selected those resulting from the digestion of protein, 
and in particular the amines which might result from bacterial 
decarboxylation of the amino-acids. It was decided therefore to 
seek for the presence of histamine, not that it was considered a priori 
that this was necessarily a causative agent of intestinal toxaemia 
under normal conditions, but since if it were found that this and 
other possibly toxic substances were present normally in the caecal 
content, under abnormal conditions of structure and function these 
might be proved operative as toxic agents. 

This proof we proposed to obtain by means of the very sensitive 
reaction to histamine which is given by the isolated uterus of the 
virgin guinea-pig. Although this reaction in itself is not a specific 
test for histamine, we considered that in this case it might be regarded 
as such, in view of the preliminary chemical treatment to which 
we subjected our material, so that, although in no cases were we able 
to obtain enough material for the chemical isolation of histamine, 
we considered that, in those cases in which we obtained a positive 
physiological reaction, its presence was established (9). We were 
able to demonstrate the presence of histamine in six cases in the 
contents of the caecum and transverse colon, but not in the faeces. We 
obtained the largest amount in a case where the activity of the solution 
by comparison with one of pure histamine corresponded with a 
concentration of 1 : 10,000 of the latter. 

We then engaged upon experiments dealing with the absorption 
of histamine and its fate in the organism, the results of which I may 
briefly synopsise as follows : 

We found (10) that injection of considerable quantities of histamine 
into the ileum produced a very prompt effect upon the blood-pressure, 
and in certain cases also upon the respiration and uterine contraction. 
This effect was most usually initiated by a sudden shock-like fall in 
the blood-pressure followed sometimes by a slight recovery, but then 
continued gradually to decline. This result was practically identical 
to that found by Dale and his co-workers when they injected sublethal 
doses of histamine subcutaneously. 

Larger amounts of histamine introduced into the colon produced 
little or no effect. There was thus a definite difference, in the rate of 
absorption at least, between the colon and the ileum. After an 
Eck’s fistula, whereby the portal blood was side-tracked into the 
inferior vena cava, a sudden fall of blood-pressure, etc., was observed 
both in colon and ileum experiments. Perfusion experiments of the 


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373 


isolated liver did not give any distinct evidence of destruction of 
histamine. This was in conformity with the findings of other workers. 

Considering the large amounts of histamine which it was necessary 
to inject even into the ileum of the cat to produce any profound 
influence on the blood-pressure, we do not consider that it is justifiable 
to draw conclusions from our experiments that histamine, if present 
in the normal human gut in the concentrations which we were able 
to demonstrate, would exert any appreciable effect upon the central 
nervous system and other systems. 

Apart from the possible effect which chemical bodies formed in 
the intestine may have upon the organism as a whole, there is the 
very important question of food-stuffs and their synthetisation into 
living tissues. Brailsford Robertson (11) has very wisely drawn 
attention to the fact that “ not only oxygen, water, inorganic salts, 
carbohydrates, fats and proteins are required for the organism of 
the body, but with the increasing refinement of our knowledge of the 
intimate chemical structure of foodstuffs, it has become increasingly 
apparent that it is not merely sufficient to supply an animal organism 
with a sufficiency of nitrogen, carbon and calories to replace its 
daily waste, but it is further necessary to supply an irreducible 
minimum of specified atomic groupings or complexes of nitrogen, 
carbon, hydrogen and so forth, “which are not synthesisable by animal 
tissues. Thus pyrrole, for example, which is an essential building- 
stone of haemoglobin, would appear to be as much an elementary 
requirement of animals as nitrogen or carbon itself, as according to 
Abderhalden they are unable to synthesise it from other carbon or 
nitrogen complexes in the diet. 

" The variety of these essential constituents of the diet with which 
we are acquainted is already very great, and is unquestionably 
destined to grow with increasing scope and refinement of investigation. 
It is highly probable that many of the raw materials from which the 
various internal secretions are synthesised are dietary constituents 
of this essential type; for example, the iminazolyl-grouping, which 
in all probability forms an essential constituent of the active principles 
of both lobes of the pituitary body, the catechol-grouping, which is 
an essential complement of the molecule of adrenalin, and the indole 
radical, which, from the observations of Kendall, would appear to 
be a component of the active principle of the thyroid, are examples 
which will serve to illustrate the essential importance of specific 
molecular groupings or arrangements of atoms, which, if not synthe¬ 
sisable by animal tissues, must necessarily form a part of the diet 
in order to maintain bodily equilibrium, and to a still greater extent, 
of course, in order to render normal growth a possibility.” 

I have endeavoured to-day in a most cursory fashion to lay before 


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ENDOCRINES IN MENTAL DISORDERS, 


[Oct., 


you what seem to me certain very important lines to be followed 
if we are to elucidate these very complex questions. The whole 
study of the endocrine glands in recent years has made progress by 
enormous strides, but one cannot help but be struck by the fact 
that through it all and over it all many theories have arisen which 
have but confused the issue. It behoves us in the future to keep 
our eyes fixed on the direct trail of scientific investigation, and not 
be drawn aside by the mirage of theory based on insufficient and 
ofttimes negligible fact. 

References. 

(1) Cannon and others.— Atner. Journ. of Physiol., vol. xxxiii, 1914, 
P- 356 . 

(2) Kendall.—Collected papers, Mayo Clinic, 1917, 1918. 

(3) Idem. —Harvey Lectures, New York, 1919-1920. 

(4) Kellaway.— Journ. of Physiol., vol. liii, 1919, p. 211.. 

(5) Dale and Evans.— Ibid., vol. lvi, 1922, p. 125. 

(6) Bacchus and Collip.— Amer. Journ. of Physiol., vol. li, 1920, 
p. 568. 

(7) Grant and Goldman.— Ibid., vol. lii, 1920, p. 209. 

(8) Barker and Sprunt.— Endocrinology, vol. vi, 1922, p. 1. 

(9) Meakins and Harington.— Journ. of Pharm. and Exper. Therap., 
vol. xviii, 1922, p. 455. 

(10) Idem. — Ibid, (in press). 

(11) Robertson, Brailsford.— Principles of Biochemistry, Phila¬ 
delphia, 1920. 


The R 6 le of the Endocrines in Mental Disorders.(f) By W. H. B. 

Stoddart, M.D., F.R.C.P., Lecturer on Mental Diseases, St. 

Thomas’s Hospital. 

The object of this paper is to raise the question whether the endo- 
crinoses are not secondary to psychical disturbance but primarily 
caused by it. 

In exophthalmic goitre we have the clinical picture of anxiety 
hysteria plus exophthalmos and goitre. The morbid fears, anxiety, 
tremors, tachycardia, palpitation, sweating, vomiting, diarrhoea, 
polyuria, are all anxiety symptoms. In many cases the origin of the 
disease is consciously traceable to a fright, usually having some 
sexual significance, and in those cases which have undergone psycho¬ 
analytical investigation unconscious psychical factors have been 

(') An address given at the Annual Meeting held in Edinburgh, July ao, 1922. 


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revealed. I regret that I have never been able to complete the 
psycho-analysis of a patient suffering from exophthalmic goitre, 
but even a short analysis has relieved many of the symptoms. More¬ 
over, I observed exophthalmos and a swollen thyroid as an acute 
symptom in numbers of people during the progress of a German 
air-raid on London. In other words there is abundant evidence 
that exophthalmic goitre is of psychical origin. I have had one case 
of exophthalmic goitre caused, like the true anxiety neurosis, by 
persistent coitus interruptus. The patient was a male, and the 
malady was cured by adjustment of his sexual life—without psycho¬ 
analysis or any other treatment. 

The aetiology of myxoedema, on the other hand, is somewhat obscure. 
Many cases are known to have suffered previously from exophthalmic 
goitre. Another factor is that myxoedema is much more common in 
women than in men (about 10 to 1), and the same peculiarity has been 
noted of exophthalmic goitre. Lastly, myxoedema occurs later in life 
than exophthalmic goitre. 

We are now capable of recognising minor degrees of both these 
conditions. We now diagnose hypothyroidism from such a combina¬ 
tion as a tendency to plethora, the appearance of a powdery substance 
in the stockings of the patient, and perhaps mental depression. As 
to exophthalmic goitre, we have only to keep our eyes open in the 
streets to see that milder degrees of this affection are extraordinarily 
common, and I would suggest the possibility that all non-congenital 
cases of hypothyroidism are a sequel of a pre-existing, though perhaps 
unrecognised, state of hyperthyroidism. If this be true, then hypo¬ 
thyroidism and hyperthyroidism are both primarily psychogenetic, 
and the incidence of both conditions would be reduced by treating 
exophthalmic goitre psycho-analytically. The surgical treatment of 
this malady reduces the output of thyroidin and thus cures the 
physical manifestations, but it does not relieve the mental symptoms, 
apprehensiveness and anxiety, which are really the fundamental cause 
of the disease. 

Another exemplification of the specific action of the mind on the 
secretion of endocrines occurs in what we call “ anxiety ” states, 
for want of a better translation of the German word “Angst,” which 
has a wider and slightly stronger meaning, extending from appre¬ 
hensiveness to anguish or dread. 

As Cannon has shown, all states of fear or dread are accompanied 
by an increased outflow of adrenalin into the general circulation. 
The adrenals are stimulated to increased activity via the autonomic 
nervous system, and, curiously enough, the overflow of adrenalin 
thus produced has the effect of over-stimulating the autonomic 
nervous system ; and it is this over-stimulation which is responsible 


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[Oct., 


for many of the physical signs of the anxiety neurosis and anxiety 
hysteria—raised blood-pressure, tachycardia, palpitation, polyuria, 
accelerated respiration, air-hunger, asthmatic attacks and disturbances 
of digestion, for example. • 

The digestive disorders in anxiety states have especially interested 
me in recent years, because I have found, sometimes with the aid 
of skiagrams recording the history of a bismuth meal, that they 
are with persistent regularity associated with gastric dilatation and 
visceroptosis. 

Now, there are two results of stimulation of the autonomic nervous 
system which are of importance in this connection. One is the 
inhibition of peristalsis, the other is closure of the pylorus. The 
inevitable sequel to this combination is failure of the stomach to 
empty itself, the retention of food in the stomach with fermentation 
of the residue and consequent formation of gas and dilatation of the 
stomach. In the late war this result of fear was so well recognised 
as to give rise to the latter-day synonym for fear—“ wind up.” In 
chronic cases this dilatation may become so extreme that the large 
curvature descends as low as the true pelvis. 

But this is not all. If you will allow me to remind you of certain 
features of the anatomy of the abdomen, you will remember that the 
transverse colon is held in position by its attachment to the large 
curvature of the stomach by the transverse mesocolon. It is true 
that the splenic flexure is supported by the costo-colic ligament, 
but there is no such support at the hepatic flexure, and when the 
stomach dilates and its large curvature descends, the transverse 
and ascending colon fall, too, the latter dragging the right kidney 
from its fatty bed, and so providing the clinical picture of viscero¬ 
ptosis with mobile kidney. 

This state of affairs is not rare. It occurs to an appreciable degree 
in every case of morbid anxiety ; but it is liable to escape observation 
unless the precaution is taken of examining the patients in the standing 
posture, when the prominence of the lower abdomen, visceroptosis, 
becomes obvious. You will probably be correct if you suspect this 
condition whenever the patient complains of pain in the back. Again, 
in seeking to determine whether the kidney is mobile, do not examine 
the patient in the recumbent posture; but get him to stand and 
lean forward, placing his hands on the couch. 

There is an item I would like to mention, although it is a little 
aside from our present discussion. Sir Arbuthnot Lane regards 
enteroptosis as responsible for certain kinks in the bowel, which 
offer obstruction to the passage of the intestinal contents; but it 
has been pointed out, on the one hand, that multitudinous normal 
kinks in a normal bowel offer no such obstruction and, on the other, 


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1922 .] BY W. H. B. STODDART, M.D. 377 

that the situation of Lane’s kinks is very much the same as that of 
Sir Arthur Keith’s sphincters, and I would like to raise the question 
whether the obstructions described by Lane are not caused by a 
contraction of Keith’s sphincters through stimulation of the sympa¬ 
thetic by an overdose of adrenalin. We would like the physiologists 
to tell us whether adrenalin induces closure of Keith’s sphincters 
just as it induces closure of the pylorus. 

The discovery of the action of fear, dread or anxiety upon the 
stomach offers an explanation of the epigastric sensation, common 
enough in asylum patients, but also well known to normal people. 
Indeed, it was mainly on account of this phenomenon that the ancients 
localised the seat of the emotions in the neighbourhood of the epigas¬ 
trium. The cardiac area was also included, presumably because of 
the palpitation and tachycardia caused by emotional shocks. I 
have wondered whether the “ sympathetic ” received its name 
for similar reasons. However that may be, we now know that 
adrenalin plays an important role in the production of all these 
-phenomena. 

It must be admitted that the foregoing remarks apply mainly to 
cases of anxiety hysteria—a malady which is not supposed to come 
within the experience of asylum physicians; but, since Prof. Freud 
has clarified our knowledge by his conception of anxiety hysteria, we 
have begun to realise that many of the cases formerly regarded as 
examples of melancholia are really cases of anxiety hysteria. 

We cannot leave the topic of adrenalin in mental disease without 
-some reference to the discovery of Cotton, Corson White and Stevenson 
that the Abderhalden reaction of the blood of epileptics is always 
positive to adrenal tissue. Now there is no evidence, and nobody 
•has ever contended, that adrenalin is the cause of convulsions. The 
•hyperadrenalism is secondary to the disease in some way, and it is 
^possibly due to anxiety and fear of impending attacks. I regret 
that I have not had sufficient opportunity of examining epileptics 
• since my attention was drawn to their hyperadrenalism ; so that 
I am unable to state whether gastric dilatation and visceroptosis are 
- common in epilepsy. Here there is an opportunity for team work in 
the Association. 

Cotton, Corson White and Stevenson also made an extensive 
investigation of the Abderhalden reaction in other mental disorders 
1(220 cases), and the only other constant relationship they discovered 
was a positive Abderhalden reaction in dementia praecox to the sex 
: glands. This is, of course, to be correlated with Sir Frederick Mott’s 
discoveries respecting the morbid anatomy of these glands in dementia 
.praecox. 

His discoveries are capable of several interpretations. So far as 


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378 ENDOCRINES IN MENTAL DISORDERS. [Oct., 

I am aware, nobody has put forward the untenable one that atrophy 
of the sex glands is the primary cause of dementia praecox. 

If I understand Sir Frederick Mott’s view correctly, it is that 
in dementia praecox degeneration of the sex glands proceeds pari 
passu —parallel with—degeneration of the nervous system, especially 
of the cerebral cortex, and therefore of the mind. He regards 
dementia praecox as an organic disease of the brain which causes 
mental degeneration. 

There is a great deal to be said in favour of this view, quite apart 
from the fact that any opinion advanced by Sir Frederick commands- 
profound respect; but there is another alternative, viz., that the 
organic changes in the brain and sex glands are secondary to the- 
mental disorder. Psycho-analytical investigation of dementia praecox 
appears to demonstrate that dementia praecox is primarily and funda¬ 
mentally a mental disease, i.e., psychogenetic. For example, quite 
frequently the patients are only children, and the malady is traceable- 
psychologically to the mother’s influence on her one darling child, 
causing him to become auto-erotic and metro-erotic. Such a factor is- 
purely mental, yet the case goes on to a stage in which the charac¬ 
teristic cortical and sex-gland changes presumably occur, and even 
such degenerative stigmata of the hands and ears as I described in 
this disease some years ago. 

If such organic changes can take place as the result of purely 
psychical processes, we are naturally led to ask what are the inter¬ 
mediate mechanisms; but, owing to our ignorance, no answer is yet 
forthcoming. From our knowledge of analogous conditions, however, 
it appears that we might be justified if we ascribed the changes to 
excess or defect of some endocrine or endocrines. And here we need 
go no farther afield in the first instance than Sir Frederick Mott’s 
discoveries. Is it not possible for a sex-gland defect to produce the 
changes ? Such a state of affairs would bring the mechanism of 
dementia praecox into line with that of anxiety states. 

The object of my contribution has been to draw attention to the 
fact that purely psychical mechanisms are capable of modifying the 
secretion of endocrines, and thus to produce considerable and even 
gross organic changes. 


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1922.] NOTES FROM A PSYCHO-THERAPEUTIC CLINIC. 379 


Notes from a Psycho-therapeutic Clinic. ( 1 ) By James Ernest 
Middlemiss, M.R.C.S., L.R.C.P.Lond., F.R.F.P. & S.Glas., 
Medical Officer, Psycho-therapeutic Clinic, Ministry of Pensions, 
Leeds. 

The intention of the present paper is to give an impressionistic 
account of the cases seen rather than a detailed and analytical descrip¬ 
tion which is necessarily beyond its scope. 

It may be said that until the institution of these clinics by the 
Ministry of Pensions there has been no field of study quite analogous 
to them either in the type of clinical material or the conditions in 
which it is encountered. Their only selective character lies in the 
fact that aetiologically they are all more or less related to the traumas 
of warfare, and ostensibly suitable for mental therapy of one sort 
or another. As, furthermore, their causal relationship to military 
service is often of the slenderest and their suitability for such treat¬ 
ment is frequently hypothetical, it will be realised that many diverse 
types of nervous disorder pass muster at the hands of the psycho¬ 
therapeutist. Herein lies perhaps its peculiar value. Many cases are 
submitted to the clinic which a cursory examination shows to be 
unsuitable either on the score of age, chronicity, or on other grounds. 
The clinic acts, in fact, as a sort of clearing house for the neuroses 
and psycho-neuroses of the war, wherein the diagnosis may be con¬ 
firmed or modified, and from which cases which are unsuitable for 
out-patient treatment may be variously drafted to mental hospitals, 
epileptic colonies, and neurological hospitals, according to their 
kind and degree. As instancing the diversity of types encountered, 
I might mention that at one time and another I have dealt with cases 
showing an antecedent history of exhaustion psychosis, acute melan¬ 
cholia, confusional insanity, epilepsy, gunshot wounds of the head, 
and congenital mental defect, as well as a large miscellaneous group, 
variously labelled as neurasthenia, shell shock, and war-shock, and 
which includes the types most usually associated with the strain of 
warfare. 

If it be permissible to speak of a typical or characteristic form of 
neurosis, pride of place must be accorded to those forms in which 
anxiety symptoms of one sort or another are the most prominent 
features of the case. On the objective side these are characterised 
by segmental or general tremors, unsteadiness of stance and gait, 
disturbances of speech functions, ranging from complete mutism to 
mere hesitancy of speech, increase of the deep reflexes, motor inco- 

(') A paper read at the Spring Meeting of. the Northern and Midland Division, 
held at the Derby Borough Mental Hospital, April 27, 1922. 


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380 notes from a psycho-therapeutic clinic, [Oct., 


ordination, with marked impairment in the precision of fine move¬ 
ments, hyperidrosis, local or general, vaso-motor instability, as 
evidenced by patchy erythema of the skin, motor tics and choreiform 
or athetoid movements of trunk, head, or limbs. 

From the subjective aspect a more or less constant feeling of 
apprehension, which may be general or determined by some particular 
situation, such as the approach of darkness, closed spaces, the presence 
of crowds, etc., marked emotional fluctuations with depressed moods 
in the morning, disturbed sleep with distressing dreams, an intolerance 
for hurry or bustle, excessive irritability with a tendency to react 
with explosive violence to trivial annoyances, morning anorexia, 
nausea and vomiting unassociated with pain and unrelated to the 
taking of food, feelings of swooning, “ falling away,” and sudden 
depletions of energy, are among the most common manifestations. 
Such, briefly, is the clinical picture presented by a case of anxiety 
neurosis. 

The close relation between the physical signs and affective states 
is at once apparent and is clearly apprehended by the subject himself, 
who instinctively avoids the contingencies of every-day life, which he 
has found by experience to elicit or aggravate his symptoms. When, 
perforce, these cannot be avoided, and he must submit to, say, the 
ordeal of medical examination, these characteristics are exhibited 
in full force, and their painful character is by no means mitigated 
by the fact that as a rule the patient, as has been said, has complete 
insight into his condition. 

An inquiry into the history of these cases shows in the majority 
that the symptoms date from a definite incident—usually a shell 
explosion in the near vicinity. There the uniformity ends, for he 
may or may not have lost consciousness; he may retain a clear 
recollection of events right up to the occurrence; he may have a 
retrogade amnesia for a variable period before it, or the whole or 
greater part of his war experiences prior to the incident may have 
been obliterated, with occasional islets of memory standing out 
above the general oblivion. 

In view of the clear-cut histories, it is impossible not to ascribe 
a certain aetiological value to sheer physical shock. As to the nature 
and degree of this supposed physical component of the trauma I 
venture no opinion, as the matter lies somewhat outside my province. 
That, however, a psychical factor plays an important, some would 
contend the predominant, rdle will, I think, be generally admitted. 

I now propose to give as concisely as may be a description of the 
treatment I have come to adopt in these cases. 

Having made myself familiar with the outline of the case supplied 
in the official documents, I ask the patient to describe the events 


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192 2.] BY JAMES ERNEST MIDDLEMISS, M.R.C.S. 381 

leading up to the illness so far as they are known to him, noting 
especially the time and the manner of onset and what he himself 
regards as the origin of his disability, after which he is asked to 
describe the course of the illness up to date and to give a full account 
of his present symptoms, explaining particularly how these affect his 
general efficiency, and in what way, if any, he has been altered in 
character and temperament. Apart from the information consciously 
imparted, one is able to gain a preliminary insight into his affective 
trends and mental orientations where these are at all abnormal or 
pronounced. This may suggest a useful line of inquiry at later 
interviews and a valuable clue to the understanding of the case. 
A complete physical examination is then made, special attention 
being paid to the nervous system and “ objective signs.” In many 
cases the material provided by this preliminary inquiry is sufficient 
to determine one’s course of action. This in my practice takes the 
form of therapeutical conversations or explanations, in which on his 
part he is encouraged to unburden himself as freely as possible. 
An attempt is made to secure at least a relative ease of mind which 
may serve as a starting-point for future endeavour. The long duration 
of the symptoms and their (to him) inexplicable fluctuations are 
presented to him as a normal and usual feature of a nervous malady. 
In this way his symptoms are divested of a little of their horror 
and incomprehensibility. He is encouraged to take long views. 
If he has improved, the fact is emphasised, and he is safeguarded 
in advance against the disappointment engendered by possible 
remissions and relapses. In short, the treatment at the outset is 
largely symptomatic, doubts and misgivings being dealt with as 
they arise. The personal relationship so set up between physician 
and patient in itself goes far to mitigate the more acute manifestations, 
and the feeling of confidence and moral support which ensues is 
freely expressed by the patient himself, who, perhaps for the first 
time in his troubled career, feels himself truly understood. 

A basis of confidence having been established, one may proceed 
further. It may be that the patient already relates his symptoms 
to definite incidents (in his career) as a soldier, and that he has by 
this time adopted some elementary therapy of his own. Where this 
connection is borne out by one’s own findings, he is by no means 
discouraged in the attempt to work out his own salvation. Where, 
however, as is frequently the case, he attributes his condition correctly 
enough to past incidents, but has consistently tried to obliterate 
them from his mind—where, in short, there is evidence of repression— 
he is encouraged to face the facts and to revive little by little the 
memory of the incidents which have left such an abiding sense of 
horror in his mind. And here, in my opinion, it is not advisable 


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382 NOTES FROM A PSYCHO-THERAPEUTIC CLINIC, [Oct., 

to force the pace, for the emotional reaction is severe and the rate of 
progress must be conditioned by the individual’s capacity to endure 
it. So far it has been assumed that these experiences, though not 
readily faced, have never been entirely shut out of consciousness— 
that, in short, the attempt at suppression has only been partially 
successful. It must be admitted that in a large proportion of cases 
this represents the actual situation. In the amnesic cases, where the 
traumatic episode and possibly whole periods of war experiences 
have been expunged from the consciousness, recourse must be had 
to other expedients. The dreams, if remembered, may be taken as 
a convenient starting-point for the resuscitation of the submerged 
experiences. By a process of free association it may be possible to 
recall a fragment of the past, around which as a nucleus other forgotten 
incidents gradually crystallise out. When no dreams are available 
I have been accustomed to induce a hypnoid state, in which apparently 
the power of recall is heightened. In one such case an isolated 
incident was all that was remembered. In the hypnoid state the 
man was asked to visualise this as clearly as possible. In doing this 
additional elements appeared in the picture. At subsequent inter¬ 
views the process was repeated, the picture being gradually enlarged 
from day to day by a process of accretion as each new feature was 
added to the main body of experiences. In this case I was impressed 
by the vividness with which the memories appeared in consciousness 
and by their authenticity—for the patient had no doubts as to the 
reality of the experiences. A dominant feature in this case was a 
stammer, and associated with the revival of the memories there 
seemed to be an unmistakable improvement in the stammer. In 
this connection I may say I have been frequently impressed by the 
extraordinary vividness with which war incidents are revived in the 
hypnoid state in cases where they have never disappeared entirely 
from consciousness. In the waking state the subject, as it were, 
knows that such and such a thing has occurred, whereas in the 
hypnoid state it is as if it actually occurred before his eyes. The only 
condition which is at all comparable in the intensity and vividness of 
sensation is the war dream, in which, as is well known, the subject 
frequently dramatises the whole episode with all its appropriate motor 
accompaniments of fear, flight, or defence. It is as if in both cases 
direct access is obtained to the subconscious—in one case by design, 
and in the other during the natural process of sleep. 

Whilst convinced of the general efficacy of this procedure, viz., 
the restoration and reintegration in consciousness of forgotten or 
repressed experiences, I am unable to record any of the startling and 
dramatic results so frequently described in psycho-analytical literature. 
If, as is natural to suppose, the tendency to suppression and dissocia- 


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1922.] BY JAMES ERNEST MIDDLEMISS, M.R.C.S. 383 

tion is related to the degree to which the suppressed material is 
unacceptable to the waking consciousness, one would hardly expect 
such sudden changes. Seeing that in many cases the incidents have 
never been forgotten, the real difficulty would appear to be in rendering 
them assimilable by the consciousness. It is in the rapprochement 
between the ego and the system of ideas against which it instinctively 
defends itself that the essential problem lies. The mechanisms 
involved in this process are probably not essentially different from 
those which underly the adjustments of every-day experience. The 
process whereby an idea or situation, at first repellant, is by repeated 
presentation to the consciousness so divested of its horror as to become 
acceptable, or at least tolerable, is too familiar to need emphasising. 
The tolerance so acquired, however, implies more than the mere 
juxtaposition in consciousness of two systems of ideas which are 
mutually incompatible, however many times repeated. Without 
distortion of the facts the situation must be presented from a new 
angle, and the redeeming features, if such there be, so stressed as 
to appeal to some strong and prevailing trend of the personality. 
By some such transfiguring agency only must it have been possible 
for many refined and sensitive souls to endure the unspeakable horrors 
of modern warfare. It may happen, of course, that the experiences 
which it is sought to suppress may be so inherently revolting as to 
outrage every decent feeling and instinct. In such cases no species 
of ingenuity can secure its acceptance by the consciousness. Rivers, 
in his book, Instinct and the Unconscious , records the case of an 
officer caught in a bombardment, and who, on recovering conscious¬ 
ness, found himself lying face downwards on the body of a dead 
German, from which the decomposing intestines protruded and 
partly filled his, the officer’s, mouth. It can be believed that no, 
kind of mental alchemy was capable of rendering a memory of this 
kind anything but hideous. The types of cases already discussed 
may be usefully contrasted with those in which the manifestations 
are somatic, rather than psychic, in character—the so-called conver¬ 
sion—or, as Rivers calls them, substitution-hysterias. In one or two 
such cases one has been impressed by the absence of mental stress 
or emotional excitement such as are associated with the anxiety 
state. It is as if the patient quietly acquiesced in his disability, 
and assumed that it called for no particular explanation except the 
one assigned—possibly some trifling wound long since healed. It is 
true that if the reality of his symptoms be questioned in any way, 
he backs up his assertions with a good deal of warmth which has 
every appearance of sincerity. In general he is as little open to 
argument as the delusional melancholic who imagines he has no 
inside. If it be true, as Rivers contends, that all these neuroses 


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384 NOTES FROM A I'SYCHO-THERAPEUTIC CLINIC. [Oct., 


represent reactions of one sort or another to the danger instinct, 
there is a great deal to support his thesis that in the substitution 
hysterias the solution is attempted on a lower evolutionary mental 
level than in the case of the anxiety syndrome. Thus may be ex¬ 
plained the completeness of the defensive mechanism and the com¬ 
parative integrity of the mental processes. Be this as it may, a 
teleological significance must be attached to these somatic manifesta¬ 
tions which at one period or another have subserved some ulterior 
need on the part of the ego. That the comparatively primitive 
mechanism just described is not the only one involved is suggested 
by the following case from civilian practice. The patient, a middle- 
aged married woman, wife of a collier in a small village, had for 
several years suffered from a functional paralysis involving both 
legs and one arm. When first seen she was quite unable to stand, 
was bed-ridden, could not dress her hair, and had to be taken about 
in a bath chair. She was said to have suffered from rheumatism 
and various internal disorders, but except for some bronchitis had, 
when I saw her, no objective signs of disease. By direct suggestion 
and massage she completely recovered the use of the paralysed arm ; 
but an attempt at hypnosis, with a view to the recovery of the leg 
functions, precipitated a typical hysterical attack, and the treatment 
had to be suspended. It transpired that she was an intelligent woman 
who had formerly been in business for herself. She admitted that 
she had married beneath her social status—her husband was a collier 
and intellectually much her inferior—and it was inferred that in 
marrying she had had to abandon many of her social ambitions. 
As a collier’s wife she was destined to a prosaic and comparatively 
drab existence. As an interesting invalid, on the other hand, wheeled 
through the streets in a bath chair and an object of unusual considera¬ 
tion and esteem, she achieved a more or less perfect compensation 
for the fuller life she had so unwillingly relinquished. The purposive 
significance of her disability and its relation to her egoistic needs 
would probably have been repudiated by the patient. That it 
existed I have little doubt, though no doubt the transference was 
facilitated by suggestion, which, as in the war hysterias, is so fre¬ 
quently a contributory factor. 

In submitting these experiences I am conscious of having long 
ago exceeded my modest intention. It is of the essence of notes 
that they should be brief; that they should have extended to such 
an inordinate length I had never anticipated. Perhaps it is one more 
instance of subconscious motivation, wherein I hope I may be 
exonerated. 


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1922.] TREATMENT OF EARLY MENTAL DISORDER. 385 


The Out-patient Treatment of Early Mental Disorder. The 
Neurological Clinic , and some of its Functions .(*) By 

A. Ninian Bruce, D.Sc., M.D., F.R.C.P.Edin., Director, Neuro¬ 
logical Clinic, etc., Ministry of Pensions, Edinburgh. 

Among the many important advances which have taken place 
within recent years in the science of medicine, none have surpassed 
in value or in extent those affecting the nervous system. One of 
the principal points which these have established, no matter from 
what direction the subject has been approached, is the recognition 
of the essential unity of the sciences of neurology and psychiatry. 
In the domain of psychological medicine, the researches of Freud 
and Jung on psychopathology and their theories of the subconscious 
and its manifestations have provided a common meeting-ground; 
the investigations of Campbell on the cell lamination of the cerebral 
cortex, and later of Shaw Bolton, have aimed at the elaboration of 
a scheme of cerebral function based on clinico-histo-pathological 
proof; the studies of Elliot Smith on the comparative anatomy of 
the brain and the development of the cerebral cortex peculiar to the 
mammalia have demonstrated some of the factors which have 
contributed to the attainment of man’s distinctive mental aptitudes, 
and eventually made possible the emergence of the human intellectual 
abilities culminating in the development of speech, and the attainment 
of intellectual pre-eminence within the human family; equally 
important is the recognition of the integrative action of the nervous 
system by Sherrington, and his views on the importance of the simple 
muscle-nerve preparation in explaining the processes involved in 
cerebral association and the significance of excitation, inhibition 
and the latent period ; and still more recently we have the investiga¬ 
tions and publications of Schafer on the influence of the endocrine 
glands on the nervous system, and of Mott on the relationship of the 
reproductive and endocrine glands to mental disease, and the light 
which this has shown on the aetiology of dementia praecox. 

These researches, and many others too numerous to mention here, 
have all consistently furnished proof from their separate standpoints 
of this essential unity. And it is very important this should be 
realised. The separation of neurology and psychiatry has done 
much to hinder the development of both: it has resulted in the 
development of nervous and mental disorders as independent studies, 
the neurologist rarely having any extensive asylum experience, and, 
on the other hand, the alienist rarely has a corresponding knowledge 
of organic neurology. It is now being recognised that a neurological 
examination is not really complete unless the mental state of the 
(*) A paper read at the Annual Meeting held in Edinburgh, July 19, 1922. 

LXVIII. 


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386 TREATMENT OF EARLY MENTAL DISORDER. [Oct., 


patient is also examined, and vice versa, and that a specialist in nervous 
disorders must possess not only a knowledge of organic neurology 
and of psychiatry, but also of psychology, both normal and abnormal. 
It is interesting in this respect to note that two such eminent specialists 
in these two subjects in New York as S. E. Jelliffe and Wm. A. White 
have termed the second edition of their text-book on the Modern 
Treatment of Nervous and Mental Diseases, the first edition of 
which appeared in 1913, Diseases of the Nervous System: a Text¬ 
book of Neurology and Psychiatry, because to have published it 
in two books, one on neurology and one on psychiatry, “ would per¬ 
petuate a distinction which the authors believe to be wholly artificial.” 

The separation of the study of nervous disorders from the study 
of mental disorders dates back to old controversies. The connection 
of mind and body was the corner-stone of Aristotle’s construction ; 
he considered that intellect presupposes sense: as he found mind 
and body invariably connected, he therefore regarded them as essen¬ 
tially inseparable. It is important to note that Aristotle began his 
study of mind from the side of body. Descartes, however, could 
conceive mind without body, and body without mind; therefore he 
concluded they were actually independent and could exist apart. 
While the Aristotelian theory developed in mediaeval times into a 
somewhat hazy materialism, the theory of Descartes led on to a 
separation of the diseases of mind and body. These two problems, 
the relation of mind and body, and the reality of external perception, 
have continued to vex philosophic thinkers from Descartes’ time to 
our own, nor will they cease from troubling us until dualism is finally 
laid to rest. 

For practical purposes the nervous system may be divided into 
three levels of activity—the vegetative, the sensori-motor, and the 
psychic. The first of these, the vegetative nervous system, is in close 
functional relations with the endocrine glands—in fact, some of 
these glands are actually part of the nervous system. The type of 
tool employed at this physico-chemical level is the hormone, and the 
symptomatology of this region constitutes the borderline of neurology 
and internal medicine. 

The second level is the sensori-motor; the type of tool here used 
is the reflex, and the function is further integration by providing 
the means for the balanced interrelations of the various motor organs 
of the body. It has to provide that all the various parts of 
the machine work harmoniously together, that the functions of the 
various organs are not only properly timed in relation one to the 
others, but also are adequately related on the basis of the functional 
demands made on them. It is to the symptomatology of this group 
that the term “ neurology ” is usually applied. 


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BY A. NINIAN BRUCE, D.SC. 


387 


The third, the highest, the psychic level, is the most complex. 
The tool here employed is the symbol, and the symbol becomes a 
carrier of energy which is translated into conduct. The function 
of this level is no longer one of simply integration of the various 
parts of the individual, but has also to do, not only with the relation 
of the individual as a whole to his environment, but more especially 
to his social environment. 

The hormone and the reflex are confined in their capacities for 
reaction within relatively narrow limits of possibilities. The symbol, 
on the other hand, is capable of infinite change and adjustment, 
and so has grown out of the necessity created by ever-increasing 
demands. The growth from the lowest to the highest, from the 
youngest to the oldest, from the simplest to the most complex, has 
been, as everywhere in nature, without gaps. We must now regard 
the mind as the end-result in an orderly series of progressions in which 
the body has used successively more complex tools to deal with the 
problems of integration and adjustment. 

With these short introductory remarks on the oneness of neurology 
and psychiatry, and on the different levels of nervous activity, we 
pass to the more particular subject of this paper, namely, the treatment 
of disorders of the higher levels of cerebral functioning at the out¬ 
patient clinic. The disturbances which present themselves for 
special consideration here are essentially those included in the terms 
“ functional nervous disease ” and “ incipient mental disease." 
These two types merge into one another so gradually and so com¬ 
pletely that it is not possible to draw a line sharply where the one 
ends and the other begins. They constitute clinically the connecting 
link between neurology and psychiatry, and are only now beginning 
to receive the attention they deserve. The war has brought them 
specially into prominence on account of the great increase in number 
of types and variety which it has produced, and the necessity for 
immediate and appropriate treatment. The treatment organised 
during the war by the War Office consisted of in-patient treatment 
only, and proved most successful, but after the war, when the whole 
question of treatment came up before the Ministry of Pensions for 
consideration, it was decided to establish out-patient clinics as well 
as special hospitals. These clinics have now been functioning for 
about two and a half years, and much useful information about the 
types of cases presenting themselves for treatment and the results 
of treatment have been obtained. The urgent present-day need 
for the establishment of such clinics in connection with our general 
hospitals for civilian cases renders the results which have been obtained 
from Ministry of Pensions clinics of much value, and the fact that 
the types of cases resulting from the war present a simpler problem 


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388 TREATMENT OF EARLY MENTAL DISORDER. [Oct., 


than those of the corresponding civilian cases in no way detracts 
from the value of the results. 

The Neurological Clinic, which was established in Edinburgh in 
the beginning of 1920 by the Ministry of Pensions, has been responsible 
for the supervision and treatment of approximately 2,000 cases. 
In order that a pensioner may become entitled to such treatment 
it is necessary that certain procedure be adopted. This consists in 
his examination previous to appearing at the clinic by a medical 
board or a medical referee, who certify that he is suffering from a 
disability requiring such treatment, and that such disability is the 
result, or has been aggravated by, his service during the war. In 
the great majority of cases a diagnosis is made of “ neurasthenia,” 
and he is then transferred to the clinic for full investigation of his 
case and for whatever treatment is required. It will, of course, 
be obvious that practically every type of nervous and mental disorder 
may come before such a clinic, and that the first requirement is an 
accurate diagnosis. It was found that these cases may be roughly 
grouped under the following headings: 

First. Cases in which the “ neurasthenic " symptom is merely 
part of some general disease, such as phthisis, diabetes, cardiac dilata¬ 
tion, pernicious anaemia, or some such type of condition. Such cases 
are immediately transferred to the wards of a general hospital for 
treatment. They incidentally illustrate the fact that the first re¬ 
quirement for treating “ neurasthenia ” is a knowledge of general 
medicine. In view of the importance of accurately diagnosing all 
cases, as far as is possible, at the first interview, the association of 
such a clinic with a general hospital is important, as the patient may 
be examined without delay or difficulty at any of the other specialist 
departments should that be considered necessary or desirable. 

Second. The second group of cases include those of the endo- 
crinopathies, of which exophthalmic goitre and thyroid disturbances 
were the most important. This was not a large group. 

Third. The third group is that of the organic nervous diseases. 
It includes all the well-known diseases—tabes, disseminated sclerosis, 
paralysis agitans, peripheral neuritis of different kinds, muscular 
atrophies, subacute combined sclerosis of the cord, and syphilitic 
lesions. Gunshot wounds of the head were fairly numerous. When 
it is realised how closely many of these diseases simulate “ functional ” 
states, it will at once be obvious how essential an intimate knowledge 
of organic neurology is in the examination of such cases. It must 
not be forgotten that in many of the cases in which the larger number 
of the symptoms were of a purely “ functional ” nature an organic 
element was also present. 

Fourth. The epileptic group. These were divided into the 


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1922 .] BY A. NINIAN BRUCE, D.SC. 389 

traumatic and the idiopathic types. The former was associated with 
gunshot and other wounds to the head. The proportion of such 
cases when compared with the number of cases of wounds to the 
head was small. The fits were frequently of the Jacksonian type, 
and the element of alcohol had to be usually carefully considered. 
The other cases—and only true epilepsy is included in this group— 
were in most cases when fully examined found to have a pre-war 
history of fits. They presented great difficulties; they were mostly 
able to get work, but none were able to keep it. They soon became 
known among employers as epileptics and their chances of employment 
became nil. The number of fits did not make much difference— 
the mere knowledge that they took fits was enough. A large propor¬ 
tion were capable of good work under suitable conditions, and were 
indeed most anxious to obtain it. There does not seem to be much 
doubt that an extension of the epileptic colony system is an urgent 
necessity. 

Fifth. The mental defective group. The number of mental 
defectives who appeared for treatment was considerable. As a 
group they do not appear to have suffered much from the effects of 
the War. Their inability to adapt themselves saved them. They 
were early sent home, or developed a state of mental confusion which 
necessitated their immediate removal to a mental ward. When 
transferred to this country they soon recovered. But the question 
of their employment then arose in an acute form. Many of them 
were found to be quite fit for good work, if under supervision. Suitable 
institutional treatment is what is required. The moment of their 
discharge from military hospitals presented a unique moment for 
their recognition and segregation, but such was unfortunately not 
possible, and the opportunity was lost. According to Goddard, 
feeble-mindedness is hereditary in a large percentage of cases, and 
is transmitted in accordance with the Mendelian formula. The 
problem which they present is of great importance to the community. 
The recognition and determination of the different grades of mental 
defect requires special study and training, and it would appear that 
such would come under the supervision of out-patient clinics. 

Sixth. The criminal degenerate. Our attention was specially 
drawn to this group by the repeated requests we received from lawyers 
for information of cases who had come into the hands of the police. 
Many were well-known characters, repeated punishments having 
had no effect whatsoever. No attention appeared to have been paid 
to their mentality. They illustrated the great help which such a 
clinic could give in such cases when working in co-operation with 
the Law Courts. It is astonishing how little there is in the literature 
of criminology which is directly helpful to those who have to deal 


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390 TREATMENT OF EARLY MENTAL DISORDER. [Oct., 

practically with offenders. Of general theory there is no lack, but 
when we come to the study of individuals there is almost no guidance. 
In view of the failure of the past and of the present to handle effectively 
anti-social conduct, and in the light of the enormous expense of 
criminality, standing in striking contrast to recent progress in many 
other fields of human endeavour, there seems the utmost justification 
for further work in the underlying causes of delinquency. The 
remarkable results which have been attained by Dr. Healy at the 
Juvenile Psychopathic Institute organised in Chicago in March, 1909, 
and later attached to the Chicago Law Courts, illustrates well the 
importance of this matter. 

Before passing from this group, attention might perhaps be directed 
to a recent publication by Dr. Briggs, of Boston, entitled The Manner 
of Man that Kills, in which the importance of this subject is demon¬ 
strated. A most careful study of the life-history of three prominent 
American murderers is given, one of whom, Czolgosz, was responsible 
for the murder of President McKinley. As a result it is shown 
that the first was a defective, the second a case of dementia praecox, 
and the third was a victim of hysteria with delusions and hallucina¬ 
tions. Dr. Briggs emphasises the point that while Society is willing 
to condemn and punish the defective or lunatic after he has committed 
a crime, it does not do anything to save him from leading a life that 
results in disaster, often in homicide; and not only so, but is liable 
to bring down with him in his tragedy innocent persons. Further 
work on this subject will be found in the volume on the Criminal 
Imbecile: an Analysis of Three Remarkable Murder Cases, by H. H. 
Goddard, published in 1915. 

Seventh. Cases found to be certifiable on the first examination. 
These include various delusional states, acute hallucinatory conditions, 
chronic alcoholic types and dementia praecox. Nothing has astonished 
me more than the failure of the general practitioner to recognise and 
realise such states. And this failure is not limited to the general 
practitioner. Cases found to be certifiable were not certified by us, 
but recommended to the parish authorities through the local pension 
committee for this purpose. Nevertheless we repeatedly found that 
cases potentially suicidal or homicidal, and reported to be so, were 
not certified. The tendency always was to wait until the tragedy 
happened, and then to rush the case into an asylum on an emergency 
certificate. This is obviously one of the principal explanations of 
the epidemic of tragedies which are being so repeatedly reported in 
the newspapers from day to day. Unless these cases are considered 
certifiable as insane, they are practically unable to receive any treat¬ 
ment. Had there been a series of out-patient clinics attached to 
large general hospitals in different parts of the country to which 


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BY A. NINIAN BRUCE, D.SC. 


391 


such cases could have been referred for examination and treatment, 
and where they would immediately have come under trained mental 
supervision, they would have been realised at once as potentially 
dangerous either to themselves or others, and transferred to the 
mental hospital before the tragedy, and not after. Clearly such 
clinics would render valuable service to the general practitioner. 
Few cases present more difficult problems to the general practitioner 
than the incipient mental case. He has not the time, even if he 
has the training, to give them the care and attention they require. 
It would be of immense help to him if there were some out-patient 
clinic available to which he could refer all such cases, in exactly 
the same way as surgical and other cases are referred to the 
corresponding surgical or appropriate clinic. An important function 
of an out-patient clinic of this nature is to recognise and remove to 
the mental hospital certifiable cases which have so far escaped recog¬ 
nition, and hence the necessity for men trained in mental work 
(and this can only be learned in an asylum) on the staff of such clinics, 
and a new line of advance for those who have decided to specialise 
in mental work is presented. 

Eighth. The eighth group is the largest, and includes all those 
cases which are usually included under the terms “ functional nervous” 
and “ incipient mental ” disorders. These two conditions merge 
into one another so gradually that no sharp dividing line can be 
found at which a separation might be drawn. Many cases considered 
to be neurasthenic are in reality mild mental derangements—a fact 
which does not appear to be yet fully realised. It is difficult to 
exaggerate the sense of illumination which is experienced in the study 
of “ neurasthenia ” after a period of residence in a mental hospital 
(the only way in which mental states may be adequately studied), 
while residence in a neurological hospital with neurasthenic and 
functional nervous cases gives an insight into nervous conditions 
which can be learned in no other way. 

I have not time in the present short address to discuss at any 
length the different types of cases which came under the present 
group. But several points stand out and are worthy of attention. 
The type of case to which the term “ conversion hysteria ” has been 
given presented no difficulty in treatment, provided the case was 
sent to us first. Unfortunately many before coming to us had under¬ 
gone long courses of treatment in or out of hospital, where the dis¬ 
ability had been regarded as of an organic nature with resultant 
fixation of symptoms. It made it clear to us how much good 
could result from the establishment of neurological out-patient 
clinics in connection with general hospitals, to which surgical and 
orthopaedic clinics could immediately transfer all cases of paralysis 


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TREATMENT OF EARLY MENTAL DISORDER. [Oct., 


and other loss of functions for which no definite causative organic 
lesion can be discovered. At present there is practically no treatment 
for such civilian cases unless they are so unfortunate as to be treated 
as if of organic origin. 

The greater proportion of the remaining cases which came under 
observation were emotional disturbances characterised by anxiety. 
At the very onset it was discovered that many patients showed 
clinical pictures which would not fit into existing diagnostic pigeon¬ 
holes. The manic-depressive group was to be recognised, but the 
rigidity of this term, which is descriptive, has confused the problem 
of classifying many benign psychoses. Although elation and depres¬ 
sion are the commonest mood anomalies in this group, they have no 
more theoretic importance than anxiety, distressed perplexity, or 
apathy. The term “ anxiety-apathy ” insanity is just as distinct a 
group and as appropriate a term as Kraepelin’s manic-depressive 
states. The symptom-complex centering round apathy is just as 
distinct as that which is centred round mania with its predominant 
characteristic of elation. 

Regarded from the point of view of adaptation and regression, 
an attempt was made to discover what was the unfavourable attitude 
of reality up against which the patient found himself placed. A 
large proportion of the cases were best understood as merely cases 
of psychological regression. Regression is a term used, especially by 
Jung, to describe a mode of reaction to the environment implying 
backward movement in time. It is the psychological opposite to 
that forward movement of life which is essential to the proper growth 
of individuality. There is a constant movement forward or backward 
of the psychic stream in accordance with the aspect that reality 
wears. If reality is favourable the stream flows forward ; if reality 
is unfavourable, the stream flows backwards. Immediately the stream 
begins to flow backwards intra-psychic tension occurs, due to the 
accumulation of dammed-back psychic energy. It is this accumulation 
which later on makes possible a new effort to overcome the obstacles 
in reality. This, of course, is normal. If, however, this accumulation 
is unable to overcome the obstruction in reality, it finds escape along 
other channels, and a neurosis results. The return to civilian life 
after a period of stress serving in the Army or Navy during the war 
was associated with conditions tending to render adaptation difficult, 
and consequently regressive symptoms appeared in a very large 
number of cases. This was undoubtedly aggravated by the need 
of rest following the mental tension and fatigue of the war. It was 
usually possible to discover the difficulties which each case presented 
without much of an analysis, and it was surprising how little often 
was the assistance necessary to enable him to regain his normal 


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BY A. NINIAN BRUCE, D.SC. 


393 


mental equilibrium. It was found that many such cases who had 
been sent to hospital were discharged worse than when admitted. 
This is to be expected, as the effect of admission to a hospital is in 
no way a help to solve the problem of an unfavourable environment— 
an environment to which he must return on leaving hospital, the 
difficulties being magnified by his absence, and in no way solved 
before his discharge. Such cases are essentially cases for out-patient 
treatment; they illustrate the fact that in a very large number of 
neurasthenic cases the problem lies in the present. 

To give an example of such a case, a pensioner was referred to the 
Clinic for “ nervousness and stammer.” The stammer was his most 
serious disability; on the least excitement he not only developed 
such a marked stammer as to make anything he said practically 
unintelligible, but usually could scarcely even produce a sound 
except of a painful nature, while his expression was most distressing 
to watch. It was found that his profession was that of an auctioneer. 
He had been treated in hospital without benefit. He had been 
repeatedly told that he would not be fit to return to such work again, 
and that he should try and discover some other kind of work in the 
country—a thing he was most unwilling to do. It was also discovered 
that his previous employer was willing to re-engage him as soon as 
he was fit. It was thought that the whole symptom was of a re¬ 
gressive character, and his employer was informed that if he were 
given a start again as he was, it was extremely likely that he would 
settle down to the work quickly, and that this in itself was the best 
treatment he could receive for his condition. Fortunately his em¬ 
ployer was willing to have him on these conditions. He returned 
a few days after commencing work, and it was practically impossible 
to detect that any such disability could have originally been present. 
He stated he had been taken back at a good wage with the certainty 
of permanent work and promotion, and that his stammer had vanished 
during the following, night. It was observed that it returned at his 
next medical board, but passed away again as soon as the board 
was over. This was the only time it had returned since he commenced 
his work. 

Cases which failed to adapt themselves even when reality was 
eminently favourable, either completely or partially, were first 
treated as out-patients. A mental exploration of a mild nature was 
undertaken, and it was usually not difficult to discover that a repres¬ 
sion or dissociation was the responsible cause. This was then worked 
out. As a general rule it was found that if the man had good and 
quiet home surroundings, and his case was not complicated by domestic 
difficulties, he did well on out-patient treatment. If, however, the 
home conditions were bad or unsatisfactory, he did best in hospital. 


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The other condition which was considered often to be most suitably 
dealt with in hospital was when the distance at which the man lived 
from the Clinic was such as to make constant attendance difficult. 
It was repeatedly found that in-patients after discharge from hospital 
required a further period of out-patient treatment before they could 
be considered fit to be finally discharged. 

It was found that an elaborate analysis was only required in a 
comparatively small number of cases. 

The group consisting of the psychoses was not large. Such cases 
were mostly sent to one of the Ministry hospitals for borderline 
mental cases. The value of these hospitals is great, as they fulfil a 
definite need. 

The reason for the present plea for the permanent establishment 
of out-patient neurological or psychiatric clinics for the treatment 
of functional nervous disorders and incipient mental troubles is 
based, not only on the urgent need of such cases for treatment, but 
also on the fact that temporary clinics of this nature established by 
the Ministry of Pensions for the treatment of such cases resulting 
from service during the war have proved beyond any possibility 
of dispute that such early supervision and treatment is successful. 
The time for the permanent establishment of such clinics is overdue. 
The idea itself dates back for many years. In 1849 the fourth report 
of the Visiting Committee of Hanwell Asylum drew attention to this 
problem. Sir Frederick Mott, in 1903, emphasised the importance 
of treatment for early and acute cases not yet certifiable. Prof. 
Elliot Smith, whose attention was directed to this subject from a 
study of “ shell-shock ” cases in a war hospital, has emphasised 
the problem still more strongly. The establishment of the Maudsley 
Hospital is a gratifying step in progress. But the time has now 
come for a full recognition of the real importance of the subject, 
and the necessity for action on an extensive scale. 

The following brief summary states some of the principal arguments 
dealing with such out-patient clinics. 

Summary. 

1. In all other branches of medicine facilities for dealing with 
disease in its initial stages are recognised as indispensable. In the 
case of borderline mental cases this has yet to come. 

2. The study of mental disorder requires a long apprenticeship, and 
the treatment of incipient cases is often a long and complicated 
process, for which the average general practitioner has seldom either 
the time or the special training necessary. 

3. It will permit of the recognition of dangerous and certifiable 
mental states at an earlier date than often occurs at present, and 


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1922.] BY A. NINIAN BRUCE, D.SC. 

thus result in their removal to a mental hospital before, instead of 
after the tragedy. 

4. It will allow the general practitioner to obtain an expert opinion 
•on all doubtful cases, and supply the early mental case with appro¬ 
priate treatment at the beginning of the illness, thus tending to cut 
-short the duration of the attack, and often prevent the necessity for 
■certification and removal to a mental hospital; or, if this be ultimately 
necessary, shorten the duration of his time in hospital. 

5. It will help to relieve the overcrowding of asylums, and thus 
leave more time for the individual treatment of those who remain. 

6. It will assist, when necessary, in the after-care of the discharged 
patient. 

7. It will allow of the examination and segregation of mental 
defectives in institutions. 

8. It will allow of the examination of epileptics with a view to 
removal to epileptic colonies. 

9. It will form a useful adjunct to the treatment of offenders in the 
Law Courts. 

10. It will serve as a teaching centre. 

11. It will serve as a centre for investigation and research. 

12. It will allow surgical and other out-patient clinics to refer 
•cases for examination whenever it is thought that nervous or mental 
.^factors are also present in the case. 

13. The clinic must work in close co-operation with the mental 
hospital, the mental defective institute, the epileptic colony, and 
the general hospital. The staff must be specialised in organic neu¬ 
rology, psychology, normal and abnormal, and psychiatry. Uncerti¬ 
fied wards for the treatment of early cases requiring in-patient treat¬ 
ment, and for acute cases of short duration, should be attached to 
the clinic. A social service organisation to assist in the investigation 
•of cases and their after-care should be also attached. 

An out-patient clinic , organised on these lines, will bring the mental 
hospital into touch with the general public through the medium of the 
general hospital. It will help to expedite the removal of the vague fear 
of illegal detention, which has not yet passed away, and it will also help 
. to remove the “ stigma ” which is still supposed by many to be attached 
4 o the legal certification of the person of unsound mind. 


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CLINICAL NOTES AND CASES. 


[Oct. 


Clinical Notes and Cases. 


The Colloidal Gamboge Reaction .(*) By D. 0 . Riddel, D.S.O.„ 
M.B., Ch.B.Aberd., and R. M. Stewart, M.D., M.R.C.P.Edin., 
D.P.M., Assistant Medical Officers, County Asylum, Whittingham. 

The subject of biochemistry is so closely related to physiology 
that any advances in the former science are bound to have important 
applications to the practice of medicine. 

We find, accordingly, that the modern development of the chemistry 
of colloids was soon followed by the introduction of a colloidal gold 
reaction for the examination of cerebro-spinal fluid. This test, with 
which the name of Lange will always be associated, has proved to 
be of great diagnostic value, especially in neurosyphilis, and is now 
regarded as one of the most important laboratory procedures in the 
examination of the cerebro-spinal fluid. A satisfactory reagent,, 
however, is extremely difficult to prepare, and any gold sol which 
deviates from the standard requirements laid down by Miller and his 
associates leads to erroneous and conflicting results. On account of 
this difficulty attempts have been made to employ other colloids 
which would be simpler to prepare, and with this object in view gum 
mastic, gum benzoin and Berlin blue have been introduced. 

The gum mastic test, devised by Emanuel and modified by Cutting,, 
is simple to perform, but has been found to give unreliable results. 

The colloidal benzoin test, which is still in its infancy, has proved 
to possess a sphere of utility which deserves a wider recognition 
than it at present enjoys. We have recently used this reaction, 
together with those of Lange and Emanuel, on the spinal fluids of 
a fairly large series of cases, and as an outcome of our experience 
we propose to describe to-day a still simpler and, we believe, equally 
reliable test, which may be called the colloidal gamboge reaction. 

The mechanism of colloidal tests has been adequately dealt with 
by Cruickshank, Brunton and others, and we do not think it necessary 
to refer to this subject here, nor shall we attempt to detail our reasons 
for substituting for benzoin a suspension of gamboge. We propose, 
rather, to detail as briefly as possible the results which we have 
obtained from the application of our test to 256 spinal fluids. 

In performing the gamboge test it is essential to use pure reagents,. 
distilled water free from acid or all trace of salts, and chemically 
clean glass ware. Further, the colloidal gamboge must be freshly 
prepared. 

(*) A paper read at the Spring Meeting of the Northern and Midland Division,. 
held at the Derby Borough Mental Hospital, April 27, 1922. 


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1922.] CLINICAL NOTES AND CASES. 

The method of performing the test is as follows: 

Stock solution. —One gramme of commercial gamboge resin is powdered and 
dissolved in io c.c. of absolute alcohol. After the lapse of forty-eight hours the 
supernatant fluid is decanted, and stored in the dark. 

Gamboge emulsion. —When the test is to be performed o'3 c.c. of the stock 
solution is added drop by drop to 20 c.c. of twice, or better, triply distilled water, 
the flask being agitated in order to obtain a homogeneous emulsion. 

Electrolyte. —This is obtained by preparing a 0 4 per cent, solution of chemically 
pure sodium chloride. 

Performance of the test. —Six small test-tubes (3 in. x ^ in.) are set up in a 
rack; in the first tube there is placed 1*8 c.c. of the saline solution, and in each 
of the remaining tubes 1 c.c. 0'2 c.c. of cerebro-spinal fluid is next added to the 
first tube (bringing the volume in this tube up to 2 c.c.), and after mixing 1 c.c. is 
transferred to the second tube, the procedure being repeated for tubes 3, 4 and 5. 
The c.c. removed from the fifth tube is rejected, the sixth tube thus serving as a 
control. In this manner a series of five dilutions is obtained, ranging from 1 in 10 
to 1 in 160. Finally to each of the six tubes 1 c.c. of the gamboge emulsion is 
added. The test may be read after allowing the tubes to stand at room 
temperature for 12 to 24 hours. 

In a negative reaction the contents of each tube remain unaltered, showing no 
trace of turbidity. In positive cases complete precipitation of the gamboge occurs 
in a given number of tubes ; the fluid becomes clear and the gamboge is deposited 
at the bottom of the tubes. 

A negative reaction is shown by a total absence of precipitation 
in all six tubes, and a curve indicating general paralysis, the so-called 
paretic curve, is shown by complete precipitation in the first three 
or more tubes. In all of our cases of general paralysis, 56 in number, 
a paretic curve was obtained. The clinical diagnosis was confirmed 
post-mortem in 16 instances. 

Some of the cases were in the earliest stage of this disease, and 
presented very few clinical signs of general paralysis, but their subse¬ 
quent course fully justified the reliance which we attached to positive 
reactions. 

It is also interesting to note that in this series two patients belonged 
to the senile type, their ages being 64 and 68 respectively. It has 
only lately been recognised that general paralysis may be encountered 
in patients even 80 years of age, and in doubtful cases of this type— 
and usually in senility, there is considerable doubt—examination of 
the cerebro-spinal fluid is of great value. 

Two cases of tabes dorsalis gave similar paretic curves, but with 
these exceptions we never obtained a paretic curve in fluids from other 
diseases. It is, of course, essential to employ only fluids which are 
free from all trace of blood or organismal contamination, as such 
may cause complete precipitation in an irregular manner. 

With regard to cerebro-spinal syphilis, we can speak with less 
confidence, as our series only comprises 11 cases, but from an analysis 
of these it appears that partial precipitation in the first three tubes 
may be taken as an indication of meningo-vascular syphilis of the 
nervous system. 


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In meningitis complete precipitation occurs in the higher dilutions, 
tubes I and 2 usually remaining negative. 

In a miscellaneous group of 183 cases the colloidal gamboge reaction 
was uniformly negative, and this in spite of the frequent presence of 
increased globulin and cell content. 

In conclusion, we would like to emphasise the value of a routine 
examination of the spinal fluids of all new admissions. Changes in 
the cerebro-spinal fluid are among the earliest findings in syphilitic 
disease of the central nervous system, and their detection affords a 
basis for treatment which, if promptly applied, may transform a 
seemingly incurable patient into a useful member of society. 


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.^ 

Reported by Dr. M. Hamblin Smith. 

Gaul v . Earl Spencer and others. 

This case, tried before Mr. Justice Darling and a jury on June 22nd 
and following days, was a civil action for damages for false imprison¬ 
ment and breach of contract. The case was brought by Miss Lilian J. 
Gaul against Dr. D. F. Rambaut, Medical Superintendent of St. 
Andrew’s Mental Hospital, Northampton, and the Managing Com¬ 
mittee of that institution. 

The plaintiff conducted her own case. She entered the hospital 
as a voluntary boarder on April 26th, 1917. On May 8th a reception 
order under the Lunacy Act, 1890, was made. Plaintiff asserted 
that this order was obtained unlawfully. It was urged by the de¬ 
fendants that proceedings were barred by the Public Authorities 
Protection Act. The judge held that they were so barred, so far 
as any alleged irregularity in the reception order was concerned, 
and that the plaintiff’s only cause of action was the alleged breach 
of contract to treat her as a voluntary boarder. This part of the 
case was then proceeded with. 

The plaintiff complained that, on arrival at the hospital, she was 
deprived of her clothes and kept in bed. She had attempted suicide, 
on the day previous to her arrival at the hospital, by taking two ounces 
of laudanum. The medical evidence was that she had never demanded 
her release while being treated as a voluntary boarder, and that her 
confinement to bed was simply part of the treatment of the condition 
arising from her attempt at suicide. The plaintiff tried to argue the 


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RECENT MEDICO-LEGAL CASES. 


399 


question of the “ morality ” of suicide, illustrating the matter by 
the examples of a number of eminent persons who are alleged to have 
committed suicide. The argument indicated the difficulties which 
arise as soon as any other view is taken of “ morality ” than that it 
is the generally accepted standard of conduct at any given time. 

In his summing-up the judge said that the question was one of 
contract. Had the plaintiff been properly treated ? The same rules 
did not apply to people who were ill as might apply to ordinary 
people. There was such a thing as wise restraint. If the plaintiff’s 
liberty was only restricted so far as was required by her condition, 
no offence was committed. 

The jury found a verdict for the defendants, and judgment was 
entered accordingly, with costs. 

We sympathize with Dr. Rambaut in the trouble which this case 
must have caused him. But the officers of mental hospitals can 
never be wholly free from the risk of worries occasioned by a litigious 
ex-patient. 

Rex v. Ernest Albert Walker. 

This case, tried at the Central Criminal Court on June 21st before 
Mr. Justice Roche, raised points of interest as regards crimes com¬ 
mitted under the influence of epilepsy. 

Walker is 17 years of age, and is described as a footman. He was 
indicted for the murder, on April 22nd, of a district messenger boy. 
He was alone in his employer’s house, in Lowndes Square, that 
evening, and about 6 p.m. he telephoned to an office for a messenger. 
A boy named Davis was sent. About 8.30 p.m. that same evening 
the prisoner had made his way to Tonbridge, where he informed a 
police constable that he “ thought ” he had committed a murder in 
London, mentioning the time at which, and the weapon with which, 
he had done it. He also said that he did not know why he had done 
it. The body of the boy Davis was found in the house. A letter 
was found, in the prisoner’s handwriting, addressed to a fellow- 
servant, in which he first described what appeared to have been a 
plan for suicide on some previous occasion, and then went on to an 
account of the way in which he had killed Davis. And a kind of 
programme was found, also in the handwriting of the prisoner, which 
gave, in much detail, the procedure which he intended to adopt 
as regards the murder, part of which was actually carried out. The 
details of this programme strongly suggest the scenes shown in a 
sensational cinema film. There was nothing to show whether 
these documents were written before or after the commission of the 
murder. 

There was a very^strong history of insanity in other members of 


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RECENT MEDICO-LEGAL CASES. 


[Oct., 


the prisoner’s family, on both sides. And there was evidence that 
the prisoner had suffered from fits since he was five years of age. 

The defence was that the prisoner had committed the murder 
during an epileptic equivalent, or a post-epileptic state. And Dr. 
E. D. Macnamara, who had examined him in prison, gave evidence 
in support of this view. The prisoner had denied all recollection of 
the suicide plan described in his letter. He remembered having rung 
for the messenger boy. He stated that, before the arrival of the boy, 
he had felt something “ snap in his head,” that he was only partially 
conscious, that he had struck the boy on the head while in this state, 
and that he remembered nothing more until he left the house. 

Dr. East, Medical Officer of Brixton Prison, gave somewhat contrary 
evidence. He had observed no symptoms of epilepsy. It is, of course, 
possible that no such symptoms occurred while the prisoner was 
awaiting trial, and nothing was published which throws light upon 
the frequency of the epileptic attacks. Still, Dr. East must have had 
the prisoner under observation for nearly two months. 

The judge left the question of epilepsy to the jury, most properly 
warning them that they must not be influenced by the recent news¬ 
paper comments on the case of Ronald True. The jury found the 
prisoner “ guilty, but insane,” and the usual order for detention 
followed. 

We feel that the proper verdict was returned. Taking all the 
published facts into account, especially the previous history of 
-epilepsy, and the very characteristic “ flight ” to Tonbridge, it seems 
most probable that this crime was committed either in an epileptic 
equivalent or a post-epileptic state. The chief peculiarity, assuming 
the epileptic theory, is that the prisoner had, at least, some recol¬ 
lection of the acts performed by him. It was this point upon which 
Dr. East appears to have chiefly relied. And Dr. Macnamara also 
seems to have felt the difficulty. But we must remember that in 
such cases absolute amnesia, although undoubtedly usual, is not 
invariably found. We should have liked to have heard more details 
of the mental traits found in the prisoner, and especially the results 
of mental tests. A peculiar variability is sometimes found in the 
results obtained with such tests, either on different days, or with 
tests of the same character on the same day. This variability is 
frequently found in epileptic subjects, and is very characteristic of 
that condition. 


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OCCASIONAL NOTE. 


401 


Occasional Note. 


Centenary of the Thesis of Bayle. 

The centenary of the presentation on November 21, 1822, to the 
Faculty of Medicine of Paris of the Thesis, entitled, “ Recherches 
sur Les Maladies Men tales,” by A. ,L. J. Bayle, in which for the 
first time the opinion was expressed that the symptoms of paralysis 
complicating insanity were those of a distinct disease with definite 
pathological signs, was celebrated in Paris on May 30th and 31st, 
1922. It will be recalled that at the Annual Meeting of the Association 
held in York in 1919 under the Presidency of Dr. Bedford Pierce, 
Prof. George Robertson, speaking on behalf of the Association, 
welcomed Dr. Colin, who was delegated to attend, as the representative 
of the Soci6t6 M6dico-psychologique of Paris. He also asked him to 
convey to the sister society the hope that the centenary of the isolation 
of general paralysis as a definite disease should be worthily celebrated 
in Paris, especially as the discovery of the symptoms and pathological 
signs of this disease were almost entirely due to the work of French 
physicians. Dr. Colin conveyed this message to our confreres, 
and as a result the three societies of Paris interested in the study 
of mental diseases, namely, the Society M 4 dico-psychologique, the 
Soci6t6 de Psychiatrie, and the Societe Clinique de Medicine Mentale, 
joined forces and made arrangements for a congress to which neurolo¬ 
gists and psychiatrists of allied and friendly countries were invited- 
The conference was a great success in every way, and was attended 
by representatives of almost all the European countries and America, 
as well as by two descendants of Bayle—Commandants Bayle and 
de Brange de Bourcia. Our Association was represented by its 
President, Dr. C. H. Bond, as well as by Prof. Robertson (President- 
Elect), Dr. Helen Boyle (Council), Dr. Donald Ross, Dr. Norah Crow, 
Dr. Winifred Buckler, and by Lt.-Col. A. W. Overbeck-Wright, I.M.S. 

M. Paul Strauss, the Minister of Hygiene, presided over the Inaugural 
Seance and the Dinner. It may be recorded that there were two 
circumstances that afforded our French colleagues peculiar satisfaction; 
the one, that our President, Dr. Bond, represented not only our 
Association, but was also delegated by the British Government, 
and conveyed a special message from Sir Alfred Mond, the Minister 
of Health; and the other, that the suggestion for celebrating in 
Paris the centenary of this great neurological discovery was first 
made in an allied country and by our own Association. 

The papers were divided into two groups. There was a historical 
section, comprising among other papers one on “ The Precursors of 
Bayle.” This included the description of the' clinical symptoms, 
LXVIII. 


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REVIEWS. 


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[Oct., 

course and post-mortem appearances of a case, No. XV, by John 
Haslam, Apothecary (Assistant or Resident Physician) to Bethlem 
Hospital, in his work entitled Observations on Madness or Melan¬ 
choly, published in 1798. This we now know to be the first un¬ 
doubted case of general paralysis recorded in literature. The second 
group comprised the present-day conceptions of general paralysis. 
The papers were of high merit and were followed by interesting 
discussions. The whole proceedings have been published under the 
Editorship of Dr. Henri Colin and Dr. R6n6 Charpentier under the 
title La Paralysie GhUrale [Maladie de Bayle) (Masson et Cie.). 

In addition to the scientific proceedings, there were receptions, 
fetes, etc., given by “ La Bienvenue Frangaise ” and private indi¬ 
viduals. The members, especially those from this country, were 
most hospitably entertained. 

In conclusion, it may be stated that Prof. Robertson was elected 
the Vice-President of the Congress, and that Dr. Bond was made 
one of the Honorary Presidents. 


Part II.—Reviews. 


The Mechanism of the Brain and the Function of the Frontal Lobes. 
By Prof. Leonardo Bianchi. Authorised translation from the- 
Italian by James H. Macdonald, M.B., Ch.B., F.R.F.P. and 
S.Glasg., with a foreword by C. Lloyd Morgan, LL.D., D.Sc., 
F.R.S. Edinburgh : E. & S. Livingstone, 1922. Medium 8vo, 
pp. xx + 348, 66 illustrations. Price 215. net. 

The author of this work, Prof. Bianchi, is well known as a dis¬ 
tinguished psychiatrist and as a pioneer in cerebral localisation, 
especially in relation to the functions of the frontal lotes. As early 
as 1888 he commenced experimental investigations upon the frontal 
lobes, and in 1894, during the session of the International Medical 
Congress at Rome, a committee composed of eminent authorities, 
including among others the late Prof. Hitzig and Prof. Henschen, was 
appointed for the special purpose of examining and reporting upon 
the monkeys that had been operated upon by Prof. Bianchi, and. 
which were still retained under observation. 

The author states that although the judgment pronounced was 
distinctly favourable, it was hedged round by many reservations. 
He further states that a number of physiologists in Italy and else¬ 
where, including Prof. Luciani, had subjected his conclusions to 
criticisms which he complains were not always dispassionate and 
unprejudiced. 

Prof. Bianchi admits that the final decision must rest upon a study 
of lesions of the frontal lobes in man. He states that he had collected 
a number of clinical cases, and had subjected published clinical cases- 


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to close examination, and it became clear to him “ that a considerable 
number, if not indeed the majority of these, could not be utilised, 
for many cases had been recorded for and against the high psychic 
functions of the frontal lobes, which in their ultimate analysis were 
destitute of any real value.” 

The author foresaw that the Great War would supply a great store 
of human material for the advancement of our knowledge of the 
physiology and pathology of the brain; he therefore decided to 
publish the present volume, which is devoted to the experimental 
aspect of the subject and to an initial phase of anatomical psychology. 
We should have wished that the translation of this work had been 
after the facts were collected in respect to lesions of the frontal lobes 
in man caused by the war. Moreover, so many advances have been 
made during the last ten years in our knowledge of the relations of 
body and mind. 

This is indicated in Lloyd Morgan’s foreword, thus: “ All vital 
changes in the organism ‘ involve ’ physico-chemical events and trans¬ 
formation of energy, but the particular way in which these events 
and transformations occur * depends upon ’ the presence of vital 
reactions. No vitality without change of energy (involution); no 
such changes of. energy without vitality (dependence). Progressive 
development of novelty is the keynote of evolutionary progress. 
New orders or kinds of relation successively emerge at ascending 
levels (chemical, vital, mental); but in their emergence much novelty 
in the course of events at lower levels thereafter depends.” 

This paragraph of Lloyd Morgan is of importance in the light of 
our present knowledge of the truth of Hughlings Jackson’s conception 
of evolutional levels. Dr. Lloyd Morgan applies this to the naturalistic 
theses which Prof. Bianchi consistently advocates: “ There is an 
order of relatedness which we call mental, but its very existence 
involves physiological changes, or more specifically the establishment 
of sets of permeable neuron routes in the central nervous system. 
Let us so far follow Semon as to give the name engram to a permeable 
system of neuron routes, then the naturalistic thesis may be summa¬ 
rised thus: Every psychological complex involves neural engrams ; 
for evolutionary naturalism every psychological complex involves 
a neural engram (permeable neuron) route, inherited or acquired; 
or if it be preferred, that all mental events involve physiological 
correlates.” 

We find no reference to the mnemic theory of Semon in the text 
of the book. 

Prof. Bianchi very rightly assumes a transformation of cosmic 
energy into neural energy, but he does not explain why or how this 
occurs, nor its relation to synaptic association and dissociation in 
connection with neural function. It is well known that all vital 
processes are dependent upon oxidation processes, and that if the 
brain be cut off from blood and its oxygen supply for six seconds, 
its highest functions cease and unconsciousness occurs. Marinesco 
has shown that the dendrites, dendrons, and cytoplasm of the neuron 
are studded all over with oxydase granules, but these are not seen in 
the nucleus nor on the axon—that is to say, all the oxidation pro- 


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cesses occur in the grey matter. It is well known that practically no 
oxidation processes occur in the axon, and that it is unfatiguable; 
presumably, therefore, the nervous current which it transmits is a 
physical change—a negative variation of the electric charge of its 
molecules. 

It is probable that a stimulus coming from without and reaching 
the cell-body of the neuron excites the nucleus which liberates a 
katalase, which, acting upon the oxydase granules, liberates free 
oxygen. A stimulus along afferent permeable neuron routes which 
have been acquired or inherited results in discharge along efferent 
permeable neuron routes. The permeability clearly depends upon 
the condition of the synaptic junction, whether it be in the first term 
of a series—a simple reflex action, or the last of the series—a complex 
reflex action, such as a voluntary action. 

We know that this synaptic junction requires an adequate supply 
of oxygen. Also we know that the endocrine organs which pour 
their secretions into the circulation have a very important influence 
in regulating the organisation and strength of nervous impulses, and 
adapting and conditioning these to meet the needs of the immediate 
situation. But these endocrine organs are under control of the oldest 
part of the nervous system—the involuntary system.of Gaskell, the 
autonomic system of Langley. Probably if Prof. Bianchi were to 
write to-day his Chapter IX, dealing with the emotions and senti¬ 
ments, he would refer to this subject and the important work of 
Cannon, Elliot and others upon the influence of the endocrine glands 
in relation to the emotions. 

As the author in his preface states that the main object of the 
book is to put on record the experimental investigations on the 
frontal lobes, it would be unfair to criticise his views regarding the 
emotions and sentiments, in which he omits to consider these from 
the biological point of view as instinctive protective mechanisms. 

According to the author’s view “ his experiments upon monkeys 
have shown that the fundamental and intermediate emotions are 
preserved (some altered) after removal of the frontal lobes, whereas 
the higher sentiments or emotions, as these are represented in outline 
in the monkey, are either absent or profoundly disturbed, corre¬ 
sponding with what is observed to follow severe injury of the frontal 
lobes in man. In the case of mutilated monkeys the conduct becomes 
reduced to simple reflexes, dissociated and inconsequential, unfurnished 
therefore with biophylactic power, whilst at the same time there is a 
prevalence of the organic reflexes of the primitive emotions (fear, 
anger). In normal monkeys, on the other hand, the conduct is 
prevailingly more protective. The animal presents an evident affec¬ 
tive intonation and is more logical, his attitude being based upon 
perceptions, experiences, and judgments, whereas the organic reflexes 
of the primitive emotions are much reduced proportionately.” 

“ After removal of the frontal lobes the social sentiment is 
abolished in monkeys ; its very nature consists of emotions, variously 
associated ideas, impulses and inhibitions, and gives no grounds for 
presupposing the existence of organs which are different to those 
of the primitive emotions.” 


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The author supports this view by a consideration of phylogenetic 
and ontogenetic investigations concerning the evolution of the brain 
and of the frontal lobes in particular, as well as by clinical and 
experimental observations which he claims are fairly constant and 
convincing. But the question arises whether this lack of sociability 
upon which the author lays such stress as a result of the destruction 
of the frontal lobes would not also be shown by a sick monkey or 
by an animal in which other silent parts of the brain, ontogenetically 
and phylogenetically of later development, had been destroyed on 
both sides. 

Prof. Bianchi gives a detailed account of his numerous experi¬ 
ments and the behaviour of the animals, supporting his conclusions ; 
he also advances arguments in favour of the highest and latest evo¬ 
lutional cerebral function being localised in the frontal lobes, by the 
assumption that the experimental condition of affairs finds a counter¬ 
part in human psychopathology. Thus he states—“ If it is true that 
primary amentia (idiocy and imbecility) finds its explanation in 
defective evolution of the frontal lobes, especially the pyramidal 
layers, more than of any other part of the brain, we may institute 
a perfect parallelism between the mentality of the monkey that has 
suffered frontal mutilation as manifested by its conduct and the 
simian environment and that of the idiot in the human environment. 
Timidity, unsociability, selfishness, absence of the sentiment of 
friendship, idleness, laziness, tics, brutality of the sexual instinct 
when present are the most conspicuous features of idiocy in the 
human subject from the point of view of sentimentality.” But the 
author, by commencing the paragraph by If it is true , implies a 
doubt whether the frontal lobes are alone affected by arrest of deve¬ 
lopment in idiocy and imbecility. Indeed there is, as Bolton’s 
careful micrometric measurements show, a general deficiency in the 
supra-granular pyramidal layer of the whole neo-cortex. However, 
the frontal lobes are the most affected, and the question arises 
whether this is due to an inborn primary neuronic deficiency of an 
evolutionally later developed cortex, or whether it may not be 
explained by precarious vascular conditions. The frontal lobes are 
more atrophied in general paralysis than other lobes of the brain, 
and before we knew that the presence of the spirochaete and the 
inflammatory reactions set up by its toxins was the essential cause 
of the decay and atrophy of the neurons, this disease was thought 
to be a primary, post-syphilitic abiotrophy of neural structures with 
secondary inflammatory conditions. Now, tendency to vascular 
stasis is a condition which would favour ,the active pullulation of 
the anaerobic spirochaetes, therefore more active inflammatory 
processes with neuronic destruction. Owing to the rotation of 
the great brain backwards, the veins which debouch into the longi¬ 
tudinal sinus enter in a direction opposite to that of the current. 
This anatomical condition would cause a tendency to venous stasis 
of the frontal lobes more than other lobes of the brain, the veins 
of which drain directly into and are less distant from the lateral 
sinuses and jugular veins. Therefore the frontal lobes are the most 
liable to venous stasis, which condition might lead therefore to 


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diminished oxidation processes and help to retard pre-natal as well 
as post-natal growth, thereby acting as a contributory factor to an 
inborn neuronic defect. This explanation may also account for the 
fact that neuron decay is more obvious in the frontal lobes in the 
primary dementias, although histological observations show that 
similar nuclear and cellular neuronic changes can be found in the 
whole neo-cortex. 

There is much in the book which will interest readers of the Journal, 
particularly the discussion on the functions of the frontal lobes. 
We would, moreover, like to call especial attention to some most 
interesting footnotes, particularly those on pp. 226-235, in which the 
author discusses in a most interesting and philosophic manner the 
history and origin of language; he does not, however, discuss the 
influence language has had in the dualistic doctrine of body and mind. 

We agree readily with the note of the translator, “ that the doctrine 
of the higher functions of the frontal lobes contained in this work is 
the outcome of many years of study and research on the part of one 
whose long record of scientific activity and achievement must claim 
our admiration and respect.” 

We are indebted to the translator and to the publishers for the 
admirable way in which Prof. Bianchi’s important researches and 
philosophic conclusions on the mechanism of the brain have been 
presented to the medical profession. F. W. M. 


Psycho-analysis and the Drama. By Smith Ely Jelliffe, M.D., and 
Louise Brink, A.B. New York: Nervous and Mental Disease 
Publishing Co., 1922. Monograph Series, No. 34. Medium 8vo. 
Pp- v + 162. Price $3.00. 

In past years many endeavours have been made to apply psycho¬ 
analytical principles to literature and other artistic productions, and 
herein some recent dramas are examined from such a view-point. In 
this way the unconscious material presented is suggestively dissected 
so that the human problems involved are demonstrated in a clearer 
form. The authors point out that the drama provides a useful outlet 
for the release of restrained and overcharged emotions on the part of 
the audience, and also permits a constructive representation of them. 
It may have healing value not only through psychic ventilation, 
but also through the solution of some unconscious conflict objectively 
presented to the spectator, who usually in no way realises this hidden 
process as part of his pleasure in the performance. It is thought 
that the consideration of such works of art from this point of view 
will not only clarify the physician’s understanding of mental life, but 
will rouse him to recognise in such a direct aid to the patient whose 
psychic burdens he is grappling with. Nine dramatic plays are 
interestingly analysed, and illustrate various phases of the unconscious 
dynamic elements in human life. These studies have been previously 
published in separate form, but their collection together is welcome, 
and they constitute very instructive reading, which should appeal 
widel Y- C. Stanford Read. 


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Practical Psycho-analysis. By H. Somerville, B.Sc., L.R.C.P., 

M.R.C.S. London : Bailliere, Tindall & Cox, 1922. Demy 8vo. 

Pp. x + 142. Price 6s. 

What would be thought of a writer who published a small book 
therein describing some theoretical considerations of surgery with 
some slight details of technical procedure, and telling his readers 
that they should then be prepared to perform major operations ? 
Such a conception is unfortunately analogous to this volume under 
review. Any medical man who has not “ the time to read the larger 
works on the subject,” and study such an intricate subject widely, 
should not presume to meddle with the mal-functioning of the human 
mind. Naively, however, Dr. Somerville suggests that those of his 
readers who wish to pursue the subject further may consult the works 
of Freud and others, and that a useful account of normal psychology 
may be found in a recent psychiatric text-book ! In the face of such 
an attitude towards the study of the theory and practice of any form 
of psychotherapy, but especially so with regard to psycho-analysis, 
it must be pointed out that a long and painstaking acquisition of 
knowledge concerning the normal and morbid mind in all its allied 
spheres must precede any attempt to deal with human material. 
The main content of these pages is devoted to a brief survey of 
Freudian principles, and it is shown how these should be applied to 
elucidate and alleviate cases of war neurosis. The practical applica¬ 
tion, however, is that of a psychological analysis, and not psycho¬ 
analysis, which is a definite method very different from what the 
author describes. The book title is thus very misleading, and it is 
to be hoped that no reader who has read this little work will consider 
himself in a position to psycho-analyse or to know adequately any¬ 
thing of its practice, for the mode of procedure given in Chapter X 
may be a guide to some sort of analysis, but not to the special method 
named in the title. We can see a distinct sphere of usefulness in 
this volume for those who treat certain types of neuroses and who 
require added insight into the mechanisms involved, but since it 
•deals mainly with war cases, it is a pity that for this purpose it was 
not published earlier. C. Stanford Read. 


Suggestion and Mental Analysis : An Outline of the Theory and Practice 
of Mind Cure. By William Brown, M.A., M.D.Oxon., D.Sc., 
M.R.C.P.Lond. London : University of London Press, Ltd., 1922. 
Crown 8vo. Pp. 165. Price 3 s. 6 d. net. 

The aim in this book is to develop the view that a sound system of 
psychotherapy is possible which combines suggestion and auto¬ 
suggestion on the one hand and mental analysis (including the 
Freudian system of psycho-analysis) on the other. Dr. Brown is of 
the opinion that “ mental conflict ” and “ bad auto-suggestion ” are 
the two general factors which operate in the production of neurotic 
symptoms, and it is upon the existence of these two factors that he 
bases his psychotherapeutic system. He finds that the mental 
conflict results in “ a weakening of mental synthesis," which manifests 


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itself in the form of increased emotivity and suggestibility and 
favours the development of bad habits of mind and body. Thus, 
while the mental conflict can be elicited by mental analysis or “ auto- 
gnosis,” a procedure which enables the patient to acquire a knowledge 
of his hidden desires and motives, there still remain pathological 
reactions which have become habitual (stammering, drug habits, 
enuresis, etc.), and which require suggestion and auto-suggestion to 
effect their cure. 

In the opening chapter the author indicates the necessity for 
assuming the existence of a subconscious or unconscious mind to 
account for the phenomena of suggestion. Few psychologists would 
be disposed to deny that processes occur apart from consciousness, 
to which the term “mental” is properly applied, but exception might 
reasonably be taken to the anthropomorphic terms in which the 
subconscious is here described. Thus the statement that “ the 
subconscious goes on to realise an idea at its own leisure ” might 
surely have been expressed otherwise. A brief outline is given of 
psycho-analysis and dreams. The author does not wholly accept 
Freud’s theories, and he suggests an alternative theory of dreams, 
the merits of which cannot be estimated, as it is here described in a 
few paragraphs. 

An account is given of the phenomena and nature of hypnotism, 
and its uses and limitations as a mode of treatment are indicated. 
Dr. Brown confines its use to cases of hysterical dissociation, and 
then not for the heightened suggestibility of the condition, but to 
facilitate the revival of repressed memories. He considers that 
repeated hypnosis has a harmful effect, and has found that patients 
who are treated in this way tend to become more weakly and less 
able to manage their affairs. Suggestion in a state of relaxation, 
withoqt artificial dissociation, he regards as a greatly superior mode 
of treatment, and an account is given of his technique in dealing with 
his cases. The subject is discussed more especially in relation to 
M. Cou6’s claims and methods. The author finds occasion to criticise 
the “ psychological background ” of M. Coup’s work, but records his 
appreciation of what he characterises as “ his extraordinarily clear 
and penetrating insight into the facts of suggestion, his transparent 
sincerity, and his untiring zeal.” On the whole, we are inclined to 
feel that Dr. Brown takes M. Cou6’s “ Law of Reversed Effort ” 
rather more seriously than it deserves. 

It cannot be said that this volume provides any notable addition 
to our theoretical knowledge of suggestion. Dr. Brown endows the 
subconscious with attributes which tend to invest the phenomena of 
suggestion with an unnecessary atmosphere of mystery, and he 
scarcely makes it sufficiently clear that therapeutic suggestion is only 
one instance of the working of an innate tendency (no more and no 
less mysterious than any of the other characteristics peculiar to living 
organisms) which exerts a profound influence upon development 
from early childhood. If we interpret Dr. Brown’s views correctly, 
it would seem that he does not believe in the possibility of a strictly 
scientific system of psychotherapy. This may be the case at present; 
and mental healing is perhaps an art (or a mystery) rather than a 


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science. Dr. Brown tends to accentuate the mysteries of “ mind 
cure,” and we suspect a strong vein of mysticism in his personal 
psychology. He contends that it is essential for the psychopatho¬ 
logist to acquire a philosophic and religious outlook in order to 
deal adequately with his patients; he finds an intimate connection 
between religion and mental healing; and he utilises mystical beliefs 
in his suggestive therapy. Now, though we do not question the 
practical value of Dr. Brown’s methods of treatment, his theoretical 
views would seem to be fundamentally unsound and contrary to the 
whole spirit of modern psychology. The scientific attitude or frame 
of mind is totally different to the religious; the two cannot be 
harmonised or the functions of priest and doctor successfully combined. 
Science has solved many of the mysteries of life, but only when, as 
its history shows, metaphysical and religious assumptions have been 
discarded and a strictly impersonal attitude taken towards experience. 
If we are to acquire a knowledge of the causes of mental illness, it 
would seem necessary to approach our human material in a similar 
way, and there is no reason to suppose that our attitude will be less 
helpful than that which Dr. Brown regards as desirable, and it is 
certainly more likely to lead to a solution of the obscure problems of 
psychiatry. Dr. Brown is a learned person, but (we fear) a teacher 
of “ divers and strange doctrines.” H. Devine. 


Juvenile Delinquency. By Henry Herbert Goddard, Director of 
the Ohio Bureau of Juvenile Research. London: Kegan Paul, 
Trench, Trubner & Co., Ltd., 1922. Crown 8vo. Pp. x + 120. 
Price 35. 6 d. 

Delinquency presents abstruse and complicated problems. And 
those presented by juvenile delinquency are of special importance. 
To deal with juvenile offenders on rational lines would go far to solve 
these problems for succeeding generations; for the recruits of the 
great army of delinquents are, in the vast majority of cases, enlisted 
when quite young. These things being so, we read this book with 
much eagerness. We were anxious to learn how Dr. Goddard, with 
his great experience and his opportunities, would assist us to compre¬ 
hend and to elucidate our difficulties. And we must confess to a 
considerable degree of disappointment. The book commences with 
a brief but a fairly adequate statement of the problem of delinquency. 
The author, however, is content to make the statement about an 
offender that “ he could not help ” committing the offence, without 
making clear what his position is on the absolutely fundamental 
question of determinism. But when we come to look for guidance 
in making scientific investigations into the cases of individual delin¬ 
quents we do not get much assistance. We have an interesting 
account of the administration of the Ohio Bureau of Juvenile Research. 
But we have little else. We have details of a number of physical 
defects found among Dr. Goddard’s subjects, without any adequate 
discussion as to what influence, if any, they are supposed to have 
upon the causation of delinquency. We are told, for instance, that 


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among 460 subjects examined, 117 were “round-shouldered,” and 
that 10 were “ pretubercular ” (whatever that may mean). It is 
not easy to see what scientific value the record of observations such 
as these can possibly have. We hear much about the occurrence of 
congenital syphilis in delinquents. And the author implies that this 
is an important causative factor. It may be so. But, before making 
definite pronouncements on this point, we should require to know 
the proportion of congenital syphilis among non-delinquent subjects. 
Strangely enough, the author does not touch the question of alcoholism. 

The author deals with the word-association method. And he 
appears to lay stress upon this as a guide in diagnosis. No doubt 
the method is often of service. But it is, after all, a somewhat 
mechanical approach to the unconscious mind. And these supposed 
short cuts to diagnosis require to be used and interpreted with the 
greatest caution. There is always the danger that such methods, just 
as with the use of the Binet scale for the estimation of intelligence, may 
distract attention from the real essential—the careful investigation 
of the individual case by an experienced expert examiner. The author 
states that uncomplicated cases of feeble-mindedness need only be 
kept under observation for “ a few hours.” We strongly demur to 
this. There are, certainly, a small number of cases in which the 
mental defect can be quickly recognized. But if hasty diagnosis is 
attempted mistakes are quite certain to be made, and nothing is 
more likely to bring our methods into disrepute. We feel that the 
ideal plan is to have every case under observation, in an institution, 
for at least a week. 

But the book may be viewed, and is perhaps intended to be viewed, 
in another light than that of a scientific treatise. It may be regarded 
as an attempt to interest the lay public, and especially those concerned 
with the administration of the law, in the investigation of delinquents. 
From this aspect we may hope that the book will be useful. Anything 
which impresses upon the public how futile, how cruel, and how 
grossly extravagant are our present methods is to be welcomed. 
The book does this. And it further points out that the only solution 
of the problems is to be found in the expert examination of individual 
cases. It is by the study of causations that we can hope to make 
progress. It is certain that the future must see a great elaboration 
of our system of examination. This examination is, preferably, to 
be conducted in institutions. But there may also be an opening for 
travelling examiners, as described by Dr. Goddard. 

The book contains no index. It would tax the ingenuity of the 
famous “ Mikado ” to devise the punishment which fits this crime. 

M. Hamblin Smith. 


The New Psychology and the Teacher. By H. Crichton Miller, M.A., 
M.D. London: Jarrold’s, Ltd., 1921. Crown 8vo, pp. 232. 
Price 65. net. 

Some words of pity must be expressed for the teachers of children 
at the present time. On the one hand they are being bombarded 
by the inventors of new methods, and on the other hand followers 


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•of Freud, Jung, etc., armed with new theories of mind, give them 
no rest. The result is that the poor masters and mistresses are con¬ 
fused. They are nervous lest by some act they may lead to a repres¬ 
sion which may do lifelong damage in the case of a child committed 
to their trust, and yet afraid to relax a discipline which long experience 
has taught to be good. 

The fact of the matter is that a little knowledge is a dangerous 
thing, and this criticism Dr. Miller has expected and has tried to 
•disarm by saying that a little vision is better than total blindness. 
This is to a certain extent true, but is not altogether a happy com¬ 
parison, because a little vision may be a distorted one, which may 
be worse than absence of sight. 

Still, it must be admitted that the new psychology has something 
to tell the teacher, and if he will only receive it, remembering it is 
very new, and like all new things not very certain, he may be helped 
thereby. The author is a follower of Jung, and the reason for the 
book is to indicate how the doctrines of this branch of analytic thought 
can be applied to increase the power of the teacher “ to help the 
■child in three principal ways—in his adjustment to reality, in his 
adjustment to authority and to the herd, and in his sex education.” 
It is to be noted that there is no suggestion that the teacher should 
analyse the child—he is only to analyse himself. Dr. Miller may pro¬ 
test against being described as a follower of Jung, as, in his preface, 
speaking of the two schools (Freud and Jung), he says no attempt 
is made to present the views of one school exclusively ; but as a 
matter of fact his dream analyses which illustrate many of his main 
points are typical of the Zurich School, and if anyone wishes to learn 
this school’s theory of dreams he could not have a better introduction 
than the present book. 

There are ten chapters with the following headings : Introductory, 
authority and suggestibility, reality and phantasy, emotional develop¬ 
ment of the boy, emotional development of the girl, the unconscious 
motive, mental mechanisms, dream symbolism, the herd instinct 
and the herd ideal, educational methods. The chapters which deal 
with the emotional development of the boy and the girl are the best 
in the book and most interesting. In that on mental mechanisms 
Dr. Miller has tried to compress into twenty pages the greater part 
of the Freudian psychology, and this, of course, is an impossibility. 
The average teacher, after reading this chapter, will probably be in 
a very fuddled condition of mind. With this exception the book is 
• easy reading, and progresses in a logical manner. There are several 
good things, some of which I am tempted to quote: “ Phantasy is 
like an air cushion—there is nothing in it, but it cases the joints 
wonderfully.” “ Christian Science is to a large extent based on a 
phantasy of health, which is a retreat from reality. The sufferer 
refuses to accept the fact that he has toothache, and describes it 
as a ‘ false claim,’ thereby making use of this same principle of 
attempting to twist reality into a congenial form, rather than adapt 
oneself to its uncongenial elements.” 

A few words must be added with reference to the form in which 
the book appears. It is well printed in easily legible type. At the 


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beginning of each chapter is a foreword summarising the contents, 
and thus enabling the lazy to skip, but more frequently inviting 
those interested to proceed. The author has the literary art, and 
his style is clear and gives much pleasure to the reader. Moreover, 
he knows how to soften the asperities of some of the hard sayings of 
Freud as regards sexual matters. If the teacher must know something 
of the new psychology, no better guide could be found than Dr. Miller. 

. R. H. Steen. 


Group Tests of Intelligence. By P. B. Ballard, D.Litt. London: 

Hodder & Stoughton, Ltd., 1922. Crown 8vo. Pp. x + 252. 

Price 6 s. net. 

Commenius, in his Great Didactic, states, “We promise, then, such a 
system of education that all the young shall be educated except those 
to whom God has denied understanding.” Dull and defective children 
depress teachers in ordinary classes, so that special means have been 
devised for their education. As Dr. Ballard indicates, when the 
fate of a child hangs in the balance, the tests applied are individual 
and viva voce. The difference between modern mental tests and the 
old viva voce examination is that in the latter the examiner trusted 
to the inspiration of the moment and did not standardise his material. 
Standardised individual tests were born in France ; the system takes 
time and cannot be applied by everyone; proper training is essential. 
Group testing was born in America, according to Dr. Ballard, and its 
mother was the stern necessity for quick decisions in time of war. 
The object of group tests is to assess intelligence roughly for various 
purposes, it being understood that when necessary any given subject 
must receive an individual examination. The underlying idea is 
that while the ordinary methods of examination indicate past attain¬ 
ments, tests should indicate future capacities—an ideal, however, as 
yet unachieved. Watts has summed up the present position as 
follows : 

1. The idea that innate capacity could be measured apart from the 
influences of education and training has proved barren. 

2. The attempt to construct a single reliable test of general 
intelligence has been given up as impossible. 

3. A series of tests, if covering a wide range of representative 
forms, will give a rough general average level of intellectual ability. 
But all average measures should be distrusted in so far as they obscure 
significant individual variation. Tests are used in schools for testing 
normal children to note status and progress and to detect defective 
or supernormal children. The first use may rightly apply to all 
teachers, the latter uses to specialists only, the group tests perhaps 
serving to indicate which children deserve or need further investigation. 

For group use tests have had to be made fool-proof, in the course 
of which their value as individual indicators has been lost. None 
the less, applied viva voce, personally and individually, and not in 
writing or by action en masse, much may be learnt from them of 
value to the clinician. They have been adapted to all grades—to 
the illiterate as well as to the genius—and full details of these now 


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in use are described by Dr. Ballard. It must be realised that the 
saying of Solomon with regard to books has a very real application 
to present-day systems of mental tests, but a knowledge thereof 
should be part of the equipment of the psychiatrist seeking to arouse 
an adequate interest in a patient to enable him to penetrate behind 
the veil of his mental mechanisms. The tests given have been 
standardised in a measure quite beyond those formerly in use for 
clinical purposes, and applied with discrimination would serve their 
purpose for clinical and individual use. Certain of these are altogether 
too abstruse. 

Dr. Ballard well states their real value for scholastic purposes 
when he points out a child with a high mental ratio is well suited for 
book-learning, whatever his calendar age may be, while the child 
with a low mental ratio never takes kindly to books. Fortunately 
such a child has a thick skin and a fine system of defensive mechanisms. 

The book may therefore be commended as a necessary part of the 
library of every medical psychologist. He will find it a valuable 
guide between wheat and chaff, since the tests described and criticised 
vary from simple common sense almost to Carrollian nonsense. 
The latter phase may be exemplified by the following American 
curiosity :— 

“ If ontogeny invariably ingeminates phylogeny, circumscribe the 
word giving the location of the Ourcq ; if not, underline the word 
that locates the mandible : England, Foot, Utah, Face, Peru, France, 
Arm, India.” 

It is deeply to be regretted that a really useful procedure in its 
own place and under proper conditions should be exposed to discredit 
by the wildness of extremists, and after perusing such there can be 
no wonder that the public is becoming alarmed at the tendency to 
substitute group tests for old-fashioned examinations, and fear lest 
otherwise worthy candidates should suffer for a lack of a specialised 
mental agility, for it is this more than anything that is measured 
when such procedures are adopted with a time limit. 

F. C. S. 


Modern Developments in Educational Practice. By John Adams, M.A., 
B.Sc., LL.D. London: University of London Press, 1922. 
Crown 8vo. Pp. vi + 302. Price 6 s. net. 

The ancient Judean sage spoke from experience when he said : 
“ Train up a child in the way he should go, and when he is old he 
will not depart from it.—Even a child is known by his doings, 
whether his work be pure and whether it be right.” The seeds of 
future actions are planted in childhood in the home, and in that 
substitute for the home and family—the school. It is then essential 
that both the student of normal psychology and the practitioner in 
mental disorders should be acquainted with the nature of the influences 
brought to bear on the children during the plastic period of youth. 
No better guide can be recommended than the present volume, ripe 
with all the experience of the author as a professor of education 


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414 REVIEWS. [Oct., 

and as director of a great training college for teachers. Education 
is a preparation for life in the world—a world in which children 
cannot live out their lives without restrictions, but in which they 
must experience not only the general restraints that come from society, 
but also the authority of some persons placed in a position of 
superiority. School must therefore prepare for the recognition of 
this, while at the same time leading to the best and freest development 
of individual character and personality. 

This volume discusses the changes in educational practice during 
the last century, and shows the relation between the new education 
and the new psychology. The key-note turns round an old sentence 
in the Latin grammar, “ Verbs of teaching govern two accusatives, 
one of the person, another of the thing ”—“• the master taught 
John Latin.” Old teachers laid most of the stress on Latin ; the 
new lay it on John. The change has slowly come about since the 
days when Rousseau expounded his views on the education of Emile ; 
education is now paidocentric. 

A very important feature concerns ideas of discipline. There have 
been three schools of thought: the old repressionists —plebotomists 
as they have been termed—now almost passed away; the impres¬ 
sionists, following the schools of Arnold and Thring, who guided 
by the influence of a dominant personality ; the emancipationists, who 
urge free discipline. The latter, however, cannot remove the teacher 
entirely. His personal influence remains, and it is useless for him 
to ask his pupils to do as I say, not as I do. Free discipline depends 
on the personality of the teacher: a “c” personality cannot allow what 
is easily done by an “a” personality. Even in the Montessori schools, 
which are supposed to be free, there are limitations. The child, it 
is true, may choose his own occupation for the time, but he must 
use the apparatus as directed; he may not play bricks with the 
didactic material. All the newer methods place the child first; 
“ Montessori ” centres all, except the apparatus round the child ; 
the “ Dalton Plan ” asks the teacher to step aside, and the children 
act as they will, provided they produce the required results ; the 
“ Gary Scheme ” builds the school around the child’s requirements ; 
the “ Play Way ” and the “ Project Method " are almost entire 
surrenders to his point of view. The child has come into his own. 
Tranio’s protest, “ No profit grows where no pleasure is ta’en,” is 
widely accepted, though few endorse completely the subsequent— 
“ In brief, sir, study what you most affect.” Interest and attention 
must be evoked. Attention may be effortful or effortless; nisic and 
anisic are suggested as terms for these, and the teacher should so 
far as possible use the latter, since the former cannot be of long 
duration. Some of the former must come sometime. All work is 
not interesting in itself to all children. Prof. Adams contrasts the 
“ old grinders ” with the “ primrose path,” and shows both must 
come in for education to be successful under present-day conditions. 
The outlines of the different modern systems coming under the latter 
category will repay study by any psychiatrist. 

There is an interesting analysis from the educationist’s standpoint 
of the changes in psychology from the old-fashioned equation : the 


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psychological = the conscious, to the modern views of the action 
of the unconscious. We are told the transition is well if whimsically 
expressed in a note of Prof. Woodworth : “ First Psychology lost its 
soul, then it lost its mind, then it lost consciousness; it still has 
behaviour of a kind.” It is pointed out that there is a closer relation 
between educational psychology and the newer psychology derived 
from a study of the neuroses than has commonly been noted. The 
threshold of consciousness is a well-known Herbartian term, and the 
former “ apperception mass ” is only “ complex ” writ large without 
any sinister meaning. The iceberg metaphor as to the relation of 
the actually conscious to the hidden is as familiar to the Herbartian 
as to the Freudian. The chief difference in the author’s opinion is 
that the educationist can take a joyous view, looking on the child 
as an inheritor of the Kingdom of Heaven with a wholesome urge or 
will-to-live, while some of the modern school of abnormal psychology 
stress the gloomy views of original sin and a peccant libido which 
would trace apparently reasoned actions to conditions scarcely 
compatible with man’s zoological title of homo sapiens. 

It is also shown that the teacher recognises the field of the medical 
practitioner in dealing with abnormal cases, which he himself is glad 
to hand over; that it is not their niftier to resolve.complexes, and 
that it is enough if they have such an acquaintance with psychology 
as may prevent them setting up unnecesary complexes by over- 
stimulated emulation or thoughtless sarcasm. The true teachers 
carry on their work in school by dealing with the pupils on a whole¬ 
some human footing. F. C. S. 


Part III.—Epitome of Current Literature. 

1. Psychology and Psycho-Pathology. 

The Psychology of Exploration. {Psyche, July, 1921.) Priestly, R. E. 

A unique account of the character reactions observed and experi¬ 
enced during Antarctic exploration. The writer deals with the re¬ 
actions of (1) the party as a whole, and (2) of sections isolated on 
special duties, or by misfortune. The life shows well-defined phases. 
The journey south and the approach to the initial goal is a time of 
high resolve, anticipation, and exhilaration. Quickly there follow 
periods of intense labour in which physique is searched to the out¬ 
most, but these are followed by times of untrammelled relaxation; 
these contrasts persist throughout, and produce the fascination so 
characteristic of polar journeys. 

The winter is a dominant environment, normally exhibiting bliz¬ 
zards, frigid temperatures, auroral scintillations in a night jet-black, 
the sighing and sobbing of the ice-pack, and gurglings, snortings, 
and blowings (of seals or inexplicable), which all react on the individual, 
at times inducing fear and refusal to work. Summer means sledging 
expeditions, and in the selection of teams of three or six compatibility 
is shown to be an absolute essential. The hardships which weigh on 


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conscious life are hunger and thirst; lack of sleep due to intense 
cold ; monotony of colour, work, companionship ; gruelling work; 
inseparability from companions; and physical dangers. Hunger 
produces a craving almost unbearable. The party talks food, thinks 
food, and dreams food. Lack of sleep is lowering physically, and the 
temperament suffers. Unvaried monotony induces a monotone of 
mood, taciturnity, intolerance of waggishness, and ready irritation. 
Conversation becomes taboo, raillery unsafe. With prolongation of 
6tress illusions become frequent and affect the whole party uniformly. 
The gruelling work leads to the obsession that companions are all 
“ slacking in the trace.” This occurs in the noblest characters, and 
among friends of tested worth. Companionship is perpetual—the 
opposite of loneliness ; in fact, homesickness is absent almost always. 
Temporary loneliness at any cost is desired, and it is impossible, 
for all tasks must be done in pairs. 

The predominant effects on mind and temperament seemed to be 
most revealed in dreams. Most prominent were dreams of food, 
relief, and disaster to companies. Food dreams were undoubtedly 
first, and among them some in great detail in which it was suddenly 
realised that a shop or restaurant lay just round the hill, where all 
these creature needs could be supplied—arrival there proved it 
closing day, and too late. To smokers the shop would be a tobacco¬ 
nist’s ; in all cases, however, the shop was closed. Relating of one’s 
dreams to one’s fellows became a relaxation. Two of the party were 
of lethargic temperament; these dreamed of feasts and always 
achieved satisfaction. The other four always awoke from the dream 
when the food was laid and did not taste of it. The two could describe 
with gusto the menus they went through. This became a grievance 
to the rest, who had to reason themselves out of the idea that an 
unfair advantage had been taken, as the feeling developed that to 
equalise matters the rations of the two should be reduced. 

Men mentally unfitted for polar work are liable to temporary 
mental aberration during or immediately after an expedition, but 
most readily in real hardship. The patient is irresponsible, and has 
the most extraordinary hallucinations. One most important con¬ 
clusion appears to emerge, viz., that the inelastic mind and tempera¬ 
ment succumbs, whereas the more highly-strung and sensitive type 
better understands unprecedented strain. John Gifford. 


a. Neurology. 

A Review of Recent Literature on Neurosyphilis. (Archiv Neur. and 
Psychiat., February, 1922.) Solomon, H. C. 

The author singles out the new edition of Nonne’s Syphilis und 
Nervensystem, and a new book by Wilhelm Gennerich, Die Syphilis 
des Zentralnervensystems, which he regards as the most important 
work on neuro-syphilis published to date. 

Are there strains of spirochaetes with predilection for the nervous 
system ? Marie and Levaditi, in 1920, reviewed the various theories 
in favour thereof. They note the infrequency with which active 


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% 

skin lesions have occurred in neuro-syphilitic cases; also patients 
infected from the latter source develop neuro-syphilis. In experi¬ 
mental work in 1913 they inoculated a rabbit with human blood 
from a case of general paresis; the disease took and was passed 
through three generations of the animal. The incubation period 
was two to three times as long as that when infection was by spiro- 
chaete from primary lesions. 

Rabbits inoculated with paretic virus are not immune to the virus 
from other sources. In the dermatropic strain average incubation 
is 42 days, in the neurotropic 95 days. By a second inoculation 
these periods are reduced respectively to 15 days and 75 days. The 
primary lesion in the dermatropic strain is indurated with marked 
border ulceration, and results in endarteritis, periarteritis with 
intense infiltration, and much subsequent new connective tissue; 
in the neurotropic type there is papulo-squamous erosion with slight 
ulceration and desquamation, the sequelae being perivascular lesions 
with little endarteritis and less new tissue formation. 

The monkey took the dermatropic, but not the neurotropic strain. 
Man receives the dermatropic type, but the experiments were not 
here successful in reproducing the neural disease. The elucidations 
have been severely criticised, and are not final, but none the less 
are among the most important contributions to the subject. 

Wile and Hasley observe that the spinal Wassermann reaction is 
positive prior to that in the blood. 

Mclver, in the primary and secondary stages of syphilis, found 
slight lymphocytosis in the majority of cases, protein increase occurs 
later, and positive Wassermann was absent, using 6 c.c. fluid ; he 
concludes it is not reasonable to assume that the spinal Wassermann 
will indicate which patients will develop central nervous system 
syphilis. 

Nicolau, in 51 primary cases, found lymphocytosis in eighteen at 
the beginning of the third week; with adenopathy this is one of the 
earliest manifestations of general infection. Pupillary inequality was 
found to be highly suggestive of cerebro-spinal lymphocytosis. 

In a series of 624 early cases of syphilis affected more than six 
months and without symptoms, 35 per cent, had abnormal central 
nervous systems. Lack of symptoms is the outstanding feature; 
few patients complain of disability in syphilitic meningitis even 
when the cerebro-spinal fluid is visibly opalescent. Hence in all 
early syphilis the nervous central system should be thoroughly 
investigated, which is rarely done by the syphilologist. 

The “ abortive treatment ” in the incipient primary period leads 
to the discharge of patients as cured, yet in such neurosyphilis develops 
later. Many writers concur in the advocation of intraspinal treatment 
to produce a negative spinal Wassermann. Solomon agrees that 
six to eight injections of arsphenamin followed by mercury leave 
a positive fluid, but intensive administration (larger and more frequent 
doses over a longer time) will produce normality in the spinal fluid— 
treatment sufficient to suppress secondary skin lesions is quite in¬ 
adequate. 

Nicolau further cautions that a persistently negative Wassermann 
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consequent on treatment is not dependable as a proof of the abortion 
or cure of the disease ; there must also be evidence of non-irritation 
of the cerebrospinal fluid. Solomon believes this one of the most 
valuable dicta recently enunciated. 

It is then definitely shown that in syphilis the cerebrospinal axis 
is early infected in many - cases. Suitable combative measures 
should therefore be immediately adopted. John Gifford. 


3. Clinical Psychiatry. 

Thyroidal Psychoses [Les psychoses thyrciidiennes ]. (Le Prog. M/d. t 

April, 1922.) Laignel-Lavastine. 

The present article is chiefly concerned with those thyroid ab¬ 
normalities which have been found associated with the so-called 
affective psychoses. The author himself has met with many cases 
of melancholia, hypomania, and anxiety psychosis, which, at the 
same time, were goitrous. Thus in a case of agitated melancholia 
presenting thyroid enlargement with signs of hyperthyroidism, 
complete mental recovery followed the removal of a thyroid cyst. 
In another case of melancholia with a large goitre the latter was 
treated by radio-therapy, with the result that the signs of hyper¬ 
thyroidism diminished and the melancholia disappeared. 

In regard to the pathology of such cases the author affirms that, 
in spite of the diversity of lesion as shown by the microscope, they 
nevertheless possess one common link, viz., the more or less constant 
presence of the cylindrical epithelial cell, which would appear to be 
the histological expression of hyperthyroidism. 

The question of aetiology is necessarily somewhat involved, having 
regard to the coincidence of thyroid disturbance and mental disorder 
in the same subject. It is a recognised fact that emotional shock 
and psychogenic factors account for the onset of many of these cases. 
In so far as the actual aetiological mechanism is concerned, Laignel- 
Lavastine supports the view originally put forward by Widal. The 
latter has shown that the mechanism is not, as was formerly believed, 
a chemical one; but that very often it is a physical mechanism— 
colloidal modifications taking place in the humours as a result of 
shock or other psychical cause. Thus we see that the emotions 
may determine not only nervous but also humoral modifications, 
which manifest themselves by changes in the colloidal equilibrium. 

The author’s clinical observations, added to the important findings 
of other writers, furnish convincing evidence in favour of the existence 
of a relationship between thyroid disturbances and mental disorders. 
It may be objected that, though thyroid modifications are frequent, 
there may be no accompanying mental perturbation. In answer to 
this the author points out that in order to have psychic manifestations 
a mental predisposition is necessary. It is therefore possible to 
understand that those persons who have not shown these psycho¬ 
logical reactions possess greater cerebral resistance. Once this 
resistance is lowered these manifestations make their appearance. 

Norman R. Phillips. 


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419 


Nocturnal Palsy. 

It is many years since this condition was described by Dr. Weir 
Mitchell, but one sees little reference^) to it, though it is not uncommon 
in neuroses originating in the war. The patient wakes from sleep 
with his senses fully alert, but unable to move a single voluntary 
muscle. He is naturally alarmed and makes attempts to move or 
speak, but without avail, till suddenly with what seems a great effort 
he regains his power. That he is really awake when in this paralysed 
state is shown by the unbroken continuity of his sensations of sight 
and hearing. One of my patients woke in daylight to see a friend 
in his bedroom. He tried to speak, but could neither speak nor 
move for some time; when he succeeded in doing so the friend was 
just as he had previously seen him. The duration of these attacks 
is variously estimated at from a few seconds to two or three minutes. 

The late Dr. Charles F6r6,( 2 ) of Bic6tre, recorded a case in which 
only the right side was paralysed ; he says nothing about speech. 

P. C. Campbell-Smith. 


4. Treatment of Insanity. 

The Treatment of the Insane in Pavilions without Detention [Le Traite- 
ment des AlierUs en “ Pavilions Libre ”]. {Bull, de la Soc. de Med. 
Ment. de Belg., February, 1922.) Laruelle, L. 

The writer’s experience shows the need of co-operation between 
magistrates and alienists. Representations which led to legal in¬ 
vestigations were made by the former confederates of an alcoholic 
woman who was improving rapidly in the sanatorium of Fort-Jaco. 
The inquiry was conducted in a spirit of antagonism and suspicion 
which spread discontent among patients. The removal either home 
or to the asylum was ordered of certain patients well suited to sana¬ 
torium care who had not asked to go. These included chronic 
psychoses without anti-social conduct, paranoias, simple dementias, 
transitory and curable psychoses, etc. In particular the removal 
home as mentally fit and wishing to leave was ordered of a blind 
paraphrenic who made a stereotyped demand for discharge to go 
to “ X, where she had the freedom of the city,” but who remained, 
though she carried the writer’s signed permit, and who refused to 
depart with her friends. Other cases, unable to exercise volition 
(1 e.g ., of stupor) were to be certified. 

These events raise wider issues. For twenty years the writer has 
conducted, with magisterial approval, an open sanatorium outside 
the Asylum at Liege for patients either throughout their illness or 
before or after asylum treatment. Experience teaches that such 
institutions increase curability, shorten the duration of psychoses, 
prevent psychic contamination and morbid imitation and lessen the 
frequency of certification. Yet apparently these and even open 
wards in asylums are against Belgian law, which allows only home 

(*) “ Deuxi&me note sur la fausse reminiscence,” Journ. de Neurol Bruxelles, 
about 1905.—(*) “ Les crampes et les paralysies nocturnes,” La Mtdeeine Moderne, 
1900, Dr. C. Fere. 


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EPITOME. 


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or asylum treatment. A reaction towards stricter legal enforcement 
threatens the many existing institutions and kills progress. Is 
illegal detention of a sane man—that man constantly mentioned 
and never found—more socially menacing than cases of incipient 
insanity, constitutional psychopathic disorder, drug addiction, 
curable insanities, harmless manias and mental infirmities ? The 
writer demands relief from his dilemma of being either a bad citizen 
contravening the law, or a bad physician withholding from his patients 
treatment in the spirit of contemporary medicine. The Soci6t6 de 
M^decine Mentale de Belgique, which has long advocated improved 
organisations for neuro-psychopathic diseases, should urge both 
toleration and changes in the law. Confinement in asylums should 
be exceptional. Sanatoria should be scientific, should have the re¬ 
sponsible physician resident and equal to asylum status, and be 
inspected sympathetically by a medical body available also for 
consultation. The patient’s material interests should be protected 
by legal authority. Marjorie E. Franklin. 

A Plea for more Accurate Diagnosis and Intensive Treatment of Syphilis 
in State Institutions. {State Hosp. Quart., August, 1921.) Ross, J. R. 

This plea for greater use of the opportunities which hospital control 
affords for the diagnosis and treatment of syphilis is based on replies 
to a questionnaire sent to institutions for the insane and mental 
defectives in U.S.A. and Canada, and on personal experience as 
superintendent of Dannemora State Hospital. At Dannemora, of 
syphilitic cases which received adequate treatment (limited by 
expense to 25 per cent.), with the exception of paretics, all responded 
by changes in the Wassermann reaction of blood and spinal fluid 
and by physical improvement, and nearly all by mental improvement, 
usually preceded by temporary loss of weight and occasionally by 
transitory mental exacerbations. Reports of four cases are given 
as examples. Treatment, the details of which are described, consisted 
in four courses of neo-arsphenamide given intravenously combined 
with mercury salicylate intramuscularly and sodium iodide by mouth, 
and with attention to diet and hygiene. Some paretics showed 
reductions in Wassermann, blood-count and globulin, but not in 
gold curve, nor has there, as yet, been a cure. General paralysis, 
however, is simulated by curable forms of neuro-syphilis. Syphilis 
may be a factor leading to loss of mental balance even without actual 
cerebral infection. A routine Wassermann test should be made on 
all inmates, and all serologically or clinically syphilitic should receive 
intensive treatment. Marjorie E. Franklin. 


Training Aides for Mental Patients. {Arch, of Occupat. Ther., February, 
1922.) Slagle, Eleonor C. 

Emphasis should be laid on the relation of directed activity to 
mental adjustment and social rehabilitation. There are three groups 
to be dealt with : {a) Patients likely to remain permanently in hospital, 


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42 I 

(1 b) recoverable hospital cases, (c) pre-hospital work at clinics. The 
candidate for training should not be too young and should be selected 
by a committee. Personality and character are of the highest 
importance, and the work demands consecration and genuine human 
love. The training is both theoretical and technical. The student 
is taught a little of general hospital administration, hospital etiquette, 
and the relation of her work to the organisation as a whole. She 
starts with the lower grades, and is taught something of the inter¬ 
dependence of the mental and physical, of the nature of habit reactions 
and methods of overcoming bad and forming good habits, including 
the habit of attention. Habit training is especially important in 
the reception service and with the unemployed deteriorating class. 
The deteriorated patients of many years’ standing are the most 
difficult of all, but the writer looks forward to a lightening of this 
burden in the future when improved methods of prophylaxis and 
treatment have been used from the beginning. However, these 
patients are entitled to a chance, and even now results are encouraging. 
The next grade is the kindergarten. Here the student learns methods 
of re-education along lines of sensory stimulation and training : colour, 
music, simple exercises, games and story-telling are employed along 
with occupations. In the grades above this patients are given 
manual occupations chosen to meet individual needs. They are of 
increasing complexity, increasing interest, and require increasing 
concentration. Still higher is the occupation centre or “ curative 
workshop,” where really beautiful work is sometimes done. Patients 
may be sent here for special observation, or before parole, or before 
passing to the “ pre-industrial ” or vocational training departments. 
The student should here make a general survey of the patient from 
the point of view of his personal needs, interests, inhibitions, emotions 
and relation to environment and the construction of a balanced 
programme of work, rest and play. 

The student during training participates in the physical work with 
patients, e.g., gymnasium and games. The play spirit is often warped, 
especially in town-dwellers; therefore games, folk dancing, gymnastics, 
playground activities, competitive games, etc., are included in the 
regime. Students are further taught to buy equipment and to utilise 
available material. Careful observation, accurate note-taking and 
written records are insisted on from the beginning, and the interpretive 
side is emphasised, for the writer finds that, while most aides under¬ 
stand crafts, many do not realise the application to mental patients. 
The results of the work have been encouraging; patients are helped 
to parole and discharge, or, if they must remain, to be happy and 
active in the hospital community. Success depends largely on the 
persistence, versatility and patience of the occupational therapist. 

Marjorie E. Franklin. 


The Philosophy of Occupational Therapy. ( Arch. of Occupat. Ther., 
February, 1922.) Meyer, Adolf. 

For thirty years—first at State Hospitals for the Insane, and later 
as Medical Director of Phipps Psychiatric Clinic—Dr. Meyer has 


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422 EPITOME. [Oct., 

assisted at the progress of occupational treatment for mental illness. 
He has seen it develop from a purely industrial type of employment 
with mainly utilitarian aims to the educational methods of occupation 
and recreation under the direction of specially trained organisers, 
in establishing which Mrs. Meyer was one of the pioneers. 

The aim should be to combine work with pleasure, and to supplement 
the centralisation involved in institutional life by individualism. 
Psychopathic disorders present problems of adaptation and of living 
and of habit deterioration. Occupational therapy helps to bring 
the patient into contact with reality, to strengthen the “ fonction 
du r6el,” to give a sense of achievement and completion especially 
valuable to sufferers from feelings of inferiority, to increase muscular 
control and to improve habits, and, perhaps most important of all, 
it develops in the patient a sense of the value of time and of perform¬ 
ance. The writer discusses in this connection the modern interest 
in “ energetics ” in physics and chemistry and “ behaviourism ” in 
psychology. 

Time, rhythm, activity are beacon lights of the philosophy of the 
occupation worker. The capacity of imagination and the use of time 
with foresight, based on appreciation of the past and the present, 
are culminating features of man’s evolution, in the higher stages of 
which he integrates the simpler phases into new entities. Rhythm 
operates throughout nature. The healthy human organism pulsates 
rhythmically between rest and activity, using and living and acting 
its time in harmony with its own nature and the nature about it, 
and feeling itself to be a self-guiding energy-transformer in the real 
world of living things. Nursing and immediate therapy are concerned 
with the arrangement of the patient’s time—the twenty-four hours of 
his day—the engagement of his interests, and the orderly rhythmic 
distribution of work and play and rest and sleep in a happy and 
natural atmosphere. There is a natural rhythm between vision and 
performance. Thought, reason and fancy are steps to action , and 
performance is the best test and expression of personality. 

Dr. Meyer warns against undue interference and meddling. Help 
should be confined to giving opportunities to individuals to develop 
along the lines of their personal interests, cravings and capacities 
with only such guidance, encouragement and stimulation as may be 
necessary. There are many ways of approach, and sometimes the 
patients’ delusions suggest lines of help. Examples are cited, e.g., 
picking hair of mattresses. This is suitable for excited cases, as it 
does not tax the attention unduly nor stimulate the larger physical 
movements. Among the handicrafts taught are raffia and basket- 
work, weaving, bookbinding, metal and leather work. Patients with 
inferiority feelings are benefited by constructive work of some 
emotional value, and which can be finished in one or two sittings. 
Praise is helpful, but an adequate standard should be maintained. 
The treatment may well begin with a regime of “ pleasurable ease,” 
the creation of an orderly rhythm in the atmosphere, with perhaps 
some music, dance and play, leading up to varied activities and work. 

In considering the wider applications of the subject, the writer 
points out that commercialism and the over-valuation of quantity 


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NOTES AND NEWS. 


423 


with neglect of workmanship in industrial life leads people to seek 
satisfaction for their interests in unproductive activities outside 
their work. Experience gained in dealing with difficult special 
needs may help to solve problems in the philosophy of ordinary life. 

Marjorie E. Franklin. 


Part IV.—Notes and News. 


MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN 

AND IRELAND. 

The Eighty-First Annual Meeting of the Association was held on 
Wednesday, Thursday, and Friday, July 19 to 21, 1922, in the Royal College 
of Physicians and in the University of Edinburgh, under the presidency, in the 
early proceedings, of Dr. C. Hubert Bond, C.B.E. , F.R.C.P., and later that of 
Prof. G. M. Robertson, M.D., F.R.C.P.Edin. 

MORNING SESSION.— Wednesday, July 19. 

Dr. C. Hubert Bond, President, in the chair. 

The Council, Educational, and Parliamentary Committees had met during the 
previous two days, July 17-18, at the offices of the General Board of Control for 
Scotland, 25, Palmerston Place, Edinburgh. 

Minutes. 

The minutes of the eightieth annual meeting, held in London, having appeared 
in the Journal, were held as read, and were approved. 

Election of Officers of the Association. 

The President proposed that the officers of the Association for the year 
1922-23 be: 

President .—George M. Robertson, M.D., F.R.C.P.Edin. 

President-elect .—Edwin Goodall, C.B.E. , M.D., F.R.C.P. 

Ex-President .—C. Hubert Bond, C.B.E. , D.Sc., M.D., F.R.C.P. 

Treasurer. —James Chambers, M.A., M.D. 

Editors of Journal. —J. R. Lord, C.B.E. , M.B., H. Devine, O.B.E., M.D., 
F.R.C.P., G. Douglas McRae, M.D., F.R.C.P.Edin. 

General Secretary. —R. Worth, O.B.E. , M.B. 

Registrar. —Alfred A. Miller, M.B. 

This was agreed to. 

He next proposed that the nominated Members of Council be : 

Sir F. W. Mott, Drs. W. F. Menzies, C. C. Easterbrook, M. J. Nolan, Bedford 
Pierce, G. W. Smith, E. Barton White. 

This was agreed to. 

Election of Honorary and Associated Members. 

On a ballot being taken, the following were unanimously elected Honorary 
Members of the Association : 

Mr. Wm. C. Clifford Smith, O.B.E. , F.R.I.B.A*, M.I.C.E., Mental Hospitals 
Engineer to the London County Council. 

Dr. Francis Florentine Pactet, ancien chef de Clinique de la Faculty de 
Mddecine de Paris; Mddecin en chef de l’Asile de Villejuif. 

Dr. Jacques Jean l’Hermitte, ancien chef de Laboratoire de la Faculty de 
Mddecine de Paris; M^decin de THospice Paul Brousse. 

A further ballot was taken, and the following were unanimously elected 
Corresponding Members of the Association : 

Prof. Schuzo Kure, of Tokyo University. 

Dr. Morowoka, of Kyushu University. 

Dr. Sano, of Gheel. 

All these gentlemen had been proposed by Dr. C. Hubert Bond, Dr. J. Chambers, 
Prof. G. M. Robertson, Lt.-Col. J. R. Lord, Sir F. W. Mott, and Major R. Worth. 


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424 NOTES AND NEWS. [Oct., 

Appointment of Auditors. 

Drs. C. F. F. McDowall and C. M. Tuke were unanimously re-appointed 
Auditors for the current year. 

Committees. 

The meeting further unanimously re-appointed the following Committees : 

The Parliamentary Committee; the Educational Committee, with the names of 
Drs. R. R. Leeper, W. M. Buchanan, and John Brander added thereto; the Library 
Committee; the Research Committee; the Handbook Committee; and the 
Post-Graduate Committee. 

With reference to the appointment of the Handbook Committee, the President 
invited Dr. Bedford Pierce to make a statement. 

Dr. Bedford Pierce*. I am glad to say that the Handbook is actually in the 
hands of the printers. It has been a laborious business getting it ready, but 
the difficulties have been surmounted, and I may say the Handbook will be a 
great improvement on the old one. At the Council yesterday it was decided to 
authorise Dr. Chambers, the Treasurer, to undertake negotiations with the 
publishers of the Handbook with regard to the difficult questions of royalty, 
copyright, and so on. 

The Report of the Council. 

The General Secretary (Major R. Worth) read the Report of the Council 
for the year. 

The number of members—ordinary, honorary, and corresponding—on December 
31, 1921, as shown in the list of names published in the Journal of Mental Science 
for January, 1922, was 666, as compared with 673 on December 31, 1920.O) 


Number of new members elected in 1921 . 50 

Number of members restored in 1921.o 

Removed according to Bye-law 17 31 

Number of members resigned in 1921 . .21 

Number of deaths in 1921.7 

Transferred to hon. members.o 


Members. 

1912. 

1913- 

1914. 

1915- 

1916. 

1917. 

1918. 

1919. 

1930. 

1921. 

Ordinary 

696 

695 

679 

644 

632 

627 

626 

626 

640 

631 

Honorary 

35 

34 

34 

34 

32 

33 

32 

26 

24 

25 

Corresponding 

*9 

18 ! 

i 

18 j 

1 

18 

18 

18 

l 7 i 

1 

9 

9 

10 

Total 

750 

747 j 

73 1 

696 

682 

678 

675 

J 661 

673 

666 


Since the last annual meeting there have been quarterly meetings held in 
London in November, February and May. 

At the November meeting a sub-committee was formed consisting of the 
President, Secretary, Treasurer, Chairman, and Vice-Chairman of the Education 
Committee, to consider the relationship of the Association to the General Nursing 
Council in respect to the training and examination of mental nurses, with instruc¬ 
tions to approach the General Nursing Council and Ministry of Health, and with 
full power to make any inquiries and to consider the situation that has arisen by 
the establishment of the General Nursing Council. 

It was also decided that the President’s address at the annual meeting in July 
should be sent to the Chairmen of Committees of Mental Hospitals in England 
and Wales. 

A resolution was passed condemning the accusations made by Dr. Lomax at the 
end of his book and the statement regarding systematic cruelty on the part of male 
and female staffs in mental hospitals. 

At the February meeting it was proposed to revise the list of institutions for the 

(*) In the Register published Jan. 1922, “ Aidan, etc.,” on p. vii, should have been 
deleted.— (Eds.). 


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1922.] 


425 


training of mental nurses and those nursing mental defectives, and Drs. Miller and 
Bedford Pierce were asked to bring forward a preliminary report. 

At this meeting were received the resignations of Dr. Dawson as Co-Editor of the 
Journal and Dr. Steen as Chairman of the Library Committee. 

It was also suggested at this meeting that a further letter be sent to the Minister 
of Health, stating that it was considered that mental nurses were not sufficiently 
represented on the Nursing Council; also that the Board of Control should be 
represented. This sub-committee was re-appointed on July 18th at the Council 
meeting. 

The following papers were read during the year : 

" The Medical Examination of Delinquents," by Dr. Hamblin Smith, Medical 
Officer, H.M. Prison, Birmingham. 

“ Forgetting,*' by Dr. H. Davies Jones, Ashhurst Hospital, Littlemore. 

“ The Use of Analysis in Diagnosis," by Dr. T. S. Good, of Ashhurst Hospital. 

"The Genetic Origin of Dementia Praecox," by Sir F. W. Mott. 

The Maudsley Lecture—“ Spme Aspects of Education in Relation to Mental 
Disorder "—was delivered by Sir Maurice Craig at the end of the May meeting. 

Informal dinners have been held after each meeting in London, and they have 
been greatly enjoyed by those attending. It is hoped that in future more members 
will endeavour to attend these dinners. 

With regard to the Maudsley Lecture, in future it was decided that the Lecturer 
should be nominated for the following three years. 

It was decided that Lt.-Col. Edwin Goodall, C.B.E., M.D., B.S., F.R.C.P.Lond., 
should be nominated as President-elect. 

It is hoped that by the end of the year the Handbook for Mental Nurses will be 
published. 

The report was adopted. 

Matters arising out of the Council Meeting. 

The President: I should now like to make mention of matters of interest 
arising out of yesterday’s Council meeting. The Council had before them a 
resolution among other items from the Scottish Division recommending that 
matrons should take part in the examination in practical nursing of candidates 
for the Nursing Certificate, and this was dealt with by two resolutions by the 
Educational Committee which I will read out for your information: (1) That 
the Educational Committee approves of the chief male and female officers of the 
nursing staff, or their deputies, being present at and taking part in the examination 
in practical nursing of candidates for the Nursing Certificate. (2) That a sub¬ 
committee be appointed to consider whether it is desirable that one or more of the 
examiners for the written part of the examination be members of the nursing 
profession, and as to the best way in which the nursing profession can generally be 
represented on the examination for the Association’s Nursing Certificate. The 
sub-committee suggested by the Educational Committee was: Prof. G. M. Robertson, 
Drs. D. K. Henderson, W. M. Buchanan, H. Wolseley-Lewis, J. R. Lord, 
Bedford Pierce, and J. F. Dixon. 

There was mention of the very important Legal Committee which the Government 
have set up arising out of the general discussion going on in the Press with regard 
to the True case, and it will be remembered that in 1896 the Association did con¬ 
sider the question of criminal responsibility, and came to an agreement that it was 
impossible at that date to offer advice of utility. We think the circumstances have 
changed since then, and that now the Association may be able usefully to offer 
something. We do not know if it will be desired ; but, if desired, we ought to be 
ready to make a statement on this matter, and so it was decided by the Council to 
form a special Committee to discuss and classify the medical aspects of the plea 
of insanity in criminal cases. We did not constitute the committee. We thought 
it was just one of those committees it takes time to consider names for, so that it 
was left to the President, the ex-President and the Chairman of the Parliamentary 
Committee to confer and select names. 

Motions Involving Expenditure of Funds. 

Other matters arising out of yesterday’s Council were that the authority of the 
meeting is required for the grant of 50 guineas for the last Maudsley lecturer, and 
the usual sanction for the expenditure in connection with the Association’s official 
guests at the Annual Dinner. These were agreed to. 


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426 NOTES AND NEWS. [Oct., 

Sir Robert Armstrong-Jones : Has any time been fixed for this special 
committee to meet ? 

The President: No. 

Sir Robert Armstrong-Jones : Because it is a fairly urgent thing, and the 
committee wants to get to work as soon as possible, and it is important that this 
committee should be able to meet fairly early and discuss procedure. 

The President: I entirely agree. The council felt that although no time was 
fixed, any attempt to form the committee there and then would be rather a mistake, 
and we could do better by taking a little leisure—by which I do not mean delay. 
I am quite sure the urgency was fully realised. 

Report of the Treasurer. 

The President: To our great regret our Treasurer is not with us. He is 
unfortunately laid up and unable to be present, so that I will ask the General 
Secretary to read the Treasurer’s Report. 

Major R. Worth then read the Treasurer’s report: 

The credit balance shown is due to the revenue derived from examination fees. 

The disbursements made for the preparation of the Handbook in 1921 were 
j£i40 8 s . 4 d. If there had not been this unusual expenditure in 1921 the revenue 
account, independent of the amount received from examination fees, would show 
an adverse balance of £g —this on the assumption that all the members would pay 
their subscriptions. The cost of the Journal for 1922 will be less than it was in 
1921. At the end of 1922 we should be in a position to estimate whether the 
increased rate of subscription provides an income which will cover the Association’s 
expenditure, independently of the revenue derived from examination fees. A large 
amount of subscriptions has been written off. This action was deferred from year to 
year in the hope that members who had served in the war would, in consideration of 
being excused their subscription for their period of service, continue their member¬ 
ship by paying the subscriptions due since their return to civilian life. A certain 
number responded to this appeal. The disbursements made for the Handbook 
have been, as in 1920, included in the miscellaneous account. Attention is drawn 
to the small number of applications for grants from the Asylum Workers’ Con¬ 
valescent Funds in order that members of the Association may remind their staffs 
of its existence. There were only two grants made in 1921 of £2 each. These 
grants were met by a final payment of £2 4 s. 2d. received from the original 
Treasurer, and interest on deposit —£2 155. lod .—a curious coincidence. 

The report was adopted. 

The Report of the Editors. 

Lt.-Col. J. R. Lord read the report of the Editors: 

At the last Annual General Meeting a small committee, consisting of the President, 
the Treasurer, Lt.-Col. J. R. Lord (representing the co-editors), Dr. F. H. Edwards 
and Dr. C. F. F. McDowall, was appointed to report as to the cost of printing the 
Journal, with power to invite tenders. This Committee reported at the Quarterly 
Meeting held in London on February 23rd, 1922. Competitive prices for printing 
the Journal had been obtained from seven printing firms of repute, based upon a 
tender representing a typical issue of the Journal. Each firm was given the details 
of additional work which would need to be undertaken. The lowest price was 
submitted by the firm which had for many years printed the Journal, and the 
recommendation of the Committee that Messrs. Adlard & Son & West Newman, 
Ltd., should continue to print the Journal was adopted by the Meeting. The result 
was very comforting to the Editors, who have been in the past much indebted to 
the printers for their reliable and conscientious co-operation in the publication of 
the Journal. 

At the last Annual Meeting the Editors were unfortunately unaware that this 
matter would be raised, and were not prepared with any facts or particulars to 
guide the meeting. This year, however, they have been careful to review the 
finances of the Journal. 

The last pre-war year’s issue (1914) was a volume of 721 pages. Owing to 
economic conditions generally the size of the Journal needed to be curtailed during 
tl\e war, culminating in 1919 in an issue of 322 pages. In 1920 the flow of work 
in the world of psychiatry began to return to a more normal volume, and it was 


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THE MEDICO-PSYCHOLOGICAL ASSOCIATION.—For the Year 1921. 

REVENUE ACCOUNT—January ist to December 31st, 1921. 

1920. Dr. Expenditure. Income. Cr. 1920. 


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428 


NOTES AND NEWS. 


[Oct., 


absolutely necessary in the interest of the Association to embody more of it in the 
pages of the Journal. The Journal for that year rose to 52 6 pages, which at 
current prices was costly. A further return to normal has been effected during 1921, 
the size of the Journal increasing to 581 pages. There are still sections which 
cannot yet be properly undertaken, such as the review of mental hospital reports, 
but medico-legal notes are being resumed this year. 

The cost of printing, reproduction of plates, etc., has been coming down since 
1921, and it is hoped that financial considerations will permit very soon of the 
Journal resuming its pre-war size. 

The financial details for 1921 are as follows. The statement can be taken as in 
general accurate: 

Printing— 

£ s. d. £ s . d. £ s. d . 

Basic cost . 513 3 2 

Trade increases 408 13 6 

- 921 16 8 

Reprints . . . 30 6 8 

Wrappers and despatch . 50 2 6 
Stationery and index, etc. 12 14 4 

- 93 3 6 


Credit— 

Sale of Journal 
Advertisement 
Grant for plates 
Maudsley Grant 


185 12 9 
24 12 7 
20 o o 
79 3 o 


1015 o 2 


309 8 4 


Cost of Journal to Association .... 705 11 10 

It will thus be seen that each quarterly copy of the Journal issued during 1921 to 
a member cost about 5 s. 6 d. 

The Editors are ever mindful of the fact that many members can only rarely parti¬ 
cipate in the meetings of the Association, and they think that if the membership of 
the Association is to be retained at its present level or increased the Journal of the 
Association must be of such a character that members feel repaid to a large extent 
for their annual subscription. 

The Editors regret that Lt.-Col. W. R. Dawson, O.B.E ., found it necessary to 
resign his position as Co-Editor. He had rendered valuable assistance to the 
Journal for many years, which embraced a period long before he was officially 
connected with it. 

They would also like to draw the attention of the Association to the voluntary 
work done by reviewers and epitomisers. No less than 36 books were reviewed and 
100 articles epitomised during 1921. This represents an amount of reading and 
close study which the Editors feel sure the members of the Association are most 
grateful for. (Applause.) 

The President : It is a very comprehensive report, and very satisfactory, and 
I take it it is received and adopted. (Agreed.) 


Report of the Auditors. 

Dr. Colin McDowall read this report: 

We have this day examined all the vouchers and books of the Association, and 
beg to report that the Balance-Sheet and Revenue Account present accurately the 
financial position of the Association. 

Dated this nth day of July, 1922. 

Colin McDowall 1 A ... 

C. Molesworth Tuke. j Hon - Audltors - 

Received. 

Report of the Educational Committee. 


Dr. A. W. Daniel : The Educational Committee beg to submit the following 
report: 

The meetings held have numbered four, and the average attendance has been 


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429 


1922.] 

twenty. During the year one case of collusion at the examination for the Nurses’ 
Certificate was dealt with, and two cases of misconduct, in one of which no action 
was taken and in the other the name of the offending person was ordered to be 
removed from the Register. 

The following institution was recognised for the training of mental nurses— 
Rempton ; and for the training of those nursing mental defectives—Monyhull, and 
The Manor, Epsom. 

The results for the year of the examinations for the Nursing Certificate are not 
yet available. The number of entrants for these examinations is as follows: 
Preliminary, 3,888; Final, 1,939. This compares with Preliminary 4,228; Final 1,382 
for the previous twelve months/ 

For the Bronze Medal two essays were received, but these have not yet been 
adjudicated. There were three candidates for the Certificate in Psychological 
Medicine, and two of these were successful. 

Two candidates presented themselves for the Gaskell Prize, and both failed to 
reach the required standard. 

The President: You have heard that report, which is quite an interesting one 
and full of the year’s good work. May I take it it is received and adopted? 
(Agreed.) 

Report of the Parliamentary Committee. 

Dr. R. H. Cole read this report: 

Y our Parliamentary Committee has held four meetings during the past year. 
The Asylums Officers Superannuation Act has been considered with regard to 
proposed amendments, but it has not been possible to proceed further with these at 
present. 

The Supplemental Register for Mental Nurses under the Nurses’ Registration 
Act having been established, your Committee has advised the Council to take steps 
to encourage mental nurses to avail themselves of registration. 

Your Committee has continued to urge the need of legislation as regards 
England and Wales for patients suffering from mental disorders in their early 
stages. It is hoped that a Bill will be introduced into Parliament this session. In 
connection therewith your Committee has carefully considered what Government 
Department should exercise supervision of such a measure, and it has expressed 
its view that the supervising body should be the Board of Control. 

Your Committee has brought before your Council the matter of reports and 
certificates, which are increasingly demanded from mental hospital medical officers 
concerning service patients and insured patients. 

I beg to move the adoption of this report. 

Prof. Ernest W. White : Arising out of this report I beg to move the following: 
“ That in the opinion of this Annual Meeting of the Medico-Psychological 
Association of Great Britain and Ireland, it is very desirable in the interests of the 
general community that all mental nursing homes and private houses receiving 
mental patients for care and treatment should be registered and periodically 
inspected officially. ,, We all know that a Bill which was slightly alluded to is 
coming very quickly. We all know the abuses in the past, which I had the pleasure 
of showing up when I was President in 1903—all the abuses then existing in some 
nursing homes. We all know this Bill will tend very largely to the ever-increasing 
treatment of patients in private care in single houses, and we all know the necessity 
therefore that the public at large and the general community should feel that these 
houses are properly administered. Now, my proposition studiously avoids any 
intrusion on the privacy of the patient. The supervision is merely that the house 
should be properly adapted and suitably administered. There is no interference 
with the privacy of the patient. But it is more than ever essential that these houses 
should be properly supervised, so that so far as possible there should be no chance 
of any harshness of treatment or inadequacy of administration, and it is with that 
object, seeing that this Bill will shortly be introduced into the House, that I 
propose this motion to-day. I honestly believe it will have the acceptance of you 
all. I believe, further, that it will not be opposed by the general public. If I had 
embodied in it the general nursing homes I believe we should have had great 
opposition from a certain section of the medical profession, but as I confine it 
strictly to our own section I do not think we ought to have that opposition, and 
therefore I feel a certain amount of confidence in proposing this to you to-day. 


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430 NOTES AND NEWS. [Oct., 

The President: This is a motion arising out of the Parliamentary Report. 
Does anybody second it ? 

Lt.-Col. J. R. Lord: Is this matter one clearly arising out of the Parliamen¬ 
tary Committee’s report ? If it is a new motion should it not have been on the 
agenda ? 

The President: I am taking this as a motion arising out of the report of the 
Parliamentary Committee. 

Dr. J. G. Soutar : I fail to see what part of the Parliamentary Committee’s 
report this arises out of. 

Lt.-Col. J. R. Lord : We should like to be quite clear about it. I have no 
doubt many of us are in sympathy with the resolution, but we would like to be in 
order in discussing it. 

The President: There being no seconder I suggest that we pass on. It does 
not mean that there is any hostility to a sentiment which must appeal to many. 

The report was then agreed to. 

Report of the Library Committee. 

Dr. Colin McDowall read this report: 

During the 1921-22 session 30 volumes in all were issued from the Lending 
Library for the use of members, while during the previous year 35 volumes were 
issued. The Reference Library has been used more largely, but no record is kept 
of the number of books referred to. No new books have been purchased during 
the last two years. There has been a charge of threepence made for postage for 
books which are sent out from the Library. This charge does not cover the actual 
cost of postage, and perhaps would be better discontinued. 

Medical periodicals have been circulated among the members who have asked to 
be placed on the list. The following is a list of the periodicals: American 
Journal of Insanity, Journal of Neurology and Psycho-Pathology, V Encephale, 
International Journal of Psycho-Analysis, and Journal of Abnormal Psychology. 
This list appears to be very limited, and will be added to should any member 
express in writing a desire to have any particular journal circulated. 

Dr. Colin McDowall, in moving the adoption of the report, said: 

I have a letter from Dr. Rayner, which he wrote to me when I sent him the 
Report. He writes saying: “ I should like to add that this list of periodicals is 
very limited, and that in the interests of scientific work in mental hospitals it is 
desirable that all foreign and other journals should be available for references to 
the medical officers. The committees of mental hospitals are responsible for the 
encouragement of such scientific work, and it is suggested that they should be 
appealed to by the Medico-Psychological Association to aid in the work of 
supplying this need. I would further suggest that in moving the adoption of the 
report you move that a small committee be appointed to carry out this appeal in 
the manner best calculated to ensure support. I would do so if I could attend.” 
Then he says rather pathetically, “ I made a similar suggestion many years ago, 
but things were very different then. I am sure that now one could get the support 
of the Board of Control and Dr. Bond.” 

I beg to move the adoption of the report. 

Dr. W. F. Mbnzies : There are no new books bought. You remember last year 
you ruled, or I ruled, that it was out of order, and it was carried by the Chairman 
of the Library Committee at that meeting, against the wish of the Council, that a 
grant should be made. Well, that was a very severe thing to do against the wish 
of the Council; still, it was done, and yet apparently the grant has not been 
expended. May I ask why ? 

Dr. Colin McDowall : I can only say no money, I understand, was available, 
and I made an application this year to the Secretary of this Association for 
money, and I am afraid I have not had an answer to that letter. I applied for 
£20. I am quite sure we will get this money, and the Association can rest 
assured books will be purchased, but it seems rather sad to think that only thirty 
books were issued last year. This 3^. a time now, I hope, will be cut off, and that 
will perhaps encourage members to apply without the fear that they will be charged 
something in addition. 

Dr. W. F. Menzies : Last year’s grant has expired. 

Major R. Worth : Might I say all applications received by the Secretary are 
promptly sent on to the Treasurer. 


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Dr. W. F. Menzies : Are we to understand that the Library Committee can get 
this £20 now P 

The President : I was going to ask. I think the Association will respond to 
this appeal on the part of the Library Committee. There is a vein of pessimism 
running through these remarks, but I do not think it is very sound, because 
although not many of these books are asked for through the post I do notice a 
good many make use of the Library. It is very rarely I go in there casually 
without finding someone making use of it. When I was a member of the Com¬ 
mittee I used to say that the members of the Association did not seem to know 
the books that were there. Some of them are quite of historical interest, which I do 
not think they would get easily elsewhere, and if there was an accessible catalogue, 
the demand I think would be very much greater. I do not think it is going to die 
a natural death. I would be very sorry, and I am going to put it to the meeting 
that we grant this £20 asked for, and we shall hear this time next year how it has 
been expended. (Agreed.) 

Dr. Bedford Pierce : With regard to the other suggestion which came from 
Dr. Rayner, I hope it won’t be lost sight of. In making inquiries I find it is not 
very common for our public asylums to have a library at hand for the use of 
medical officers, and yet it seems to me to be a very small expense to keep it 
going, and I think if it was put before the mental hospital committees it would 
be favourably considered. My Committee were always willing to buy new books 
for the benefit of assistant medical officers, and there is now quite a respectable 
library, and I think that should be general in our institutions. The annual expense 
is very trifling if you only purchase new books as they come out, and I hope 
Dr. Rayner’s suggestion will be accepted. 

The President : May I take it this is referred to the Council as suggested ? 
(Agreed.) 

The Sub-Committee on*Post-Graduate Study. 

The President : With regard to the Post-Graduate Committee, of which I am 
Chairman and Lt.-Col. Lord is Secretary, we would have liked to report further, 
and the fact that there is no report is entirely my fault. The Sub-Committee has 
had several meetings, but my time has been so completely filled that I have not been 
able to co-operate in the production of a report, but with the cessation of the 
occupancy of this Chair I hope an easier time in one or two directions is in 
store for me. 

Dates of the Annual and Quarterly Meetings. 

The quarterly meetings for the ensuing year were agreed to as follows: 
November 23rd, 1922, February 22nd, 1923, May 24th, 1923. The next annual 
meeting would probably be held in London. 

The Maudsley Lectures. 

The President : It has been suggested, and I think it is generally agreed, as 
regards the Maudsley Lectures, that it will be better for the sake of both lecture 
and lecturer that a longer notice should be given than hitherto, and that appoint¬ 
ments must be made as far as possible for three years ahead. The three years’ 
notice would begin next year. Subject to their respective consents being obtained, 
the next Maudsley lecturer will be Dr. Clark, Professor of Psychiatry in the Uni¬ 
versity of Toronto, then Dr. Carswell in 1924, and Dr. Percy Smith in 1925. 
With regard to Dr. Clark, of Toronto, seeing that he has been given but little 
time in which to decide whether he will accept the invitation or not, it has been 
suggested that he be offered an option of two dates, namely, May, 1923, or the 
next Annual Meeting. 

Election of Candidates as Ordinary Members. 

The President appointed Dr. G. Douglas McRae and Dr. F. H. Edwards as 
scrutineers for the ballot. 

The candidates were all elected as follows: 

R. Mary Barclay, M.A., M.B., Dipl. Psych. Edin., 15, Rankeillor Street, 
Edinburgh. 

Proposed by Drs. G. M. Robertson, W. McAlister, and E. Connell. 


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George Gibson, D.S.O ., M.D., F.R.C.P.Edin., Deputy Commissioner, General 
Board of Control, Scotland, 23, Cluny Terrace, Edinburgh. 

Proposed by Drs. Hamilton C. Marr, James P. Sturrock, and W. M. 

Buchanan. 

Albert William Gregorson, M.D., Ch.B., F.R F.P. & S.Glasg., Assistant 
Medical Superintendent and Physician, North Middlesex Hospital, Silver 
Street, Upper Edmonton, N. 18. 

Proposed by Drs. E. Laval, H. Yellowlees, and R. Worth. 

Douglas Chalmers Watson, M.D., F.R.C.P.Edin., Physician, Royal 
Infirmary, Edinburgh ; 11, Walker Street, Edinburgh. 

Proposed by Drs. G. M. Robertson, C. H. Bond, and R. Worth. 

Ralph Athelstanr Noble, M.B., Ch.M.Sydney, D.P.M.Camb., Medical 
Superintendent, Red Cross Hospitals for,Nervous Diseases, N.S.W., 
Australia; Neurologist, Ministry of Pensions, England; c/o Commonwealth 
Bank of Australia, 36, New Broad Street, London, E.C. 

Proposed by Drs. C. H. Bond, J. Macpherson, and T. S. Good. 

Sir Frederick Willis, K.B.E., C.B. 

At this stage the President intimated the names of several members who had 
written regarding their inability to attend the Annual Meeting, and on the motion 
of Sir Robert Armstrong-Jones a message of sympathy was sent to Sir Frederick 
Willis, the Chairman of the Board of Control for England and Wales, who was 
unable to be present owing to his having undergone a serious operation. 

Demonstration by Dr. Chalmers Watson. 

The President: You will notice on Friday there is a paper to be read by 
Dr. Chalmers Watson, and in connection with his paper he has gone to very great 
trouble in arranging in his ward in the Royal Infirmary a demonstration which 
you are invited to visit any day this week. I am sure you will find it of the 
greatest interest, and the opportunity should not be missed. I think the lesson 
to be learned from it is the value and urgent call there is now for the constant 
use of a clinical laboratory in connection with every-day clinical medicine. 

Paper. 

‘‘The Out-patient Treatment of Early Mental Disorder. The Neurological 
Clinic, and some of its Functions,” by Dr. A. Ninian Bruce (see p. 385). 

The President : 1 may say we are all very much obliged to Dr. Bruce for the 
extremely interesting, practical and important paper he has just read. It touches 
on so many items in which I have personally much at heart that it is with consider¬ 
able self-restraint that I am going to sit down and suggest that some others should 
at once commence the discussion. There are a great many here to whom many 
of his points appeal in their work, present and past. 

Sir Frederick Mott : I have listened to Dr. Bruce’s paper with great interest. 
It appeals to me very much, especially his view that neurology and psychiatry are 
inseparable, and for that reason in connection with the Diploma of Psychological 
Medicine we require all persons to pass in neurology, and I am quite certain the 
medical officers in mental hospitals have greatly benefited by this teaching they 
have had. I was particularly interested in Dr. Bruce’s statement of the unity of 
the psycho-neuroses and the psychoses, because I think it is very difficult to draw 
a hard and fast line between them. With regard to the psychoses, I have myself 
made some observations which seem to show they are one group. You have women 
coming into the mental hospital, and you do not know whether they will get well 
and be discharged, or whether they will be discharged and come in again, or 
whether they will remain and develop dementia and never leave the mental 
hospital. I have cases in which they were diagnosed as confusional insanity 
where they have come in again and remained as dementia praecox cases. These 
cases died later in life, and one finds the same changes in the brains of these 
cases as in the cases which never recovered. With regard to dementia praecox 
in males, I have found the same there. I have found marked regressive atrophy 
of the testicles, so that I think there is the material at hand from which to 
associate all these cases in one great group. With regard to the state of the 


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ovaries, you will find the same regressive atrophy in cases of the psychoses, 
and general inadequacy at the highest cerebral levels. I should like to say I 
think there is a material reason why this highest level should be liable to 
degenerative changes. If you regard the anatomical development of this highest 
level which forms the great bulk of the nervous system you will see it is developed 
from very few of the protomeric cells of the neural tube. You may have an arrest 
in development, or you may have a breaking down in adolescence from psycho¬ 
logical or pathological stress. I have numbers of cases in which an imbecile breaks 
down, in which you find an arrest of development of the supragranular pyramids, 
and then the acute change in all the cortical layers. Then again in cases which 
were admitted for confusional insanity and cases of dementia praecox you find the 
same degenerative changes, so that I think we must regard this disease rather as 
on a material basis, and I am sure myself that we do not know enough yet about 
the influence of the endocrine glands, but Dr. Kojima investigated no cases I 
made post-mortems on, and very carefully weighed the endocrine glands, and when 
one compares that examination with what one finds in hospital cases you see how 
frequently the endocrine glands show abnormality. On those lines I think we find 
important evidence to explain some of the mental conditions we know do arise. I 
entirely agree with Dr. Bruce with regard to the out-patient treatment of a large 
number of cases, and if it is possible to keep these clinics separate from the mental 
hospitals, because by that means you will get them early. You will not get them 
early if they think these clinics are half-way houses to asylums. On these grounds 
I think it is very desirable in a city or town where there is a mental hospital if they 
established a clinic it should be away from the mental hospital if possible, but have 
an expert from the latter to see the cases. (Applause.) 

1 Dr. T. C. Mackenzie : Those of us who were Edinburgh trained under Sir Thomas 
Clouston twenty or twenty-five years ago recognise in what Dr. Bruce has said to-day 
an echo of what our great teacher emphasised so constantly and persistently—early 
treatment of incipient mental disease, removal of the stigma, and so on. Another 
point is that one feels that there is an immense amount of hypothesis yet underlying 
the work which Dr. Bruce has covered in his paper this morning. It is not even 
theory, and I think Sir Frederick Mott has said what many of us feel, that we 
are on more sure ground in approaching the subject from the side of physiology 
and pathology. 

Dr. W. R. Dawson : I have been much interested in this paper, but I think on 
many points the reader is in the position of preaching to the converted. We are all 
in favour of treatment outside a mental hospital as long as it is safe to do it. As 
regards the closer association between psychiatry and neurology I have long 
thought this a very important subject. I remember in an address delivered so long 
ago as 1899 urging strongly there should be a rapprochement between them. I am 
perfectly certain that the more the two coalesce; the more the psychiatrist assists the 
neurologist, and the more the neurologist understands the view of the psychiatrist; 
the better will be the results for the patients of both. I was President of the Special 
Medical Board for almost the first two years of its existence in Dublin, and I can 
confirm what Dr. Bruce said about the difficulty in dealing with pronounced nervous 
cases or mild mental cases because there were not the same facilities in the way of 
neurasthenic hospitals as since the war. I hope during the next few years to see the 
development of the establishment of these outside clinics. I should like to emphasise 
what Dr. Bruce and Sir Frederick Mott have said, that although these clinics should 
be outside the mental hospitals, they should have a man with mental hospital 
experience connected with them always. The danger is that men who have had no 
real experience except what they have picked up in private practice will be appointed 
to posts like these. I do not want to disparage such men, but I think the result of 
taking a man who has had no real training in the treatment of mental disease will 
not be good for the clinic or for the patient. 

Dr. J. G. Soutar : It is true, as has been stated, that much of the nature of 
pure hypothesis is associated with the conception of the psychic origin of the 
disabilities which we are discussing. I do not think that this criticism has validity 
to discourage investigation on psychic lines. So far physiologists and patholo¬ 
gists have failed to explain phenomena observed in many instances. In a large 
number of cases definite degeneration occurs. In these, treatment on psychic lines 
can have no influence except on coincident secondary functional manifestations. 
There are, however, many cases which in their symptoms seem to be identical with 

LXVIII. 30 


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[Oct., 


those in which definite alterations in structure have been ascertained, yet they 
recover, and often quickly, under **psychic ” treatment. We are groping after the 
understanding of this. Hence the necessity for tentative hypotheses to give 
direction to investigation. 

Dr. J. F. Dixon : I have just one remark to make, and that is with regard to the 
training of the future specialists at the outdoor clinics. I think if I am correct Dr. 
Bruce envisaged a time when the asylums will be filled with chronic and dangerous 
lunatics, and there will be none of any other type there. I think the medical 
superintendent of such an institution will hardly be equipped from his experience 
and training to undertake the successful treatment of patients in the out-patient 
department, because he will then have had no experience of recent cases. 

Dr. G. Douglas McRae : I agree with Dr. Dixon. The public are already 
very strongly prejudiced against asylums and asylum treatment. I think you, 
Mr. President, last year drew attention to that very forcibly, and I think the point 
should not be lost sight of. We have been struggling for years to make our asylums 
hospitals. There is scarcely an asylum that has not got a thoroughly equipped 
hospital for acute cases connected with it. Many of the cases never go in among 
the chronic and supposed dangerous lunatics. They pass through the hospital 
department, and are treated by men who understand the disease as far as any hypo¬ 
thesis can enable them to do so. I strongly deprecate the suggestion that the asylum 
of the future is going to be filled and packed with chronic lunatics. 1 deprecate it 
because the vast majority of the asylum patients are by no means dangerous. A 
great many of them are simply mildly demented, and unable to earn their living 
and conduct themselves in ordinary society. Their weakness is not such a terrible 
condition that they deserve the stigma—public ignorance is the stigma—and 
1 think we ought to stand up more firmly for our asylums and get the public to 
understand what work we really do. I do not think we ought to leave the public 
under the impression that the mental specialist is a man who deals with chronic 
dangerous lunatics. I say if you have an individual who is so dangerous he 
ought to be irf a state asylum. The ordinary asylum ought to be a hospital 
for the care of mental cases, not a place for incarcerating people. Immediately 
a patient becomes dangerous we ought to pass him over to the Government as 
dangerous, and leave ourselves free as medical men to look after the other patients. 
I object to the asylum being selected as a place where a lot of dangerous lunatics 
are to be incarcerated. 

Dr. H. Yellowlees : In connection with what Dr. McRae has just said, may I 
state one thought that has occurred to me, namely, is it not extraordinary that the 
old fallacy that a dangerous case has any connection with a chronic case has once 
more been allowed to go unchallenged altogether? In many instances it is the 
recoverable cases that are frequently the most dangerous. 

Dr. Donald Ross : At the risk of being discourteous, I should like to express 
my disappointment with the title Dr. Bruce has chosen for his paper.^) While the 
substance of his paper was largely taken up with teaching us a good deal of what 
really we as psychiatrists know, I think the general public as well as anybody else 
wants to have it pointed out to them that we do know something about these 
things. A patient of mine who recovered said that the greatest stumbling-block 
in the welfare of mental cases was the general practitioner. 

Dr. T. S. Good : I happened to come from Oxford, and there the public do not 
believe that the mental doctor is a man to be left out altogether. At one time people 
had fear of witchcraft, they had fear of being shut up in the mental hospital, but now¬ 
adays things have changed. It is up to us to educate the people by showing we 
are not people who want to shut them up. As regards treatment, it is only by 
investigating both the psychic and the physical side of our cases that we can do 
any good. 

Luncheon. 

By the kindness of the Chairman, Sir James Adam, O.B.E., and the managers 
of the Royal Hospital, Morningside, members of the Association and their ladies 
were entertained to lunch at the Royal Arch Halls, Edinburgh. Sir James Adam 
presided. He was supported by other managers, members of the General Board 
of Control for Scotland, and others. This hospitality was much appreciated by the 
numerous guests. 

( l ) Original title of paper Dr. Bruce read was “ The Out and the Inside Treat¬ 
ment of Early Cases of Mental Disorder.”— Eds. 


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AFTERNOON SESSION.— July 19. 

Thanks to the Retiring President and Officers. 

Dr. T. C. Mackenzie : I feel it a very great honour, and at the same time the 
responsibility has been laid upon me somewhat suddenly and very unexpectedly, to 
be asked to propose a vote of thanks to the Officers and Council of the Association. 
I rise to do so with feelings of considerable embarrassment, and I hope members 
will not expect too much of me in the performance of this duty. We all are aware 
of the amount of work that is entailed by occupancy of the Chair of this Association, 
and I think we are equally agreed upon the manner in which Dr. C. Hubert Bond has 
discharged these duties and responsibilities. (Applause.) He has occupied the 
Chair at a time when the whole of lunacy administration, in which he is, in his 
official position, particularly interested, including psychological medicine and 
National mental hygiene, has been raised and canvassed, and the Association has 
to be congratulated that in such a year Dr. Bond has been its official head. 
(Applause.) 

I have also to express our thanks to our Treasurer, Dr. Chambers, who is 
unable on account of illness to be present this afternoon. I feel again my unfit¬ 
ness to speak of so devoted and revered a member of our Association as Dr. 
Chambers. I have met him on different occasions, and I think it is recognised 
that in Dr. Chambers the Association possesses not only an official in whom it 
can very securely trust its purse and financial matters, but a member of very 
special gifts and charming manner. We all deeply regret his absence this 
afternoon. 

As to our General Secretary, Major R. Worth, I have not been a Divisional 
Secretary, but I have some knowledge of what the work of a Divisional Secretary 
must be ; but what it must be to be General Secretary of the Medico-Psychological 
Association of Great Britain and Ireland—and I may say particularly in the present 
circumstances of Great Britain and Ireland—none of us perhaps can estimate, 
but we do assure Major Worth that we appreciate very cordially the energy and 
capacity, the tact and courtesy and all the other desirable qualities that he has 
exhibited. (Applause.) 

I have also to refer to the debt we owe to our Registrar. Dr. Miller, unfortunately, 
for reasons of illness in his own family, is also unable to be present at this Annual 
Meeting. Well, Sir, I speak with some sense of what Dr. Miller may be feeling 
with regard to one important department of the work of the Association, and I 
imagine, that metaphorically speaking, he is rather tearing his hair over the work of 
obtaining results for the recent Nursing Examination. But that is only one point 
of the work and the worries that the Registrar of this Association has to carry 
through. Dr. Miller has been a long-established holder of his present office, so 
that it is quite unnecessary for me, I am sure, to repeat what has been said on many 
previous occasions of the debt which the Association owes to its Registrar. 
(Applause.) 

There are also the Editors of the Journal. Every department of the work of the 
Association is onerous, exacting and responsible, and we have already had before 
us this morning the report of the.Editors of the Journal, from which the Association 
understands the difficulties that have arisen of late, and also how they are over¬ 
coming them. I think the Association owes its very hearty thanks to the Editors 
of the Journal. (Applause.) 

I should like to include in the vote of thanks—I cannot pretend to go through 
all the officials of the Association, and all those occasional members who act in an 
occasional official capacity, so to speak—but I should not like to sit down without 
reminding you of our indebtedness to the Chairmen and Secretaries—more particu¬ 
larly the Secretaries, as our Chairmen will admit—of the Parliamentary Committee 
and of the Educational Committee. I should like the Association to know and to 
understand that Dr. G. W. Smith, the Secretary of the Handbook Committee, is a 
man who has done a vast amount of very hard and exacting work for the Associa¬ 
tion, and I think the Association ought to include him very heartily in its votes of 
thanks to-day. (Applause.) 

There are others to whom I might refer. I might mention the Examiners. 
Their work has become very onerous. It is no joke to examine so many thousands 
of examination papers. It means a great deal of work to go through them con¬ 
scientiously and correct them. 


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With these remarks I hope I have been sufficiently inclusive. I may have made 
some omission, and if so I express my apology and regret for it, but I have very 
much pleasure in asking the Association to accord its very genuine and very hearty 
thanks to all the Officers and the Council of the Association. (Applause.) 

Dr. J. G. Soutar : When I followed Dr. Mackenzie this morning in the discus¬ 
sion there was just a shade of difference of opinion between us, but there is no 
difference between us on this subject, and 1 have pleasure in seconding the vote 
of thanks he has proposed in that delicate way of which he is a master, in a 
speech which has, I hope, let the different gentlemen referred to realise how highly 
we appreciate their services. I can only say they are carrying on the work of the 
Association in the spirit of a past of which we have reason to be proud of. 

The vote was carried by acclamation. 

The President: My penultimate duty in the chair is to return thanks on behalf 
of myself and all the officers and members of the Council of the Association for this 
vote of thanks for our labours, and the way you have received it. With regard to 
the officers there is no one in a better position than myself to endorse every word 
both Dr. Mackenzie and Dr. Soutar have said, and I take the opportunity gladly 
of expressing my own great debt of obligation to them. My position as President 
would have been absolutely impossible without their ever-ready help and the 
long-tried advice of the Council. It is not for me to add anything to what has 
been said by Dr. Mackenzie and Dr. Soutar, but as one behind the scenes you 
will pardon me if I do just accentuate the remarks in one direction, and that is to 
emphasise anything that can be taken to refer to Dr. Buchanan, the Secretary of 
the Scottish Division. We have started evidently on what is going to be an 
extraordinarily successful meeting, and 1 know that your new President and the 
General Secretary will endorse everything I might go on to say of how much we 
are already, and will be still further, indebted to Dr. Buchanan for the success of 
this meeting. These are nearly the last words I am entitled to address to you as 
President, and I will make them brief. You all know that I entered on my duties 
with very great diffidence, but that was banished by the fact that 1 very quickly 
found that I was among both new and old friends, and that there seems to be 
something more than a feeling of sympathy between us. Papers and discussions 
are a sine qud non to a Society that pretends to be scientific, and I take this oppor¬ 
tunity of thanking most cordially all those—and they are many—who have con¬ 
tributed papers for their help in my year of office. The more discussions we have 
the better, and among future ones I hope the Association may ere long, if I may 
venture to say so, take up the question as to whether we are satisfied with our 
nomenclature on mental disorders, and whether it has not outlived itself. But 
after all is said and done, I believe the chief value of these meetings is that we get 
to know each other’s difficulties and our ties of fellowship are constantly being 
strengthened. I want to give one word of apology and regret that I have not 
attended the Divisional Meetings. It was my firm intention to attend every one, 
or at least one in every Division. I have only been successful on one occasion ; 
the will was there, but the exigencies of other work made it impossible. Finally, 
mention of these Divisional Meetings prompts me to say that during my year I 
have been greatly impressed by the growing importance of our Association : 
whether it can ever aspire to an addition to its name I do not know. The increasing 
attendance of members and others resident in the Dominions and other parts of 
the Empire is a source of both satisfaction and strength to us and, without elabora¬ 
tion of my thoughts on the matter, it does seem to me that the desirability of 
approaching those members with a view to forming Overseas Divisions might well 
be considered; including minor changes in the constitution of our Association 
whereby, from time to time, we might find our President outside the British Isles. 
(Applause.) 

Installation of the New President. 

The President: Professor Robertson, my final duty is, to my mind, an extra¬ 
ordinary inversion of the proprieties. Though an Englishman, cannot 1 yet say 
that I was brought up in this city, at the feet of Gamaliel—you being my 
Gamaliel P So that if Fate had it in mind that there was to be this induction 
ceremony between us it ought to have been the other way about. The explanation 
of that no doubt is simple and relates merely to the rotation of the occupancy 
of the Chair, whose orbit circumstances occasionally force to be erratic. It has 


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1922.] 

given me, however, one of the greatest pleasures of my life; namely, to be President 
of the Association, and to come to my old University city and find myself in the 
position of inducting my old colleague and the Professor of Psychiatry into this 
Chair. In divesting myself of this badge and investing you with it, may I wish you 
most heartily a happy year of office. It cannot be happier than mine. That it 
may be equally so, and that is the best wish I can give you. (Applause.) 

Prof. G. M. Robertson (the new President) thereupon took the chair. 

The President: Dr. Bond, Ladies and Gentlemen,—I have to express my 
most grateful thanks to the Members of the Medico-Psychological Association 
for the honour they have done me in electing me their President, and I have 
also to thank my old friend and colleague—I will not say pupil—Dr. Bond, 
for the very kind remark which he has made regarding myself when installing 
me as his successor. I may say it has been an additional pleasure to me to 
have succeeded my old friend Dr. Bond. Dr. Bond, however, has set so high a 
standard of efficiency as President of the Association that I feel it is almost hope¬ 
less to aspire to follow in his footsteps. I will do my best, however, and I know I 
can depend upon the officials of the Association, as he has done during his term of 
office, including the General Secretary, Treasurer, Registrar, the Editors, and the 
Divisional Secretaries, to help me as they ever helped former occupants of the 
presidential chair. I wish to take the opportunity of saying how exceedingly sorry 
I am—and I am sure all of you are—that Dr. Chambers, our revered Treasurer, 
and Dr. Miller, our Registrar, are unable to be present to-day. Without these 
two officials—I might almost say permanent officials—the meeting does not seem 
to be quite itself. Now, the first duty of the President is to deliver his address, 
and the subject I have selected is a simple one, in which, however, I have been 
deeply interested, and I hope that it may help the public, who are really the 
audience to which I speak, and create in their minds an accurate picture of the 
modern mental hospital, its work and its ideals. The title I have selected is that 
of “ The Hospitalisation of the Scottish Asylum System.” 

The President then delivered his address, which was listened to with the greatest 
interest (see p. 321). Many passages were heartily applauded, and evidently voiced 
the sentiments of the audience generally. 

Sir Robert Armstrong-Jones : I rise with feelings of very great pleasure at 
being honoured to move the resolution of thanks. The address was all too short. 
The first key-note of the address was hospitalisation, and the second the gospel of 
human kindness—that is to say, skill in treating a disease in order to cut it short, 
and especially kindness, forbearance and sympathy in dealing with this illness, an 
illness which we all know is the greatest terror to the human race, and equally so 
both to the rich and to the poor. I would like to say that this address strikes me 
as a new departure. It preaches the quality of the heart rather than the quality of 
the head. It also raises to a very high level the value and excellence of administrative 
capacity by which our patients benefit. We wanted an address of this kind, and 
I have felt it is opportune. There is nobody who has felt the calumnies and odious 
assertions made with regard to the mental hospitals more than myself. They have 
also taken hold of the public mind, and this address, I venture to say, will go 
further than any address I have ever heard in reassuring the layman’s mind. It 
is an address that ought to have been delivered earlier, but we have it now. I have 
long watched the upward and distinguished career of Prof. George Robertson, and 
I have watched him from Perth to Stirling, and Stirling to Edinburgh, where he 
is now the able successor of Sir Thomas Clouston. Prof. Robertson’s great energy 
and great capacity for management augur well for this Association. May he have 
a very successful year, as I know he will have a very arduous one. I have been 
asked to move this resolution because I am one of his oldest friends. I think I 
am the oldest member present of this Association, and I was your Honorary General 
Secretary for nearly ten years. I have the greatest pleasure in asking you to pass 
a very cordial and hearty vote of thanks for the excellent address to which we have 
listened. (Applause.) L J 

Dr. W. R. Dawson : I have very much pleasure in seconding the vote of thanks 
proposed by Sir Robert Armstrong-Jones. I had the less hesitation in doing 
so since Sir Robert Armstrong-Jones was to precede me, and I knew from my 
previous acquaintance with his powers that his proposal of the vote of thanks would 
leave very little responsibility on my shoulders. Nevertheless even if he had left 
more it would have given me great pleasure to undertake it for various reasons, not 


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only because Prof. Robertson is an old friend, but because of the great position 
he holds in the School of Edinburgh and at Momingside Royal Hospital. I 
consider it one of the greatest honours of my life to have been formerly, if only 
for a short time, a member of the staff of the latter institution, and to have 
received my first training in psychiatry from Sir Thomas Clouston. We are not 
supposed to discuss the address, but there is just one point 1 should like to make, 
and it is that this address, which gives so excellent an account of the progress and 
advance of psychiatry in Scotland, shows that this progress has come entirely from 
within. It has not come from officious criticism on the part of busybodies who 
think they know better than the men who have studied the subject for a lifetime. 
It has come from the Committees, the Superintendents and others associated with 
the asylums themselves, all of whom have striven to improve their specialty and to 
do their best for the patients placed under their charge, and I entirely agree with 
what Sir Robert Armstrong-Jones has said, that the more wide publicity the address 
gets the better it will be not only for those who are associated with the asylums but 
for the public themselves and the patients and their friends. I have no doubt Prof. 
Robertson will have a successful year of office. He has begun well, and I have no 
doubt he will continue better. For these reasons it gives me the greatest possible 
pleasure to second the vote of thanks, which I am sure will be passed with 
acclamation. 

The motion was accepted with great enthusiasm. 

The President : I have to thank you all for the kind way in which you have 
voted me this thanks for the address which I have just delivered to you, and it has 
been particularly pleasing to me that this vote of thanks should have been proposed 
by Sir Robert Armstrong-Jones from the other side of the Border, and by Dr. 
Dawson across the Channel. I trust that this address of mine may be of some 
service in calming the agitation of certain people—an artificial and improperly 
stimulated anxiety—but I feel that the general public as a matter of fact does not 
take the real interest in the care of the insane or the mentally afflicted that it ought 
to take. I think myself that they really are on the whole somewhat apathetic, 
and all they are interested in at the present time is anything in the way of a scandal, 
or criticism. The real interest in the care of the insane I do not think exists, 
therefore it behoves us all the more to do a certain amount of education of the 
public. I think more should be done on these lines. After all, the strength of any 
movement for the care of the mentally afflicted must come from the general public. 
I was very pleased indeed by the reference Dr. Dawson made to the fact that most 
of these reforms had come from the mental hospitals and from those in charge of 
them. I feel we have been most unjustly dealt with, and had we not had the 
interested and sympathetic help of our Committees, influenced no doubt by the 
medical officers charged with the care of the insane, we would have been much 
further back than we are at the present time. I do not think there is any country 
in the world in which the insane as a whole are treated so well, and certainly I 
know of no country in which they are treated with more consideration and kindness 
than in Great Britain. I have to thank you all for the way in which you have 
listened patiently to my address. (Applause.) 

Tea was then served and the meeting adjourned until the following day. 

The President-Elect’s Garden Party. 

On the previous afternoon (Tuesday, July 18) Prof. G. M. Robertson (President- 
Elect) and Mrs. Norman Ritchie held a reception at Tipperlinn House, Morning, 
side, to which members and their ladies were invited. There were many guests, 
and music, tea, tennis, clock golf and warm sunny weather all went to make 
the occasion an enjoyable one. It was a happy reunion of members drawn from all 
parts of the Kingdom, and a pleasant prologue to the more serious business of the 
morrow. 

THE DINNER, July 19, 1922. 

The Annual Dinner was held in the Hall of the Royal College of Physicians, 
Edinburgh. The President (Prof. G. M. Robertson) presided over a company 
numbering about 150. The guests included the Rt. Hon. Lord Provost Hutchison 
and Mrs. Hutchison, Principal Sir Alfred Ewing and Lady Ewing, Sir George 
Paul, Sir Arthur Rose and Lady Rose, Sir Robert Philip, Sir David Wallace and 
Lady Wallace, Mr. J. G. Jameson, M.P., Sir John Findlay, Mr. R. Scott MoncriefF, 


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the Rev. Dr. Fisher, Prof. Meakins, Sir James Adam and Lady Adam, and others. 
There were also present Prof. Roger, Dean of the Faculty of Medicine of Paris, 
and three of his colleagues from Paris and Lyons. The croupiers were Major R. 
Worth, Dr. John Keay, and Dr. W. M. Buchanan. 

“The King.” 

“The Prince of Wales.” 

The President submitted these toasts, which were honoured in due form. 

“The City of Edinburgh.” 

Dr. J. G. Soutar : Mr. President, My Lord Mayor (Laughter)—I beg pardon, the 
atmosphere of the south still clings to me—My Lord Provost, Ladies and Gentle¬ 
men,—When the President asked me to propose the toast of “The City of 
Edinburgh ” I was rushed into acceptance by that wave of emotion which the very 
mention of her name is apt to arouse in those who have known Edinburgh and 
therefore loved her. It might be that some of my psychological friends from the 
south see in this bit of self-revelation evidence of that emotionalism which they 
associate with what in their politeness they would call senectitude, avoiding the more 
frankly expressive term “ senility.” An active emotional response is the normal 
reaction to the stimulus which Edinburgh affords to those who really know her. I 
am experiencing the difficulty of putting into cold words the reason for and explana¬ 
tion of the charm which Edinburgh exercises, and of the grip it retains on those who 
for long have dwelt elsewhere. So much can be said that I am embarrassed, not by 
the poverty, but by the plenitude of the material. Of the many possible lines of 
thought which I might follow in proposing this toast, I ask you not to think of 
Edinburgh as a city in the ordinary sense, as a place of streets and squares, of fine 
buildings, beneficent institutions, renowned educational establishments, as the seat 
of enlightened civic government—though for all these she is famous—and of the 
beauty of her situation as an enduring joy-feast. I ask you rather to think of her 
as a potent and persisting suggestion, an atmosphere of influence, an environmental 
force which silently but irresistibly moulds succeeding generations of plastic youth 
to the tradition of spiritual, intellectual and political freedom, for which through 
its long and varied history Edinburgh has unflinchingly maintained her claim. 
The influence of tradition which Edinburgh inspires is the city’s invaluable gift 
to her own and her adopted children. In its formative effect on character, it 
gives potency and purpose to the academic learning which Edinburgh’s famous 
schools so amply afford. I give you therefore “The City of Edinburgh,” with 
which I have the privilege of associating the Rt. Hon. the Lord Provost, who, by 
the choice of his fellow citizens, is the representative and the guardian of that fair 
home of fine traditions. 

The Right Hon. the Lord Provost, in replying, said: I must first of all thank 
Dr. Soutar very sincerely for the way in which he proposed this toast. I thank 
him also for the new title which he gave me. I have acknowledged many titles in 
the position I hold, but he has endowed me with another one which I will always 
treasure. I have occasion to reply to the toast of Edinburgh very frequently, but 
I always do so with a feeling of trepidation; but after all the City of Edinburgh 
does not need an advocate; she requires no spokesman, as Dr. Soutar has said. 
Edinburgh is known all over the world, and regarded with respect and with admira¬ 
tion for the beauty of her surroundings. These are natural acquirements for which 
she always has been and will be respected and admired and loved. But we cannot 
always live in the past. I am reminded of the fact that her fame is largely due to 
the medical school attached to our city. For long generations the Edinburgh 
School of Medicine has been famed for its pre-eminence in medicine and surgery, 
and as the science of psychiatry becomes better known I trust the School of 
Edinburgh will take a foremost place in that science also. We feel very honoured 
that your Association has chosen the City of Edinburgh for its meeting this year. 
And may I add a personal note—we feel very proud that Prof. Robertson is 
President this year. (Applause.) We in Edinburgh feel it is a well-deserved 
honour that he has been elected to this position, and we feel it redounds to the 
credit of the School of Medicine of Edinburgh. I should like to accord a very 
cordial welcome to the Association, and to those distinguished French visitors who 
are staying with us at present. (Applause.) We welcome them as honoured 


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guests, and we hope they will take away with them very pleasurable recollections 
of their visit to Edinburgh. I thank you, Sir, for the way in which you have 
proposed the toast of “ The City of Edinburgh.” (Applause.) 

11 The University of Edinburgh.” 

Dr. C. Hubert Bond : In all the ups and downs of a thirty years' professional 
life, nothing has stirred greater emotion in me than finding myself, albeit one of 
the least in her kingdom, called upon to give beneath her very shadow the toast of 
this venerable and illustrious University. To many of us permitted by the courtesy 
of the College—whose Royal Charter of 1681 antedates the birth of even the 
University’s Medical Faculty—to make good cheer in this beautiful hall, this toast 
is really one of Alma Mater in the fullest sense of those words; and to me, as it 
surely must equally be to others similarly privileged, it is with a feeling of grateful 
pride that I can claim to range myself among her alumni. 

And what is the University whose health I am going to ask you to drink ? Is it 
her stately buildings—old, new and ancillary—to which the visitor to the Queen of 
the North may perchance ask to be directed ? Much could I say concerning them, 
for they are hallowed by memories and friendship which it would be pleasant to 
revive. But suffice it therefore to say that of her buildings she may well be proud, 
for representing more than utility they, as it were, appear “to satisfy some faith ”; 
and, as that faith can never have contemplated anything short of thd fulness of 
life, it will not be taken as unfilial to name some that so far have not emerged 
from abstract to concrete, and to point to the absence, for instance, of any 
University Temple; of that “fourth estate,” a University Press; and—save 
perhaps for women and pace University Hall—the absence of any residential 
colleges. Personal reflection and a watch on the lives of juniors have convinced 
me that, admitting with deep gratitude the many and great, and in some measures 
unique, advantages of an Edinburgh education, the lack—outside seminar and 
laboratory—of the training and discipline begotten of college comradeship, and 
still more of that confraternity engendered by the healthy rivalry between several 
colleges, is a disadvantage which, I humbly submit, ought not indefinitely to be 
overlooked. To meet it the Union and the Athletic Club have done all they can, 
and for the use of the latter the recent purchase by the University of a second field 
is of good augury. 

But no! Visit and admire them, within or without, as well as you may, it is 
not her buildings, not the static but the dynamic, energising and live University 
whose health we wish to drink. There are her three great officers—the Chancellor, 
a post which for over thirty years has been filled by the Earl of Balfour, accepted 
by the world as guide, philosopher and friend; the Vice-Chancellor and Principal, 
Sir Alfred Ewing, who to the University's great advantage is able to bring both 
inspiration and breadth of vision, as well as indefatigable energy, in the discharge 
of the multiplex and onerous duties of his office, and with whom I shall couple 
this toast; and thirdly, the Lord Rector, in whose triennial election the franchise 
is vested in the students, and mention of whom entitles me to include in our toast 
the health of the Prime Minister himself. As Rector he is President of the 
University Court, a body corporate endowed with very wide powers, administrative 
and disciplinary, and in which, by the ex-officio presence of the Lord Provost and 
an Assessor, the fortunes of the University and City are happily identified. It is, 
however, with the supreme functions of teaching and research that we associate 
the University; and, though we certainly will not omit from our thoughts her 
nearly 5,000 undergraduates—for it is they, to-morrow's mankind, with their annual 
tide of freshmen, drawn from all parts of the Empire and clamorous for knowledge, 
that provide her with perennial youth, imperialise her influence, guard her gates 
from the worm, and are the mainspring of her existence—nevertheless the core of 
our toast is appropriately the Senatus Academicus and the six Faculties. 

The Kingdom of Knowledge is not only itself boundless but is devoid of dividing 
lines within, and it is only our own limitations that impose these subdivisions in 
teaching; but admitting their necessity—which, as it bids fair to increase, behoves 
a resolute guard against water-tight compartments, and especially does this 
danger beset medicine—we cannot but admire, and the University can justly be 
proud of her organisation for teaching and her success in continuing to attract 
teachers of eminence, not a few of whom we know as of world-wide fame. That 
they have entered into a great heritage, the creation of illustrious predecessors. 


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they would be the first to acknowledge, and also that it does but add to their 
responsibility. As to the efficiency with which this is discharged, an eloquent 
witness is the proportion of Edinburgh’s over 13,000 graduates who have not only 
acquired honourable positions, but who, in response to the inspiration caught from 
their teachers, are themselves making still more brilliant the torch of knowledge. 

This is mainly a medical gathering, and it will not be misconstrued if, for a 
moment, I single out the Faculty of Medicine. It takes some years, but thirty 
must certainly be enough and to spare, to provide that perspective needed rightly 
to appreciate what Edinburgh did for us. In my day—and it would surprise me if 
the same does not still hold good—we even dared to complain that we had too 
many lectures; among us this evening is an old friend of mine whose father said 
he would have sent him to Edinburgh had he been able to afford him two pairs of 
breeches to each suit. (Laughter.) Be that as it may, there were certainly no 
“wall lectures” ; nor, recollecting the crowded benches at optional courses, can the 
credit for attendance at the others be claimed by the stalwart janitors with their 
card-collecting propensity ; yet I am inclined to think that had we had a little more 
breathing time in which to work up and digest our scribblings, they would have 
been of still greater value. But, of my happy college days—and they were very 
happy—the two dominant notes now in my mind are, first, the complete and whole¬ 
hearted devotion of our professors and other teachers to the interests of the 
students; and second, the fact that we were made to think , both in lecture and at 
bedside—questions were put to the class which we were told to sleep on and think 
about, and the answers, sometimes from the lips of a student, were given next day. 
One of our Dons, affectionately known to us as “ Honest John ” (Cheers)—but he 
was by no means the only one—was particularly fond of this form of mental tonic, 
and while a. multitude of his recited facts have faded from my memory, I can still 
recall all his questions and their answers. So long as the chord of these two notes 
rings true, Edinburgh teaching will ever be second to none. 

You are impatient for me to give place to Sir Alfred Ewing, but permit me 
reference to just one other point, the omission of which you would not lightly 
forgive. In our own specialty of psychological medicine Edinburgh has taken a 
momentous and pioneer co-ordinating step, one which, subject to local considera¬ 
tion, it is the hope of my colleague Commissioners of the Board of Control to see 
adopted in the vicinity of each University in England and Wales, namely, a linking 
upon an official and permanent basis of the duties of the medical staff of mental 
hospitals with teaching and research within the University. Edinburgh has not 
only instituted a chair in Psychiatry—at least one English University for years has 
possessed such a Chair—but she has entered into an arrangement with the 
managers of the famous Royal Edinburgh Hospital at Morningside, under which, 
for the future, the posts of Physician-Superintendent and Professor of Psychiatry 
become a joint appointment, election to which is vested in the two bodies. 

Not the least part of our satisfaction in the matter is the circumstance that the 
first occupant of this most important position is the newly installed President of 
our Association, Prof. G. M. Robertson (Applause), whom, not doubting but 
that his advice has been a material factor in the arrangement, we most heartily 
congratulate, as well as Sir James Adam and the other managers of the Royal 
Hospital at Morningside for their enlightened generosity in presenting ^10,000 
towards the endowment of the Chair. If not out of order, may I add that to bring 
psychological medicine—where it should be—within the main current of general 
medicine, one step further seems needed, namely, to make this union a triad, the 
additional partner that I have in mind being the Royal Infirmary. 

I have detained you far too long. Edinburgh University is what all the world 
knows her to be. She fills, not a niche, but a sphere, whose void is unthinkable. 
Enthroned on crags in the Metropolis of the North, still more so is she in the 
hearts of all who know her. Therefore, all hail to the Thistle and Castle and 
Book! The Toast is “The University of Edinburgh,” and with it I couple the 
name of the Vice-Chancellor and Principal, Sir Alfred Ewing, K.C.B. (Applause.) 

Principal Sir Alfred Ewing, in replying, said : For some time back I have 
very unwillingly been obliged to admit in myself a tendency towards what Dr. 
Soutar has so pleasantly described as senectitude rather than senility, but to¬ 
night I have a much more difficult question before me. For the first time I find 
some doubt as to my mental stability ! (Laughter.) And the reason is plain. Our 
President and the late President between them have a little conspiracy to test 


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the condition of my mind by administering to me a series of severe shocks. It 
was only when, after sitting down to dinner, I opened this programme and turned 
from the first page—which is wholly delightful—to the second that I learned I 
was amongst the speakers. But that is not the only test which your President has 
applied. In the course of conversation he has told me to-night what I never knew 
before—that I am a Deputy Governor of his insane asylum. (Laughter.) That is 
a responsibility from which I naturally shrink, a responsibility which I never con¬ 
templated. I suppose one has to qualify for it in the same way as one has to qualify 
for the bar—by eating dinners ; but if they are all like this one I shall enter on 
my training with a comparatively light heart. Dr. Soutar said something about 
the power of persistent suggestion ; although I am not a medical man I have heard 
of Dr. Cou 6 , and I am afraid the suggestion before me is to take the form of 
saying, “ Every day and in every way I am becoming madder and madder.” 
Perhaps the best way to fit oneself for the post of Deputy Governor will be to read 
over again that admirable textbook on the subject, which was written by a 
member of the family of one of your predecessors, Mr. Storrer Clouston, under 
the title of The Lunatic at Large. (Laughter.) The President has given me 
another shock by reminding me that the University and the Asylum are in a sense 
next door neighbours, the University playing fields are coterminous, or, as we say 
in Scotland, march with the grounds over which he exercises governing control. 
The two are only separated, I believe, by a low wall, over which it is easy to jump. 
(Laughter.) We have now a professorship of psychiatry, which we owe to the 
Governors of the Asylum. It gave us particular satisfaction to think that the first 
occupant of the professorial chair is our distinguished President. Our meeting 
to-night has the balance of its sanity largely restored, if I may say so, by the 
presence of guests from the other side of the Channel. (Applause.) We welcome, 
as the Lord Provost has already said, with the greatest interest and pleasure the 
presence of Prof. Roger and his colleagues from the University of Paris as 
visitors to the Medical School of Edinburgh. I hope when they return they 'will 
clearly distinguish between the normal sane inhabitants of Edinburgh and you 
gentlemen who are on a visit here. (Laughter.) This great Association is, I 
believe, founded upon nothing less than an Imperial basis. It is not simply British ; 
it includes Ireland and all the Colonies. I have no doubt in Ireland, which you 
are shortly to visit, you will find much to work upon. Your colonial relation¬ 
ship tends to strengthen the ties between the Mother Country and the Colonies. 
Whatever else the University is it is essentially an Imperial institution, drawing 
its pupils from the ends of the earth, and sending them back with the torch of 
knowledge lighted to the ends of the earth, where they diffuse that light. This 
is a great function of our Edinburgh University. It has become even a greater 
function than it used to be with the increase of numbers and the increase of 
importance of University work in the judgment of the public. More and more 
the world is looking to the Universities for guidance in the conduct of life, and if 
civilisation is to survive, if it is to get out of the slough in which it finds itself, it 
will be, I think, largely through the influence of the Universities. (Applause.) 

“The General Boards of Control.” 

Mr. J. G. Jameson, M.P.: I have been selected for the honour of submitting to 
you the toast of “ The General Boards of Control of the Insane ” in this country-. 
I have noticed frequently that it is a custom of after-dinner speakers to express a 
mild surprise when the honour of proposing a toast has fallen upon them, and to 
say it might more properly have fallen upon some other lady or gentleman. I do 
not know if it is the desire or expectation of any of our audience that I should 
follow that procedure to-night, but in case it is I should just like in one word to 
tell you how it comes that I am standing here to-night. My friend on my right. 
Sir James Adam, the King’s Remembrancer, came to me yesterday and said that 
the proper person to propose this toast of “ The General Boards of Control of the 
Insane” would clearly be one of their own beneficiaries, one of the people under 
their control, but owing to the unavoidable absence of a duly certified mental 
defective, that you, Mr. President, thought that this toast should be entrusted to 
a Member of Parliament, and Sir James added that when he was consulted he had 
no hesitation in saying that I was the man for the job. (Laughter.) I belong to 
that unfortunate race of people called not only politicians, but lawyer politicians. 


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•who are known to be the low-water-mark of humanity. (Laughter.) I think he 
had in his mind when he asked me to come the precedent of that English lawyer 
who provided in his will for a home for the insane, and added, 14 1 have made 
all this money out of habitual litigants, and I think it is only restitution to give 
it to a home for the insane.” (Laughter.) I do not know, Sir Arthur Rose, if there 
are more than the appropriate number of my professional brethren under your 
control, but I may say the last time I visited one of these commodious and luxurious 
'establishments under your supervision was when I went to see a very dear friend 
of mine who comes from my own part of the country, and who was described by 
.an old farmer’s wife to me in the very Christian and tolerant spirit of that country^ 
side as “ an awfa guid man but a perfect martyr to the delorium trimens.” 
{ Laughter.) I was delighted and surprised to meet there a very large body of my 
professional brethren who had disappeared from my ken for many years. I will 
only mention one. He is a man who is well known to us, and who is there 
very comfortable and very happy, and who did very well in the war, because in 
the beginning of the war, in August, 1914, he wrote to the Chancellor of the 
Exchequer offering the dreadnought, which was accepted, but three days later 
he wrote again that on consideration he had come to the conclusion that it 
would be better to withdraw and cancel his offer of the dreadnought because he 
thought it would be more useful to pay off the National Debt. (Loud laughter.) 
It was only then that the Chancellor of the Exchequer thought that there must 
be something wrong. (Laughter.) Well, I am bound to say so little did I know 
of the activities of the Board of Control that when it was first suggested to 
me my own base politician mind thought that the Board of Control related to 
the Liquor Control at Carlisle, but on it being made clear to me I betook myself to 
Oliver and Boyd’s Almanac , and there I found that the activities of Sir Arthur Rose 
in Scotland are very onerous and very special. It is said in that profound book 
of learning that in Scotland every lunatic who is maintained by the public funds 
is under the immediate and personal care of the General Board of Control. When 
I read these words I pictured Sir Arthur going round the 7,000 lunatics of Scotland 
-and shaking hands with these lunatics, which I am certain he does. (Laughter.) 
Before this dinner I was talking to an asylum doctor and he told me with what 
•eager delight the visits of the General Board were looked forward to, how carefully 
*he welcome of these descending angels was prepared and with what sorrow their 
departure was regarded, and the old humdrum life recommenced. I am reminded 
that it was some time ago that I heard an Englishman remark to a Scotsman about 
the larger percentage of mental defectives in Scotland as compared with England, 
and the Scotsman gave a reply, which will be assented to by at least every Scotsman 
present, because he said, “ I don’t wonder at that, but you must remember that 
a person who would be held mentally deficient in Scotland might be thought a 
-very clever person in England.” (Laughter and applause.) There was just 
one other thing I gathered from Oliver and Boyd, and that was that the ultimate 
decision rested with the Board of Control as to who was and who was not insane. 
That is a terrible question, surely. Few of us are so stout-hearted that we can 
listen to such a question without tremor, and if I am lavishing praise upon the 
Board you will understand that the gratitude is with a lively sense of favours to 
•come. (Laughter.) Who is insane, and who is not insane—that is a very serious 
question. Perhaps the strongest view was put by the lunatic himself, who was 
asked, 11 Why are you here in the asylum ? ”, and he said, “ Well, I said the rest of 
the world was mad, and as the rest of the world said I was mad, I must have made 
a mistake.” We can only hope that if that position comes near any of us you will 
behave in a way in which justice is tempered with mercy. (Laughter.) I have to 
couple this toast with the name of Sir Robert Armstrong-Jones, the Lord 
'Chancellor’s Visitor for England, and with the name of Sir Arthur Rose. That 
name of the latter gentleman has become almost a household word in Scotland. 
As you will see, he is a warrior, with the coveted letters of D.S.O. after his name, 
and the coveted title of Colonel, and he is very well entitled to both of them. He 
is also the friend of the smallholder. I have therefore very much pleasure in giving 
to you the toast of the General Boards of Control, coupled with the names of Sir 
Robert Armstrong-Jones and Sir Arthur Rose. (Applause.) 

Sir Robert Armstrong-Jones : As time is short, I will merely content myself 
by reciting to you the story of a Judge at Assizes. There was a very black 
record against the prisoner, but he asked the prisoner if he had anything to say 


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for himself, and he replied “ No/’ whereupon a person in the body of the Court got 
up and said, “ I have something to say about him.” The Judge then asked the 
prisoner if he had any objection to his friend speaking. The prisoner replied* 
“ No, but hang me first.” That is exactly my position now, and you do not want 
to hear me. My friend, Dr. Soutar, has referred to two definite characteristics 
of the Scot—firstly education, and secondly, caution. I will give you an example 
of the second. A clergyman of the Church of England announced that after 
the service there would be a silver collection, whereupon promptly two Jews- 
fainted, but they were carried out by sixteen Scotsmen ! (Laughter.) As regards- 
education, I was reminded of a story related to an Englishman that there was not 
a single Scotsman who was not connected with the University. The Englishman 
arrived in this beautiful city of Edinburgh to verify this when he met a young 
girl and he asked her, “What are you?”, and she said, “ I am a beggar, sir. ,r 
“ What is your mother? ” “ My mother is a beggar.” “ What is your father? 99 
“My father is in jail.” “Have you any other relations?” “Yes, I have a 
brother.” “What is your brother ? ” “ My brother is in the University. My 

little brother happened to have four heads and he is in a glass bottle in the 
University”! (Laughter.) Now, may I say that the people who are departures 
from the normal are well looked after by the members of the Board of Control. 
You have heard already from Dr. Bond what is being done—what the Universities 
have done—with regard to teaching and to the care of those who are departures- 
from the normal. I leave the rest to Sir Arthur Rose. 

Sir Arthur Rose : At this late hour 1 feel I cannot do very great justice in 
replying to this toast. Might I, however, say with regard to one of the questions- 
put, that the statutory oath under which 1 labour debars me from answering it, but 
I am not going to take advantage of that; I would rather put forward the plea of 
inexperienced youth—youth in the sense that I am probably the youngest recruit 
in the work in which the members of this Association are interested. I have very 
recently joined the General Board of Control of Scotland, and what struck me 
was the extraordinarily happy relationship which existed between the local 
authority and other governing bodies—a friendship which has contributed so- 
enormously to the success of this great work in Scotland. I can assure you that 
the Board of Control is thoroughly imbued with the same spirit, and as far as they 
are concerned will continue to be so. I might also add that I hope the speech, 
which the President delivered to-day will be read by the public. I hope it will be 
read and digested by the public in preference to the reports of the Boards of 
Control. May 1 say that in Scotland we are extremely proud of our asylum 
system, but at the same time great success is like after an excellent dinner— 
it does not conduce to further effort. We must safeguard against the feeling 
that we cannot progress further. I was glad the President indicated the lines oit 
which we could progress further in Scotland, namely the lines of increased clinicai 
and pathological research work in our asylums. If our superintendents and the 
managing bodies can take these words to heart, and can do something to push, 
forward the work in Scotland, I can assure them in advance of the hearty support 
in every possible way of the Board of Control. (Applause.) 


“The Medico-Psychological Association of Great Britain and 

Ireland.” 

Sir Robert Philip, in proposing the toast of the Association, said : I think I 
may fairly claim that the toast which has been committed to me is the toast of the- 
evening. The evening is far spent and the night is close at hand. We must 
regard the place it occupies on the toast list as an expression of the fine altruism 
of the Society. Your Society is not quite young; it has reached what we may call 
the interesting age, very young societies, like people, are less interesting. You are 
81 years of age; for a Society that is, I fancy, equivalent to the delightful age of 
35 or 40. Your baptismal name is suggestive. The first part suggests that strong 
Roman feature which is associated with the control and care of the madman. As 
intermediary between the keeper and madman you have done very well. There 
was a time when it was thought necessary to protect the madman from his fellow 
men, and his fellow men from the madman, and he was chained up to the stone 
wall of his cell. But thanks in large part to the influence of Pinel of France and 


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Tuke of England, the madman has regained his liberty. He is now treated as a 
man whom we respect, whom we are out to help in every possible way. The 
second part of your name recalls the influence of Greece. You have dipped into 
the deepest problems of human life. Whenever a new aspect of philosophy appears 
you have tried to apply it in respect of the treatment of the insane. If sometimes 
the pendulum has seemed to swing too far to one side it has swung back to the 
middle line of truth. I want to say what a great pleasure it has been for those of 
us who are attached to the Royal College of Physicians to see you in this hall. It 
has been a very real pleasure for two reasons. In the first place, as you sit here 
to-night you are surrounded by the portraits of some of the great departed, and 
among those there are three that I must refer to on this occasion. The first is a 
man who did not in his time get the credit that he should have got, I mean 
Prof. Laycock; the second is Sir John Batty Tuke, who was devoted to the 
advance of scientific medicine; and the third is Sir Thomas Clouston, so long 
associated with the great institution Prof. Robertson presides over; master of his 
art and grandfather of the lunatic at large. (Laughter and applause.) And now 
for the second reason. You have been, may I say, particularly happy in your 
choice of President. (Hear, hear.) Prof. Robertson is a man who, both in the 
University and in this College, we all honour. I asked him if there were any points 
to which I should refer. He reminded me that it was due to this College that the 
Royal Asylum for the Insane, so loyally presided over by Prof. Robertson, was 
founded so far back as 1792. We were the first donors of £25 for the purpose 
of erecting an asylum for the insane. Lastly, I would like to say that, so far as this 
Royal College is concerned, no Fellow is trusted more than Dr. Robertson. He is 
regarded as one of our wisest counsellors. We look to him filling the chair he is 
now occupying as President of the Royal College. (Applause.) 

The President, in reply, said: At this very late hour you do not expect a speech 
of very great length from me. On behalf of the Medico-Psychological Association 
I have to thank Sir Robert Philip, the President of this College, for his apprecia¬ 
tion of the good work done by our Association. This is not the occasion nor is it 
the time to enlarge upon the nature of this work. I may just refer, however, to 
the work that is done in the training of mental nurses in the duties of their 
profession, which has been really beyond all praise. I have to thank Sir Robert 
for his pleasant reference to my predecessors, the portraits of whom appear on 
these walls. I have to thank the guests who have honoured us here to-night, 
including the Lord Provost, the Principal of the University of Edinburgh, the 
Chairman of the General Board of Control, the President of the Royal College of 
Physicians and Surgeons, the Deputy Keeper of His Majesty’s Signet, and other 
dignitaries. The Chairman of the Board of Control in England unfortunately is 
unable to come owing to illness. I may also say that we have the representative 
of the Norwegian Board of Control. We are on extremely friendly terms with 
the Boards of Control. I desire to take this opportunity of thanking the managers 
of the Royal Hospital at Morningside, and I may say it gives me great pleasure to 
express in this hall our appreciation of what they have done for us, seeing, as the 
President of this College has just told you, that the institution was really founded 
here by that well-known and able man, Andrew Duncan, who was then President 
of this College. I would be failing in courtesy if I did not thank the ladies for 
their presence here to-night. (Applause.) 


“ France.” 

The President : I wish to say that we are proud to entertain tour Professors of 
the Faculty of Medicine of Paris, including, amongst those, Prof. Roger, the Dean 
of the Faculty, and also a Professor from the Faculty at Lyons. These gentlemen 
are the honoured guests of the University, and before singing “ Auld Lang Syne,” 
which follows, I wish, in order to show our appreciation of the civilising influence 
of France, and to show our appreciation of the scientific work she has done, and to 
show our unbounded admiration of the fortitude and endurance of the French 
people in the late war, to ask the ladies and gentlemen to drink with me to 
France. (Applause). 

The toast was cordially honoured, and the proceedings afterwards terminated 
with the singing of “ The Marseillaise ” and M Auld Lang Syne.” 


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MORNING SESSION.— Thursday, July 20. 

At the Physiology Lecture Room, University New Buildings, the 
President presiding. 

The President: There has been a slight change made in the arrangements for 
this Annual Meeting. Instead of having papers, we have decided this year to get 
addresses from men who have made reputations in the study of these particular 
subjects which appear on the Agenda. As you are aware, a great deal of recent 
theories circle round the influence of the endocrine and internal secreting glands, 
therefore I thought it would be of advantage to us if we could get someone who 
has made his mark in the study of this to open the series of addresses, and I 
naturally appealed to Sir Edward Schafer. He kindly agreed to do this, and I 
wish to say it was at the cost of a good deal of inconvenience to himself. 

Addresses. 

u The Influence of the Endocrine Glands on the Nervous System.” By Prof. 
Edward Sharpey Schafer, LL.D., D.Sc., F.R.S. (see p. 347). 

The President : We have had a most instructive and interesting address on a 
most difficult and complex and important subject. One of the difficulties the 
ordinary physician has in connection with this matter is the difficulty of obtaining 
in condensed form, that is easily comprehended, the most recent and authoritative 
views. As Sir Edward has told us, investigations are proceeding constantly, on a 
very widening circle, and it is only by an address such as we have listened to 
to-day that we get anything like a grasp of the situation. I therefore ask you 
to give a most cordial vote of thanks to Sir Edward Schafer for his most valuable 
address this morning. (Applause.) 

“ The Investigation of the Relationship of the Reproductive and Endocrine 
Glands to Mental Diseases,” by Sir F. W. Mott, K.B.E., LL.D., F.R.S. 

Mr. President: I feel great diffidence in following my old teacher Sir Edward 
Schafer in this subject of which he has taught us so much. When your President 
asked me to take up the application of endocrinology to mental diseases, I felt I 
had a task before me that was impossible. I looked up endocrinology and I got 
completely dazed looking through the differences of opinion that were expressed; I 
therefore thought it would be better if I gave you a short account of my own work with 
a lantern demonstration. I should have written an address if it had been possible, 
but I did not feel it was possible to follow Sir Edward Schafer adequately in a 
subject which is difficult and as yet only beginning. Therefore with apologies for 
what I am going to say I will simply show lantern-slides, and endeavour to explain 
the work I am actually responsible for myself. I do so with a good deal of 
trepidation in the face of the master of the subject, after his extraordinarily 
illuminating address, which will be of the greatest benefit to this Association, 
because it opens out to them the whole subject comprehensively, and it will indicate 
to many young men the way to investigate disease, and to always look with a critical 
mind upon the results. I am sure when I show these slides I do so with humility, 
because I feel there is a great deal I cannot explain. But these are facts as far as 
I can give them, and I think if we collect only facts that are reliable then we can 
draw conclusions, but not before. 

[The theatre was then darkened, and Sir Frederick Mott proceeded to give a 
resume of his recent work on the pathology of dementia praecox, especially from 
the point of view of endocrinology, illustrating his remarks by lantern-slides of 
microphotographs, etc. He covered to a large extent the ground of his recent 
papers on this subject and announced the results of his most recent investigations. 
Readers are referred to previous numbers of this Journal, and to the Archives of 
Neurology and Psychiatry , from the Pathological Laboratory of the London 
County Mental Hospitals, vol. viii, 1922. See also his most recent paper with 
illustrations on p. 333. The meeting had the advantage of seeing many of the 
latter shown on the screen.— Eds.] 

On the light being resumed Sir Frederick Mott continued: 

To sum up with regard to the relation of these changes of dementia praecox, 

I would say this, that it is not the absence of the interstitial cells or degeneration 
of the interstitial cells that causes the changes in the brain, although we know 


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these cells energise the whole tissues of the body, but the genetic inadequacy 
which is shown by the fact that the two structures in the body are specially liable 
to undergo a premature atrophy. If we try to associate the absence or the partial 
absence* of the hormone or the autacoid of the glands with the changes in the 
brain, then people would say, “ Why does not castration produce dementia 
praecox ? ” So that I think the safer explanation of the facts would be that these 
structures which have been later developed have been developed from very few of 
the original protomeric cells of the neural type. Of course the stress may come 
from physiological conditions. Take the stress of puberty, take the stress of the 
woman who is in child-birth ; that is a normal physiological condition, yet we 
know half the cases of dementia praecox are in married women and it comes on 
during pregnancy or parturition. Then as regards psychological stress, people 
seem to think I do not lay much stress on the psychological stress. I think the 
psychological stress influences the whole of the endocrine system. Therefore, if 
you have got your endocrine system upset that will affect these structures which 
are most liable to take such stress. Then there is the pathological stress. In fact, 
these people have a narrow physiological margin to work upon. If you can 
avoid this form of stress, then you will avoid a breakdown. But are we doing a 
service to the nation by keeping these people alive ? (Applause.) 

The President*. Sir Frederick Mott is one of the members of our Association 
of whom we are most proud. There is no man who has done a greater amount of 
work and original research than he has—researches on very original lines. Not 
only that, he is a member we can call on at any time for a paper, and he never fails 
us. For many years he has been a standby to our Association, and he has been a 
credit. Some of his observations as regards the effects of the internal secretions 
from the reproductive glands open up a very wide field of speculation. I therefore 
ask you to give him a very hearty vote of thanks for his address this morning. 
(Applause.) 

“ Observations relating to the Sympathetic and Para-Sympathetic Systems.” 
By J. J. Graham Brown, M.D., F.R.C.P.Edin. 

Mr. President,—You may recall that when you did me the honour of asking me to 
speak here I hesitated. I hesitated not only because the subject is an extra¬ 
ordinarily difficult one, but also because it is almost impossible to compress what 
ought to take about a dozen lectures into the space of half an hour. That is 
really the essential difficulty. You will remember that the autonomic system 
consists of two great divisions—the sympathetic and the para-sympathetic. Now, 
Sir Edward Schafer has spoken a great deal about the sympathetic, and that 
relieves me of something I would have had to say. I shall therefore speak chiefly 
of the para-sympathetic system, and almost entirely of its clinical aspects. But 
perhaps you will allow me to refresh your minds in regard to the anatomy of these 
two great divisions, and in a word but very briefly. You will remember that the 
sympathetic system has its cells of origin in the intermedio-lateral tract of the cord. 
In the case of the para-sympathetic system the outflow arises from three different 
regions of the central nervous system. There is the outflow from the mid-brain, 
the outflow from the medulla, and the sacral outflow. The outflow from the medulla 
is very complicated, and the most important part of it as far as clinical work is con¬ 
cerned is that which takes place through the vagus. These two divisions— 
sympathetic and para-sympathetic—are in large measure antagonistic in their 
action. Nearly every organ of the body is innervated by both. But in regard to 
their action there is this very great difference : the action of the sympathetic is 
as a rule a general action—it is developed with this intention—whereas that 
of the para-sympathetic is very much more local. Let me give you an example 
of their antagonism. The father of a professional friend of mine was a clergyman. 
He suffered very badly from asthma, but at the same time he was very anxious to per¬ 
form the duties of his office. He was frequently confined to bed for days at a time, 
but when Sunday came he insisted on going to his church. He had often to be 
carried up the steps of the pulpit, but the moment he began to preach the bronchial 
spasm relaxed and his voice came clear and strong. The excitement of attempting 
to preach stimulated his sympathetic; this in turn relaxed the spasm of the bronchi, 
and for the moment the symptoms disappeared. The para-sympathetic causes 
contraction of the muscular wall of the bronchi, and the exact reverse is the action 
of the sympathetic. In most persons these two great divisions are in equipoise— 


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that is to say, they balance each other more or less completely. But in perfectly 
normal persons there are times when one or other dominates. You will remember 
quite well Cannon’s various forms of experimentation, in which he showed that 
fear, dread and danger caused marked stimulation of the sympathetic. On the 
other hand, if the para-sympathetic becomes dominant, the tendency is for the man 
to be mentally depressed. Furthermore, there are certain mental conditions in 
which one or other of these outflows may be stimulated and excited. The 
feeling of disgust causing vomiting is an excellent example of this. The senti¬ 
ment of shame is a stimulus to the para-sympathetic system. But there is a 
perfectly normal action in which in perfectly normal circumstances and individuals 
the para-sympathetic system dominates—that is, during sleep. In calm slumber 
all the sympathetic stimuli seem to be in abeyance. That system is no longer 
stimulated. Consequently the para-sympathetic system is, as it were, left to itself. 

I forget who it was who said that night was the time of the smooth muscle. 
That is not quite correct; it is the time of the smooth muscle innervated 
by the para-sympathetic system. That is why asthmatic attacks so often occur 
early in the morning. It is on that account that colic is usually apt to occur 
during the night, and the pangs of labour also start during these hours. Conse¬ 
quently the obstetrician who is repeatedly called out night after night must not 
attribute these nightly calls to feminine perversity. Apart from those persons in 
whom these two divisions are in equipoise and who are in the majority, there is 
a certain number of people on the one hand in whom the sympathetic system is 
distinctly dominant, and, on the other hand, a certain number of persons in whom 
the para-sympathetic system is relatively more powerful. The cause of this 
dominance is often toxic in origin. The para-sympathetic subject may be to all 
appearance perfectly normal. He may have no marked symptoms whatever, but 
on examination the clinical picture he gives us will reveal his condition. Now as 
a general rule (I am going to safeguard myself because there are all sorts of excep¬ 
tions) behind the clinical terms sympathetic and para-sympathetic hypertonus 
there lies a distinct and important truth. Let us picture a para-sympathetic case. 
He comes into your consulting room and sits down. You will probably find that 
he is rather stout and in complexion more often dark than fair. His pupils on 
the whole seem rather small; his features are coarse, especially his nose; his 
skin is sallow, very likely greasy; and his palms will be moist. His mental con¬ 
dition tends to be that of depression. He is usually of distinct mental ability, and 
when you come to examine him carefully he will probably tell you that his 
saliva is rather copious. His pulse is rather slow, and if he is a dyspeptic he will 
complain of having pain three or four hours after meals. Under such conditions 
dieting may be made too stringent. I recall a case I saw some years ago of a lady 
about 30 who had this condition. She had seen various physicians, and they 
had strongly impressed upon her that if she found any particular article of food 
caused her pain she was not to take it again. The result was that when she 
came to me she was subsisting solely on a little skim milk. She was of average 
height and only weighed 5 st. 3 lb. I put her on belladonna and alkalies and 
dieted her carefully. In some eight weeks she weighed over 8 st., and her 
recovery has been maintained. Cases such as we have been considering are 
termed by the Vienna school cases of Vagotonia. The nomenclature is incorrect, 
for as a general rule the whole para-sympathetic system is in a state of hypertonus. 
In addition to that the description given by members of that school is to a certain 
extent misleading, too theoretical, and not in accordance in many particulars 
with proved facts. Nevertheless a certain basis of truth is undoubtedly present. 
Have we any means of determining whether there is hypertonus of the para¬ 
sympathetic system P Slowness of the pulse suggests vagal inhibition ; the oculo¬ 
cardiac reflex is of high diagnostic value; the rapid return of the pulse-rate after 
exercise is suggestive, and, in an adult, marked variation in the rate of the pulse 
during the two phases of respiration is a sign of the kind of which we are in search. 
Apart from gastric complications, if there is vagal hypertonus the peristaltic move¬ 
ments of the stomach will be very marked and the secretion of hydrochloric acid 
abnormally great. A high glucose threshold may be looked upon as corroborative 
evidence provided the renal threshold is normal. I have not said anything about 
the action of drugs for I see that an address is to be given on that subject 
to-morrow. [The lecturer illustrated his address, of which this is a mere outline, 
by instructive diagrams and drawings.— Eds.] 


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The President we are very much indebted to Dr. Brown for showing us how 
one may apply facts supplied by the physiologist and pathologist in our investiga¬ 
tion of clinical cases. We have to thank Dr. Brown for his most interesting 
address. I ask you to afford him a very hearty vote of thanks. (Applause.) 

Luncheon. 

The members and their ladies were the guests of Sir Hugh Arthur Rose, 
D.S.O., Chairman of the General Board of Control for Scotland, and of Lady Rose, 
at luncheon, in the Hall of the University Union. The toast of “ The University 
Union,” proposed in eloquent terms by Prof. Ernest W. White, was responded 
to by The Rev. W. C. S. ,Angus, President of the Union, in words at once graceful 
and humorous. 

AFTERNOON SESSION.— July 20. 

At the Physiology Lecture Room, University New Buildings, the President 
presiding. 

Addresses. 

“ The Inter-reaction of the Endocrine, Sympathetic, and Central Nervous 
Systems in Organismal Toxaemia, with Special Reference to Emotional Distur¬ 
bance.” By David Orr, M.D. 

Mr. President. —I was exceedingly glad to receive the invitation from Prof. 
Robertson to come and give you a short address on the subject which is on 
the programme. I am rather afraid that the title is somewhat too ambitious, 
and I am rather afraid also that time is short. I shall endeavour, however, 
to put a few broad principles before you—principles, I think, which are relative 
to the close association between neuro-pathology and psychiatry. I think the 
best thing, in the first place, is to define my own position on the matter. I am by 
training, perhaps, more a pathologist than a psychologist, although I have had the 
opportunity of doing a little psychology. I often feel that there is a tendency at 
the present day to take too narrow a view of our subject. I am inclined to the 
opinion that some concentrate too much on pathology, while others concentrate 
far too much on psychology, and I often think with regard to that curious imaginary 
line that is drawn across the medulla and separates the neurologist from the 
psychologist, the line which always reminds me of that imaginary equator round 
the globe, that it would be a good thing if a tactful and scientific Father Neptune 
took both schools across the line and baptised them in the new faith. Now, I 
can only bring two points before you to-day, and the first is that the sympathetic 
nervous system is a very important factor in the determination of the localisation of 
lesions in both the spinal cord and the brain. The second is that the cerebral 
nervous system and the endocrino-sympathetic system are interdependent. In¬ 
flammation, of course, is the basis of pathology, and pathology is the basis of 
medicine. I will show you what I mean. As we know, there are certain lesions 
of the spinal cord which are called system lesions. Some are degenerative, due to 
traumatic lesions higher up, others are due to infection along the nerves. That 
is the subject that has been dealt with already, but I wish to draw attention to 
lesions which are non-systematic. The lesions to which I refer are found scattered 
along the postero-medium septum. They are also found round the periphery 
column. Now, at first sight one would say the explanation of these lesions is 
perfectly simple. It is due to toxaemia. It is, of course; but that is not an 
explanation, because when you come to examine the cord in serial section the 
first thing you find is that they are distributed in a most peculiar manner— 
that they are distributed, if you catch them early enough, between dorsal I and 
lumbar II. You will also find that the lesion decreases from the cervical region 
downwards. So one begins to think, Well, there must be another factor in this. 
Knowledge of anatomy is useful. The argument resolves itself into this : here you 
have those lesions distributed in an area which is controlled by the sympathetic 
reflex, and therefore the sympathetic system must have something to do with it. In 
order to test this certain experiments were conducted, and in order to exclude any 
absorption along peripheral nerves toxins were introduced into the abdominal 
cavity, and it was found that precisely the same distribution occurred, and at 
once one had to face the question: What r 6 le does the sympathetic play in the 

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determination of these lesions ? The argument, of course, had to be carried a 
little further. I need hardly mention that the existence of sympathetic nerves in 
the brain was steadily denied until 1907, but on reviewing the work I think one must 
come to the conclusion that there are sympathetic nerves in connection with the 
cerebral vessels. Certain experiments were made, and certain lesions were found. 
[The speaker here, with the help of diagrams, showed how disturbances of the 
sympathetic lead to nutritional changes in the nervous system and their effect on 
the emotional state, etc.] As you know, neurologically we are provided with nerves 
which subserve our life of relation—that is to say, our limbs and special senses, 
and with nerves that subserve our life of nutrition, and the nerves of nutrition 
convey impulses which form the basis of our sense of well- or ill-being. Frequently 
people are inclined to look on the nervous system as a lot of separate entities ; they 
talk about pre-central and post-central groups, etc. I am rather inclined to regard 
those centres as centres of maximum excitability, but the whole brain, the whole 
spinal cord, and the whole sympathetic system with it, acts as one, otherwise the 
human body would be out of harmony and could not adapt itself to its environ¬ 
ment. Now, my reason for making that statement is this : you are acquainted 
with Cajal’s law of dynamic polarisation and the law of avalanche. Cajal has 
shown that any simple stimulus impinging on one cell is transmitted to thousands 
of others; hence stimulation of one cervical area must affect the whole cortex. 

I would enter a strong plea for us looking much more broadly, not only at the 
anatomy, physiology and pathology of the nervous system, but at the genesis 
of psychology. We have come to a pass when I think, as I indicated before, we 
are getting into little water-tight compartments. Each man is doing his little job, 
but I do not think we are looking at the question broadly enough. During the 
war, when one had the opportunity of seeing those cases of shell-shock, one was 
struck tremendously by the physical reactions which followed psychic trauma, 
and one could not help but think that the shock had a directly deleterious action 
upon the ductless glands, and that the chemical products again reverberated upon 
the psyche and established a vicious circle. I had intended to say something 
about ductless glands—a subject for which I have got the greatest respect, but time 
does not permit. I will just simply close my remarks by saying that if this subject 
of psychiatry is going to advance at all we shall have to take a far broader and 
far more biological view of the whole question. (Applause.) 

The President : The work that Dr. Orr has done in connection with the 
pathology of the nervous system is well known to all of us. It is of the very 
highest quality, and it has helped us to understand many of the changes in the 
nervous system. Dr. Orr has, since the early days of his work, I think, himself 
taken a broader view of mental troubles, and he has also now included the 
psychical factor in his estimation of the changes that take place in the nervous 
system. In the practical address we have had from him he shows how there is, 
as he said, a vicious circle established by which all these factors are combined 
together. I have to ask you to give him a very cordial vote of thanks for his 
most interesting address. (Applause.) 

“ The Influence of Chemical Substances on the Endocrine Glands and Nervous 
System.” By Prof. J. C. Meakins, M.D., F.R.C.P.Edin. (see p. 367). 

The President : In the scientific work which Prof. Meakins does in the Edin¬ 
burgh University he sets a model to the medical student of the present day how he 
should investigate disorders and disease. You will have observed how cautious 
and careful he is in drawing deductions, and how he warns us not to be led astray 
by the mirage of theory. You see how thoroughly versed he is in organic 
chemistry, how he has applied his knowledge of chemistry to the study of diseased 
conditions, and how he has combined his researches with living organisms asso¬ 
ciated with disorders and disease. He has, in his address to us to-day, I think, 
pointed out to us the possibilities that exist in many of the obscure cases of mental 
disorder we have to deal with. I therefore ask you to give a very hearty vote 
of thanks to Prof. Meakins for his most instructive and admirable address. 
(Applause.) 

" The Mental Factor of Some Endocrinopathies.” By W. H. B. Stoddart, 
M.D., F.R.C.P. (see p. 374). 

The President : Ladies and Gentlemen,—This series of addresses would not 


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have been complete unless we had had one on the influence of the psychical factor 
In the production of these disturbances. Dr. Stoddart has told us that these 
psychical mechanisms produce endocrine secretions, and these secretions may 
influence and produce changes in the nervous system, and therefore I ask you to 
accord him a hearty vote of thanks for his address. (Applause.) 

These addresses were suggested by me in order that we should not take narrow¬ 
minded views of the treatment of mental disease. They all lead up naturally to 
the discussion that we are to have to-morrow morning, which will be initiated by a 
paper by Dr. Chalmers Watson. After that there will be an open discussion, at 
which every one of the members of the Association who have had practical 
experience of the care and treatment of mental disease will be able to say something. 
But, after the series of addresses we have had, no one will be able to say there is 
only one method of treating mental disease. It is perfectly obvious the factors are 
complex. No one can say by the treatment of the psychical factors you will get 
recovery, nor by any other special treatment. We all frequently hear in medicine 
of the vicious circle, but there would appear to be also a physiological circle. The 
nervous system, as more than one speaker has said, is a complete whole, involv¬ 
ing the whole organismal functions, and if one function of the body is disordered 
it is almost certain other functions of the body are likewise disordered, and the 
organism as a whole suffers. There is a tendency to look at this question from 
one point of view—one to look at it from the organic point of view, and the other 
from the point of view of the disturbance of endocrine secretions. A third person 
might look at it from the point of view of chemical substances to be absorbed. 
All these questions are related, and in the treatment of disease you must take a 
wide outlook. I therefore hope that as many of you as possible will turn up 
to-morrow in the Hall at the College of Physicians, in order to discuss the practical 
aspect of this question as dealing with the treatment of the patients whom we have 
under our care. 

“At Home” at Craig House, Morningside. 

In the evening many members and their ladies availed themselves of the kind 
invitation of the Chairman and Managers of the Royal Hospital, Morningside, to 
an “At Home” at Craig House. The splendid baronial hall and its adjoining 
drawing rooms and galleries were greatly admired, and a delightful orchestra, the 
much-appreciated efforts of several fine singers and the cheery hospitality of the 
hosts enabled the guests to spend a happy and restful evening. 

MORNING SESSION.— Friday, July 21. 

In the Hall of the Royal College of Physicians, the President presiding. 

Discussion on the Treatment of Mental Diseases. 

Paper. 

“ The Treatment of Intestinal Toxaemia.” By Chalmers Watson, M.D., 
F.R.C.P.Edin. 

(This paper will be published in the Journal for January, 1923, with illustrative 
plates.— Eds.) 

The President : I will commence my remarks with a story. A friend 
of mine, a married lady, had taken her husband, with feelings of admiration, 
to see an old nurse, an old retainer of the family. Said the married lady: 
“Well, Janet, what do you think of my husband?” Janet looked the husband 
up and down, and turned to my friend and said, “ You have pickit weel.” I felt, 
when listening to Dr. Chalmers Watson’s address, that I had “ pickit weel ” in 
selecting him to open this discussion this morning. I am sure every one of you 
was impressed with the finished address which he gave us to-day, covering the 
whole ground from beginning to end, and speaking without faltering for a moment. 
I think it was as fine an address as I have listened to for a very long time. What 
has pleased me most is that he really covered, in his opening remarks, the whole 
ground, and introduced into this address, which is to form the basis of a discussion 
of treatment, references to all the setiological factors which those physicians and 
physiologists described to us at our session yesterday. He informed us that he 
did not ignore the genetic factor, to which Sir Frederick Mott drew particular 


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attention in connection with the development of dementia praecox, nor did he 
ignore the psychic factor. In fact he laid very great stress on that, and perhaps 
went in some respects further than the majority of us would go—not further than 
I would go, but there are others who might say he went as far as it was possible 
to go. He referred also to the bacteriological factor and the factor of intoxication, 
indeed he really covered the whole ground of the aetiology of mental and nervous 
disease. The main portion of his address, however, was, as it ought to have been, 
a practical address on treatment, and I think, by describing his own methods 
with one or two selected cases, he demonstrated to us how all these aetiological 
factors which I have referred to can be brought usefully into the treatment of 
particular cases, and how it is impossible to say that one method of treatment 
is the cause of the recovery of the patient, but how by a combination of all these 
various forms of treatment you may get happy results. Now, there are many 
people here who are able to speak on these several aspects of the treatment 
of insanity, and I would ask these gentlemen, therefore, to continue the discussion 
which has been so ably opened by Dr. Chalmers Watson. 

Sir Frederick Mott: I have listened to Dr.Chalmers Watson’s most eloquent 
address with great interest. Yesterday I had the opportunity of seeing the 
demonstration which he gave in his clinical laboratory, and it impressed me very 
much indeed, because as a practical physician—for I am a physician; at least I 
was connected with a general hospital for thirty years as well as with the asylum 
service—I am perfectly convinced that his attitude towards this subject is the 
right one. I believe that pre-disposition is the most important factor, and 
that stress, whether it be physiological, as we see it in the case of women in 
parturition, in pregnancy or in involution, or from the effects of toxaemia of any 
kind whatever, reveal or excite this pre-disposition, and that pre-disposition depends 
upon a narrow physiological margin in the highest psychic level. I quite agree 
with Dr. Chalmers Watson in his view with regard to the importance of the 
psychological element, because anxiety, we know, produces a profound effect 
upon the whole endocrine system. I have had plenty of evidence in support of this 
during the war among cases I saw of soldiers who suffered with an anxiety 
neurosis. I saw many soldiers suffering from contemplative fear, which was still 
persistent owing to the fact that they suffered with terrifying dreams connected 
with the war, and many of these men had all the signs of a disturbance of the 
endocrine system. They had tachycardia, high blood-pressure in many instances, 
and signs of exophthalmos and tremors, and as the anxiety passed off so the 
symptoms disappeared. I regard all these conditions causing disturbance of 
the endocrine system, may have a profound influence on the metabolism of the 
neurones. If you have a mental conflict going on the metabolic conditions 
are interfered with, particularly when sleep is disturbed by dreams or by 
insomnia. When you have that condition there is no doubt a tendency to 
constipation. The two seem to go together—mental depression and consti¬ 
pation. I am reminded of a story of Voltaire. Voltaire was engaged in 
conversation with an Englishman one evening. Both were very pessimistic, 
and they resolved to commit suicide the next day. I suppose Voltaire was pulling 
the Englishman’s leg. He met him on the bridge where he was to jump from, 
and he said, 14 Pardonnez moi, monsieur, j’ai bien dormi, le lavement a bien 
operd, et le soleil est tout k fait clair aujourd’hui.” 

There is no doubt that while the epithelium of the intestine is in an unhealthy 
condition the absorption is more difficult than if the epithelium is in a normal 
condition. That is why a large number of patients in asylums suffer from dysentery. 
I have made a lot of post-mortems on people who suffered with dysentery. Some¬ 
times the bowel was enormously distended, sometimes contracted, and the whole 
epithelium affected. The absorption of toxins in the bowels consequently plays 
an important part in exciting mental conditions. This would also be an important 
factor in making chronic a condition of mental disease. I would like to ask 
Dr. Chalmers Watson whether he has noticed any difference in the bacterial flora 
of the faeces if the faeces are not examined fresh. We have been doing in the 
laboratory at the Maudsley Hospital a number of researches upon typhoid and 
para-typhoid, and we found unless we got the faeces quite fresh we were unable to 
isolate these organisms owing to the rapid growth of the colon bacillus and 
other organisms. With regard to the streptococci, one finds often in the stool 
streptococci, and I regard that as evidence of the existence of a pathogenic 


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organism. This new method of culture Dr. Chalmers Watson has introduced will 
be of the greatest value, and it is based on a good sound principle, namely, that 
the organisms in the intestine have been accustomed to certain food to grow 
upon, and hitherto we have not given them that food, and so by introducing that 
into it as media it is able to cultivate these organisms which we were unable to do 
before. With regard to vaccines, I think that a good deal is attributed to vaccines 
which may be due to other causes. After all, a great many of these people have 
been for a long time absorbing the toxins of the organism, and I think unless 
vaccines are given on really scientific principles it is more by suggestion than 
anything else that they act. Now Dr. Chalmers Watson emphasised the 
importance of suggestion upon these cases which have been under his care. One 
can imagine his personality will have a most profound effect on his patients, 
because it would certainly inspire them with confidence, and that is a most 
important factor. I think if doctors paid a little more attention to the human 
side of treatment we should hear much less of Christian Science, faith-healing, 
neuro-induction and Cou^-ism. (Applause.) 

Prof. Ernest W. White: I have had some thirty years’active experience in public 
asylums and I am very interested to-day in this paper on the treatment of intestinal 
toxaemia, and I should like to make a few practical remarks bearing thereon. In 
the first place, in these cases of intestinal toxaemia we have to consider whether 
the toxaemia is the cause of the insanity or is the result. Many cases of chronic 
insanity suffer undoubtedly from intestinal toxaemia, and we have to resort to 
various measures of treatment. Undoubtedly our old chronic cases in the asylum 
always suffer from constipation, and, as Sir Frederick Mott has just said, there is 
not the slightest doubt that it is due to the unhealthy condition of the intestinal 
walls. The asylum dysentery which has been so marked up to a few years ago— 
at least in my time—was most marked in many of those old chronic cases. I found 
myself that a large proportion of my patients who suffered from dysentery were the 
old chronics who had persistently for years and years suffered from constipation, 
and not had the attention to their bowels which they should have had. We 
resorted to lavage of the stomach in cases of melancholia, especially senile melan¬ 
cholia, and we found that they were materially improved by it. Undoubtedly the 
main line of our treatment should be by utilising the organs of elimination. 

Dr. H. Crichton Miller: I speak to-day under the disadvantage of not having 
had the pleasure and privilege of hearing yesterday’s discussion, which bore largely 
upon this point. Dr. Chalmers Watson’s opening address was one of unusual 
interest. The only criticism I would venture to make is that Dr. Chalmers Watson 
has given us—no doubt unintentionally—an over emphasis on one or two sources 
of auto-intoxication. He has stressed the importance of intestinal stasis and 
urinary infection. I am very ready to admit their importance, but we must not 
forget numerous other sources of infection hardly less important, such as tonsils, 
teeth and naso-pharynx. Of the cases that I see many have been examined in 
regard to intestinal and urinary absorption, but very few have been submitted to 
dental radiography. Of the many who have not been so examined a considerable 
proportion show definite evidence of one or more dental abscesses. Such a case as 
the one Dr. Chalmers Watson described is frequently the subject of a general 
streptococcal infection of which the intestinal and urinary symptoms are only 
partial manifestations. Now we cannot afford to let ourselves think in short and 
easy terms of toxaemia and mental disorders. We must keep in mind a much more 
complicated chain of cause and effect. I suppose you will all agree with me when 
I say that the deeper our investigations go the more apparent it becomes that few 
toxins produce their primary effect on neural tissue. In most cases the toxin 
primarily attacks the more sensitive endocrine tissue, and it is through the impair¬ 
ment of endocrine function that emotional disequilibrium arises, and from that in 
turn that mental derangement proceeds. It is easy for us to think of a toxaemia 
and melancholia as cause and effect, and to bracket them in our minds as sufch. 
But unless we estimate the patient’s endocrine condition at the moment we are 
guilty of loose thinking. Dr. Chalmers Watson has said that there should be no 
two schools of thought in regard to the psychic and physical factors. Dr. Chalmers 
Watson is an idealist and his view is utopian. There are two schools of thought; 
there always will be two schools of thought. Are we not all equipped with 
binocular vision, yet how common is “the lazy eye” ? By prejudice, either native 
or acquired, we all have a bias to the physical or the psychic. Ideally we should 


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approach a case equally prepared to discover a physical or a psychic aetiology, 
and—what is more—equally interested in either case. How many of us can claim 
this freedom from bias P Few, I venture to think. At the present time there are 
two strong currents of new thought in regard to mental disorder. The one tries to 
attribute everything to a physical cause, the other to a psychic. The one traces 
all mental phenomena to hormones, the other to complexes. The miracles of 
endocrinology are trumpeted from New York, and the marvels of psycho-analysis 
from Vienna. Between these cross-currents we must keep our bearings, and we 
shall not succeed unless we approach the problem in general and each case in 
particular with that freedom from bias which I have referred to as so essential and 
so unusual. And while we are giving an unbiassed hearing to all these new theories, 
we must bear in mind that it is contrary to the scientific spirit to reject as invalid 
the fruit of countless human observations simply because it does not happen to fit 
into a new theory. Take as an example the question of the criminal type. The 
psycho-analysts have long been busy in reducing all delinquency to terms of com¬ 
plexes and repressions. Now this accords ill with the general impression that 
criminality tends to be associated with certain physical characteristics, and in 
particular it collides with Lombroso’s historic work. But if we turn to the endo¬ 
crinologists we find that they are at any rate attempting to correlate—in terms of 
endocrine pattern—physical and psychic characteristics. Now it seems to me that 
while we study the emotional and intellectual reactions of our patients, we should 
concurrently, and with no less zeal, investigate this psycho-physical relationship in 
terms of endocrine function. It will take years of very patient observation no 
doubt, but ultimately we should be in a position to think of any given case of mental 
disorder in terms of a triple aetiology: (a) Endocrine pattern, linked to native 
qualities, both physical and psychic; (b) endocrine history, including the physio¬ 
logical crises, toxic impairment, etc.; (c) emotional history, covering emotional 
traumata, conflicts, repressions, and so on. With regard to the first of these 
categories, I venture to submit that in the sympathetic trio of endocrines (the 
thyroid, pituitary, and adrenals) we have the origin of two great principles of 
human activity—the creative urge and the power urge. I would suggest that the 
thyroid is the gland that stands for creation, and therefore for procreation. The 
pituitary seems to represent the subjective or imaginative power principle; the 
adrenal appears to originate the objective or immediate power urge. These 
speculations I throw out merely to indicate how relevant to our investigation of 
any given case is a consideration of the endocrine equilibrium. Take, for instance, 
a simple case of depression. Let us suppose the patient is a woman. What of her 
thyroid ? It is functioning inadequately. She feels her creative power is ebbing. 
It may be that she longs for another child. It may be that she is an artist and 
finds her power of artistic expression leaving her. Or take a man suffering from 
depression. What of his adrenal function? Is he conscious of a loss of drive in 
his business due to a progressive hypoadrenia ? If so, we can well understand his 
depression. Such every-day examples illustrate the necessity for thinking in terms 
of the mental and the physical concurrently, and not only concurrently but without 
bias, for it is only thus that we can hope to reach that one school of thought which 
Dr. Chalmers Watson has idealistically held out before us as the right one. 

Dr. T. C. Mackenzie : I must confess to a feeling of depression at the character of 
our discussion, and also, if I may say so, the character of the only paper this morning. 
The subject for discussion down on the Agenda is the treatment of mental disease. 
I am depressed because it appears to me to have been approached from a very 
extremely narrow arc. I think a very considerable amount of what Dr. Chalmers 
Watson said to us this morning, and said to us in a very interesting manner, has 
been repeatedly said before, and the accumulation of facts for which he made so 
strong and so reasonable a claim is one that has not been lost sight of by the 
members of this Association. A vast number of facts along the lines of the 
investigation he indicated have been collected and established. My friend 
Dr. Shaw, for instance, has collected a very great number of facts. He worked 
under Dr. Bruce at Murthly, of whom perhaps it might be said there is no greater 
authority on conditions of the blood in the insane. I think a certain amount of the 
work Dr. Chalmers Watson indicated has also been done already by Dr. Bruce. 
I was rather interested in what my friend Dr. Crichton Miller said. He spoke of his 
occupying a middle position between the section he calls his psycho-analytical 
friends and the other body whom he refers to as the materialistic workers. And 


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he also spoke of the lazy eye. We members of the Medico-Psychological Associa¬ 
tion do, I think, keep an open eye on every side and reap what benefit we can. 
With regard to psycho-analysis : as Dr. Chalmers Watson said, I have read a good 
deal of it, but I do not really know much about it! Sir Frederick Mott did a 
good thing in emphasising the importance of humanity in the treatment of mental 
disease, and it seems to me humanity and common sense will carry us very far 
into the treatment of our fellow sufferers. 

Dr. Donald Ross : This question of intestinal toxaemia was written about long 
ago. I cannot remember who the author was, but I have an old book which I 
picked up somewhere in which the author not only laid great stress on that, he 
went even further. He advised that every case should be given an emetic first 
of all as a routine to empty the stomach, and then treat the whole bowel with 
antiseptic. I would like Dr. Chalmers Watson to try that. Prof. Chiene used to 
advise us all to read a book published about 1812—Hamilton “on Purgatives”— 
and apply its principles in every department of medicine and surgery. Then 
Dr. Chalmers Watson said he was very much struck by Dr. Chambers’ report. 
I think you will find the same facts in almost every report. Every person who 
becomes insane is physically ill. The treatment is to aim at removing as many 
of the underlying conditions as possible. I recall a case that occurred in France 
of a poor fellow who had had persistent vomiting, and came down to me after being 
treated by a psychologist. There happened to be a great push on at the time and 
I had not time to attend to him properly until after the rush was over, which was 
four or five days later. In the meantime he was treated with a dose of castor oil 
and milk diet. When next I asked him how he was keeping, he said, “ I am 
perfectly all right now, of course,” adding that “ up there ” they had hypnotised 
him and given him bully beef and biscuits, but here he had been put on the proper 
treatment. 

Dr. Helen Boyle: I did not intend to speak at all to-day, but I do feel keenly on 
this subject. I think sometimes the mental attitude is responsible and sometimes 
the physical, and much more common is it to find that they are all responsible. If 
you can remove one of them the patient will be better, but if you can remove them 
all the patient will be well. I should just like, therefore, to emphasise the fact that 
has already been stated—that the treatment of the nervous case is greatly influenced 
by the treatment of the patients’ friends. I was particularly glad to see the 
demonstration at the Infirmary. I had a case not so very long ago which I should 
very much like Dr. Chalmers Watson’s opinion upon. I did all I could for the 
patient, and I got her into very good condition. Then I left her for a little while 
and she had a relapse. It is very difficult to know how to get the intestinal con¬ 
dition into such a state that it will be permanent. I am sure continual lavage 
becomes a perfect obsession. 

Dr. C. Hubert Bond: It would be impertinence to attempt to discuss the 
paper when I unwittingly did not give myself the opportunity of hearing the whole 
of it. But I can get out of it by saying I have had the advantage of discussing 
this matter frequently with Dr. Chalmers Watson in London. All I would like to do, 
if I may, is just to point the moral as I see it, and it is that the powerful and con¬ 
vincing address, such as we have heard, only emphasises the fact that we cannot 
afford to be without a laboratory in our hospitals, and a great many of you have 
not got one, and if you have it is not in use. Autogenesis, I think, was mentioned 
by Dr. Chalmers Watson, or one of the others, and doubtless that explains a good 
many of our recoveries, but there are something like 37 per cent . or thereabouts 
that do not recover, and the absence of their recovery is without adequate reason. 
To come back to my point, I am sure the moral is we cannot afford to do without 
a laboratory in full working order in competent hands as an adjunct to every 
hospital. Personally I do not believe in the combination system of laboratories. 
Do not misunderstand me. I do not disbelieve in the supreme value of a great 
organised laboratory with which several of the mental hospitals are affiliated; I do 
believe in them, but I do not think they can ever take the place of the daily work 
in the laboratory. If the hospital is big enough it may want more than one 
laboratory. May I say that it is not often that we have a recruit to our Associa¬ 
tion who on the day or thereabouts of his election promptly furnishes us with a 
paper or an address of the quality we have had from Dr. Chalmers Watson to-day, 
and I am sure we most heartily welcome him as a member of the Association. 
(Applause.) 


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Dr. W. R. Dawson : I have not myself been directly engaged in the treatment 
of mental or other forms of disease for the last ten or eleven years, but I have 
always taken the point of view which Dr. Chalmers Watson has so eloquently 
expressed, and so very properly impressed upon us as to its importance, and in a 
much less thorough way I have always endeavoured to tackle my cases from the 
material side, at all events by making a thorough physical examination of every 
case as it came under my care. And I should like before going any further to 
emphasise what Dr. Bond has just said with regard to the importance of a 
laboratory in every asylum. Dr. Chalmers Watson has pointed out that it need 
not be very elaborate, that for clinical purposes something very much less than one 
expects in the case of a joint laboratory like the one at the Maudsley will do. 
After all this is really an extension to the mental hospitals of what we find in all 
clinical hospitals. We expect a good pathological laboratory available somewhere 
to do the elaborate work which is required for the examination, for instance, of 
specimens from the nervous system and elsewhere, but we also want attached if 
possible to every large ward—certainly to every division of the hospital—small 
laboratories where clinical work can be done, and this is all that one asks in the case 
of a number of asylums. I think the ideal system would be to have a small clinical 
laboratory connected with every asylum, and in addition to that one of our central 
laboratories for a number of asylums in the country. With regard to the substance 
of the very eloquent address we have had from Dr. Chalmers Watson, I do not 
intend to take up any time in criticising the points, even if I felt capable of doing 
so; but there is one point I would like to call attention to, and that is the 
bacteriological infections of the lower bowel, which undoubtedly do produce 
some effect, whether through the endocrines or something else, upon the 
nervous system, and which may arise from a failure, not of the endocrines in the 
first instance, but of the organs of digestion. There is one case in particular that 
occurs to my mind. This was a medical man who was under my care a good 
many years ago. He was a cocainist, and he came in for a peculiar nervous 
condition which was produced by cocaine. When he had been under my care for 
some time he called my attention to some very peculiar objects which he was 
passing from his bowel, and on investigation it was found he was suffering from 
muco-membranous colitis. In regard to the membranous condition one came 
to the conclusion that the pancreatic digestion was the fault. I should say he had 
been suffering from constipation for years, and after trying a number of things he 
himself hit on a method of treatment which eventually proved satisfactory—that is 
to say, he had practically a lavage every morning, a plain injection of hot water, 
and he also took a pancreatic preparation which was given in a particular form of 
tabloid. He also took a certain amount of saline. By these methods his colitis 
was cleared up and his constipation disappeared. His mental condition 
improved very much, so that after a considerable time—he stayed with me for a 
considerable time, because he rather liked being there, and he began doing patho¬ 
logical work, which had not been his speciality before he left and studied 
abroad. He did most admirable pathological work. I may say the membranes 
were simply loaded with bacteria, and I have no doubt that these bacteria 
and the irritation which they set up contributed to some extent at all events, 
to his mental troubles. That is, I think, a point which is worth while 
bearing in mind, and it may be necessary to tackle the digestion in order to 
restore normal affairs in the bowel. I have listened to the discussion with great 
interest, and I should like personally to thank the speakers for the large amount of 
information and the different points of view which they have presented to us. 
(Applause.) 

Dr. Dods Brown : With regard to what Dr. Chalmers Watson said about 
washing out the bowel, for many years in certain cases we have practised that in 
the hospital I am connected with, in depressed cases, and I feel convinced that 
very often the prospects are most excellent. But that is not the only treatment. 
Whether that in itself helps the patient I do not know, but my own feeling is 
that it does. With regard to what Dr. Chalmers Watson said about vaccine 
treatment, I remember when I was Senior Assistant at Morningsidegiving vaccines 
to mental patients. The vaccines were prepared from the urine of patients, but I 
confess I do not think we saw any material benefit from these vaccines. Certainly 
the number of patients treated was not very large, but I think we carried on this 
form of treatment in a sufficiently large number of cases to make one think that 


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the treatment was not very beneficial. Another form of treatment which I should 
like to mention is that which Dr. Donald Ross and I carried on and published 
some years ago, and that is the treatment by the use of colloidal metals. Of 
course we are glad to carry out any treatment in the hope that good results may 
follow. Several of the cases showed definite improvement. 

A Member: I had no intention of making any remarks, and much more so 
because I was in the unfortunate position of not hearing Dr. Chalmers Watson's 
paper. We are not all materialistic, and I am sure we are not all psycho-analytic. 
As members of this Association I think we ought to take up a middle attitude. As 
far as the endocrine glands are concerned, if you put your patient into the best 
physiological conditions then the chances are the ordinary tendencies of health 
will have free scope, and that is a matter we can all do. As regards psycho¬ 
analysis, what we see of those cases is probably not a fair sample. I think the 
patients we see mostly are not fit subjects for psycho-analysis. 

Dr. Chalmers Watson, in reply, gave expression to the pleasure and 
gratification which had been given him by the interest and appreciation which 
the members of the Association had shown in his remarks. Time would not 
allow of him dealing at any length with many of the points which had. emerged 
in the discussion. He would content himself with referring to a few of the more 
salient ones. Sir Frederick Mott had raised an important point in his reference to 
the condition of the intestinal epithelium; that was a vital part of the problem. 
As a result of a number of observations specially directed to the point, he had not 
found any appreciable difference in the flora when examined within periods 
ranging from an hour or two up to twelve or eighteen hours. It should at all 
times be kept in view that the terms “ intestinal stasis " and 44 intestinal toxaemia " 
were in no way synonymous. Intestinal stasis existed, sometimes in marked degree 
and for a lengthy period, without apparently inducing any notable symptoms of 
deranged health. Later, however, these supervened, and, in the speaker's view, 
their development was largely dependent upon the occurrence of minute lesions of 
the epithelial lining of the bowel. In focussing his remarks, as he had largely 
done, on the intestinal route of infection or intoxication, he wished to make 
perfectly clear that he recognised other important sources of infection or intoxica¬ 
tion. Dr. Miller had referred to the teeth, gums and tonsils; the naso-pharynx 
and uro-genital tract, especially in women, are also channels to be kept in view. 
A striking example of an acute mental disorder resulting from a bacterial infection 
of the genital tract is puerperal mania. In regard to oral sepsis, it should be kept 
in view that in cases of long-standing oral sepsis, the mere removal of the septic 
focus by extraction sometimes failed to yield any benefit to the patient; this in 
many cases was undoubtedly due to the fact that the intestinal tract had become 
secondarily infected and now acted as a primary source of infection. All were 
agreed as to the practical value of aperient remedies in many cases of mental 
disorder, but we possessed little knowledge of the precise method of their action. 
The main object of the speaker was to emphasise the need for a more thorough 
investigation of cases of mental disorder, on simple clinical and simple bacterio¬ 
logical lines, by correlating the results of the investigation of the intestinal tract 
by means of bismuth meals, with (a) the naked eye and microscopic examination 
of the contents of the large bowel as revealed by the study of the stools and double 
wash-out, and ( 6 ) the more systematic examination of the urine, especially in 
regard to its cellular and bacterial content. In this connection the speaker drew 
attention to the value of the Saccha rose milk agar medium, introduced by him 
as a primary culture medium capable of throwing new light on the intestinal flora in 
health and disease. His experience led him to think that a recognition of the facts 
described would prove of value in arriving at a truer knowledge of the aetiology of 
mental disorders and also prove of value in treatment. By a little co-ordinated 
effort, on these lines, on the part of asylum physicians it would be an easy matter 
to secure, in the course of a year or two, the data available from a preliminary 
series of, say, 500 cases of selected mental disorder. There was, in the speaker’s 
view, no doubt whatever that the result of such an inquiry would add greatly to our 
present knowledge of the aetiology and treatment of mental disorders, and the 
information so obtained would further in all probability be of great value to the 
general physician in the study and treatment of other general medical disorders. 

The President : As this sitting terminates the work of this Association at its 
Annual Meeting, before we depart I wish you to give a hearty vote of thanks to 


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458 NOTES AND NEWS. [Oct., 

Dr. Buchanan, our Divisional Secretary, for the painstaking and onerous duties 
he has performed so well for these meetings. He has attended to all the details, 
and it is only those who have been officials of this Association who know the 
amount of detailed work that has to be attended to to make a meeting of this kind 
a success. I hope all of you leave with pleasant recollections of this Annual 
Meeting; at any rate, we have done our best to make it pleasant, agreeable and 
instructive for you. (Applause.) 

Sir Frederick Mott: I have very great pleasure in seconding the vote of 
thanks, and I should like at the same time to express my gratitude, and in 
expressing my gratitude I feel I am expressing the gratitude of the whole 
psychological profession for the extreme kindness, hospitality and cordiality with 
which the Association has been received in Edinburgh, which is greatly owing to 
our President, Prof. Robertson. 1 am sure we are all very grateful to him for the 
admirable manner in which the meetings have been conducted, and the way in 
which we have been received in Edinburgh. But it is not new to me to come to 
Edinburgh to be well received. 1 have had that pleasure on several occasions 
before, and I am sure we are all very grateful to the whole of the Faculty for the 
way in which we have been received here. I have very much pleasure in seconding 
the vote of thanks to Dr. Buchanan, under whom the arrangements have been so 
admirably carried out. (Applause.) 

The President*. In thanking you on behalf of Dr. Buchanan and myself 
for your vote of thanks, I would just conclude by saying I was very pleased 
to see what an excellent photograph has been taken yesterday, and I would 
like the authority of the Association to present in its name a copy of this 
photograph to Sir Arthur and Lady Rose, who were our kind hosts yesterday, 
and 1 also think that a copy might be presented by this Association to the General 
Board of Control in Scotland for their kindness in giving us the use of their offices 
for our Council and Committee. (Applause.) 

This concluded the Annual Meeting held at Edinburgh in 1922, and likely to be 
memorable in the annals of the Association. 

Excursions. 

The report of the Annual Meeting would be incomplete without reference to a 
number of delightful motor trips to places of interest in and around Edinburgh 
arranged especially for ladies accompanying members by the Ladies’ Committee. 
They included a tour through the Scott country, calling at Melrose Abbey and 
Abbotsford, a visit to Linlithgow Palace with tea at Champfleurie by the kind 
invitation of Sir James and Lady Adam and a visit to Bangour Village Hospital, 
where Mrs. Keay dispensed hospitality. 

To Lady Wallace and the Ladies’ Committee not a little of the general success of 
the Annual Meeting was due, and for their kindly co-operation the Association is 
grateful. 

[Members who have not already ordered copies of the photograph of the group 
taken in the New University Quadrangle can do so from Mr. John Moffat, 125a, 
Princes Street, Edinburgh. Price 45. 6 d. t including printed list of names.— Eds.] 


PARLIAMENTARY NEWS. 

August 2 nd, 1922; Asylum patients' claim to discharge .—Mr. Robert 
Richardson asked the Minister of Health if he was aware that two Ex-service 
men—J. Wickenden at Long Grove and C. S. Norris at Banstead—were being 
detained in these two asylums respectively, while their parents in each instance 
were exceedingly desirous to undertake complete responsibility in regard to them 
and to give them comfortable homes and every care; that the wife of each, for 
reasons of their own, refused their release; that the wives’ refusal was backed up 
by the medical official of the Pensions Ministry, who had decided that they must 
remain where they were and continue to be treated as lunatics on pain of loss of 
dependents’ allowance; that the Board of Control had referred the case of these 
two private patients to the visiting committee, which had by the Act no power 
over the discharge of private patients; that the attempt to bar their discharge was 
inoperative, since the medical superintendent had failed to prove (in accordance 
with Section 74 of the Lunacy Act) that they were dangerous and unfit to be at 


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Jarge; that the delegation of powers of intervention to the Pensions Ministry was 
contrary to the provisions of the Lunacy Act; that, in the case of C. S. Norris, the 
•decision of two independent doctors under Section 49 had been overridden by 
illegal reference of his case to a visiting committee, whose function was restricted 
to dealing with paupers; and, in view of the indignity thus perpetrated on Ex-service 
men, would he take steps to see that they were not any longer deprived of liberty, 
.and that they were indemnified for the injury done them by a lump sum to enable 
them upon immediate discharge to find their way back to a self-supporting position 
in life.—Sir Alfred Mond replied: I am fully acquainted with the facts of these 
two cases. The Ministry of Pensions are empowered to pay an allowance to the 
wives while the husbands are detained under institutional care. But if the patients 
-are discharged contrary to medical advice, that allowance would cease. The 
visiting committee has power in regard to the discharge of all patients whether 
private or public by virtue of Section 77 of the Lunacy Act, 1890; there has been 
no occasion for the issue of a certificate under Section 74 of the Act, because no 
application for the discharge of the patients has been made by the person entitled 
to do so under Section 72 (2) of the Act. The recommendation of one of the 
doctors who examined the patient Norris under Section 49 of the Lunacy Act was 
that he should be given leave of absence on trial. This was properly referred to 
the visiting committee, in whom rests the power to permit such leave of absence 
under Section 55 of the Act. I cannot concur in the view that any indignity has 
been perpetrated on these Ex-service men, and the hon. Member is in error in 
regard to his interpretation of the legal points. I am satisfied that the patients are, 
at present, properly detained, but their cases will be kept under careful observation. 

August 4th, 1922; Women Members of Asylum Committees .—Sir Robert 
Newman asked the Lord Privy Seal whether, in view of the fact that there were 
over 30,000 women patients of unsound mind in borough and county mental 
hospitals which had no women members of the visiting committees of those 
asylums, the Government would consider the advisability of granting facilities 
during the Autumn Session! or the passing of the Lunacy (Visiting Committees) 
Bill, or, that the Government would themselves undertake to pass a measure of 
their own having the same object in view.—Mr. Chamberlain replied: The 
Ministry of Health is preparing a Bill which will deal, amongst other things, with 
the subject referred to in the question. 


Incipient Insanity : Proposed Government Bill. 

It is understood that Sir Alfred Mond, as responsible for the Board of Control, 
has under consideration the draft of a Bill to enable persons suffering from incipient 
mental disease to be treated in public or private mental hospitals without certi¬ 
fication. As the result of some informal conferences, the Minister hopes that 
something like an agreed measure may be presented and in such short compass as 
to secure prompt passage. The proposal follows upon a pledge given by the 
inclusion of a clause to deal with this matter in the ill-fated Miscellaneous Bill 
which Dr. Addison submitted in September, 1920. All the various provisions of 
that Bill had to be sacrificed, but the importance of this subject has grown rather 
than diminished in the interval. It remains to be seen exactly what is contem¬ 
plated. Broadly, the idea is that while the rich have resources available for curative 
care and attention, the poor have not, and that to afford facilities should prove 
economical in the long run, while avoiding for many the stigma of insanity and 
so inviting a freer use of existing facilities for treatment. It is pointed out that 
35 per cent . of the certified patients in asylums are discharged in the course of 
time as recovered, and this is held to encourage the institution of methods for 
dealing with such trouble at an early stage if the patient is willing to take advan¬ 
tage of the opportunity. If the project meets with support county councils might, 
under improved financial conditions, be willing to provide separate homes or 
annexes for such sufferers.—( British Medical Journal , July 1st, 1922.) 


EDUCATIONAL NOTES. 

London County Council .— The Maudsley Hospital .— Lectures and practical 
•courses of instruction for a Diploma of Psychological Medicine, fifth course, 
1922-1923. 


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Part I.—(I) Eight Lectures on the Anatomy of the Nervous System. By Sir 
Frederick Mott, K.B.E., M.D., LL.D., F.R.S., F.R.C.P. On Tuesdays, at 2.30 
p.m., commencing on October xoth, 1922. The evolution of the nervous 
system in the animal series; physiological levels; macroscopic and microscopic 
anatomy of the nervous system; the neurone concept; the projection, association 
and autonomic systems; ultimate distribution of the cranial nerves, spinal nerve 
roots and sympathetic nerves; the meninges—cerebral arteries and their distribu¬ 
tion—the intra-cranial venous and lymphatic systems; the congruence of structure 
and function in the brain ; the congruence of experimental investigation with 
anatomical observation; the clinico-anatomical methods of investigating the func¬ 
tions of the central nervous system—spinal cord—medulla oblongata—pons— 
cerebellum—mesencephalon—basal ganglia—cerebral hemispheres; the cortex 
cerebri in relation to cerebral localisation, including the cerebral mechanism of 
speech ; the structure of the endocrine and reproductive organs. 

Practical Instruction and Demonstrations: Methods of staining nervous tissue 
and preparing it for microscopical examination ; the living nerve-cell—the nerve- 
fibre ; degeneration and regeneration of nerves; distribution of sections, illustrating 
the principal diseases of the nervous system, for mounting as a permanent 
collection. 

(II) Eight Lectures on the Physiology of the Nervous System. By F. Golla r 
M.D., F.R.C.P., Physician, St. George’s Hospital. On Fridays at 2.30 p.m.,. 
commencing on October 13th, 1922. Reflex action—co-ordination and proprio¬ 
ceptive system; motor system, including muscle and nerve; sensation—fatigue— 
localisation and reference of sensation, normal and abnormal—special senses— 
mental work and fatigue; methods of investigation; physiology of the emotions; 
endocrinology; the autonomic system ; action of alcohol and drugs; physiological 
chemistry; trophic and vegetative functions. 

Practical Instruction and Demonstrations: Physiological Chemistry: Chemistry 
of the nervous system, and cerebro-spinal fluid; metabolism—vitamines and food 
deficiency; physico-chemical methods as applied to bio-chemical research; blood 
and urine analysis—acidosis, uremia, uric acid. 

Practical Physiology: Physical concomitants of emotion ; recording reflexes and 
tremors in man; action of drugs on autonomic system; the study of reflex action 
in the spinal animal. 

(III) Eight Lectures on Psychology. By Henry Devine, M.D., F.R.C.P. On 
Thursdays, at 2.30 p.m., commencing on October 12th, 1922. Definition and scope 
of psychology—behaviour—adjustment—classification of responses—instinct— 
habit—thought—relation of mind and body—the psycho-physical organisation as a 
biological unit—integration—methods of psychological investigation ; analysis and 
classification of modes of consciousness; cognition—sensation—perception— 
imagination — memory—association—judgment; conation—attention—volition ; 
affection—emotion — mood — sentiment; personality — temperament — character; 
sleep—dreams —suggestion—hypnosis—dissociation ; illusion—hallucination — 
delusions—disorders of attention; fatigue—effects of drugs on reactions. 

Practical Instruction and Demonstration: Sensation—psycho-physical methods— 
statistical methods—reaction times—association—memory—intelligence tests— 
muscular and mental work. 

Part II: Part II will follow in January, 1923, about which a further announce¬ 
ment will be made as to times and lectures. 

Fees: For the whole course of Parts I and II, ^15 15s.; for Part I, separately, 
£10 ios.; for Part II, separately, ^10 10s.; for one single series of lectures in 
Part I, £\ 4s.; for one single series of lectures in Part II, £2 2s. 

Inquiries as to lectures, etc., should be addressed to “The Director of the 
Pathological Laboratory,” Maudsley Hospital, Denmark Hill, S.E. 

The Tavistock Clinic for Functional Nerve Cases, 51, Tavistock Square, W.C. 1. 
—A course of six lectures on “ Symbolism ” will be given by J. A. M. Alcoek, 
M.R.C.S., L.R.C.P., on Wednesdays, at 5.30 p.m., beginning October 18th. 

(I) Instinctive mind; ways of “thinking”; the “unconscious.” 

(II) States of consciousness; dream state; waking state; subjectivity. 

(III) Personality; complexes; resistances; repression; non-expression. 

(IV) Personality and functions; classes and types according to complexes and 
according to essential features. 

(V) Collectivity ; myths and myth motifs. 


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(VI) Rebirth symbolism ; analogies with mysticism. 

Fee for the course, £ 1 is. Tickets to be obtained in advance from the Hon. 
Lecture Secretary at the Clinic. 

National Hospital for the Paralysed and Epileptic , Queen Square, Bloomsbury, 
W.C. 1.—Syllabus of post-graduate course, October 9th to December 6th, 1922. 
The course will consist of the following subjects: Lectures on the pathology of 
the nervous system, by Dr. Greenfield, on Mondays and Thursday, at 12 noon. 
Out-patient clinics, on Mondays, Tuesdays, Thursdays and Fridays, at 2 p.m. 
Lectures and demonstrations on neurological ophthalmology, by Mr. Leslie Paton, 
on Wednesdays, at 3.30 p.m. Clinical lectures and demonstrations, on Mondays, 
Tuesdays, Thursdays and Fridays, at 3.30 p.m. 

The fee for the whole course, including Mr. Paton’s lectures, is ^14 14s.; but 
these lectures may be taken separately for a fee of £6 6s. Any part of the course 
may be taken separately at a special fee. Special arrangements will be made for 
those unable to take the whole course. Fees should be paid to the Secretary of 
the Hospital at the office on entering for the course.—C. M. Hinds Howell, 
Dean of Medical School. 


LABORATORY OF THE SCOTTISH ASYLUMS. 

Twenty-Fifth Annual Report by the Pathologist, 1921. 

During the year sixty-one asylum cases were investigated and reported upon. 
In fifty-two of these the investigations required were bacteriological, in six histo¬ 
logical, and in the remaining three of the nature of laboratory tests. In most of 
the cases in which a bacteriological investigation was made, autogenous vaccines 
were supplied for treatment. Five visits were paid to asylums outside of Edinburgh 
for the purpose of investigating cases. Dr. P. Vieyra (attached to the Royal 
Edinburgh Asylum) worked in the Laboratory from the beginning of October to 
the end of December. 

My research work has been directed mainly to the investigation of the chronic 
bacterial infections occurring in cases of dementia praecox. The results of this 
investigation, up to the end of June, were recorded in a paper read at the annual 
meeting of the Medico-Psychological Association in July. In October arrangements 
were made by the issue of a circular for the systematic bacteriological investigation 
and treatment of a new series of cases of dementia praecox. The response of the 
asylum staffs to this invitation has, on the whole, been good. The results of 
treatment in some cases have been such as to give encouragement to those who 
hope that this hitherto incurable form of insanity will yet be made amenable to 
treatment at an early stage of its development. On the bacteriological side the 
evidence steadily accumulates that all cases of early dementia praecox suffer from 
extremely severe chronic bacterial infections of known neurotoxic character, 
involving chiefly the intestinal tract. The exact part that these chronic infections 
play in the causation of the malady has still to be defined, but there is already clear 
evidence that their suppression results in benefit to the patient. It must be 
remembered, however, that the detection of a chronic infection does not always 
imply that it is possible to eradicate it by any means yet known to science. The 
example of chronic infection by the tubercle bacillus should be sufficient to warn 
us against forming extravagant expectations of easy cure in dementia praecox. 
Moreover, chronic infection in this disease is only one of several factors in its 
pathogenesis. Three other important factors that require further investigation 
are—(1) those that are purely psychological, (2) the effects of disorders of internal 
secretion, and (3) the auto-intoxication dependent upon intestinal stasis. The 
special importance now being attached to the last in America requires that it 
should be made the subject of careful investigation here also. I believe that this 
factor and the disorders of internal secretion are mainly consequences of the 
intestinal neurotoxic infections, and that suppression of these at an early stage 
would be sufficient to prevent the development of the malady. This view is borne 
out by the completely successful results of treatment in two very early cases in 
which the characteristic intestinal infections were present. Both were treated by 
therapeutic immunisation ; all of the disquieting symptoms disappeared, and the 
patients remain well after two years. Unfortunately, cases of dementia praecox, 


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before they reach a mental hospital at all, are generally suffering from what is 
really an advanced phase of the morbid process, and have already sustained some 
degree of irreparable brain-damage. Nevertheless it should be possible to arrest 
the progress of the disease at this stage, and to return many of the patients to their 
homes, to be useful members of the community. It may be hoped that under the 
new arrangements for hospital treatment of early cases of insanity, foreshadowed 
by recent public discussions, opportunities will be afforded for the investigation 
and treatment of cases of dementia praecox at a much earlier stage-than that at 
which it is generally possible to deal with them at present. 

It is hardly necessary for me to dwell upon the enormous saving in money that 
would result from even the moderate success of therapeutic immunisation in early 
cases of dementia praecox and other forms of acquired insanity. It may be said, 
however, that at the present moment there is nothing else in the scientific horizon 
that holds out any good hope of saving the country fron\ the necessity o£ soon 
enlarging existing asylums and incurring greatly increased expenditure for custody. 
In my judgment, the knowledge of the relation of insanity to bacterial infection 
has now reached a point at which it would pay the asylums of this country to 
support laboratories for the bacteriological investigation and treatment of early 
cases of insanity. As regards the continuation of research work upon this subject 
in Scotland, it is for the Asylum Boards to decide whether they wish to have the 
benefit of the results of many years of breaking and tilling of new ground in this 
Laboratory, or whether they are going to allow these labours to come to an end 
just when they are promising an excellent harvest. Better facilities for research 
are urgently needed, and money is required for the extension of the investigation 
into other fields that must be investigated. 

W. Ford Robertson. 

The Laboratory, 

10, Morningside Terrace, 

Edinburgh; 

February 20, 1922. 


OBITUARY. 

James Middlemass, M.D., F.R.C.P.Edin. 

James Middlemass was born in Edinburgh in 1862, and was educated at 
George Watson’s College and at Edinburgh University. He first obtained the 
degrees of M.A. and B.Sc., being especially interested in chemistry; but later he 
took up medicine, and in 1888 he graduated M.B., C.M., with honours. He then 
studied at Strassburg, and on returning to Edinburgh was for a time Resident 
Physician in the Edinburgh Royal Infirmary. Having taken his M.D. he was 
elected F.R.C.P.Edinburgh. In 1890 he was appointed Pathologist in the Royal 
Edinburgh Asylum, where in due course he occupied the post of Senior Assistant 
Physician. 

In 1898 he became Medical Superintendent of the Sunderland Borough Asylum 
at Ryhope, a position which he retained till his death. In 1918 he was appointed 
lecturer on mental diseases at the College of Medicine, Newcastle-on-Tyne. In 
1898 he married Miss Elkins, the sister of his predecessor at Ryhope. He had 
two children, a son and a daughter. Of his extremely happy married life this is 
not the place to speak. 

He was somewhat run down when, early this year, he went to Scarborough for 
a golfing holiday. While staying there he was attacked with appendicitis, and, 
in spite of several operations, septic trouble developed. After a distressing 
illness, borne with extraordinary patience and fortitude, he died on May 2nd, 1922. 

A memorial service, attended by representatives of the Borough Council and 
members of the profession, was held at Ryhope Church, but the actual interment 
was at Edinburgh, and at this a number of his personal friends were present, 
including several members of the Medico-Psychological Association. 

In the early part of his professional life Dr. Middlemass contributed many papers 
to the medical journals. For thirteen years, dating from 1905, he reported the 
latest advances in psychological medicine for the Edinburgh Medical Review —a 
task for. which he was peculiarly qualified by his wide reading and his knowledge 
of German. Two noteworthy articles, " Developmental General Paralysis,” and 


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“ Traumatism and General Paralysis/’ appeared in the Journal of Mental Science , 
to which he contributed a large number of reviews. 

In association with the late Sir Thomas Clouston and with Dr. Ford Robertson, 
he wrote a series of articles on pathology in relation to mental disease. Another 
paper of great value, on “ Night-Nursing in Asylums/’ was written in conjunction 
with Dr. Elkins. In this it was clearly demonstrated that noise, turbulence and 
degraded habits could almost be abolished during the night in a mental hospital if 
the nursing were effectively organised. The advantages of dormitories over single 
rooms were also explained. The writer of the present record has had opportunities 
of seeing the practical result of the methods advocated at the Sunderland 
Asylum ; and the quiet and good order which prevailed in all the wards during the 
night were most remarkable. 

Dr. Middlemass was an active member of the Medico-Psychological Association, 
-attending the general and branch meetings with regularity, and often contributing 
papers. He was particularly interested in the training of nurses, and wrote a 
section for the old edition of the Handbook for those engaged in mental nursing. 
He was, moreover, a hard-working member of the Committee appointed to revise 
this handbook. To state the authorship of the various sections is not customary, 
but his contributions, which dealt chiefly with practical nursing, were of the utmost 
value. The sincerity and enthusiasm of the writer are manifest throughout. It is 
pleasant to think that his words will influence the profession of nursing for many 
generations, since whatever changes take place, the high ideals and principles 
which he enunciated are too fundamental to require revision. 

Dr. Hubert Bond, the President of the Association, in referring to the loss which 
it had sustained, stated that at an early date Dr. Middlemass would have been 
asked to accept the Presidency. But this was not to be ! 

Of all his other activities it is impossible to speak in detail. He was held in 
great regard in Sunderland, being twice President of the Sunderland Branch of the 
British Medical Association. His expert knowledge and practice in psychiatry by 
no means cut him off from the general body of the medical profession ; while his 
independent position made his services invaluable during the controversies con¬ 
nected with the introduction of the panel practice and with military service. As 
chairman of the War Committee he discharged a delicate and heavy task with 
marked success. 

James Middlemass was tall and spare, and at first sight he looked delicate; but 
in reality he possessed great endurance. He was an adept at games of all kinds, 
excelling at golf, cricket, tennis, curling, billiards, and whatever he took in hand. 
“ It was always a pleasure to play with him,” writes one friend; “ he possessed the 
true sportsman’s instinct, and * played the game ’ whether he won or lost.” 

He loved the country and the open air, and long expeditions on foot. It was a 
privilege to spend a holiday with so interesting a companion. In 1908 the present 
writer accompanied him to Berlin, and on our return journey we visited the theatre 
at Brunswick. There Middlemass sat next to a lady, who joined in our conversa¬ 
tion when she heard us speaking English. After a time she said suddenly : 

“ I cannot understand why you English are so blind! You will not heed 
warnings, and you refuse to listen to Lord Roberts.” 

It transpired that she was the wife of a German officer. Middlemass was deeply 
impressed, for he was a regular reader of the Spectator , which at that time had 
published articles about Germans which many of us thought unfair and injurious. 
The year 1914 showed that the chance conversation was prophetic ! 

If success may be measured by personal influence for good, James Middlemass 
achieved great success. All who knew him—old fellow-students, colleagues, 
pupils, friends, the members of his Committee and of the hospital staff, speak with 
touching and striking uniformity of his integrity, unselfishness and sound 
judgment. We realise keenly how much we shall miss him, how we relied upon 
his judgment, and how readily he spent himself for others. 

He came of a musical family, and he played the ’cello well. By his fellow 
students he was regarded with admiration, now and then tinged by envy, because 
he did his work with such apparent ease, seemed able to choose the right course 
of action so surely, and was so quiet, imperturbable and trustworthy. As one of 
his old companions writes: “We might do well and aim high (I do not mean in 
the worldly sense); he did better and aimed higher. He was the disciplined 
servant of his ideals.” 


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One old friend, himself a distinguished man, who knew James Middlemass from 
his boyhood, writes : 11 There is not a single recollection of him I wish to blot out. 
He was one of the best men I ever knew. . . . He was absolutely unassuming, 

true to the heart’s core, strong with the strength that goes hand in hand with 
gentleness and courtesy and love. A genuine son of consolation, he laid his great 
gifts of intellect and skill at the door of those who needed them sorely.” 

Another, now a University professor, writes: 11 He certainly possessed all-round 
powers, and I feel he would have taken an eminent place in almost any branch of 
the profession. I may add that he was of a gentle and kindly nature, unselfish 
and absolutely upright in his dealings with his fellows, and always ready to help 
anyone. I cannot recall anything spoken or done by him with a taint of the 
unworthy.” 

41 A peace-maker, and one who never undertook to do a thing without doing it,” 
writes one friend; while another says, 44 His ability had nothing theatrical 
about it.” 

James Middlemass certainly never sought the limelight. Perhaps, indeed, he 
was too reticent, quiet and unassuming to win all the distinctions to which his 
achievements entitled him. But his influence was profound, and it is a cause for 
thankfulness that he turned his attention to psychological medicine, since he was 
uniquely fitted to help people in mental distress. 

Though he rarely discussed religion, he was a man of deep religious convictions, 
and all who knew him will realise the aptness of words quoted by the Chairman of 
his Committee, Mr. Councillor Taylor, who wrote, 44 What nobler epitaph can any 
man have than this, 1 After he had served his own generation faithfully, by the will 
of God, he fell on sleep.’ ” 

It seems fitting to conclude this brief record of our friend by a sonnet written by 
his sister: 

Remembrance. 

James Middlemass , M.D. 

Thanks for the rain upon the thirsty ground, 

Thanks too for tears that ease the burdened heart; 

But thanks supreme for memories that dart 
Their shaft-like glory through the grief around. 

Computing these, what are the riches found ? 

Fair chronicles of one who played his part, 

As friend and true physician, with an art 
In wise and patient, gentle ways that bound 
To him the hearts of many in strong faith 
And love and leal devotion. Can such power, 

Of origin divine, be held of death 
And wither in the dust like any flower ? 

Nay, ’tis alive—immortal aftermath— 

To bless us when we reach death’s golden hour. 

Bedford Pierce. 

May , 1922. 


Marriott Logan Rowan, M.D., R.U.I. 

We regret to announce the death, on August 6th, at St. Anne’s-on-Sea, of Dr. 
Rowan, who since 1915 has filled the post of Medical Superintendent of the Derby 
County Mental Hospital. He was a native of Carrickfergus, co. Antrim, being 
born there in 1871, and received his medical education at Queen’s College, Belfast. 
He was a graduate of the Royal University of Ireland, taking his medical degrees 
M.B., B.Ch., B.A.O., in 1900 after a distinguished arts career. He received the 
degree of M.D. in 1903 and took up psychiatry in 1904, when he was appointed 
an assistant medical officer at the same hospital of which he subsequently became 
the medical chief. His health had been failing for some time, but his end came 
quite suddenly, much to the distress of his many friends and relatives. His loss 
was keenly felt at his hospital, where he had endeared himself to both staff and 
patients. He leaves a widow and two young children, to whom we extend our 
sincere condolence. 


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NOTICES OF MEETINGS. 

Quarterly Meeting. —November 23, 1922, at the Bethlem Royal Hospital. 
Subject: “ The History of General Paralysis,” by the President. 

South-Eastern Division. —October 24, 1922, at Virginia Water. 

South-Western Division. —October 27, 1922, at Bath. 

Northern and Midland Division .—October 26, 1922, at Stafford. 

Scottish Division. —November 21, 1922, at Edinburgh : Address by M. Cou£. 
Irish Division .—November 30, 1922; April 26, 1923. 


APPOINTMENTS. 

Archdale, M. A., M.B., B.S.Durh., Medical Superintendent, Sunderland 
Borough Mental Hospital, Ryhope. 

Bartlett, G. N., M.B., B.S.Lond., Medical Superintendent, Derby County 
Mental Hospital, Mickleover. 

Dawson, W. S., M.A., M.B., M.R.C.P.Lond,, Senior Assistant Medical Officer, 
The Maudsley Hospital, Denmark Hill, S.E. 5. 

Gilfillan, J. A., M.D.Glasg., D.P.M.Lond., Second Assistant Medical Officer, 
City Mental Hospital, Humberstone, Leicester. 

Mapother, Edward, M.D.Lond., F.R.C.S.Eng., Medical Superintendent, The 
Maudsley Hospital, Denmark Hill, S.E. 5. 


LXVIII. 


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INDEX TO VOL. LXVIII. 


Part I.—GENERAL INDEX. 

Abbott, Henry Kingsmill, obituary, 207 

Albino rat, vascularity of the cerebral cortex of the, 290 

Album of Past Presidents, 196 

Albuminuria with casts, frequency of, in epileptics following frequent seizures, 88 
American Psychiatric Association, 317 
Analysis in diagnosis, use of, 196 
„ use of, in diagnosis, 229 
Annual meeting, 423 

Aphasia, global, and bilateral aphasia due to an endothelioma, 189 

Appointments, 465 

Arneth count in insanity, 267 

Asylums, charges against, 206 

„ system, Scottish, hospitalisation of the, 321 
Auditors, appointment of, 424 
„ report of the, 428 
Australia, psychiatry in, 317 

Bacillary dysentery in asylum, 96 

Barium sulphate meal, passage of a, in ten cases of dementia praecox, 5 
Basal ganglia, functions of the, 153 
Bayle, centenary of the thesis of, 401 

“ Bilious attack" and certain other morbid phenomena to the epileptic state, 198 
Biological basis of sexual regression and its sociological significance, 187 
Board of Control and the Geddes Report, 206 
„ „ committees of inquiry, 206 

Cerebellar fits, 86 

Cerebro-spinal fluid, colloidal gold reaction in the, 66 
Certification of children of school age, 302 
Chairmen, list of, iii 

Childhood and adolescence, fantasies of, as a source of delusions, 33 
Childhood, the golden period for mental hygiene, 300 
Children of school age, certification of, 302 
Chorea degeneration, 188 
Clinical notes and news, 157, 266, and 396 
„ psychiatry, 87, 190, 293, 418 
Colloidal gamboge reaction, 396 

„ gold reaction in the cerebro-spinal fluid, 66 
Committees, election of, 424 
Council and officers, list of, 1 
„ report, 424 

Convalescent fund for mental nurses, 110 
Cranial injuries and Korsakoff’s psychosis, 89 
Crichton-Browne, Sir James, resignation of, 178 
Criminal, treatment of the, 198 


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467 


Delinquents, medical examination of, ioi, 254 
Delirium tremens, Nissl's Stabchenzellen in, 95 
Delusions, fantasies of childhood and adolescence as a source of, 33 
Dementia praecox cases, study of the trend in a group of, 190 
„ „ genetic origin of, 306, 333 

,, „ paranoid, intellectual status of patients with, 88 

,, „ passage of a barium sulphate meal in ten cases of, 5 

„ „ prognosis of, 191 

,, „ reaction in, to vagotonic and sympathicotonic criteria, 87 

Dendrites of the Purkinje cells, peculiar changes found in the, 96 
Diagnosis, use of analysis in, 229 

Diastase-content of the urine in 120 cases of mental disorder, 1 

Dinner, annual, 438 

Dysentery, bacillary, in asylums, 96 

Editors, report of the, 426 

Education and training, relation of, to mental disorder, 210 
Educational Committee Report, 428 
„ notes, 108, 201, 459 

„ practice, modern developments in, 413 

Election of members, 100, 195, 305, 310, 312, 431 
Encephalitis lethargica, mental disorder resulting from, 169 

Endocrine glands and the central nervous system, some chemical influences in 
regard to the, 367 

,, „ relation of, to mental disease, 446 

Endocrines, role of the, in mental disorders, 374 
Endocrinopathies, mental factor of some, 450 
Epilepsy, nature of so-called idiopathic, 292 
„ Nissl’s Stabchenzellen in, 95 

,, pathogenesis of, from the historical standpoint, 193 
,, reflex, 189 

„ treated with luminal, 94 

,, use of luminal sodium in, 166 
Epileptics, frequency of albuminuria with casts in, 88 
Epitome of current literature, 84, 184, 289, 415 
Examination for Nursing Certificate, results, no 

„ „ of Mental Defectives, results, 114 

Excursions on the occasion of the Annual Meeting, 458 
Exploration, psychology of, 415 

Fantasies of childhood and adolescence as a source of delusions, 33 
Financial statement, 427 
Fits, cerebellar, 86 
Forgetting, 263 

„ discussion on, 104 

Garden Party at Morningside, 438 
Gaul v. Earl Spencer and others, 398 
General paralysis, 293 

,, „ is treatment worth while ?, 299 

Generative organs, internal secretions of the, 350 
Genetic origin of dementia praecox, 306, 333 
Glioma, Nissl’s Stabchenzellen in, 95 
Goldsol test in mental disease, 54 

Hallucinations, lilliputian, 266 

Handbook for mental nurses: discussion at annual meeting, 99 
Herd instinct, critique of the theory of, 245 
Heredity, general paralysis and, 293 
Honorary and associate members, election of, 425 
,, members, v 

Hospitalisation of the Scottish asylum system, 321 
Huntington’s chorea, hereditary transmission of, 188 


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468 


INDEX. 


Incipient insanity, proposed Government Bill, 459 
Insane, treatment of, in pavilion without detention, 419 
Insanity, Arneth count in, 267 

„ forms in which it expresses itself, 295 
,, treatment of, 92, 191, 298, 419 
Intelligence, group tests of, 412 

„ of normal persons, testing, 184 

„ tests, 85 

Internal secretions, influence of, on the nervous system, 347 
Intestinal toxaemia, treatment of, 450 
Irish Division, 313 

„ meetings, 200, 313 

Journal, cost of printing, report by the Editors, 194 
Juvenile delinquency, 409 

Kleptomania from the medico-legal point of view, 97 
Korsakoff’s psychosis, cranial injuries and, 89 

Lethargic encephalitis with myoclonus and bulbar attacks, 86 
Library committee report, 430 
Lilliputian hallucinations, 266 
Long Grove Mental Hospital, Epsom, 317 
Luminal in the treatment of epilepsy, 94 
„ „ „ insanity, 92 

„ sodium, use of, in epilepsy, 166 
Lunacy Reform Conference, 205 
Luncheon at Edinburgh, 434 

Macpherson, Sir John, knighthood of, 280 
„ „ retirement of, 315 

Maudsley Hospital, syllabus of lectures, 207, 460 

„ Lecture, third, delivered by Sir Maurice Craig on " Some Aspects of 
Education and Training in Relation to Mental Disorder,” 210 
„ lectures, 431 

„ lecturers, list of, iv 

Medal, bronze, the Association’s, 106 
Medico-legal cases, recent, 271, 398 

Medico-Psychological Association, adjourned annual meeting, 99 

,, „ eighty-first annual meeting at Edinburgh, 423 

„ „ meetings, 99, 194, 304 

Meetings, notices of, 114, 208, 431, 465 
Members, election of, 100, 195, 305, 310, 312, 431 

,, honorary and associate, election of, 423 

„ list of, v 

„ of the Association, vii 

Mental After-Care Association, 203 

„ diseases, relationship of the reproductive and endocrine glands to, 446 

,, „ treatment of, 450 

„ disorder, out-patients, early treatment of, 385 

,, „ relation of education and training to, 210 

,, „ rtle of the endocrines in, 374 

„ ,, treatment of early cases of, 432 

„ hygiene, 300 

„ ,, National Council of, 278 

Middlemass, James, obituary, 462 

Myoclonus and bulbar attack, lethargic encephalitis with, 86 

Nissel’s Stabchenzellen in the cerebral cortex in general paresis, senile dementia 
epilepsy, glioma, tuberculous meningitis, and delirium tremens, 95 
Northern and Midland Division meetings, 197, 311 
Notes and news, 99, 194, 304, 423 


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INDEX. 


469 


Notices by the Registrar, no 

,, of meetings, 114, 208, 319, 465 
Neurological clinic and some of its functions, 385 
Neurology, 86, 188, 290, 416 
Neuro-syphilis, review of recent literature on, 416 

Obituary.—Abbott, Henry Kingsmill, 207 
Middlemass, James, 462 
Rowan, Marriott Logan, 464 
Turner, John, 318 
Occasional notes, 171, 278, 401 

Occupational therapy at Kankakee, Illinois State Hospital, 191 
„ „ philosophy of, 421 

Officers and Council, election of, 423 
„ list of, i 

Oral infection, relation of, to mental diseases, 291 
Oxford Clinic, description of, 17 

Paralysis, general, pathogenesis of, 192 
Paraphrenia, 157 
Parathyroids, 365 

Paresis, general, Nissl’s Stabchenzellen in, 95 
Parliamentary committee, report of the, 429 
„ news, 107, 201, 313, 458 

Patients, mental, training aids for, 420 
Pathology, 95, 192 

Personality, diagnosis and evaluation, 289 
Post-graduate study, sub-committee on, 431 
Precocity, intellectual and criminal, in a German child, 90 
President, installation of, 436 
Presidents, list of, iii 

Psychiatric research, ends and means of, 115 
Psychiatry, clinical, 87 

„ progress of, in the Union of South Africa, 175 
„ trend of, in England and Wales, 171 

Psycho-analysis and the drama, 406 
„ practical, 407 

Psychological foundation of belief in spirits, 84 
Psychology and psycho-pathology, 184 

„ and psycho-therapy, 23, 184, 415 

„ new, and the teacher, 410 

„ of exploration, 415 

Psychopathic inheritance, nature of the, 236 
Psycho-pathology, 289 
Psychoses, change of phase in, 48 
„ thyroidal, 418 

Psycho-therapeutic clinic, notes from a, 379 
Psycho-therapy, psychology and, 23 
Puerilism, case of, 91 

Purkinje cells, axons and dendrites of the, peculiar changes found in the, 96 

Report, twenty-fifth annual, of the Pathologist to the Laboratory of the Scottish 
asylums for 1921, 461 
Report of the Council, 424 
„ of the Editors, 426 

„ of the Educational Committee, 428 

„ of the Library Committee, 430 

,, of the Parliamentary Committee, 429 

„ of the Treasurer, 426 

Reproductive glands, relation of, to mental disease, 446 
Reviews, 180, 281, 402 


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470 


INDEX. 


Rex v. Ernest Albert Walker, 399 

Rex v. Ronald True, case reported by Dr. M. Hamblin Smith, 271 
Rowan, Marriot Logan, obituary, 464 

Scottish asylum system, hospitalisation of the, 321 

Scottish asylums, twenty-fifth annual report of the Pathologist of the Laboratory 
for the year 1921, 461 
Scottish Division, meeting, 199, 312 
Senile dementia, Nissl’s Stabchenzellen in, 95 
Sequestrations, voluntary, and liberty psychoses, 297 

Sexual repression, biological basis on, and its sociological significance, 187 
Sociology, 97 

South-Eastern Division, 106, 309 

South-Western Division, 106, 310 

Spirits, psychological foundations of belief in, 84 

Spirochaetes, serum and spinal fluid, 192 

Stansfield, Lieut.-Col. T. E. K., retirement of, 109 

Strychnine in the treatment of melancholic depression, 298 

Suicide among soldiers at the psychiatric hospital at Mombello, 297 

Sympathetic and para-sympathetic systems, 447 

Syphilis, accurate diagnosis and intensive treatment of, 420 

Tests, intelligence, 85 
Thyroid, internal secretions of the, 354 
„ physiological action of the, 356 
Thyroidal psychoses, 418 

Toxaemia, organised endocrine, sympathetic and central nervous systems in, 

449 

Treasurer’s Report, 426 

Treatment of the insane in pavilions without detention, 419 
Tuberculous meningitis, Nissl’s Stabchenzellen in, 95 
Turner, John, obituary of, 318 

Urine, diastase content of the, in 120 cases of mental disease, 1 
Venous stasis, 144 

West Ham asylum, ex-service patients in, 313 


Part II.—ORIGINAL ARTICLES. 

Beaton, Thomas, change of phase in the psychoses, 48 
Bedford, P. W., goldsol test in mental disease, 54 
Blachford, J. V., functions of the basal ganglia, 153 
Brown, William, psychology and psycho-therapy, 25 

Bruce, A. Ninian, out-patient treatment of early mental disorders : the neuro¬ 
logical clinic and some of its functions, 385 
Craig, Sir Maurice, some aspects of education and training in relation to mental 
disorder (Third Maudsley Lecture), 210 
Davies-Jones, C., “ forgetting,” 263 
Fox, J. Tylor, use of luminal sodium in epilepsy, 166 
Good, T. S., the Oxford clinic, 17 

,, ,, use of analysis in diagnosis, 229 

Goodall, Edwin, and Scholberg, H. A., note on the diastase-content of the urine 
in 120 cases of mental disease, 1 
Goodall, Edwin, see Stanford, R. V. 

Hyslop, Theo. B., venous stasis, 144 
Knox, Robert, see Stanford, R. V. 

Kraepelin, Prof. Emil, ends and means of psychiatric research, 115 

Leroy, Dr., lilliputian hallucinations. Communicated by Dr. J. W. B. James, 266 


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INDEX. 471 

Macphail, H. D., mental disorder resulting from encephalitis lethargica, 169 
Mapother, E., and Martin, J. E., fantasies of childhood and adolescence as a source 
of delusions, 33 
Martin, J. E., see Mapother, E. 

Meakins, Jonathan C., some chemical influences in regard to the endocrine glands 
and the central nervous system, 367 
Middlemiss, James Ernest, notes from a psycho-therapeutic clinic, 379 
Mott, Sir F. W., genetic origin of dementia prsecox, 333; discussion on, 306 
Nolan, M. J., paraphrenia, 157 
Ponder, Eric, Arneth count in insanity, 267 
Riddel, D. O., colloidal gamboze reaction, 396 

Robertson, George M., hospitalisation of the Scottish asylum system. Presidential 
Address delivered at Edinburgh, 1922, 321 
Rutherford, H. R. C., nature of psychopathic inheritance, 236 
Schafer, Sir E. Sharpey, influence of the internal secretions on the nervous 
system, 347 

Scholberg, H. A., see Goodall, Edwin. 

Smith, M. Hamblin, Gaul v, Earl Spencer and others, 398 
„ „ Rex v. Ernest Albert Walker, 399 

,, „ medical examination of delinquents, 254 

„ ,, Rex v. Ronald True. Report of case, 271 

Stanford, R. V., and Goodall, Edwin, the passage of a barium sulphate meal in 

ten cases of dementia praecox, 5 

Stoddart, W. H. B., role of the endocrines in mental disorders, 374 
Suttie, Ian D., critique of the theory of " herd instinct,” 245 
Whitelaw, W., colloidal gold reaction in cerebro-spinal fluid, 66 


Part III.—REVIEWS. 

Adams, John, Modern Developments in Educational Practice, 413 
Ballard, P. B., Group Tests of Intelligence, 412 

Barb£, Andrd, Examen des Alienas, Nouvelles Methodes Biologiques et Cliniques. 
Preface by J. Sdglas, 1921, 82 

Bianchi, Prof. Leonardo, Mechanism of the Brain and the Function of the Frontal 
Lobes, 1922. Translated by James H. Macdonald, M.B., with a foreword by 
C. Lloyd Morgan, F.R.S., 402 
Briggs, L. Vernon, Manner of Man that Kills, 1921, 183 

Brown, William, Suggestion and Mental Analysis: An Outline of the Theory and 
Practice of Mind Cure, 407 

Buckley, Albert C., Basis of Psychiatry (Psycho-Biological Medicine): A Guide to 
the Study of Mental Disorders for Students and Practitioners, 281 
Core, Donald E., Functional Nervous Disorders: Their Classification and 
Treatment, 1922, 288 

Craig, Sir Maurice, Nerve Exhaustion, 1922, 283 
Fliigel, J. C., Psycho-Analytic Study of the Family, 1921, 285 
Goddard, Henry Herbert, Juvenile Delinquency, 1922, 409 
Hirschfeld, Magnus, Sexualpathologie. Dritten Teil, pp. xi, 74 
Jelliffe, Smith Ely, Psycho-Analysis and the Drama, 1922, 406 
Kempe, Edward J., Psychopathology, 1921, 78 

Kraepelin, Emil, Einfuhrung in die Psychiatrische Klinik. Fourth Edit., 3 vols., 

I 9 2I » 77 

Miller, H. Crichton, New Psychology and the Teacher, 410 
Mitchell, Dr. T. W., Psychology of Medicine, 1921, 184 

Robertson, W. Ford, Therapeutic Immunisation in Asylum and General Practice. 
1921, 81 

Ruggles-Brise, Sir Evelyn, The English Prison System, 180 

Sidis, Boris, Symptomatology, Psychognosis and Diagnosis of Psychopathic 
Diseases, 1921, 75 

Somerville, H., Practical Psycho-Analysis, 1922, 407 


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Part IV.—AUTHORS REFERRED TO IN THE EPITOME. 


Benon, R., 89 
Berges, Gaston, 92 
Bremer, F., 189 
Brousseau, 91 

Courbon, Paul, 90, 297 
Craigie, E. H., 290 

Dawson, W. S., 96 
Dupouy, R., 86 

Feiner, L., 86 
Fernald, G. C., 289 
Flugel, J. C., 187 

Harms zum Spreckel, H., 
188 

Hartenberg, P., 298 
Jung, C. G., 84 
Kasak, 193 


Kirk, O. C. 

Kraepelin, Emil, 295 

Laignel-Lavastine, 418 
Lange, Johannes, 184 
Laruelle, L.,419 
Lehnche, R .,89 
Leroy, R., 86 

MacRobert, R. G., 86 
Meyer, A., 421 
Moody, W., 96 

Noda, U., 95 
Novick, N., 88 

Pagniez, P., 292 
Potter, H. W., 191 
Priestly, R. E., 415 

Raphael, T., 87 
Rawling, E., 88 


Root, W. R., 291 
Rosenhain, E., 189 
Ross, J. R.,420 
Ruete, 192 


Truelle, 91 

Uyematsu, S., 96 

Watts, F. f 85 
White, W. A., 300 
Williams, R. R., 191 
Wimmer, A., 97 
Wright, W. W., 190 


Sacchini, G., 297 
Scharnke, 192 
Shrubsall, F. C., 302 
Slagle, E. C., 420 
Solomon, H.C., 299, 416 
Sutton, B. E., 191 


ILLUSTRATIONS. 

Photo-micrograph to illustrate Dr. Nolan’s article on “ Paraphrenia,” 158 
Photo-micrographs to illustrate Sir Frederick W. Mott’s article on the “ Genetic 
Origin of Dementia Praecox,” 346. 



I 

ADLARD AND SON AND WEST NEWMAN, LTD., IMPR., LONDON AND DORKING. 


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Full text of "The Journal Of Mental Science. 68.1922 Minnesota"

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